As United Nations (UN) member states meet in New York on Monday and Tuesday to discuss the political declaration to be adopted at the General Assembly’s High-Level Meeting (HLM) on Pandemics in September, there are growing concerns that the current draft is weak and proposes an over-reliance on the World Health Organization (WHO) to manage future pandemics.

The current draft – pared down from 58 to 15 pages – has dispensed with a number of critical concerns, particularly about how future pandemics will be governed, located almost entirely with the WHO.

The most vocal criticism of the draft comes from the co-chairs of the Independent Panel for Pandemic Preparedness and Response, which has proposed a high-level independent oversight group to govern global pandemic responses.

“We are gravely concerned that the opportunity presented by the High-Level Meeting and the expected Political Declaration on Pandemic Prevention, Preparedness and Response is being squandered,” wrote Ellen Johnson Sirleaf and Helen Clark in an open letter released on Sunday.

“The current draft of the political declaration… does not express the commitments required of heads of state and government to transform the international system of pandemic preparedness and response. Instead, it reads as a health resolution,” they add.

The Independent Panel has published a road map to deal with future pandemics, that sets out recommendations on governance, equitable access to pandemic countermeasures, preparedness and surge finance, the need for clear rules and roles, and for a stronger WHO.

“Only international, multilateral, and multi-sectoral collaboration can safeguard the world from the next pandemic threat,” according to the Independent Panel.

Pointing out that the success of the WHO negotiations currently underway to develop a pandemic accord is not guaranteed, Sirleaf and Clark reiterate their view that “sustained highest-level political leadership on pandemic preparedness and response” is essential between and during health crises. 

“This is required to ensure protection to health, societies and economies, and to stop outbreaks from becoming pandemics,” they add.

Describing the UN HLM as “a one-time and historic opportunity to commit to lasting and transformative change to pandemic preparedness and response”, they add that if member states “only tinker with the language” of the current draft, “the efforts to agree to the declaration will be wasted”.

Meanwhile, Nina Schwalbe, a principal visiting fellow at the UN University’s International Institute for Global Health, also expressed disappointment with the draft.

“Rather than a strong declaration that commits UN Member States at the highest level to fundamentally change how they address all aspects of pandemic prevention, preparedness, and response, it covers everything from hand hygiene to pollution,” commented Schwalbe on Twitter.

https://twitter.com/nschwalbe/status/1677334373954203651

Image Credits: Wikimedia Commons.

Sexual asssault
Families go to an Ebola treatment centre to visit a family member held in quarantine in Beni, North Kivu region, Democratic Republic of Congo.

The World Health Organiztion (WHO) has been far too slow in providing financial, psychological and legal assistance to victims of sexual assault and exploitation committed by its staff in the Democratic Republic of Congo (DRC) during the 2018-2020 Ebola response, a veteran international investigator said at a WHO press conference on Friday.

Hervé Gogo, presenting his assessment of the World Health Organization’s (WHO) performance since the scandal first came to light in 2020, said that the problems are endemic to the United Nations (UN) system as a whole and that solutions need a system-wide approach.

“It took too much time,” Gogo said of the WHO support extended to over 100 victims in DRC who were raped, abused or lured into having sex in exchange for jobs or money by UN and WHO staffers. “Something needs to be done to streamline the process … particularly on the question of assistance to victims and survivors.”

Gogo’s findings are part of his review of WHO’s compliance with recommendations made in 2021 by an independent enquiry commissioned after The New Humanitarian uncovered the sexual abuses committed by over 80 UN and WHO staff in the DRC.

UN-wide provisions to victims are “not sufficient”

A health worker checks a child potentially infected with Ebola being carried on the back of a caregiver at the Ebola Treatment Centre of Beni, North-Kivu province, Democratic Republic of Congo, during the 2018-2020 Ebola outbreak.

The United Nations system lacks legal provisions for victims to receive compensation directly from the UN without first obtaining a favourable court ruling against one of its agencies. This process can take years, and even if the victim can identify the perpetrator – many cannot, as UN staffers often used fake credentials – proving the organisation is responsible for the actions of the abuser can be next to impossible.

This system is “not sufficient” to support victims of sexual abuse, said Gogo.

“Is it really possible to stick to this orthodoxy? Victims are faced with an impossible task,” he said. “We all really want victims to get compensated: The question is how. It all depends on member states to figure out how to create a mechanism of compensation without waiting for the court process to end.”

