West Virginia National Guard’s Task Force Chemical, Biological, Radiological and Nuclear (CBRN) Response Enterprise (assist staff, medical personnel, and first responders of an Eastbrook Center nursing home with COVID-19 testing in April 2020.

As pressure intensifies on World Health Organization (WHO) member states to finalise a pandemic agreement by May, insiders are concerned by the snails’ pace of negotiations – primarily because they believe the negotiators have spent an inordinate amount of time on contentious issues while neglecting more procedural issues.

After two years of negotiations, the eighth meeting of the intergovernmental negotiating body’s (INB) entered its seventh day on Tuesday with a number of key discussions still confined to sub-groups rather being presented as text proposals because of disagreements.

A joint meeting between the INB and the Working Group on Amendments to the International Health Regulations (WGIHR) last Friday provided a rare public glimpse into the slow pace of talks. 

The WGIHR is updating the IHR, world’s only binding agreement on public health emergencies with pandemic potential, as these were found wanting during COVID-19 – and some of their work overlaps with the INB. 

The joint meeting was aimed at ironing out how the overlapping areas would be addressed – yet the Bureaux of both groups ended up withdrawing two of their four process proposals because of lack of agreement. 

Some influential outside groups have hosted private meetings with negotiators in an attempt to break the impasse and ensure that the next pandemic is guided by equitable access to vaccines and medicines not the COVID-era vaccine nationalism.

Most recently, the International Peace Institute and the Permanent Mission of Costa Rica in Geneva hosted a retreat for some INB negotiators over the past weekend. But it is too early to tell whether this has resulted in any positive results.

No obligation to ‘right to health’

INB co-chair Precious Matsoso and Pandemic Action Network’s Aggrey Aluso at last week’s civil society hearings.

Meanwhile, voices outside the process have been growing louder with important interventions from civil society and scientists in the past week.

The Pandemic Action Network hosted two short sessions in Geneva last week for civil society to express their views on the draft directly to INB members. Over 100 organisations stepped up to do so – although the first session was marred by a handful of vocal anti-vaxxers opposed to the WHO.

While some civil society organisations used their two-minute slots to lament their exclusion from negotiations, some important interventions were made. These include the draft agreement’s narrow definition of “vulnerable people”, no obligation on countries to ensure citizens’ right to health or human rights monitoring during pandemics, and the potential for national laws to neutralise any pandemic agreement. 

Meanwhile, a group of 290 scientists from 36 countries warned that unless a pathogen access and benefit-sharing (PABS) system is agreed on – currently Article 12 – there will be no vaccine equity in the next pandemic.

At this stage, the INB Bureau has been unable to provide text for an updated Article 12 because of disagreements.

Benefits for information-sharing

“Across all fields, scientists from the global north have frequently extracted data and samples from the global south without the permission of the people there, without collaborating meaningfully — if at all — with local scientists, and without providing any benefit to the countries where they conduct their work,” according to to nine key scientists leading the group in a commentary in Nature.

The group recommends that the negotiations “take lessons” from the 2011 Pandemic Influenza Preparedness (PIP) Framework “to streamline the sharing of influenza viruses with pandemic potential, as well as vaccines and other benefits”.

“Under the PIP Framework, 14 manufacturers have promised that when the next influenza pandemic starts, they will share up to 10% of the vaccines that they make (around 420 million doses) with the WHO. In exchange, these companies have access to a global network of laboratories and their flu samples. The PIP model shows significant promise, but is so far untested and applies only to influenza.”

The scientists propose that under the proposed PABS system, scientists would share pathogen samples and data. In exchange for access to these, manufacturers of vaccines or therapeutics would give at least 20% of their products to the WHO (half for free, and half at affordable prices). 

“If Article 12 is weakened or dismantled, it will be a monumental setback for global health justice – and for the global scientific community,” they warn.

“Although today’s scientific community has embraced the ideals of open data sharing, the world is no closer to a fair system for sharing vaccines and therapeutics. Intellectual property, not benefit-sharing, is the antithesis of open science.”

INB8 ends on Friday afternoon, with the ninth meeting scheduled for 18-29 March. However, a further meeting is likely after this given the slow pace.

Image Credits: U.S. Army National Guard/Edwin L. Wriston.

UNEP executive director Inger Andersen at UNEA-6

The sixth United Nations Environment Assembly (UNEA-6), which opened in the Kenyan capital of Nairobi on Monday, is focusing on multilateral action to tackle climate change, biodiversity loss and pollution.

Around a million species are headed towards extinction, global temperature records were smashed in 2023 and pollution remains one of the world’s leading causes of premature death.

“It is time to lay political differences aside and focus on this little blue planet, teeming with life. Time to lift our sights to our common goal: a pathway to a sustainable and safe future,” said Inger Andersen, Executive Director of UN Environment Programme (UNEP). “We do this by agreeing on the resolutions before UNEA-6 to boost multilateral action for today and tomorrow, and secure intergenerational justice and equity.”

The assembly, the world’s highest-level decision-making body on the environment,  will consider some 19 resolutions on issues including pesticides, land degradation and drought, the environmental aspects of minerals and metals, and, support to the Global South to mitigate to the triple crisis.

“We are living in a time of turmoil. And I know that in this room, there are people who are, or who know, those deeply affected by this turmoil. Our response must demonstrate that multilateral diplomacy can deliver,” said Leila Benali, president of UNEA-6 and Morocco’s Minister of Energy Transition and Sustainable Development. 

“As we meet here in 2024, we must be self-critical and work towards inclusive, networked and effective multilateralism that can make a tangible difference to people’s lives,” she told the record-breaking 7000 delegates from all 193 UN member states at the start of the assembly.

 

 

“We must also include voices beyond government, of youth, indigenous peoples and local communities, by focusing on issues of gender and human rights, and leaving no one behind,” Benali added.

“It is time to lay political differences aside and focus on this little blue planet, teeming with life. Time to lift our sights to our common goal: a pathway to a sustainable and safe future,” said Inger Andersen, Executive Director of UNEP. “We do this by agreeing on the resolutions before UNEA-6 to boost multilateral action for today and tomorrow, and secure intergenerational justice and equity.”

