WHO's New Leadership Team
The World Health Organisation is losing track of the evolution of COVID-19 as governments lose interest in reporting data about the virus.

Fewer than 20 countries worldwide still report COVID-19 hospitalization and ICU data to the World Health Organization (WHO), leaving the UN health body blind to the impact and evolution of the virus in most of the world, agency leaders said Friday.

The decline in data reporting is a major setback for the WHO’s efforts to track the pandemic. Without reliable data, the WHO cannot accurately assess the burden of disease, identify new variants, or target its resources where they are most needed.

“We don’t have good visibility of the impact of COVID-19 around the world,” said Dr. Maria Van Kerkhove, who leads the WHO’s COVID-19 task force. “It is really important that surveillance continues, and this is on the shoulders of governments right now.”

Out of the 243 countries and territories party to the WHO, the UN health body has data on cases for just 103 of those. Only 19 countries and territories continue to report hospitalization data, while just 17 report data on cases that end in the ICU. The number of countries reporting COVID-19 deaths has fallen to 54.

“While we are certainly not in the same situation that we were in a year ago or two years ago, SARS-Cov-2 circulates in all countries right now,” said Van Kerkhove. “It is still causing a large number of infections, hospitalizations, admissions to the ICU and deaths.”

The current set of dominant COVID-19 variants can still cause the “full spectrum” of disease, from asymptomatic infections to severe disease and death, Kerkhove said.

The continued circulation of the virus also puts individuals at risk of joining the millions of people around the world suffering from the effects of long COVID. Research into the prevalence of long COVID worldwide estimates the number of people affected as high as 65 million — likely a vast underestimate.

“COVID remains a global health threat, and data available to WHO continues to decline,” WHO Director-General Dr Tedros Adhanom Ghebreyesus said at a media briefing on Friday. “We continue to call on all countries to strengthen surveillance, sequencing and reporting so we can assess the risk of new variants.”

Image Credits: Guilhem Vellut.

A health worker provides treatment to a malnourished child in Yemen.

For most people, electing the regional director – or chief health officer – for the Eastern Mediterranean Region (EMRO) of the World Health Organization (WHO) will not set the pulse racing.  Is this just another shuffling of chairs around the world’s bureaucratic table? Even among global health nerds, it will trigger just a faint tremor.

Yet the role matters to 22 countries spanning the Arab World from Morocco to the Gulf and extending across West Asia to Pakistan. They come together as the Regional Committee for the Eastern Mediterranean to select a new regional director on 10 October to helm the health aspirations of over 700 million hopeful people.

EMRO is one of six regional offices, the directors of which have almost complete authority for executing WHO’s health policies and programmes under its decentralised constitution.  

EMRO’s regional director election comes at a time of health’s increased geopolitical importance due to unpleasant global competition around the COVID-19 pandemic.  Today’s heavily securitised world has also realised that the might of nations is measured not just by guns. Healthy people make content, creative citizens and, ultimately, stronger nations.

EMRO’s life-and-death lottery

WHO EMRO is made up of 22 countries that differ vastly in income and health expenditure.

How is EMRO doing? Its people live 71.4 years, a little under the global average of 73 years. But this hides grave inequalities from Qatar’s 80 years to Somalia’s 55.4 years. Five other nations don’t make it past 66 years.  It is similar with maternal mortality: 620 Afghan women lose their lives for every 100,000 live births, compared to 223 globally. Kuwait does best with seven mothers’ deaths while seven countries are way off the SDG target of 70 maternal deaths per 100,000 live births by 2030.

Why does the region’s heath lag so far behind?  The main cause is that this is the world’s most conflict-torn corner, with two-thirds of its people directly and indirectly affected. Furthermore,  healthcare is brutally instrumentalised with facilities and workers attacked in Yemen, Syria, Iraq, Afghanistan and Pakistan.  Food has been denied in several conflicts with Sudan and Somalia generating starvation headlines and stratospheric malnutrition rates. 

Furthermore, glaring socio-economic gaps hallmark the region. Some of the world’s richest countries – Qatar, the United Arab Emirates (UAE), Saudi Arabia, Bahrain, Kuwait and Oman – are in the same administrative group as Pakistan, Palestine and Egypt, which barely get into the middle-income category, while others like Afghanistan and Yemen remain mired in abysmal poverty.   

This life-and-death lottery is detailed in WHO’s own health observatory, EMRO expends $669 per capita on health – half of the average global spending.  That is skewed further by profligate nations spending $1500-2500, masking other countries that spend less than $150 per person. 

Thousands of Somalis escaping drought and conflict are living in sprawling settlements on the outskirts of towns, like this one in Baidoa in south-central Somalia.

The new regional director needs courage

In such a diverse and divided region, the new regional director will have their work cut out. For starters, they must go courageously where others fear to tread and defend humanity by speaking out without fear or favour. But they must also be astute in walking the fine line between promoting health as a bridge for peace and over-politicising health’s humanitarian mission.

It is our human tendency to get de-sensitised to long-standing suffering and inequalities. Therefore, the incoming regional director will have to be super-human. They must feel stronger outrage about unfairness and injustice, possess greater compassion for misery, burn more intensely with urgency,  be smarter at delving into root causes and shine a brighter light on the path ahead.

Of course, these virtues are nowhere to be found in the sober language of the regional director’s job description. But they should be core considerations for EMRO member states. Can they rise above their usual politicking to unite for the collective good, knowing that the massive health risks they face know no boundaries?

They have six impressive candidates with a range of qualifications and experiences to choose from. Iraq has nominated pharmacologist Najim Abbas Jabir Al-Awwadi and Morocco has proposed former health minister Anass Doukkali. Pakistan has suggested health systems expert Abdul Ghaffar and Iran has put forward health policy professor Ali Akbari Sari. Sudan has nominated its goodwill health ambassador Ahmed Farah Shadoul and Saudi Arabia has proposed the sole woman, clinical and public health specialist Hanan Hassan Balkhy.  If elected, she would be EMRO’s first-ever female regional director, other WHO regions having passed that milestone earlier.

 Consolidation or change?

Whoever is elected, it is not too early to consider their desired legacy from a potential  5-10 years in office. Will they be a transformer or consolidator of business-as-usual?

The business-as-usual approach will see the incumbent – however technically proficient and managerially efficient  – see illusionary progress while presiding over strategic decline. To elaborate: even if the WHO/EMRO leadership does little, health indicators will continue to improve in most countries. Because, thanks to external stimuli, especially the private sector, they will get richer, stabilise some conflicts, improve governance here and there, expand key health capacities, and roll out new technologies wherever they prove useful. 