Despite the delays in assistance reaching victims, Gogo said the UN health agency’s efforts since the crisis are “more than a good start” to the overhaul of its sexual abuse and exploitation policies.

Search for justice continues in DRC

WHO to Share Information with Congolese Court in Sexual Abuse Cases of 13 Women

WHO has provided support to all 115 survivors of sexual assault in the DRC identified by the independent commission report regardless of whether the perpetrators were affiliated with WHO or other UN agencies, said Dr Gaya Gamhewege, the agency’s lead official in prevention and response to sexual misconduct.

WHO is also providing legal support to victims who decided to pursue local court cases against their alleged abusers. The agency has also complied with requests for information from local authorities in DRC about 16 people linked to WHO who are facing legal action in the country. Gamhewege did not provide any further information on the status of the cases.

“WHO will continue to support any and all survivors who need more support, even if they are affiliated to allegations by personnel from other agencies,” she said.

WHO terminated seven consultants in after finding sufficient evidence of misconduct in the wake of the scandal, Gamehwage said in an interview with Health Policy Watch in April. The agency also posted 14 former staff and consultants identified as alleged perpetrators by the Independent Commission on the UN ClearCheck database, blacklisting them from being hired in the UN.

‘Not a single finding’ showing Tedros knew about abuse claims or cover-up

WHO Member States re-elected Dr Tedros Adhanom Ghebreyesus to serve a second five-year term as Director-General of the WHO in May 2022.

Gogo, who previously served as a senior judicial officer in the UN mission in DRC, was emphatic that no evidence implicating WHO Director-General Dr Tedros Adhanom Ghebreyesus or his inner circle in covering up the sexual assaults in the DRC has been uncovered.

“There is not a single finding about any decision or any information that was shared DG,” Gogo told reporters. “There is nothing to hide.”

No high-ranking WHO officials have been disciplined as a result of the sexual assaults in the DRC. Three senior managers at the agency who were accused of covering up the allegations were reinstated in January after being cleared of charges by the UN Office of Internal Oversight Services (OIOS), which investigated the cases at the request of WHO.

WHO Direct-General Dr Tedros Adhanom Ghebreyesus told the WHO Executive Board they were reinstated because claims of managerial misconduct were “unsubstantiated”.

But a copy of the confidential OIOS report seen later by Health Policy Watch made clear the managers were not found innocent in the cover-up: They were saved by a legal loophole.

The report found that WHO policies at the time of the Ebola response in the DRC did not require manages to report sexual abuse allegations when the victim was not a direct “beneficiary” of WHO aid. Incidents involving women in the “broader community”, such as local residents or volunteers, were not covered by the reporting policies. This loophole has since been closed.

“UN OIOS did not find that managerial misconduct was substantiated against anybody,” said Gamhewage. “That’s really all I have to say on that.”

Mired in scandals, WHO says it is charting a new course

On a visit to the Congolese city of Goma in November 2022, WHO’s Dr Gaya Gamhewage committed to supporting survivors of sexual assault of the Ebola outbreak.

The UN health agency has been mired in a new wave of sexual misconduct scandals since British medical doctor Rosie James alleged a senior WHO official groped her at the World Health Summit in Berlin last October.

WHO received an increased number of sexual misconduct allegations reported in the first half of 2023. Gamhewage told reporters that WHO received 48 allegations of sexual misconduct in the first six months of the year. Six of the allegations have been supported by evidence and are currently being processed.

The uptick in reported cases is a “proxy indicator” that the agency’s accountability systems are improving, said Gamhewage.

“We know that when there were no allegations it didn’t mean that there were no cases,” said Gamhewage. “It is just that people did not have the confidence and the trust to come forward.” 

WHO has become more aggressive in pursuing sexual assault allegations in an effort to rehabilitate its image after years of scandals.

In April, Temo Waqanivalu was dismissed for allegedly harassing a James at the conference in Berlin.

In early May, Peter Ben Embarek, a senior WHO scientist leading the agency’s investigation into the origins of the COVID-19 virus, was also dismissed for sexual misconduct. Embarek was the sventh WHO staff member to be dismissed for sexual misconduct in the previous six months.

Since then, however, no new disciplinary actions against WHO personnel have been announced.