 “UNEA-6 comes at a time when the world is also called upon to accelerate the implementation of the UN 2030 Agenda if we are to stay course on sustainable development. Unfortunately, for millions in the developing regions of the world, including here in Africa, poverty still remains a daily reality while economic inequality is increasing globally,” said Soipan Tuya, Kenya’s Cabinet Secretary for the Environment, Climate Change and Forestry. 

“It is against this backdrop that the world will be looking to us here in Nairobi this week to renew hope. And hope we must provide.”

UNEP is advocating for nature-based solutions and ecosystem-based approaches to meet Social Development Goals. The organisation is working with governments and organisations that are looking at projects ranging from afforestation to river revivals.

The Assembly is set to have more than 30 official side-events and associated events, ending on 1 March.

Image Credits: X.

Dr Jackline Kisota (centre) and colleagues involved in making eco-friendly sanitary towels.

After Kenya banned plastic bags back in 2018, an academic’s quest for alternative packaging has led to the development of eco-friendly sanitary towels.

Dr Jackline Kisota wants her product to empower young girls while also conserving the environment she told the launch last October, which was graced by potential investors and UN representatives.

According to the Kenyatta University academic, her product is expected to favourably compete with products already on the market in terms of cost, health impact and environmental concerns.

In 2018, the Kenyan government banned single-use plastic bags to align with climate change mitigation protocols, and this caused difficulties for shops and market vendors who did not know how to package their goods for sale.

Kisato’s venture started out as a project to find a commercial use for banana stems, which were considered useless by farmers and would usually be left to rot away on farms. 

‘’I started looking at this project from an entrepreneurship point of view, on how I could commercialise banana stem fibres. The government had just banned single use plastic bags and market vendors needed alternatives to serve their customers,’’ Kisato said.

Period poverty

But Kisato had already noted the struggles that some university students had to access sanitary towels, but it was not until she started her banana stem fibre project did she realise that she could tackle the girls’ plight. 

‘’While walking along the hallways one day, a student on campus stopped me and asked if I could help her with a packet of sanitary pads. This incident shocked me as, for a long time, I had assumed ‘period poverty’ was only experienced amongst high school girls,’’ Kisato said.

‘’My research also found that poorly disposed sanitary towels also formed part of the pollution problem since they were composed of plastic,’’ she explained.

Kisato applied to the Kenyan National Research Fund (NRF) in 2018 for help to develop eco-friendly plastic bags and sanitary towels, and in 2020 the NRF granted Kenyatta University $61,625  for the project with Kisota as principal investigator.

Her research team is made up of scholars from different departments and institutions, including PHD and Masters students.

Engineering

‘’I lead a team of engineers from the Kenya Industrial Research and Development Institute (KIRDI), whose task is to reverse engineer machines that can extract fibre from banana stems and use them to create eco-friendly packaging material and sanitary towels,’’ she said. 

“I also have researchers from Moi University whose work was to turn the extracted fibre into soft materials for use.”

The project also interviewed 400 high school girls from low-income areas of Gatundu, Kibera and Kawangware where they found out that more than half the girls in these areas could hardly afford sanitary pads.

Kisato’s research also found that, due to affordability and limited access, African girls used each  sanitary towel for longer than girls from developed countries, and were thus at greater risk of getting bacterial infection.

‘’The recommended period for one to have on a sanitary pad is about three hours, which means that it should be changed at least three times a day to avoid any risk of infections. This is, however, not the case for many girls in Africa due to poverty,’’ Kisato explained.

‘’We decided that adding anti-microbial properties to our product would make it as good or even better than what was in the market,’’ said Kisato.

Menstrual myths

The research team also found out that there was a lot of myth surrounding menstrual flow amongst young girls, a fact that led to a lot of stigmatizations which made it difficult for them to properly understand how to use sanitary towels.

Some of the notable ideas that the young girls told each other concerning menstrual flow including that it is a curse from God, girls who had periods were considered dirty and impure and their faces would become pale from losing blood.

‘’These are beliefs that need to be done away with by encouraging parents and the government to openly speak about monthly periods with young girls,’’ Kisato said.

These substances have been extracted from banana stems to make eco-friendly sanitary towels

‘’The sanitary towels in the market have a component in them called hydrogel which enables them to retain fluids for longer and are also lined with plastic sheets to prevent any leakage. Our intention is to replicate the same but use bioplastic materials which can degrade as opposed to the normal plastic that is being used’’.

To ensure this, they sought the expertise of Edwin Madivoli, a chemistry lecturer at the Jomo Kenyatta University of Agriculture and Technology (JKUAT).

‘’My role is to ensure our sanitary pads are of the same quality as what is in the market while maintaining an eco-friendly nature, which is the main agenda of this whole project,’’ Madivoli said.

‘’I am tasked with the development of bioplastic hydrogel and finding a way to incorporate anti-microbial properties into our products to protect the users from possible infections,’’ he added.

‘’As they are left to dry up on the farms, banana stems are known to produce large amounts of methane which is a harmful greenhouse gas that contributes to the climate change problems that we are trying to tackle, added Madivoli. ‘’Having an alternative use for the stems therefore limits the greenhouse effect in the atmosphere.’’

Madivoli said that most banana farmers usually do not know what to do with the stems once they have done their harvest and this project gives them a way to earn some extra income as they expect to buy the stems from them at 25 cents per stem.

‘’This project will not only be environmentally friendly but will also create jobs for the people who go to cut the stems from the farms while also finding use for the biomass that the farmers thought was useless,’’ he concluded.

The Research Scholarship and Innovation Fund (RSIF) has contributed $56,250 to enable Madivoli’s research, while the Kenya National Innovation Agency (KENIA) has made a $5000 contribution.

Eco-friendly packaging

Stephany Musombi, one of Kisato’s students who specialises in textiles, has been tasked with coming up with quality packaging materials.

‘’Apart from the banana fibre, I am also experimenting with other biomass such as pineapple and seaweed,’’ Musombi said. If I can find a way to make this work, the project will open up a market for seaweed and pineapple biomass.

Once it is up and running, they intend to source banana stems from counties such as Kisii, Muranga, Embu, Meru and parts of western Kenya.