But such gains are threatened by bigger vulnerabilities. Climate change is heating the Mediterranean and the Middle East at twice the global average with devastating environmental and health impacts. Five of the 10 biggest disasters over the past two years were spawned here, including massive floods, droughts and earthquakes. 

In August 2022, massive floods in Pakistan displaced some 33 million people.

Some 127 million people – 37% of the world’s humanitarian caseload – come from this one region due to a combination of disasters, conflicts, and displacement. WHO’s middling performance on humanitarian assistance in this region needs urgent augmentation.

Concurrently, as the region ages, the burden from non-communicable diseases (particularly diabetes, cardiovascular and lung conditions and cancers) increases. Already 70-80% of deaths occur from NCDs. Other conditions such as substance abuse are surging.

Thus,  business-as-usual in EMRO implies regression. We already see this with continuing neglected tropical diseases such as leishmaniasis, and the emergence of new pandemic-potential agents such as MERS, or the re-emergence of old conditions such as tuberculosis and polio.  

Health systems are struggling in the Middle East and West Asia where health professionals are scarce in poor countries and, although sufficient in the rich ones, skewed towards specialised hospitals. Universal health coverage (UHC), the aspiration that all should receive quality healthcare without personal financial hardship, is still a dream when nearly half the population don’t access 16 essential services.

Healthcare demand will always outstrip provision and traditional health system mantras can never catch up. Will WHO EMRO’s new leader be capable of thinking outside the box? It means breaking old moulds and casting new ones – causing discomfort within WHO and member states. Will they have the guts for that?

Look inwards first for resources

Even if the incoming regional director goes down the egg-breaking, omelette-making track to transform healthcare, they can’t do it on their own. They must build partnerships and garner significant additional resources.

This must start internally inside WHO where its over-staffed headquarters operates out of Geneva, the world’s third most expensive city. Fortunately, WHO Director General Dr Tedros is committed to decentralisation, and although he faces resistance to pushing that through, the incoming regional director should hold him to that pledge. Meanwhile, they must do their utmost to radically reshape EMRO’s regional and country offices to make them investment-worthy.

The new regional director should resist holding out the begging bowl to traditional OECD (mostly Western) donors. The pennies received are not worth the self-respect expended. Multilateral development banks should be pushed to do more. But the real resourcing transformation must be within the region. After all, generosity towards the needy and suffering is an integral part of the region’s dominant religion and culture.

Gulf states are already giving more: $ 9.2 billion in official development assistance in 2022 led by Saudi Arabia ($6.2 billion) and UAE  ($1.4 billion). But such aid tends to be volatile and skewed towards emergency relief and the health sector’s share is small. The regional director must be politically skilled at changing that and establishing long-term health investment – and not donor-recipient – relationships.

Is all this too much to ask from the new WHO EMRO regional director?  No – because it is do-able. Anything less is a betrayal of trust and a missed opportunity to better the lives of people who deserve better.

Mukesh Kapila is a physician and public health specialist who has worked in 120 countries, including as a former United Nations (UN) Resident and Humanitarian Coordinator in Sudan and a UN Special Adviser in Afghanistan.

 

Image Credits: WHO Yemen, Mercy Corp/ TNH, Rahul Rajput.

Amidst the vibrant rhythms of Africa, a less audible rhythm beats – an alarming rise in cardiovascular diseases (CVDs) and non-communicable diseases (NCDs). Between 50% and 88% of deaths in at least seven African countries are due to NCDs, according to the 2022 World Health Organization (WHO) Noncommunicable Disease Progress Monitor. Yet, the realm of research has yet to fully recognize the magnitude of this symphony. 

The cacophony of these diseases is not confined to developed nations; Africa bears witness to their increasing impact, largely unseen by the global research community. Against this backdrop, we stand resolute in our commitment to shifting the focus to the African narrative in cardiovascular medicine.

Closing research disparities: Unravelling the findings 

We are two young cardiologists, both graduates of Egypt’s esteemed medical schools. One of us went on to pursue his career in the United States, where he is now a rising researcher at the Department of Internal Medicine at Yale School of Medicine in New Haven, Connecticut. The other, determined to make a difference in his country, dedicated himself to the demanding work of a physician-scientist in Egypt.

Our paths converged when we decided to address the striking lack of randomized clinical trials (RCTs) in Africa. This scarcity robs the continent of vital disease-specific and population-specific data, which stalls progress in clinical outcomes. This deficiency has global implications, as it dampens cardiology research on a global scale by preventing researchers from tapping into a vast, diverse, and treatment-naive population.

Our journey led us to a comprehensive evaluation of African-led clinical trials in cardiovascular medicine over the past three decades. We recently published our findings in a research letter in the journal Circulation: Cardiovascular Quality and Outcomes.

About 80% of RCTs came from 3 countries (Egypt, Nigeria, and South Africa). Yet, 37 African countries didn’t produce a single RCT.

Our analysis revealed a stark reality: only approximately 2% of published and registered clinical trials in cardiovascular medicine originated from Africa. However, within this fraction, we found a tale of perseverance and determination.

We examined a total of 179 trials from African countries from 1990 to 2019. Egypt, South Africa and Nigeria were the most notable contributors, with Egypt leading the way. The number of African-led trials surged over the past decade, with 2010 to 2019 witnessing a remarkable increase.

The primary outcomes assessed in the trials included biochemical and cardio-metabolic markers, hemodynamic outcomes, clinical events, and patient-related outcomes. African trials often had small sample sizes, few participating centers and short follow-up periods.

The impact of published trials from different countries was measured using the H-index, a metric that gauges the impact of scientific research by tracking how many times a published paper is cited by other researchers. South African publications had the highest impact score, followed by Egypt and Nigeria. A significant number of trials were not published as open access, and risk of bias assessment showed that a significant number of studies had unclear or high risks of bias.

It is estimated that only 2000 cardiologists practice in Africa (≈1 cardiologist for 600,000 individuals)

Collaborations transcended borders, as African centres actively participated in 45 multinational trials, contributing valuable insights to global research endeavors. On the issue of funding, the researchers noted that 91 trials did not disclose their funding sources, while 20 disclosed no external funding. Of the remaining 68 trials, 35.7% had funding from private sources, 28.6% from academic sources, 28.6% from governmental sources, and 7.1% from non-governmental sources.