“Culture is changing,” Gamhewage said in her concluding remarks. “But we have a long, long way to go.”

Image Credits: Flickr: World Bank / Vincent Tremeau, UNICEF/Vincent Tremeau, WHO.

European Union.
The EU is updating its air pollution directive for the first time since 2008. The new laws are expected to take effect in late 2023 or early 2024.

BRUSSELS – European Union citizens suffering from health effects caused by air pollution could soon be entitled to seek financial compensation from polluters under a proposed revision of the EU’s pollution regulations. The  proposal is part of a broader overhaul of EU air pollution laws, expected to be completed in late 2023 or early 2024, said a senior European Commission official Thursday.

The interests of European citizens are already protected by an array of legal umbrellas. Companies can be held liable for misleading consumers in their marketing; airlines are required to compensate customers for cancelled or delayed flights; and breaches of consumer privacy or competition laws frequently result in heavy fines.

But no mechanism exists to protect people from breaches of air pollution limits or pollution from industrial sites like chemical factories, industrial farms or coal plants. And that has to change, said the European Commission’s Veronica Manfredi. 

“If we protect the economic interests of our citizens so well, maybe it is also time to have similar protections for their lungs,” said Manfredi, director of Zero Pollution and Green Cities at the European Commission. “Even just loss of time is recognized by the European Court of Justice (ECJ) as damage.”

She was speaking at an event: Cleaner air: Time to capture the benefits, hosted by the European Policy Centre.

Penalties, damages and access to justice

Air pollution
Air pollution is responsible for over 300,000 premature deaths in Europe every year.

The new air pollution rules navigating the EU’s lawmaking labyrinth are the first update to the bloc’s Ambient Air Quality Directive (AAQD) since 2008. The AAQD sets binding air quality standards for a range of air pollutants harmful to human health such as nitrogen dioxide (NO2), fine particulate matter (PM2.5), and ozone which apply to all member states.

The tighter rules proposed by the Commission aim to end the impunity by which polluters across the EU breach air pollution limits. Updated penalties would levy fines proportionate to the financial turnover of companies breaking air quality rules to offset any economic benefit drawn from the breaches.

The Commission proposal is furthermore based on the EU’s “collective redress” model for consumer protection, which allows consumer and public organizations to seek collective settlements on behalf of consumers.

The Representative Actions Directive, which was adopted in 2020 and came into full force across the bloc in June, empowers consumers to seek financial compensation for damages in areas such as data protection, financial services, and air travel. The update to the AAQD would allow individuals to do the same for health damages caused by air pollution. 

“We are envisioning something similar for people that are victims of pollution problems that lead them to health issues,” said Manfredi. “The new provisions entail a clear legal basis for the first time for people whose health has been damaged by air pollution to seek compensation.”

Cost-benefit paradox

Air pollution
The average annual population-weighted a PM2.5 concentration in European countries for 1990 (left) and 2019 (right). The European Environmental Agency estimates 96% of urban EU citizens are exposed to PM2.5 levels above WHO standards.

Europe stands to gain hundreds of billions of euros from cleaner air. EU-wide benefits of meeting the air quality targets set by the Commission are estimated to be between €42 billion and €121 billion anually, according to a new report by the European Policy Center (EPC) published on Thursday. The costs of implementing the rules is less than €6 billion per year.

“It is a paradox that we have a seven-to-one benefit ratio, but then there are still lots of resistance and concerns,” said Stefan Šipka, lead author of the EPC report. “And that is actually the lowest [estimated] ratio.”

Premature deaths from air pollution have fallen by two-thirds from an estimated one million deaths in the 1990s to around 300,000 deaths in the EU region today. Implementing the stricter air quality limits set out by the Commission successfully could reduce that number yet again by over 75%, experts estimate. 

“It is still an absolutely unacceptable number,” said Manfredi. “It puts into tragic perspective even the number of appalling deaths we have experienced during the – after all – just two year COVID-19 pandemic.” 

The European Parliament’s Environment, Public Health and Food Safety (ENVI) Committee has approved the revision of the Ambient Air Quality Directive in June – a major step towards the finish line.

But the directive needs to clear votes in the European Parliament and the EU Council, the body representing EU member states, before it is finalized. 