Kisato expects her product to hit the market this October, where she plans to make it more affordable for all. Her intention is to team up with startups or established companies that deal with toiletries.

‘’The cheapest sanitary packet in the market costs Ksh 140 ($1). We expect ours to go as low as Ksh100 (70 cents),” Kisato concluded. 

Kisato’s products are currently awaiting the approval by the Kenya Bureau of Standards (KEBS) before they can finally start mass production.

Kenyatta University’s Vice Chancellor, Paul Wainaina, lauded the project stating that it will enable the country to meet its industrial needs while conserving the environment.

Checking for standing water
Dengue cases have increased fourfold in some parts of the Americas

In 2023, the Americas saw the highest recorded number of dengue cases of all time, with a total of 4,565,911 cases and 2,340 deaths, said the Pan American Health Organization (PAHO) in a recent call for stepped up efforts to control Aedes aegypti, the primary mosquito vector of the dengue virus.  

And already in the first six weeks of 2024, dengue cases have outpaced last year’s record, causing over one million cases, said PAHO in a recent epidemiological alert.  

Dengue cases graph
Dengue cases in 2024 are on track to exceed the 2023 record.

Describing the increase as “exponential,” it said the current trend represents a 157% increase in infections this year over the same period as last year, and a 225% increase over the last five years. 

PAHO has called on member states to strengthen awareness campaigns, including stepping up community participation to reduce mosquito breeding sites and encouraging people to seek timely medical attention. 

Aedes aegypti mosquitoes typically breed in sites such as water containers as well as in urban waste, including items such as discarded tyres where rainwater often accumulates.

As the virus doesn’t have a cure and repeat infections can even be more severe, surveillance and control of mosquito breeding sites is critical to reduce dengue transmission and illness,  particularly the most severe form of the disease,  dengue hemorrhagic fever. 

PAHO also emphasised the importance of continuing surveillance, early diagnosis, and timely treatment of dengue cases. 

PAHO also notes that monitoring chikungunya and Zika is also important as increases in dengue often indicate the circulation of these other mosquito-borne viruses, which can cause severe fever as well as premature birth and birth defects. 

Southern Cone worst affected

Some 80% of all dengue cases occur in the Americas region, but the Southern Cone sub-region including Argentina, Brazil, Paraguay, and Uruguay is worst affected. In 2023,  71% of cumulative cases were in this sub-region. 

Another seven countries and territories have seen a sharp increase in cases, including Colombia, Costa Rica, Guatemala, Guadeloupe, French Guiana, Martinique, Mexico and Peru, PAHO reports.

Dengue is also a serious problem in South East Asia where infection rates have increased by almost 50% in recent years. 

Worldwide, cases are projected to increase as warming climates, urbanisation, and shifting rainfall patterns allow Aedes aegypti to survive and thrive in previously unfavourable settings and regions.

State of emergency declared in Brazil

Brazil has been especially burdened with over 800,000 cases reported in the first six weeks of 2024, a fourfold increase when compared to last year. 

Graph of dengue cases in the Americas
Brazil accounts for over 70% of all dengue cases in the Americas

In the midst of the worst outbreak in years, four Brazilian states have declared public health emergencies as record heat and above-average rainfall has increased mosquito breeding sites. 

To make matters worse, all four dengue serotypes (DENV-1, DENV-2, DENV-3 and DENV-4) have been reported circulating in Brazil, as well as in Costa Rica, Honduras, and Mexico. 

Simultaneous circulation of the different serotypes increases the chance that an individual could become reinfected by another serotype more severely, shortly after having recovered from the first infection. 

In response, Brazil’s health ministry increased emergency public health funding, for dengue outbreaks and other emergency events to $300 million. 

These funds are to be directed to Brazil’s vaccination efforts. Brazil plans to vaccinate 3.2 million people this year, using the recently approved Japanese Takeda Pharmaceutical’s Qdenga vaccine. The vaccine was recently approved by the European Medicines Agency, but has only been used in Brazil thus far. 

The vaccine holds immense promise, but the real test will come in April, when dengue cases in the Americas are expected to peak.

Image Credits: PAHO/WHO, PAHO, PAHO .

A much higher percentage of the population has experienced “persistent” COVID-19 infections lasting more than 30 days than initially assumed, according to new research by the University of Oxford.

The study, published on February 21 in Nature, found that one to three of every 100 infections may last a month or longer.

The scientists, using data from the Office for National Statistics COVID Infection Survey (ONS-CIS), found 381 individuals with the same viral infection for a month or longer – including 54 whose persistent infection lasted two months and two over six months – out of 77,561 infections detected through ONS-CIS between November 2020 and August 2022.

In some cases, the infecting lineage had gone extinct in the general population. More than 90,000 ONS-CIS participants were sampled monthly for almost three years.

What “we uncovered is striking, given the leading hypothesis that many of the variants of concern emerged wholly or partially during long-term chronic infections in immunocompromised individuals,” the authors wrote in their paper. “As the ONS-CIS is a community-based surveillance study, our observations suggest that the pool of people in which long-term infections could occur, and hence potential sources of divergent variants, may be much larger than generally thought.”

In other words, the study debunks an assumption that new variants are only formed because of prolonged COVID-19 infections in immunocompromised individuals. This new study shows that the prevalence of persistent COVID-19 infections in the general population may be much higher and, therefore, also play a role in the evolution of the virus.

Electron micrograph of a cell heavily infected with SARS-COV-2 virus particles.

Persistence and Long COVID

Relatedly, the authors found that people with persistent infections lasting for 30 days or longer were 55% more likely to report having long COVID than people with more typical infections.

“Although the link between viral persistence and Long COVID may not be causal, these results suggest persistent infections could contribute to the pathophysiology of long COVID,” said Co-lead author Dr Katrina Lythgoe of Oxford’s Department of Biology and its Pandemic Sciences Institute.

The paper carefully points out that not every persistent infection can lead to long-term COVID-19, and not all cases of long-term COVID-19 are due to persistent infection. “Indeed,” said Lythgoe, “many other possible mechanisms have been suggested to contribute to Long COVID, including inflammation, organ damage, and micro thrombosis.”

Nonetheless, “these results suggest that persistent infections could be contributing to the pathophysiology of long COVID,” the paper reads.