Our research letter underscores several critical points. First, there is a need for increased investment in training cardiovascular researchers, beyond just cardiologists, to strengthen the research workforce in Africa. Second, it is important to allocate more resources for research and development in African countries, in line with the local disease burden and international recommendations.

Third, initiatives like the Clinical Trials Community platform and the Pan-African Clinical Trials Registry have the potential to improve research infrastructure and collaboration. Lastly, there is a need for multifaceted interventions to address barriers to clinical research in Africa, including regulatory frameworks, electronic medical records adoption, and institutional partnerships.

Forging a new path: Towards inclusivity and impact

Of the 179 trials included, 54 (30.2%) were performed in collaboration with another African (n=42) or non-African center (n=33), most commonly in Europe and the USA.

Together, we can overcome the disparities impeding Africa’s research progress. Our findings have revealed challenges that, once addressed, could amplify the continent’s contributions. Trials across the continent often have limited sample sizes, are conducted at a small number of participating centres, and have short follow-up periods. The intricate dance of collaboration also extended beyond African borders, with European and North American centers partnering to enhance the scope and impact of research.

To unleash the true potential of African-led clinical trials, key changes are needed. Increased investment in training for cardiovascular researchers, beyond just cardiologists, would enrich the research landscape. Clinical research is a cornerstone of sustainable progress, and local governments must invest more in it.

A symphony of change 

As the curtain falls on our story, the call for change echoes. To harmonise Africa’s cardiovascular research and amplify its impact on the world, we need multifaceted interventions. Expanding clinical research sites, standardising regulatory frameworks, and widely adopting electronic medical records will strengthen Africa’s research infrastructure.

Open-access publishing and robust institutional partnerships are our allies in the journey towards progress. The song of African science, once muted, now crescendos as we work to break down barriers and illuminate a path toward equitable cardiovascular knowledge. In this rhythm of change, we are architects of transformation, orchestrating a symphony of research that resonates far beyond the boundaries of continents and borders.

Dr Ahmed Bendary is Associate Professor in the Cardiology Department at Benha University, a member of the Egyptian Society of Cardiology and a Fellow of the European Society of Cardiology (FESC). He also serves on the Board of the Egyptian Association of Vascular Biology and Atherosclerosis (EAVA), is part of the abstract reviewing committee for the European Society of Cardiology (ESC) Congress and serves as associate editor for The Egyptian Heart Journal (TEHJ).

Dr Abdelrahman Abushouk is an Internal Medicine Resident at Yale-New Haven Hospital. He earned his medical degree from Ain Shams University.

Image Credits: CC.

A fire in a favela in Brazil: Poorer countries are least equipped to mitigate the health effects of the climate crisis.

The 28th United Nations climate conference, scheduled to open on 30 November in Dubai, has pledged to elevate health issues, but non-communicable diseases – which are set to become dramatically worse as temperatures rise – are nowhere on the agenda. Prevention of climate– and heat-related diseases need to be on the formal Conference of Parties (COP) 28 negotiating agenda – not just on the sidelines.

Humans are facing unprecedented health impacts from heat

Wildfires across Canada, Hawaii and Algeria, killer heat waves from Texas to India, China, southern Europe, and Morocco, and summer temperatures in the middle of the winter season in Argentina and Chile. The relentless, heat-related effects of climate change are more and more manifest – along with their human toll in terms of deaths and diseases from acute heat stroke to chronic kidney disease.   

As UN Secretary-General Antonio Guterres said recently: “The era of global warming has ended. The era of global boiling has arrived. The air is unbreathable and the heat is unbearable. And the level of fossil fuel profits and climate inaction is unacceptable.” 

And the impacts on health are mounting faster and faster. 

According to the latest report of the Intergovernmental Panel on Climate Change (IPCC), the world could see over nine million climate-related deaths annually by the end of the century in a high emissions scenario – more than any other disease risk factor we face today.

Amongst the growing list of climate-related health effects – which range from vector-borne diseases to hunger and undernutrition – non-communicable diseases (NCDs), particularly those linked to extreme heat, have received far too little attention. 

This is despite the fact that heat-related mortality, also linked to cardiovascular disease and other NCDs, will rise significantly by 2030 particularly under high emission scenarios, according to the IPCC.  Asia, North Africa and the Middle East will be most seriously affected – but Europe and North America will also be badly affected. 

The Intergovernmental Panel on Climate Change’s projection of climate-related deaths.

Extreme heat, NCDs and ‘wet bulb temperature’ survival threshold 

To understand how deeply and directly extreme heat affects health, it’s important to look at the basic physiology of how we humans function in “normal” temperatures and cope with temperatures that rise above our comfort levels.   

Our human thermometer is attuned to maintaining a body temperature of about 37 ℃.  We can tolerate higher temperatures for short intervals if we don’t exercise or work hard, have adequate shade and water and dress in clothes that permit sweating to self-regulate. 

This is how people have survived in tropical and desert regions for millennia. However, even in these regions, daytime temperatures remained, on average, around 32℃ – well below body temperature, with even lower night temperatures.  

Above a certain threshold, humans can only survive for a few hours since we cannot reduce our body temperature by sweating. This threshold, called the “wet–bulb temperature”, is a measure of the combination of temperature and humidity. Visually, imagine a wet cloth wrapped over a thermometer. 

Theoretically,  the wet bulb temperature threshold of survivability is defined as 35℃ – and this is for only a few hours of exposure. However, for healthy adults pursuing normal activity levels outdoors, the safe range is considered to be closer to 30℃–32℃.

The wet bulb temperature threshold also varies geographically in hot – dry and warm – humid climates so there is not one absolute defined threshold for human survival.

For instance, 37℃ in a relative humidity of 50% would be equivalent to a wet-bulb temperature of 28.3 C But with 99% humidity, air temperature of 37.5 C would be equivalent to a wet-bulb temperature of 37 C as well – above the survivability threshold. 

Another metric called the wet bulb globe temperature (WBGT) measures heat stress in direct sunlight. It is similar to the wet bulb temperature but also takes into account wind speed and solar radiation, and is often used to set heat exposure limits for outdoor workers.

What is clear, however, is that as the world warms, more tropical and temperate regions are seeing temperatures rise more frequently beyond the safety zone for more hours and days in the year.  This is now happening visibly, very much along the lines of scientific predictions.  