See the related Health Policy Watch story on a new TDR Global Health Matters podcast here:

https://healthpolicy-watch.news/impossible-to-have-healthy-people-on-a-sick-planet-fighting-back-against-air-pollution/

Image Credits: Sébastien Bertrand, Daniel Moqvist.

Women
A major burden of collecting water falls on women and girls.

Water and sanitation crises across the world affect women and girls more than men and boys, particularly since the responsibility to collect water in seven out of 10 households without individual water supply falls on the female family members. 

This is a key message in the latest edition of the joint WHO/UNICEF report on progress on household drinking water, sanitation, and hygiene (WASH) 2000-2022 the first to provide a look at data from a gender perspective. 

The data conclusions dovetail decades of observations about the disproportionate impacts of unsafe and inaccessible water, sanitation and hygiene on women and girls.   

Globally, 1.8 billion people live in households without a source of water on the premises, the report finds. 

Women and girls, regardless of their age, bear a little over twice the burden of fetching water from sources outside their homes compared to men and boys. This leaves them with much less time to engage in education and employment, among other activities. 

In almost all the countries surveyed for the report, men and boys spent less than 10 minutes per day fetching water for such households, compared to 53 minutes per day for women and girls.  

WASH
Time spent by people fetching water.

Lack of access to sanitation and hygiene 

And if the lack of an on-site water supply eats into the time available for education or employment of women and girls, inadequate sanitation facilities makes their lives even more precarious. 

“Unsafe water, toilets, and handwashing at home robs girls of their potential, compromises their well-being, and perpetuates cycles of poverty,” said Cecilia Sharp, UNICEF director of WASH and Climate, Energy, Environment and DRR (CEED). “Every step a girl takes to collect water is a step away from learning, play, and safety.”

WASH
Proportion of world population having access to safely managed sanitation services as of 2022.

“Women and girls not only face WASH-related infectious diseases, like diarrhoea and acute respiratory infections, they face additional health risks because they are vulnerable to harassment, violence, and injury when they have to go outside the home to haul water or just to use the toilet,” said Dr Maria Neira, WHO director for Environment, Climate Change and Health, about the reports findings. 

WASH and Sustainable Development Goals 

Access to safely managed drinking water around the world has improved from 69% in 2015 to 73% in 2022, with a sizable improvement in rural areas. However, 2.2 billion people worldwide still lack access to safely managed drinking water in 2022. 

If the world is to achieve the Sustainable Development Goal (SDG) for Clean Water and Sanitation (SDG-6), it has to accelerate progress by three to six times, the report pointed out. 

Accessibility to drinking water is closely correlated with the level of income in a country, it stated. 

In a high-income country, almost all households have access to safe drinking water on site, or within a 30-minute walk. In contrast, in low-income countries, less than a third of the safe drinking water sources are located within the premises of a household. And only half of households can access a safe drinking water source within a 30-minute walk.

Sanitation even further behind 

Progress on sanitation lags even further behind. 

Around 3.4 billion people across the world still lack access to what WHO and UNICEF define as a “safely-managed” sanitation point – which they both define as an improved latrine or better.  And while access to safe sanitation sources has risen in the past seven years from 49% in 2015 to 57% in 2022 – that’s still far behind safe water access. 

Open defecation continues to be a widespread practice in some 36 countries – with rates of 5%-25%. Among 13 countries, at least one in four persons regularly defecate in the open, including Chad (63%), Niger (65%), and South Sudan (60%) . 

The practice not only increases people’s risk of exposure to disease pathogens but also makes it difficult for women and girls, in particular, to maintain privacy and dignity, as well as making them vulnerable to physical, sexual, or verbal violence. 

Image Credits: Photo by Rifath @photoripey on Unsplash, UNICEF. WHO, UNICEF, WHO.

Aspartame
Sugar crystals with aspartame in it (Round, white materials in the image).

WHO is set to release new data on Friday, 14 July on the carcinogenic risks of consuming aspartame, the artificial sweetener that is omnipresent in low-calorie soft-drinks, sweets and other processed foods, its head of nutrition, Dr Francesco Branca confirmed on Wednesday. 

A full WHO risk assessment on safe levels of exposure to the sugar substitute, which hasn’t been assessed since 1981, is due to be completed this week by the WHO and Food and Agriculture Organization’s Joint Expert Committee on Food Additives (JECFA), Branca said, speaking at a WHO press briefing on Wednesday. 