Rendition of the SARS-CoV2 virus, whose genetic code was shared by a Chinese scientist online, and to the world, only days after WHO announced the outbreak of a novel coronavirus in Wuhan.

Mutation Rates

What about the rate of mutation?

Some people who developed persistent infections had many mutations, suggesting they could act as reservoirs to seed new variants of concern. However, this was only sometimes the case.

“Certain individuals showed an extremely high number of mutations, including mutations that define new coronavirus variants, alter target sites for monoclonal antibodies, and introduce changes to the coronavirus spike protein,” the authors wrote. “However, most individuals did not harbour a large number of mutations, suggesting that not every persistent infection will be a potential source for new concerning variants.”

However, co-lead author Dr. Mahan Ghafari of Oxford’s Pandemic Sciences Institute in its Nuffield Department of Medicine, cautioned that the data from ONS-CIS did not include details about the medical history of people with persistent infections, so it was unknown how many of them were immunocompromised, such as with cancer, advanced HIV, etc.

He said the hope is that there would be further studies to better understand these individuals who developed persistent COVID and their health implications, and also to better understand how likely it is for these persistent infections to transmit highly mutated variants to the rest of the population.

Coronavirus
Coronavirus

Variant Reinfections

Finally, the scientists also found rare infections with the same variant. They identified only 60 reinfections by the same major lineage, suggesting that infection does build at least some immunity in infected individuals from the same variant.

“Our observations highlight the continuing importance of community-based genomic surveillance both to monitor the emergence and spread of new variants, but also to gain a fundamental understanding of the natural history and evolution of novel pathogens and their clinical implications for patients,” Ghafari said.

Image Credits: peterschreiber.media/Shutterstock , Flickr – NIAID, Flickr.

Silpa Wairatpanij (left) and Jesús Carlos Soto
Silpa Wairatpanij (left) and Jesús Carlos Soto

By 2050, around 70% of the global population is projected to reside in urban areas. While cities provide numerous advantages, they can also pose health risks to people and the environment.

“Thoughtful planning and creation of inclusive urban spaces can have a significant impact on reducing the number of deaths attributed to poor air quality, road traffic accidents, and, of course, chronic diseases,” says Dr Garry Aslanyan, host of the Global Health Matters podcast. “It also has the added benefit of enhancing social connections in city environments that can often feel isolating and lonely.”

But how can we transform our cities to be healthier places?

In the latest Global Health Matters podcast episode, Aslanyan is joined by Silpa Wairatpanij, Committee Member of the Thailand Walking and Cycling Institute Foundation in Bangkok, and Jesús Carlos Soto, Head of Guadalajara’s Mobility and Transportation Department. They discuss strategies for cities to enhance themselves, including expanding pedestrian and cycling infrastructure and decreasing road accidents, pollution, and associated health concerns.

1 – Gather Data

“The most important thing is scientific evidence,” says Wairatpanij. “Showing the emotional effect of changing the street, changing the city’s environment, is not enough. It doesn’t convince people to follow along.”

Wairatpanij suggests gathering lots of information, including public data. It’s crucial to hold onto this data, especially after making positive changes in the city. This way, you can show how these changes have helped, encouraging the government and local authorities to implement similar improvements in the future.

2 – Involve Civil Society

Soto says that the involvement of civil society is essential to make change.

“We have a very active and organised civil society promoting mobility as a human right here in Guadalajara and in Mexico, in the whole country, and this involvement wants to make the rights of cyclists and pedestrians visible, the right to the city, the defence of the environment, have provoked that in Mexico and Guadalajara, we have taken important steps in this regard,” he tells Aslanyan.

3 – Believe Traffic Fatalities Can be Prevented

Soto also says it is essential to know that the goal of reaching zero deaths and zero serious injuries from road accidents is possible. A fundamental first step is to know and understand the causes of these road traffic fatalities.

4 – Know Political Costs are OK

Finally, “there will always be political costs of doing the right thing,” Soto says. “Do not be afraid of the political costs if you do things correctly, very well planned with scientific evidence-based decisions and with the support of civil society organisations.”

In Thailand, where diseases rank as the leading four causes of death and road accidents follow closely as the fifth, Wairatpanij and his organisation have been promoting walking and cycling in the city instead just for sport and exercise. Today, he is working with the Partnership for Healthy Cities (PHC) to redesign the city streets to have more space for side walks and less space for cars through lane reductions, narrowing lanes and extending side walks at the crossing junctions, amongst other changes.

“It’s been an ongoing process … and we hope that by changing the environments of the cities to accommodate walking and cycling … it reduces sedentary activities, people have more activities, and that would reduce the cause of non-communicable diseases,” Wairatpanij says.

In Guadalajara, where more than 650 premature deaths linked to poor air quality happen each year, and road traffic is the second cause of death, Soto has been working to increase bicycle and pedestrian strips considerably.

“We know that every kilometre that is pedalled avoids emissions that affect health and generate cardiovascular improvement for the people using bicycles,” Soto says.

Listen to previous episodes of Global Health Matters on Health Policy Watch.

Image Credits: Global Health Matters Podcast.

South Africans in Pretoria protest against Uganda’s Anti-Homosexuality Act just before it was signed into law in 2023.

In January, Ugandan LGBTQ activist Steven Kabuye was stabbed multiple times by two men travelling on a motorbike and left for dead on the outskirts of Kampala, the country’s capital city.

The 25-year-old, who had received several death threats after Uganda’s Parliament passed its Anti-Homosexuality Act last May, criminalising LGBTQ people, said that the attackers made no effort to rob him but were intent on stabbing him in the neck.

Uganda’s new law is one of several global examples of growing repression against sexual minorities. Earlier, Indonesia outlawed extramarital sex – effectively also criminalising same-sex sexual relationships. Last year, Russia banned the “international LGBT movement,” and some US states have introduced anti-transgender laws.

A multitude of countries are making it harder for women and girls to participate in everyday life as autonomous citizens independent of male relatives. Many don’t allow harm reduction strategies for people who inject drugs, such as offering them less harmful substitutes. Numerous others are making it harder for civil society organisations to get foreign grants.