We have already breached the 1.5℃ target over land  

World Meteorological Organization, August 2023

The 2015 Paris Agreement set a global temperature limit of 1.5℃ above pre-industrial levels, based on knowledge of the harmful ecosystem and health impacts of temperatures rising above this threshold.  

Yet the average global temperature increase since pre-industrial times is already 1.15 ℃ according to the World Meteorological Organization (WMO). On land, we have already passed the threshold of 1.5℃ warming, with a mean temperature increase of 1.59 ℃ since pre-industrial times, according to the IPCC.

This last July was the hottest month ever on record, WMO recently warned. And with the arrival of El Niño, the warming phase of surface waters in the tropical Pacific Ocean, we are going to surpass the 1.5℃ threshold for parts of every year. 

“WMO is sounding the alarm that we will breach the 1.5°C level on a temporary basis with increasing frequency,” said WMO Secretary-General Petteri Taalas on 17 May. 

El Niño, he warned, “will combine with human-induced climate change to push global temperatures into uncharted territory. This will have far-reaching repercussions for health, food security, water management and the environment. We need to be prepared.”

This will push nearly one-third of humanity outside the earth’s “human climate niche” by the end of the century with “high temperatures linked to issues including increased mortality, decreased labour productivity, decreased cognitive performance, impaired learning, adverse pregnancy outcomes, decreased crop yield, increased conflict and infectious disease spread,” says Professor Chi Xu at Nanjing University in China. 

While until now, most land areas of the earth have been habitable, even if conditions may sometimes be harsh, but by the end of this century, large areas of the populated world will be virtually uninhabitable. 

The drought in the Horn of Africa has impacted approximately 4.5 million Somalis, and around 700,000 people have been forced to leave their homes.

Heat-related increases in chronic disease 

So what are the health impacts of the temperature rises that we are seeing? In acute instances, extreme heat can lead to sudden organ failure and death. 

Anecdotally, we’ve already seen many more such cases during this year’s summer in the northern hemisphere. A 13-year-old girl cycling home from school, was one of 15 people that perished in extreme heat in Japan and the Republic of Korea in the first weekend of August. 

In June, the deaths of a 14-year-old boy and his stepfather in Big Bend National Park in Texas in 48°C heat also gained a lot of attention in US media. 

But the stories that hit the headlines are only the tip of the ‘heat–berg’. Uncounted numbers of outdoor workers, such as farmers and construction workers, are likely to have died from heat-related conditions over the past months and weeks. A 44–year–old road worker in Milan and two construction site workers in Jesi and Brescia were among the workers who died from heat this summer, for example. 

Over time, however, chronic extreme heat exposure also can trigger or exacerbate a range of NCDs such as kidney disorders, hypertension, and chronic cardiovascular and respiratory diseases – leading to more premature deaths.

And as usually happens, it is the elderly, children, pregnant women and outdoor workers – a large proportion of which are also poor and marginalized – who are among the worst affected. 

Heat and workers’ health 

With regards to outdoor workers, few countries have yet paid sufficient attention to heat-related health. In the US, for instance, the federal Occupational Safety and Health Administration (OSHA), lacks any kind of official labour standard for heat and health standards to protect workers. 

In some cases, laws have even moved backwards. The Texas State Legislature recently passed a bill nullifying local ordinances in the cities of Austin and Dallas that required employers to give construction workers water breaks of 10 minutes every four hours. The bill was signed into law in late June, just as a deadly heat wave gripped the state. 

Indeed, by any public health standard, this is the opposite of the direction in which we need to move to create decent work and workplaces in the climate change era. Indirectly, as well, heat waves pose a particular threat to livelihoods, socioeconomic output and reduced labour productivity – affecting mental health, nutrition and other health determinants. 

Heat stress among workers, if not properly managed, can also lead to injuries and significant losses of productivity. 

A construction worker in Texas, where the state legislature recently removed some health protections for outdoor workers.

Other NCD risks related to climate change 

Heat is not the only climate-related driver for NCD morbidity and mortality – which is in turn responsible for 74% of the total global deaths. 

Climate change depletes food supplies, increasing hunger and malnutrition in multiple pathways. These include direct damage to crops, livestock and fish catches from rising land and ocean temperatures, as well more complex ecosystem events – for example, pest invasions such as the massive locust swarms seen over the past couple of years in the Horn of Africa.

Increasingly, low-income countries in Africa and elsewhere are also experiencing a triple burden of undernutrition and malnutrition, including micronutrient deficiencies; overweight and obesity, as a result of increased consumption of sugary drinks and other industrialized, ultra-processed foods, and decreased consumption of fresh, indigenous food varieties. As a  result, more people living with diabetes, hypertension and cancers in developing countries.

Due to rising sea levels, freshwater systems in vulnerable Small Island Developing States (SIDS) are threatened by the increased salinity of groundwater supplies, which is increasing daily salt intake of island inhabitants – and thus risks of hypertension and related NCDs. 

A multi-year drought in Uruguay has had severe consequences for the freshwater supply, leading the authorities to add brackish water to the drinking water supply, enhancing dangerous salt levels. 

People living with NCDs also are at particular risk during and after extreme weather events such as floods and storms, which interrupt routine healthcare services and access to life–saving medication, such as insulin. The displacement and trauma of extreme weather also exacerbate mental health conditions – a factor highlighted at the recent Ministerial meeting on SIDS.

Addressing the heat and health crisis 

While rich countries are affected as well, it is often the same low- and middle-income regions most vulnerable to the effects of climate change that are also the least prepared to cope with its health impacts – including heat-related ones. 

Of the 17 million premature deaths annually from NCDs, some 86% already occur in low- and middle-income countries.  

So what can we do to combat and counter these trends?  We must act both in climate forums like COP28, as well as in global health forums and national health systems and across sectors nationally, regionally and globally. 

Stronger health systems : NCD diagnosis, prevention and treatment are poorly integrated into primary health care and universal health coverage (UHC) of many low- and middle-income countries, and these interventions are often not considered part of UHC. 

Primary healthcare facilities lack simple diagnostic technologies to measure blood pressure, blood glucose levels, and peak expiratory flow (an indicator of respiratory diseases). 

They also lack basic medicines listed in WHO’s Package of Essential NCD (PEN) interventions. Investments must be strengthened to cope with today’s already large NCD burden – and prepare better for tomorrow – including more heat–related diseases. 

Additionally, facilities in many low-income countries lack even a minimum functioning infrastructure for energy, clean water, sanitation and waste. Ensuring these services is essential to ensure the uptake of modern technologies for the prevention, detection and control of NCDs. Next month’s UN High-level meeting on UHC is an opportunity to strengthen the commitments.