“The assessment of aspartame has been,in the first place, a hazard identification process. This has been closed. This is now followed by a full risk assessment process,” Branca said. “The two assessments will be then put together in a final release that will be completed and disseminated next week – a full risk assessment will be available next week.”

His comment came days after a Reuters report stated that aspartame is set to be declared as “possibly carcinogenic to humans”, by the International Agency for Research on Cancer (IARC), a WHO-affiliated agency that recently completed a separate assessment process on the sweetener. 

The new IARC monograph is due to be released 14 July, simultaneously with the JECFA assessment.  

IARC’s assessments looks at carcinogenicity, WHO evaluates exposure risks 

While IARC’s assessments look at whether a substance is potentially hazardous, or not, the JECFA assessments look at how much, if any, of a product is actually safe to consume, a WHO spokesperson explained, in a comment to Health Policy Watch.  

“In its Monographs Programme, IARC conducts hazard identification, which is the first fundamental step to understand carcinogenicity. Hazard identification aims to identify the specific properties of the agent and its potential to cause harm, i.e., the potential of an agent to cause cancer. 

“The classifications reflect the strength of the scientific evidence as to whether an agent can cause cancer in humans, but they do not reflect how high the risk of developing cancer is at a given exposure level.

“The JECFA Programme (Joint FAO/WHO Expert Committee on Food Additives) conducts risk assessment, which determines the probability of a specific type of harm (e.g., cancer) to occur under certain conditions and levels of exposure.  

“The evaluations are independent but complementary and are conducted one after the other in the months of June-July 2023,” the spokesperson explained. 

“Given the close collaboration between the IARC Monographs and the WHO/FAO JECFA Secretariat, we have planned to present the results of both evaluations at the same time.” This will allow to clearly communicate the different purposes of a hazard 

Aspartame’s links with health conditions

Along with cancer, aspartame has in the past been linked to a wide range of serious health conditions. A 2 July roundup by the US-based public health group, Right to Know, cites evidence around the sweetener’s links to cardiovascular disease, Alzheimer’s seizures, stroke and dementia, along with a range of head, stomach and mood disorders, and even weight gain. 

In May 2023, the World Health Organization signaled a change in its policies, advising the public not to consume non-sugar sweeteners for weight loss, including aspartame. The recommendation was based on a systematic review of the most current scientific evidence, which suggests that consumption of non-sugar sweeteners is in fact associated with increased risk of type 2 diabetes, cardiovascular diseases and all-cause mortality, as well as increased body weight.

Even so, evaluations by the US Food and Drug Administration (FDA), and the European Food Safety Authority have so far rebuffed claims that there is significant evidence of health risks. The FDA states that aspartame is “safe for the general population under certain conditions of use.

A “possibly carcinogenic to humans” IARC classification, which is the classification reportedly assigned to aspartame, is the lowest cancer classification level on the agency’s scale – other than “not classifiable at all”. 

It means that there is some limited evidence that the additive causes cancer in humans. 

“Probably carcinogenic” is the next step in the scale – in which red meat belongs along with glyphosate, the widely used weedkiller, first marketed by Monsanto and now controlled by Bayer. 

Substances with the most robust evidence receive the highest classification – “carcinogenic”.  Those range from outdoor air pollution and diesel exhaust to processed meat and asbestos. All have convincing evidence showing they cause cancer, IARC says.

National regulatory agencies have not always followed IARC’s recommendations.  For instance, the US Environmental Protection Agency still considers glyphosate to be “not likely to be carcinogenic in humans.”

Image Credits: Maxwildcat, CC BY-SA 4.0.

Malaria
A resident of Tanzania tucked into a mosquito net, to protect himself from mosquito bites.

Twenty-two months after the world’s first malaria vaccine RTS,S was approved by the World Health Organization (WHO), 12 countries in Africa will soon receive 18 million doses. A second, arguably more efficient, vaccine against malaria is currently in the queue for WHO approval. 

Meanwhile, distribution of the 18 million RTS,S doses is to be carried out jointly by WHO, Gavi and UNICEF, according to WHO Director-General Dr Tedros Adhanom Ghebreyesus, speaking at a media briefing Wednesday from WHO’s Geneva headquarters.  

“At least 28 African countries have expressed interest in receiving the RTS,S vaccine,” Tedros said. “The second vaccine is currently under review for prequalification, and if successful, provides additional supply in the short term.”