International alliance of conservatives coalescing to roll back rights

Leaders of US conservative Christian group Family Watch International meets with Uganda’s first lady and other government officials in April 2023 to encourage passage of a new Ugandan anti-homosexuality law.

Internationally, an alliance of socially and religiously conservative countries is coalescing around efforts to roll back a range of sexual and reproductive rights already won in international agreements and meetings – with countries such as Russia, Iran, Syria and Nigeria acting as the ringleaders.

At the recent World Health Organization’s (WHO) executive board meeting, for example, Russia objected to a reference to the “WHO LGBTIQ+ community” in a routine report from the WHO Director-General to the International Civil Service Commission that covers issues such as WHO administration-staff relations, pay scales and benefits.

A reference to the LGBTIQ+ community in a routine WHO civil service report drew the ire of some conservative member states at the January 2024 WHO Executive Board meeting

Russia described the phrase as “terminology which spreads concepts which are not recognised by everyone and which contradict the values and religious beliefs of quite a large number of countries.”  Russia was supported by a bloc of African member states, and Syria, speaking on behalf of WHO’s Eastern Mediterranean Region. After nearly three dozen other countries, including the US, Canada, Europe and a number of Latin America countries,  expressed support for the Director General’s commitment to diversity equity and inclusion, and gender equality in the workforce, the EB agreed to “note” the report “along with the divergence of views that exist on the board as a whole.”

Also at the EB, six other draft World Health Assembly decisions and resolutions that underwent preliminary review were challenged by a group of member states “over language on gender equality” – primarily objecting to “gender-responsive” health systems, Women in Global Health also noted.

These concerted attacks on LGBTQ people, women and girls and other groups designated as key populations at heightened risk of HIV (sex workers and people who inject drugs) have made it harder for HIV advocacy groups to reach people most at risk of HIV infection, sexual and reproductive health experts and advocates say.

The war between ideology and science

Andriy Klepikov, Alliance for Public Health

“It is a war between ideology, prejudice and stereotypes on the one side and evidence-based science on the other side,” said Andriy Klepikov, executive director of the Alliance for Public Health, one of the largest HIV and TB NGOs in Ukraine and Eastern Europe.

“Countries like Russia are neglecting all the evidence [which shows] where the HIV epidemic is going up as a result of punitive law and repressive policies,” he added. He was speaking at a World Health Summit event on Ending the AIDS Epidemic in Light of the Shrinking Civic Space in October, 2023.

“We even have UNAIDS data showing how vulnerable people who use drugs, men who have sex with men, sex workers, and transgender people are.”

According to the UNAIDS 2023 global summary, almost a quarter of new HIV infections (23%) were in Asia and the Pacific, where “numbers of new HIV infections are rising alarmingly in some countries.”

Winnie Byanyima, the executive director of UNAIDS, launching the 2023-Global AIDS update report in July 2023.

“Steep increases in numbers of new HIV infections have continued in eastern Europe and central Asia since 2010 (49% increase) and the Middle East and North Africa (61% increase). These trends are due primarily to a lack of prevention services for people from marginalised and key populations and to the barriers posed by punitive laws, violence and social stigma and discrimination,” according to UNAIDS.

“The vast majority of countries (145) still criminalise the use or possession of small amounts of drugs; 168 countries criminalise some aspect of sex work; 67 countries criminalise consensual same-sex intercourse; 20 countries criminalise transgender people; and 143 countries criminalise or otherwise prosecute HIV exposure, non-disclosure or transmission.”

Global Fund notes’ increasingly hostile laws’

Meanwhile, the most recent report of the Global Fund’s Technical Review Panel, released in October 2023, notes “increasingly hostile laws, policies, and practices in several countries.”

“These include new or increased enforcement of laws criminalising same-sex sexual relationships, high levels of stigma, barriers to organisational registrations, and acknowledgement of harmful norms by applicants, which are greatly risking the fragile gains that have been made over the years.”

Twenty-two countries where the Global Fund supports programmes are classified as “closed” by the CIVICUS 2023 National Civic Space Ratings.

These are “mostly in the Middle East, North Africa, and Central and South Asia, where repression is extreme, and any criticism of the state is met with severe penalties.”

“Another 42 are classified as repressed, mostly in Africa, Asia, and Central America, and 32 are classified as obstructed, mostly in Africa and Asia.”

Thousands protest anti-LGBTQ laws in Budapest, Hungary in 2021.

Some want to ‘extinguish’ key populations

Civil society groups trusted by critical populations have traditionally been the most successful in bringing marginalized groups and individuals into the circle of HIV prevention, diagnosis and treatment, using non-judgmental advocacy and frank, science-based language.

“AIDS has always been seen in the minds of people as a dirty lifestyle,” explained Peter Wiessner from Action Against AIDS based in Germany, also speaking at the World Health Summit session.

“To prevent HIV transmissions, we thought it was necessary to address the cause of the transmission. So all of a sudden, there were discussions on anal intercourse, on oral sex and all of that,” he added.

“Luckily, our government understood that officials don’t have the language. They don’t have the knowledge. They don’t know how the communities live. So they invited and provided this open space for the communities to develop programmes and to finance these.”

But Wiessner adds that countries such as Iran, Russia and some Gulf states want to “extinguish” key populations and fight against their recognition at international health forums in ways that sometimes make the consensus-based policy and strategy agreements “almost meaningless.”

“The UN high-level meeting’s declaration on Universal Health Coverage does not even mention key populations that are so important in the fight against HIV, like gay men, drug users, and sex workers. They are not mentioned because some of the governments don’t want these groups to exist,” Wiessner added.

HIV infections growing most rapidly in eastern Europe and central Asia

Eastern Europe and Central Asia have seen the fastest-growing HIV epidemic in the world, with an increase of nearly 50% in newly infected people since 2010.

HIV prevalence is 1.2% amongst adults (15–49 years) but 7.2% amongst people who inject drugs, a significant driver of infection. However, a shortage of data from Russia makes it difficult to draw definite conclusions.

“Russia has neglected all evidence-based interventions, like methadone-based opiate treatment as part of a harm reduction programme for people who use drugs,” said Klepikov. “[Last] August, the parliament voted for the prohibition of transgender people.”