Early warning, heat action plans and workers’ health: During California’s recent heat waves, the City of Los Angeles opened “cooling centers” to protect people who lacked adequate home cooling. 

With emergencies now becoming routine, more cities and countries need to consider the development of heat and health guidelines and action plans. 

As part of this, occupational health standards should be assessed and strengthened, to protect workers better from climate-related and particularly heat-related diseases. and particularly for outdoor workers. WHO may be called upon to support this process with evidence-based guidelines with regard to safe temperature thresholds for outdoor work, and relief measures such as the provision of shade, water, and cooling breaks and devices.  

Advocacy at COP28 

At COP28, we in the health sector need to advocate for increased recognition of the health problems associated with climate change – problems which the recent series of extreme heat waves may be finally raising to the top of our political awareness. 

This needs to go beyond rhetoric and lead to greater access for the health sector to international climate financing, such as the Green Climate Fund, and the Loss and Damage Fund, as well as through the World Bank and regional development banks.

Investments in policies to reduce greenhouse gas emissions should be recognized and assessed in terms of their co-benefits for health as well as to climate – such as transforming food systems to make them more sustainable and resilient as well as healthier. 

We need to retool tax and financial incentives for linked climate and health actions. This includes the removal of harmful subsidies not only on fossil fuels but on agricultural commodities like sugar and intensive livestock production. 

Two years ago, the COP26 Health Programme and the Alliance for Transformative Action (ATACH) were launched by WHO and partners outside the formal COP agenda. It established building blocks to protect the health of people from climate change, such as addressing the barriers faced by countries to access finance to address climate change and health. 

Proactive climate measures can improve health 

Well-designed climate mitigation measures can not only avoid increases in NCDs but can even reduce existing NCD risk factors, blunting the epidemic increase in such diseases.  For instance, measures to ensure clean energy and transport will reduce air pollution; policies to promote walking and biking may reduce weight and lower blood pressure. 

Policies supporting the production and consumption of healthy, locally produced fresh foods, particularly plant-based foods, and discouraging excessive red meat consumption, would lower greenhouse gas emissions in agriculture and result in healthier diets. 

In addition, planting trees and shrubs with crops could both increase the resilience of crops to droughts and excessive rainfall runoff, reduce CO2 emissions as well as improve health.

We have illustrated some of the ways in which climate change and NCD are interlinked and suggested that actions to manage them must be aligned. These two crises have one thing in common: they can be prevented. 

Going beyond ‘health’ rhetoric to action  

But this requires strong and deliberate policies by brave political leaders – as well as more explicit recognition of the health impacts of climate change and the co-benefits of mitigation and adaptation in all aspects of climate action. 

It appears long forgotten, but Parties to the UNFCCC are committed to considering the public health implications of their climate policies. We need formalized discussions on how to fully integrate health-incentivising climate policies into countries’ nationally determined contributions (NDCs) under the Paris Agreement, and the reporting requirements for National communications. This should include the systematic quantification of health co-benefits of climate change mitigation and adaptation commitments – which would reduce the huge burden of NCDs. 

Only after such health impacts and benefits are fully counted, can health also have the seat it deserves at the table of climate funding and investment decisions.  

During the seven years we have left to fulfil the 2030 Sustainable Development Agenda and to achieve the target of a one-third reduction in premature deaths from NCDs, which is intertwined with our climate agenda, we need to see a lot more courage from national governments and leaders than we have seen in the past 30 years. 

Human health is in fact the lynchpin in the two processes.

The declaration of a COP “Health Day” and a Health Ministerial Meeting at the Climate Conference are important steps. But this needs to be followed by concrete action to reduce and reverse our planet’s spin into an abyss of worsening climate and human health impacts – including NCDs, which constitute the biggest global health epidemic of our time.

Dr Bente Mikkelsen

Dr Bente Mikkelsen is WHO’s Director of the Department of Non-communicable Diseases.

Dr Maria Neira is WHO’s Director of the  Department of Environment, Climate Change and Health 

Marit Viktoria Pettersen is a consultant for the WHO’s Integrated Service Delivery in the Department of Noncommunicable Diseases.

Image Credits: Denys Argyriou/ Unsplash, UN-Water/Twitter , Josh Olalde/ Unsplash, WHO, World Economic Forum, Maria Neira.

climate emissions
Fossil fuel combustion is a leading source of global warming and harmful air pollution.

Almost 50 organisations have written to the head of the upcoming United Nations climate change meeting, Conference of the Parties (COP) 28, calling for substantive progress against air pollution, which they describe as “the nexus of climate and health”.

With 100 days to go until COP28 in the United Arab Emirates, the groups organised by the Clean Air Fund, have written to president-designate Dr Ahmed Al Jaber, asking him to “put air pollution firmly on the agenda and to catalyse national commitments and international funding to improve air quality”.

“Air pollution is a pervasive public health crisis and an accelerator of climate change,” the letter notes.

The letter anticipates that the global stocktake process to evaluate progress towards meeting the goals of the Paris Climate Change Agreement, which concludes at COP28, “will be a devastating reality check, showing that countries are massively off track from their commitments”.

“Ninety-nine percent of the world’s population breathes air that fails to meet WHO guidelines. The main drivers of air pollution are also sources of greenhouse gases, the largest culprit being the combustion of fossil fuels. 

“This interconnectedness means that a full stop to burning fossil fuels is essential to unlock the enormous co-benefits of clean air. We emphasise that clean air cannot be solely achieved by carbon capture technologies, which do not address all toxic pollutants and particulates, such as black carbon which also accelerates warming. Only measures which result in better air quality will deliver the public health co-benefits of climate action.”

The letter reaffirms the Global Alliance on Health and Pollution’s most effective interventions to reduce fine particulate matter (PM2.5) and carbon dioxide emissions to improve heath involve replacing coal with renewable sources of energy for total power production; replacing diesel and gasoline-powered vehicles with electric vehicles; eliminating uncontrolled diesel emissions and preventing crop burning and forest fires.

It adds a further demand for “comprehensive air quality monitoring to demonstrate progress towards WHO Air Quality Guideline levels and campaigns to demonstrate the benefits of clean air to health, families, and communities to further build public support for climate action”.

“COP28 must deliver tangible progress to end all fossil fuel subsidies, as a way to unlock progress across the negotiations,” the signatories state.