At the briefing, the WHO Director General also condemned the rising incidents of gender-based violence in Sudan, including conflict-related sexual violence against women and girls who have been internally displaced due to the clashes. 

“I’m appalled by attacks on healthcare as well as increasing gender-based violence in the country,” Tedros said. 

His comments coincided with a joint statement, several UN agencies called for an immediate end to the use of such instances of gender-based violence as tactics to terrorize people.

The malaria vaccine race

Tedros said that the RTS,S vaccine has already been administered to over 1.6 million children in Ghana, Kenya, and Malawi and has proven to be safe and effective. The initial shipment of RTS,S vaccines will go to Benin, Burkina Faso, Burundi, Cameroon, Democratic Republic of the Congo, Liberia, Niger, Sierra Leone and Uganda, in addition to Ghana, Kenya, and Malawi, according to a WHO statement.

Developed by GlaxoSmithKline (GSK), the vaccine was initially tested between 2019-2021 in a pilot study in Ghana, Kenya, and Malawi, in which 800,000 children aged 5-17 months received the vaccine. The study found that severe malaria infections were reduced by 30% and hospitalizations 21%, while mortality declined by 10% among children receiving the vaccine. 

The other vaccine, R21/MM, developed by Oxford University, has achieved much higher rates of efficacy – as much as 75%. But that was in smaller Phase 2B trials, while a larger Phase 3 trial is still underway. 

Even so, the vaccine was recently approved by Ghana and Nigeria, which hope to begin manufacturing the vaccine soon. However, it has not yet been approved by WHO under its “Prequalification programme” insofar as the trials performed so far were notably smaller in comparison to the massive real-world trials conducted on the GSK vaccine. 

Already, more than 1.5 million children in these countries have received over 4.5 million doses of the GSK vaccine, according to Dr Kate O’Brien, head of WHO’s Immunization Department. 

She flagged the lack of adequate supply of the GSK vaccine, however, saying that the time is ripe for a second malaria vaccine. 

“We’re very much looking forward to the review of the second malaria vaccine through both our regulatory processes and our policy processes,” O’Brien said. “And, if that review of the evidence leads to recommendations, we would expect a significant increase in the supply in the short term.”

Sudan conflict: increase in sexual violence

Since April 2023, the UN Human Rights office in Sudan has received credible reports of 21 incidents of conflict-related sexual violence against at least 57 women and girls. The victims include at least 10 girls. In one case, as many as 20 women were reportedly raped in the same attack, the statement revealed. 

The office added that Sudan’s ministry of social development also has received at least 42 alleged cases of conflict-related sexual violence in the capital Khartoum, and 46 such cases in the Darfur region. Given that sexual violence is severely underreported, it is feared that the actual number of cases is much higher.

“I’m appalled by attacks on healthcare as well as increasing gender-based violence in the country,” Tedros remarked, adding that the ongoing violence is preventing survivors of gender-based violence from accessing much-needed healthcare services. 

“Women and girls must have unhindered access to the care they need, particularly survivors of sexual violence and women that need support through pregnancy and birth health.”

There have been 50 attacks on healthcare infrastructure in Sudan, in which 10 people were killed and 21 injured since April 2023, when clashes erupted in Khartoum. 

The current conflict in Sudan has internally displaced over 800,000 people, and over 220,000 more have fled the country. 

On Monday, violence escalated in Sudan’s Darfur region, where a group of armed forces and the Rapid Support Forces (RSF) clashed with each other. The region borders Chad, and the recent clashes have resulted in thousands of people fleeing to Sudan’s western neighbor seeking refuge in camps. 

This situation has made providing health support to the affected persons difficult, according to Dr Olivier le Polain, WHO’s incident manager for Sudan. He said that the flow of information from the region to the WHO is limited due to the security situation currently in place. 

“We are very concerned about the situation in Darfur which, by all accounts, is very dire. We also have very limited information in Darfur given the security situation at the moment… We know that conflict is intensifying, some of which is along ethnic lines,” he said, adding that the agency along with its partners is trying to provide the necessary medical and healthcare support to people on either side of the border – Chad and Darfur. 

Image Credits: Peter Mgongo.

Air pollution
Air pollution is the 10th leading cause of death in the European Union.