Maximina Jokonya, Y+ Global

Maximina Jokonya, a leader of Y+ Global, the global network of young people living with HIV, warns that “we haven’t been paying attention to what has been brewing underground in anti-rights groups.

Key populations have become scapegoated by laws and criminalisation across sub-Saharan Africa, warns the South African-based Jokonya.

“It is embedded in issues around culture, religion and traditional norms, where the downside is coercion around gender roles and social norms.”

The anti-rights groups are well-funded, adds Jokonya, which enables them to “influence laws and politicians,” she says.

Space is shrinking all over the world

UNAIDS deputy executive director Christine Stegling

And while Uganda’s Anti-Homosexuality Act has become a kind of poster-child for shrinking civil society space, this is happening to a lesser extent all over the world, UNAIDS deputy executive director Christine Stegling warned.

Often, discriminatory laws are only repealed when civil society organisations are litigated, such as the repeal of anti-LGBTQ laws in Botswana.

Furthermore, many NGOs are barred from “accepting money from the outside” or made to register as “foreign agents” if they do, and “these are ways of stifling civil society engagement,” Stegling adds.

The AIDS response has shown the power of communities to address infection and drive development and human rights, and this is an essential lesson for new pandemics, Stegling concludes.

Editor’s note: Stegling, Jokonya and Wiessner also were addressing a session of the World Health Summit in Berlin on “Ending the AIDS Epidemic in Light of the Shrinking Civic Space.”

Image Credits: Alisdare Hickson/Flickr, WHO/EB 154 , Lydia Gall/ Human Rights Watch.

Heavy-duty trucks and buses spew out soot, including climate-changing black carbon and health harmful PM2.5 on a highway.

A new report finds that the European Union, Japan and the Republic of Korea have been “dumping” used, and highly polluting trucks and buses on low- and middle-income countries. Heavy duty trucks and buses account for as much as 63% of PM2.5 pollution emissions from road vehicles globally.  

A new UN report has exposed a lucrative but highly controversial trade in used heavy-duty vehicles (HDVs) from rich countries to poorer ones that is vastly exacerbating the load of toxic pollutants in developing cities and interurban roads. Such vehicles are a “major” contributor to air pollution and climate emissions including CO2 and black carbon as well as other diesel and soot particles deeply harmful to health as well as contributing to global warming, according to the report. 

The report, Used Heavy- Duty Vehicles and the Environment: A Global Overview of Used Heavy-Duty Vehicles: Flow, Scale and Regulation, was released Thursday by the UN Environment Programme (UNEP) and the Climate and Clean Air Coalition (CCAC) at the sixth session of the UN Environment Assembly, in Nairobi. 

The bulk (60%) of the vehicle exports come from just three countries and regions – Japan, the European Union and the Republic of Korea. 

Between 2015-20, the period of study, Japan exported about 1.3 million such vehicles, the most vehicles in terms of volume and value – although Japan didn’t release the value. The EU exported 1 million and sold another million within the EU for a total of $21 billion, and South Korea exported about 134,000 units worth $850 million. The US is also a major exporter but its data on new and used vehicles is combined and will be disaggregated and analysed for a report next year. 

High income countries’ vehicle markets are saturated – so older vehicles are offloaded abroad

The three major exporters are all high-income economies with ownership levels of such vehicles saturated, so the sales of new trucks or buses are mainly to replace old ones which are then exported. 

The report tracks export patterns of used trucks and buses to some 146 countries, 122 of which are low and middle-income countries in Asia and Latin America, as well as Africa. 

From the EU, 20% of used heavy duty vehicles are sent to Africa, with Nigeria, Tanzania and Zimbabwe on the top of the list, while in terms of the Middle East and Asia, big importers include Jordan and Afghanistan. Other countries, such as Myanmar, get a significant portion of their used vehicles from Japan.

Only about one-third of the 146 importing countries have adopted Euro 4 or better standards for cleaner emissions and vehicles, something that would end the import of the oldest and most polluting vehicles.  

Adopting the highest vehicle emissions standard, Euro 6 or equivalent, across all 146 countries, coupled with the introduction of cleaner, low-sulphur diesel fuels, would result in 300,000-700,000 avoided premature deaths by 2030, the report also estimates. 

Three out of every five used HDVs are still exported to wealthier countries such as Saudi Arabia, and the United Arab Emirates. There is also a heavy trade in used vehicles moving from western to Eastern European Countries and Russia, the report notes. 

But these countries tend to have tighter emission norms so they don’t get the most polluting vehicles; some countries like the UAE also re-export these vehicles to Africa, as well as high-income Chile re-exporting to Paraguay. 

Countries in black are the biggest importers of used heavy-duty vehicles. The arrows show the patterns of used HDV exports from Japan, the European Union and South Korea primarily to Russia, eastern Europe, and the Global South.

Dumping trucks and buses: Small in number, high in pollution

The trade imposes higher human health, as well as economic and climate costs on the most vulnerable nations, UNEP officials said. 

“You have air pollution, more greenhouse gas emissions, more energy use (higher fuel consumption), more cost to the individual,” Sheila Aggarwal-Khan, Director of Industry and Economy Division, UN Environment Programme, adding that incentives for both exporters and importers to shift to cleaner vehicles are insufficient. “You really need to be looking at heavy-duty used vehicles during the transition to e-mobility.” 

While heavy-duty vehicles comprise only about 3.6% of the $1.2 trillion global automobile trade, they represent the lion’s share of vehicle exhaust emissions dangerous to human health. 

They account for 44% of the emissions of on-road nitrogen oxides, which contribute to childhood asthma and chronic lung disease, as well as impeding lung development. Heavy duty vehicles also account for 63% of vehicle emissions of fine particulates (PM 2.5), which are responsible for a significant proportion of deaths from cardiovascular disease as well as lung disease and cancer. PM 2.5 emissions also are increasingly linked to a range of other disease conditions from low neonatal birth weight to dementia. 

All in all, road traffic is a major contributor of air pollution globally, which causes about 8.3 million deaths annually.   

Illegal shipment of end-of-life vehicles

The report also refers to studies that show “illegal” shipment and “dumping” of end-of-life vehicles which are sent to Africa, Asia,Latin America, and Eastern Europe instead of being scrapped. 