A recent report from the World Health Organization noted that the global high emissions trajectory continues, nine million people per year will die annually from climate-related causes by the end of the century.

 

Image Credits: Ella Ivanescu/ Unsplash, Chris LeBoutillier.

WHO Traditional Medicine Summit 2023

PUNE, India – The World Health Organization’s (WHO) two-day summit on traditional medicine, held last week in the Indian city of Gandhinagar, was an attempt to start a dialogue about how to integrate evidence-based traditional medicine into modern medicine – but many were disconcerted about social media posts from the global health body that appeared to offer support for unproven treatments.

In addition, with India as summit co-host, Indian officials and programmes that have made controversial, unscientific claims were also given prominence.

At the start of the summit, WHO Director-General Dr Tedros Adhanom Ghebreyesus urged delegates to “use this meeting as the starting point for a global movement to unlock the power of traditional medicine through science and innovation”.

“I urge you all to identify specific, evidence-based and actionable recommendations that can inform the next WHO traditional medicine global strategy,” said Tedros, adding that countries should commit to examining the best way to include traditional, complementary and integrative medicine (TCIM) into their national health systems.

Dr Bruce Aylward, WHO’s Assistant Director-General, Universal Health Coverage, also highlighted the need for a “stronger evidence base” that could enable countries to “develop appropriate regulations and policies around traditional, complementary, and integrative medicine.”

Despite WHO officials’ stress on evidence-based treatment, some of its social media messaging appeared to endorse contentious medical systems such as homeopathy. One such Twitter post (see below) had over 5.3 million views, and provoked thousands of comments.

Many critics said the post appeared to be promoting untested treatments. Timothy Caulfield, a Canadian professor of health law and science policy, said that he found the WHO tweet “frustrating”, and asked how naturopathy, homeopathy and osteopathy  could be considered “traditional”., and warned against “legitimizing harmful pseudoscience” such as homeopathy.

“The WHO social media posts are, after all, an extension of the organisation and might be seen as an official position of the organisation,” Dr Anant Bhan, a global public health and bioethics researcher based in Bhopal, told Health Policy Watch. 

“You cannot detract from your core messaging which is around evidence-based medicine and the need to support it, including for public health policy. Once that starts happening, it will cause confusion,” said Bhan, adding that many people would not be able to discern the finer details of the WHO tweet.

The WHO late conceded that its tweet “could have been better articulated” but did not remove it.

 

Controversial Indian officials and programmes

The summit also allowed co-host India to promote controversial officials at press conferences – most notably, joint secretary of the Ministry of Health and Family Welfare (MoHFW) Lav Agarwal. During the COVID-19 pandemic, Agarwal repeatedly linked rising COVID-19 cases to a meeting held by a Muslim group, driving misinformation and stigmatization in an already charged religious environment in the country. 

Lav Agarwal (second from left), a senior health official in the Indian government who has been a prominent presence in the run-up to the traditional health summit was responsible for misinformation and stigmatization in the early weeks of the pandemic.

India’s Ministry of Ayurveda, Yoga, and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) also announced at the summit that it is in discussions with Malaysia about how to cooperate on traditional medicine and homeopathy. The official inclusion of homeopathy in the Ministry of AYUSH has long been a subject of controversy in India. 

Integration opportunities and challenges

While this is the first global summit on traditional medicine, the WHO has made attempts to include traditional medicine since 2014 when the first global 10-year strategy for traditional medicine was approved, and Tedros told delegates that the summit is likely to be a regular event.

There is clearly a demand for such summits. Preliminary findings from the WHO Global Survey on Traditional Medicine 2023, which were shared at the summit, indicate that around 100 countries have TCIM-related national policies and strategies.  

“In many WHO member states, TCIM treatments are part of the essential medicine lists, essential health service packages, and are covered by national health insurance schemes.  A large majority of people seek traditional, complementary and integrative medicine interventions for treatment, prevention and management of non-communicable diseases, palliative care and rehabilitation,” the WHO noted in a media release after the summit, which ended last Friday.

The WHO envisions a complementary role for traditional medicine, one in which it can be used alongside modern medicine in preventive healthcare as well as rehabilitation. 

For example, Professor Stefano Masiero, who chairs the rehabilitation unit at the Padua University-General Hospital in Italy, told the summit that the integration of traditional and complementary medicine could create a comprehensive rehabilitation experience. 

Meanwhile, Dr Hans Kluge, WHO Regional Director for Europe, told delegates at the close of the summit that they have “gently shaken up the status quo that has, for far too long, separated different approaches to medicine and health.” 

“By taking aim at silos, we are saying we will collaborate all the more to find optimal ways to bring traditional, complementary and integrative medicine well under the umbrella of primary health care and universal health coverage,” said Kluge, urging the need for “better evidence on the effectiveness, safety and quality of traditional and complementary medicine”.

But Dr Shyama Kuruvilla, lead for the WHO Traditional Medicine Global Centre, said “we have a long journey ahead in using science to further understand, develop and deliver the full potential of TCIM approaches to improve people’s health and well-being in harmony with the planet that sustains us.”

India currently holds the presidency of the G20 group of countries and the Traditional Medicine Global Summit coincided with the meeting of the health ministers of the G20 countries, who represent around two-thirds of the world’s population.

Image Credits: WHO, Ministry of AYUSH, India.

Two-thirds of US adults say either they or a family member have been addicted to alcohol or drugs – but the impact of alcohol still substantially out-paces that of drugs, despite the country’s massive opioid epidemic.

This is the finding from a survey of a representative sample of US adults conducted last month by KFF, which was released this week.

More than half of those (54%) polled said someone in their family had been addicted to alcohol, and 13% reported that they may have been addicted to alcohol.

Slightly over a quarter reported family members who were addicted to an illegal drug (27%) or prescription painkillers (24%) while 5% said they may have been addicted to prescription painkillers, and 4% reported a possible addiction to illegal drugs.

Opioid impact

US overdose deaths reached record levels in 2022, with almost 110,000 people dying – mostly as a result of fentanyl overdoses.

In the survey, 42% of people reported they or a family member have experienced opioid addiction in comparison to 30%  in suburban and 23% in urban areas. 

More Whites (33%) than Hispanics (28%) or Blacks (23%) report personal or familial experience with opioid addiction. 

Among those who say they or a family member experienced addiction to prescription painkillers, alcohol, or any illegal drug, less than half (46%) report they or their family member got treatment for the addiction. 