Ministers of Health and Environment from WHO’s European Region, meeting this week in Budapest, are poised to adopt a Declaration pledging to tackle climate, pollution and biodiversity risks that account for about 15% of disease burden in the 53-nation region.

Health and environment ministers from WHO’s 53-member strong WHO European Region are meeting in Budapest this week to agree on an agenda that aims to redouble action on health challenges related to climate change, pollution and biodiversity loss. 

A ‘Budapest Declaration’, set to be adopted on Friday, contains a set of new commitments by countries to tackle the environmental causes of ill health, which lead to  some 1.4 million deaths annually, according to a new WHO report released Wednesday on the opening day of the three-day conference. 

“Everyone has the right to a clean, healthy and sustainable environment. Yet the triple environmental crisis – climate change, pollution, and biodiversity loss – threatens our very existence and that of our planet, our home,” said Dr Hans Henri P. Kluge, WHO Regional Director for Europe, at a press conference announcing the commitments at the Budapest event. 

“The Budapest Declaration offers concrete actions to improve the environments people live in, decrease the disease burden, reduce health inequalities, relieve pressured health systems and enhance our collective resilience to future pandemics,” he added.

Air pollution tops list of pollution-related deaths

Press conference on the first day of the ministerial conference of WHO’s European Region to discuss policies to tackle the health impacts of environmental and climate issues.

The new WHO report, “A healthy environment in the WHO European Region” provides a breakdown of the estimated 1.4 million environment-related deaths in the WHO European Region – which extends from the United Kingdom to the borders of China.  Air pollution tops the list with an estimated 570,000 deaths. Other key quantifiable risks include: 

  • 269,500 deaths from toxic chemicals exposure
  • 150 000+ deaths due to household air pollution from smokey coal, kerosene and biomass cookstoves;
  • 33,500 deaths from unsafe water, sanitation and hygiene amongst the more than 77 million people lacking access to safely managed drinking water;
  • 24,600 deaths from lung cancer caused by emissions of radon, a naturally-occuring radioactive gas leaking into homes.

Global warming, biodiversity and greenspace loss are growing factors 

People crowded in a fountain in central Berlin during a heatwave in summer 2018.

The report also points to climate change and biodiversity as growing factors in disease risks – whose health impacts have not yet been fully assessed. 

However, in 2022 alone, at least 20 000 people died from extreme heat in what was the hottest summer ever recorded in Europe, the new WHO report states. 

And over the past 50 years, some 148 000 lives were lost from extreme temperatures – comprising most of the 159 000 deaths attributable to climate-related storms, floods and extreme weather.

In urban areas, almost two-thirds of populations lack adequate access to green space close to their homes.  By providing shade for cooling and filtering the air, green spaces have a protective health effect that can reduce natural-cause mortality by nearly 1%, the report notes.

Roadmap of actions

A tram stopped in front of Budapest central station in 1988.

As part of the Budapest Declaration, countries will be pledging to take a series of actions to reduce harmful pollution emissions and mitigate climate impacts.

The actions range from safer waste management and switching to zero-emission transport systems to greener and healthier built environments. Actions in the health sector, including decarbonizing health systems and improving the climate literacy of health workers. 

There is a special emphasis on including youth voices and empowering youth organizations.

The 10 million disability adjusted life years in 2019 caused by ambient air pollution in Europe every year.

“The [Budapest] declaration is accompanied by a roadmap of actions. Member states can choose which things to focus on but we actually are urgently asking every country: Please take all actions aboard as much as you can,” said Brigit Staatsen, Chair of the European Environment and Health Task Force, at the briefing.

“The current and future generations are and will be affected by the triple crisis (climate change, biodiversity loss and pollution) and the effects of climate change on physical and mental health,” said Sara Cozzone, youth representative, Associazione A Sud – Ecologia e Cooperazione (Association South – Ecology and Cooperation). 

She added that tackling climate and eco-anxiety, which is increasingly being felt by young people, has to be a matter of urgency on the agenda of European institutions.

Environment and Health Process Partnerships for knowledge sharing

A new mechanism – Environment and Health Process Partnerships – will also be launched to facilitate collaborations and share knowledge on specific environmental and health challenges.  

Apart from challenges due to the changing climate, European countries are also facing a rapidly aging population, rising chronic diseases, and health workforce shortages as well as energy, cost of living, and geopolitical crises. Together the issues are exerting tremendous pressure on the healthcare systems. 