“It can’t be that countries become the dumping grounds of obsolete materials of other places,” says Martina Otto, Head of Secretariat, Climate and Clean Air Coalition (CCAC). 

There is growing awareness that such exports of very poor quality vehicles to the global south are “unacceptable” said Rob de Jong, Head of Sustainable Mobility Unit, UN Environment Programme, and some “movement” among policymakers. But clear policies and guidance are yet to be developed.  

The report is thus part of an effort to put the issue higher on the policy agenda. 

Heavy duty vehicle emissions standards throughout the world. Blue shading shows countries with vehicle standards of Euro 4 and above. Euro 6 is the cleanest standard, primarily used in high income Europe, North America and Asia.

“We’re going to help these countries make sure those old vehicles are not exported from Europe,” de Jong said, adding that clear metrics need to be set, against which UNEP can further monitor exports and imports. “So … this shared responsibility is important. But the first exporters have now started to move. 

As of now “none of the exporting countries are making sure that these vehicles are road-worthy, have emission filters working, or are anything that can be exported,” de Jong said. “The countries with very poor regulation are attracting the worst quality of used trucks and buses, vehicles that may be 20 years old, that may have 500,000 or a million kilometres on their odometer.”

Under de Jong’s leadership, UNEP and the Climate and Clean Air Coalition (CCAC) have forged a series of global initiative promoting the uptake of low sulphur fuels and cleaner HDV technologies in developing and transitional countries.

‘Shared responsibility’ by exporters and importers 

UNEP and CCAC have thus called for ‘shared responsibility’ between exporters and importers of used vehicles. This means vehicles must be checked by high income countries prior to export to ensure they meet certain emissions standards. At the same time, in lower-income countries, emissions standards need to be raised. Regional harmonisation of standards is also important; heavy duty vehicles are commonly used for cross-border transport. 

The report comes at a time when several nations in the Global South have protosted the EU for imposing a carbon tax on imports to European bloc. 

Last year, the EU launched the Carbon Border Adjustment Mechanism. Those who stand to lose the most are likely to be developing countries that may find  technologies to cut CO2 emissions unaffordable right now. 

Demand for used trucks in low and middle-income countries is rising at about 10% a year in the absence of domestic manufacturing capacity – which is either low or non-existent, and heavy duty vehicles continue to be essential to countries’ economic development, the report’s authors say. 

The report also considered heavy duty vehicle exports from three other major economic blocs, the US, China and India. The US data for export of new and used heavy-duty vehicles wasn’t segregated so that analysis will have to be done separately next year, report authors say. China’s share in the global production of these vehicles is HDV 67% but its share in the export of used trucks and buses is low. India, although one of the world’s top five producers of new HDVs, has a global share in the marketplace of only 3%, following on after China (67%), Japan (9%), the USA (5%) and Mexico (3%).

Image Credits: UNEP, UNEP.

Digital technologies can improve equity and access to healthcare

“In a digital age, health workers should not have to carry a separate device for each disease or be required to fill out both paper and electronic records,” said WHO Director Dr Tedros Adhanom Ghebreyesus on Tuesday.

He was speaking at WHO’s launch of the Global Initiative on Digital Health – where officials cut a ribbon at the virtual press conference marking the launch of a new network of that aims to accelerate a 2021 WHO Global Strategy on Digital Health. 

The initiative centers around the creation of a WHO managed network involving governments, donors, NGOs and private firms, which are invited to sign up as members to the collaboration and knowledge exchange.

Digitalization of health care solutions can help provide more equitable access to quality healthcare;  faster and more accurate diagnosis of patients, and better tracking of patients and their health conditions.

“Sitting in a community clinic, one person can get services through telemedicine from a renowned physician from the capital city,” remarked Meerjady Sabrina Flora, director general of Health Services in Bangladesh, speaking at the launch.

But current digital health systems also are fraught by gaps and overlaps that are “some of the main challenges we face,” said Dr Tedros.

‘Network of Networks’

“Our goals are to support, enhance and accelerate national and regional digital health information,” said Bianca Rouwenhorst of the Dutch Ministry of Health. The initiative is more of a portal, a “network of networks” facilitated by WHO than a specific action plan, she said.

Its four pillars ensure good communication, knowledge transfer and collaboration between entities. The goal is to “respond to the complex digital health ecosystem by aligning investments, strengthening the enabling environment and enhancing quality assured technical support.”

Four main pillars of the Global Initiative on Digital Health

In the network design, a new ‘Country Needs Tracker’ and the ‘Country Resource Portal’ will connect philanthropies and bilateral partners, creating a space for an exchange of products, services and knowledge addressing specific existing needs.

Other pillars focus more on the “how” of digitalisation, accelerating effective information and practice sharing, for instance, providing regularly updated tools for managing digital transformation.

According to its makers, the initiative has the potential to not only provide an information platform but also shift digitalisation projects from a focus on individual products to a more holistic, national infrastructure focus.

Global Strategy on Digital Health goals

“GIDH will leverage existing evidence, tools and learnings in digital health and focus efforts on creating new quality assurance building blocks when needed,” stated Derrick Muneene, Head of WHO’s Digital Capacity Building and Collaboration team, which will lead the network’s development.

Hopes are that the network will lead to a more detailed WHO agenda for enhancing modern technological advances used in health globally. The knowledge exchange, transparency, technical and financial support that can spur from DIGH implementation can mean a step forward in reaching the 2025 goals.

“A carefully planned digital health future should be one where systems speak to one another, reducing the burden on workers and the people they serve,” remarked Dr Tedros. The Initiative on Digital Health promises to bring it closer.

Image Credits: WHO.

A severely injured patient is evacuated from Nasser Medical Complex by the WHO and partners.

International humanitarian law is clear that “even if health care facilities are being used for military purposes, there are stringent conditions which apply to taking action against them, including a duty to warn and to wait after warning”, said Steven Solomon, the World Health Organization’s (WHO) principal legal officer.

“Disproportionate attacks are strictly prohibited. All combatants should understand that health facilities and health workers are off limits. Targeting them, or militarising them, are both prohibited,” added Solomon in response to a question about Hamas using Gaza hospitals as military bases.