However, more Whites (51%), than Blacks (35%) or Hispanics (35%) received treatment. 

“Experiences with addiction and overdose are widespread, with large shares across income groups, education, race and ethnicity, age, and urbanicity all reporting some experience, though some groups report higher incidence than others,” notes KFF. 

“Overall, one in five adults (19%) say they have personally been addicted to drugs or alcohol, had a drug overdose requiring an ER visit or hospitalization, or experienced homelessness because of an addiction.

“The share increases to a quarter (25%) among adults with a household income of under $40,000 a year.”

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at KFF. The survey was conducted between 11-19  July online and by telephone among a nationally representative sample of 1,327 US. adults in English and Spanish.

Image Credits: Chuttersnap/ Unsplash.

A mural appeals for South Africans to get vaccinated against COVID-19.

The South African High Court has ordered the country’s health department to hand copies of all its COVID-19 vaccine procurement contracts, negotiations and agreements to a non-governmental organisation, Health Justice Initiative (HJI).

The Pretoria High Court ruling on Thursday comes in response to a court application by HJI for access to the contracts, arguing that the government had a constitutional requirement to be transparent and adding that it wanted to assess the legality and cost-effectiveness of the contracts.

The health department has 10 days to provide HJI with copies of all its COVID-19  vaccine procurement contracts, memoranda of understanding and agreements relating to a wide range of pharmaceutical companies and vaccine procurement groups.

These include Pfizer, Janssen/ Johnson & Johnson, Serum Institute of India, local generic company Aspen, China’s Sinovac, as well as the African Union Vaccine Access Task Team (AU AVATT) and COVAX.

Judge Anthony Millar said that the contracts were in the public interest as more than 30 million vaccines had been administered in South Africa with a budget of R10 billion (around $530 million) being allocated to cover this in 2021 alone, according to GroundUp.

Inflated prices, onerous terms

“This is a massive victory for transparency and accountability,” said HJI in a media release on Thursday.

“The contracts concern substantial public funds, and the contracting process has been marred by allegations that the government procured vaccines at differential, comparatively inflated prices and that the agreements may contain onerous and inequitable terms including broad indemnification clauses, export restrictions, and non-refundability clauses.”

In 2021, the South African health department itself complained about the onerous indemnity requirements that Pfizer had tried to extract in exchange for vaccines.

Then health minister Zweli Mkhize had told parliament that Pfizer had demanded that it be indemnified against civil claims from citizens with adverse vaccine effects and that the government put up sovereign assets as collateral to settle such cases, as reported by the Bureau of Investigative Journalism.

After a public outcry, Pfizer backed down on its demand for government assets as collateral but was still believed to have been indemnified against claims in many countries.

In fact, the global vaccine access platform, COVAX, established a No-Fault Compensation Program for Advance Market Commitment (AMC) Eligible Economies to ensure that people who experienced serious adverse effects from COVID-19 vaccines in poorer countries could receive compensation.

South Africa and other low- and middle-income countries were unable to procure vaccines for some months after they were available in Western countries as they had relied on COVAX. COVAX had ordered vaccines from the Serum Institute of India (SII). However, the Indian government banned SII from exporting its COVID-19 vaccines in April 2021 during the height of that country’s pandemic.

The collapse of the COVAX-SII deal forced South Africa to scramble to procure vaccines directly from pharmaceutical companies, paying a suspected premium for these.

Noting increasing reports of corruption within the healthcare sector, HJI added that “we cannot have a healthcare system shrouded in secrecy.  Procurement must be held in check, as it will involve powerful multinational companies, particularly from the pharmaceutical industry.”

During the pandemic, Health Minister Mkhize himself was forced to resign after it emerged that his family had benefitted from a COVID-19 communication contract the health department had awarded to a company run by a close friend.

Precedent for pandemic accord negotiations?

The HJI added that the judgement would assist in bolstering “provisions on transparency and accountability” in the current pandemic accord negotiations “where worrying attempts are being made to water down transparency”.

HJI had previously tried to get access to the contracts via the Promotion of Access to Information Act (PAIA), but the health department had refused to release the information, describing it as “confidential”.

Meanwhile, the judgement has been hailed by the People’s Vaccine Alliance.

“Pharmaceutical companies should never be allowed to operate without public scrutiny, particularly in a pandemic. But in South Africa and many other countries, governments were forced to sign up to strict secrecy clauses for their populations to access lifesaving vaccines and medicines,” said Mohga Kamal-Yanni, policy co-lead for the People’s Vaccine Alliance.

“This landmark decision shows that the public can take on powerful pharmaceutical companies and win. We hope to see more cases like this around the world.”

Noting that “transparency and equity must be at the heart of the world’s response to health crises”, Kamal-Yanni added that “people have a right to know how much pharmaceutical companies are charging them for lifesaving vaccines and medicines, and that right must be enshrined in the pandemic accord and the International Health Regulations.”

The South African Department of Health said that it “will study the judgement and respond in due course”.

Image Credits: Medecins sans Frontieres.

Dr Hans Kluge, WHO Regional Director for Europe.

Dr Hans Kluge, regional director of the World Health Organization (WHO) in Europe,  has warned member countries to maintain their COVID-19 infrastructure and genomic surveillance amid a “gradual increase in cases, including hospitalizations, in some European countries”. 

“COVID has not gone away. While its impact currently isn’t as severe as earlier, millions, especially the most vulnerable, remain unprotected in the WHO Europe Region. Worryingly, barely 11% of people across Europe & Central Asia have gotten their second booster shot,” Kluge noted in a media release.

Kluge cited infrastructure such as early warning systems, variant tracking and vaccine boosters for at-risk groups. 

“Key to reducing the risk of COVID-19 & other respiratory viruses is better ventilation in our buildings. That’s why WHO Europe is facilitating our region’s first-ever indoor air conference in Bern on 20 September 20, with the Geneva Health Forum,” said Kluge.

Globally, nearly 1.5 million new COVID-19 cases and over 2500 deaths were reported in the last 28 days (10 July to 6 August 2023), an increase of 80% and a decrease of 57%, respectively, compared to the previous 28 days, according to the WHO’s latest weekly COVID-19 report. 

While five WHO regions have reported decreases in the number of both cases and deaths, the Western Pacific Region has reported an increase in cases and a decrease in deaths. As of 6 August 2023, over 769 million confirmed cases and over 6.9 million deaths have been reported globally. 

 

Image Credits: WHO.