Earlier, WHO Director-General Dr Tedros Adhanom Ghebreyesus reiterated his call for a ceasefire in Gaza, describing the situation as “inhumane”.

Steven Solomon, WHO principal legal officer

Paralysed patients moved

Over the past few days, the WHO has assisted to move 32 patients from the Nasser Medical Complex in southern Gaza, following “a week-long siege” and “a military raid”, according to a  WHO statement.

“Patients transferred included three suffering from paralysis – two of them with tracheostomy – and several others with external fixators for severe orthopaedic injuries. Two of the paralyzed patients required continuous manual ventilation throughout the journey, due to the lack of portable ventilators,” the WHO reported.

“As of 19 February, only 12 out of 36 hospitals with inpatient capacity are still functioning, and only partially. There have been more than 370 attacks on health care in Gaza since 7 October,” according to a statement issued on Wednesday by the Principals of the Inter-Agency Standing Committee that includes the WHO, UNICEF, UN Women and a range of humanitarian agencies.

“Diseases are rampant. Famine is looming. Water is at a trickle. Basic infrastructure has been decimated. Food production has come to a halt. Hospitals have turned into battlefields. One million children face daily traumas,” they added, calling for an immediate ceasefire, the release of all hostages and the safe passage of aid into Gaza.

“Rafah, the latest destination for well over one million displaced, hungry and traumatized people crammed into a small sliver of land, has become another battleground in this brutal conflict. Further escalation of violence in this densely populated area would cause mass casualties. It could also deal a death blow to a humanitarian response that is already on its knees,” adds the committee.

Tedros described Gaza as “a dead zone”: “Much of the territory has been destroyed. More than 29,000 people are dead. Many more are missing, presumed dead and many, many more are injured.” 

Severe malnutrition has increased from under 1% before the war to “more than 15% in some areas” – one in six children under two years of age – and “we note with apprehension that the World Food Programme cannot get into northern Gaza with supplies”, he added. 

“What type of world do we live in when people cannot get food and water? Or when people who cannot even walk are not able to receive care? What type of world do we live in when health workers are at risk of being bombed as they carry out their life saving work? 

“What type of world do we live in when hospitals must close because there is no more power or medicines to help save patients and they’re being targeted by a military force?” he asked.

“We need a ceasefire now. We need hostages to be released. We need the bombs to stop dropping and we need unfettered humanitarian access. Humanity must prevail.”

Dr Teresa Zakaria, WHO health emergency intervention technical officer.

Tereza Zakaria, WHO health emergency intervention technical officer, added that the WHO was unable to provide proper assistance to people in Gaza because of operational challenges.

“​​The biggest challenge at the moment is in what happens after supplies get inside Gaza. And this is where things things get extremely challenging because of road damage or lack of security,” said Zakaria.

“Many of the missions that we are jointly planning with other humanitarian partners are being denied or not facilitated. So that’s a major challenge. And that’s just one amongst many other operational challenges that renders our current humanitarian response not sufficient; really just a tiny drop in the ocean.”

‘Even wars have rules’

Earlier in the week, seven United Nations experts issued a statement calling for an  independent investigation of “credible allegations” of extrajudicial killing, sexual assault and other forms of violence against Palestinian girls and women by Israeli forces.

“We are particularly distressed by reports that Palestinian women and girls in detention have also been subjected to multiple forms of sexual assault, such as being stripped naked and searched by male Israeli army officers. At least two female Palestinian detainees were reportedly raped while others were reportedly threatened with rape and sexual violence,” said the experts, who include Reem Alsalem, Special Rapporteur on violence against women and girls, and Francesca Albanese, Special Rapporteur on the situation of human rights in the Palestinian territories occupied since 1967.

However, Israel’s UN Mission in Geneva described the rapporteurs’ claims “despicable and unfounded” and condemned their silence regarding “the horrific sexual violence and gender-based violence perpetrated by Hamas on and since October 7”. On Wednesday, Israel’s Association of Rape Crisis Centers also delivered a detailed report to UN Women compiling dozens of eye-witness accounts of rapes, gang rapes and instances of sexual mutilation allegedly committed by Hamas on 7 October, when Hamas-led forces invaded some two dozen Israeli communities near the Gaza border, killing more than 1200 people, mostly civilians.

Dr Mike Ryan, WHO’s executive director of health emergencies, said that the WHO did not have any knowledge of the specific incidents referred to by the UN rapporteurs,  but “the use of sexualised violence and conflict is well recognised and increasingly used”.

“We’ve certainly had the reports of sexual violence against female Israeli hostages in Gaza. We now have allegations of sexual violence and and extrajudicial killings on the other side. I think all of these require investigation by the appropriate authorities. Because even war has rules.”

Patients being evacuated from Nasser Hospital by the WHO and partners.

Treating NCDs in emergencies

Next week, the WHO has convened a meeting in Copenhagen to “discuss how to include and integrate non-communicable diseases (NCDs) into the preparation and responses to emergencies”, Tedros told the briefing.

People living with NCDs such as diabetes, heart and lung disease and cancer are facing a “precarious situation” in conflicts, “especially those who depend upon lifesaving commodities like insulin, dialysis, cancer medicines”, he added.

“We’ve seen a huge caseload in places like Gaza for untreated cancer patients, people who’ve lost access to their hypertension and diabetes medications, people who don’t have access to dialysis any more,” added Ryan. 

“We saw exactly the same pattern in Yemen. We saw exactly the same pattern in Syria. We’re seeing exactly the same pattern in Sudan. 

“When you displace six million people in an already fragile situation and you move two million them across the border and you scatter four million of them across the country in the middle of an open war, and you attack healthcare facilities and you occupy those facilities that are used for the purposes of military purposes, then people will continue to get sick. They will stay sick, and they will ultimately die from diseases that they don’t need to die from.”

Ryan added that the global increase in NCDs brought “a new complexity” to emergency care, particularly in cases where the diagnostic process is complex and needs, for example, CT scanners and laboratory tests? 

“We have to find ways to adapt our care to adapt our diagnostic and care process so that it does the best it can in those situations.”

-Elaine Ruth Fletcher contributed to the editing and reporting on this article.

Image Credits: WHO EMRO.