Dense smoke over Sudan’s capital, Khartoum, which has been the centre of conflict between warring factions over the past four months.

As the war in Sudan enters its fifth month, the leaders of 20 United Nations (UN) agencies and humanitarian organisations are urging the warring parties and the international community to urgently scale up peace efforts for the sake of Sudanese civilians.

Violence in Sudan has spiralled out of control since April when a power struggle between the Sudanese army and the paramilitary Rapid Support Forces (RSF) erupted into a full-blown war. 

The fighting has displaced more than four million people, left 14 million children in need of humanitarian aid, and pushed six million Sudanese people “one step away” from famine, the UN said on Tuesday. 

Around 4,000 people — including at least 435 children — have been confirmed dead, though many more are believed to have been caught in the cross-fire. Some 1.5 million children are expected to fall into crisis levels of hunger by September, while women and girls have been left at the mercy of paramilitaries known to use rape as a weapon of war.

“People have witnessed their loved ones gunned down. Women and girls have been sexually assaulted,” the UN and humanitarian agency leaders said in a joint statement on Tuesday. “People are dying because they cannot access health care services and medicine. And now, because of the war, Sudan’s children are wasting away from lack of food and nutrition.” 

Overflowing morgues in the capital, Khartoum, are leaving thousands of corpses rotting on the streets, as doctors and medical organizations warn the decaying bodies and arrival of the rainy season risk unleashing a cholera outbreak the country’s medical infrastructure is not prepared to handle. 

Nearly all hospitals in Khartoum have been rendered inoperable, Save the Children said in a statement this week, a grim reality that has persisted since the conflict began. Medical staff numbers in the country are also dangerously low, and those facilities that remain operational are at the mercy of frequent power outages.

The closure of hospitals across Sudan is also forcing pregnant women to make a harrowing choice: either risk a dangerous journey through war-torn streets to reach a functioning medical facility, or give birth at home, often without any medical assistance.

“Medical supplies are in scarce supply. Time is running out for farmers to plant crops that will feed them and their neighbours,” UN and humanitarian agency leaders said. “The situation is spiraling out of control.” 

A ‘senseless’ war

Protestors chant for “peace, freedom, and justice” in front of the military headquarters of 30-year dictator Omar al-Bashir during Sudan’s 2019 revolution.

The humanitarian crisis caused by the war stands in stark contrast to the hopes ignited just five years ago by the civilian overthrow of dictator Omar al-Bashir. 

Bashir’s brutal 30-year rule over Africa’s third-largest country looked set to end with a transition to democracy, but in 2021, General Abdel Fattah Burhan and Mohammed Hamdan “Hemeti” Dagalo – the two men now vying for control of Sudan – jointly ousted the civilian-led transitional government, dashing hopes for a brighter future and raising fears of a civil war.

Volker Türk, the UN High Commissioner for Human Rights, said in a statement on Tuesday that the “senseless” war in Sudan was “born out of a wanton drive for power”. 

This war of egos has led to “disastrous” results, including “thousands of deaths, the destruction of family homes, schools, hospitals and other essential services, massive displacement, as well as sexual violence, in acts which may amount to war crimes”, Türk said.

Sudanese women faced a sharp increase in sexual violence after Burhan and Hemeti’s coup in 2021.

A year after the military takeover, the International Service for Human Rights reported that Sudanese women – whose bravery became the face of the revolution against al-Bashir just a couple of years earlier – were facing “an unprecedented crisis with escalating gender-based violence, conflicts, hunger and political instability”.

“After the revolution, whenever women talked about representation or participation or [the need] to include women’s rights … [male] politicians just said ‘this is actually not the right time’ and ‘these women are so annoying,” Linda Marwan, a women’s rights activist who was arrested during the revolution against al-Bashir in 2019 told Foreign Policy. 

Then the war arrived.

Women pay the price for a war of men

Sudanese women, many of whom became leaders of the 2019 revolution in the hope of securing their rights, are being targeted by soldiers using rape as a weapon of war.

Reports of sexual assault in Sudan have increased by 50% since the war began, according to the UN Population Fund.

Liz Throssell, a spokesperson for the UN Human Rights Office, told reporters in Geneva on Tuesday that the UN has verified at least 28 cases of rape. Amnesty International has confirmed reports of rapes and abductions of girls as young as 12 years old. 

The Sudanese government’s Unit for Combating Violence Against Women (CVAW) warned last month that verified rape cases may represent as little as 2% of the total. Data on rapes and sexual assaults during conflicts is notoriously inexact; a fact that underscores the UN Security Council’s characterization of rape as “war’s oldest, most silenced and least condemned crime”. 

Rapes and gender-based violence surge during conflicts. UN data, which is incomplete, estimates that between 250,000 and 500,000 women and girls were raped in the 1994 genocide in Rwanda, and at least 200,000 in the Democratic Republic of Congo since 1996. 

A recent investigation by Al Jazeera into the use of rape as a weapon in the war in Sudan found that the conflict is no exception to the historical pattern of sexual violence escalating during wartime.

Z, a human rights researcher in Sudan who works with rape victims who spoke to Al Jazeera on the condition of anonymity, said: “Rape is being used as a weapon by both sides. The reports we’re getting now are just the tip of the iceberg.”

“You’re dealing with a conservative Muslim community, where women’s bodies are a symbol of honour, of purity … the symbolism is very complicated,” Z said. The cultural context enmeshed in the conflict has made women’s bodies “part of the battlefield”, she explained.  

In a report published earlier this month, Amnesty International found almost all reports of rape accused the paramilitary Rapid Support Forces (RSF), though Sudanese army personnel were blamed in a minority of cases. 

The RSF is a descendant of the feared Janjaweed militia that participated in the genocide in Darfur, in which around 300,000 people were killed. 

Hemedi, the general who heads the RSF, led Janjaweed paramilitaries that burned villages, killed civilians and raped ethnic Africans across his native Darfur. These crimes led to the indictment of his then-commander, al-Bashir, by the International Criminal Court for war crimes and genocide. 

“Enough is enough,” Fatima Hashim, a leader in the grassroots movement to overthrow al-Bashir and women’s rights activist, told Foreign Policy. “I think men have destroyed Sudan. What has the army done? The war in South Sudan. The war in Darfur.” 

“It’s been 67 years since independence, and those men haven’t done anything [for] Sudan,” she said. “They made it worse.” 

Image Credits: CTNSIS, Ola A .Alsheikh, CC.