This week’s meeting in Budapest is the seventh such environment and health ministerial conference, whose aim is to devise and promote innovative policies to support long-term health and well-being of people in the WHO European Region.

The Conference was convened by the WHO Regional Office for Europe in collaboration with the United Nations Economic Commission for Europe (UNECE) and the United Nations Environment Programme (UNEP). 

Image Credits: Mariordo, CC, CC.

tuberculosis
The entrance of Sun City Prison in Johannesburg, South Africa.

Karabo Rafube was born to a single mother in 1982 in Soweto, a sprawling township south of Johannesburg, South Africa. His mother abandoned him three months later, and Rafube was taken to live with his father.

In the final years of apartheid, Soweto was a harsh place to grow up. His father already had an existing family, and Rafube says he was never welcome in his new home.

“About fifteen people lived under the same roof,” Rafube recalled in an interview with Health Policy Watch. “There were two bedrooms, one kitchen, and one TV room. It was very crowded.”

His father and stepmother had both died of diabetes by the time he turned fourteen. After his stepmother passed away, Rafube was adopted by a prominent local businesswoman who ran a fish and chip spot, a neighbourhood liquor store and a butcher shop. 

“My life started to change,” Rafube said. “Even in school I was able to concentrate.”

But one winter’s day in July 2001, after returning home from playing football in Pretoria, Rafube was arrested. He was accused of providing information on how to access the businesswomen’s house to two people who had been caught breaking in earlier that day. Rafube denies knowing the two individuals involved.

Soweto
Soweto Township was established by South Africa’s apartheid government in the 1930s to separate blacks from the white population of Johannesburg. Today, it is the largest black urban settlement in Africa, home to over 2 million people.

At 19 years old, Rafube was taken to prison to await trial. His bail was set at 3000 Rand, worth around $500 today. With no family to turn to for help, Rafube awaited trial in prison for the next two years.

“I was all alone,” he recalled. “Awaiting trial, that’s when hell broke loose.”

Rafube was squeezed for space from the moment he entered the transport van that first carried him to Sun City Prison on the outskirts of Johannesburg. He was placed in a cell with 150 other inmates on arrival at the prison.

“Our cell was overcrowded, it was packed. There was one shower, one toilet, it was so small,” said Rafube. “We were not screened for anything.”

A few months into his incarceration, still awaiting trial, Rafube started to feel weak.

“I saw myself losing weight dramatically, and suddenly I had sores all over my body from head to toe,” said Rafube. “I didn’t know what was going on.”

Rafube sought help from the prison nurse, but he was turned away. His condition worsened over the coming months, and several of his cellmates started to develop symptoms. As their health deteriorated and numbers climbed, the prison hired a new nurse who would change the course of their lives.

“She made sure that I was screened for TB and HIV,” said Rafube. “She actually cared about me.”

When the test results arrived, Rafube was finally diagnosed: he had TB. After months of suffering, he was put on a six-month treatment course that set him on the road to recovery.

New Study First to Track Prison TB Globally

tuberculosis
Estimated tuberculosis incidence in prisons by country in 2019.

Prisons have been associated with tuberculosis for decades. But unlike other high-risk groups such as people with HIV, global and regional data on the incidence of TB in prisoners has never been systematically collected – until now.

In a sprawling global study of TB in prisons in 193 countries published in the Lancet last week, researchers from the Boston University School of Public Health (BUSPH) found prisoners are nearly ten times more likely to contract TB than people living on the outside.

Around 125,000 of the 11 million incarcerated people worldwide developed TB in 2019. Nearly half of all cases in prisons are undiagnosed.

“Prisons are closed settings where we should be detecting 100% of those with TB,” said Anthony Harries, senior advisor at the International Union Against Tuberculosis and Lung Disease. “If you go to prison, you should not also have to contend with a high risk of getting TB.”

tuberculosis
Estimated new tuberculosis cases and notifications among incarcerated individuals in 2019 for countries with the highest number of incarcerated people.

Undiagnosed TB in prisons can have serious health consequences for both prisoners and the communities they return to, as prisoners who are unable to access medication or diagnosis may spread the disease to others when they are released.

Incarceration periods can be very short, and many people frequently cycle between prison and the general population. Incarcerated people can also be transferred between prisons, increasing the risk of infections spreading to new communities beyond their walls.

“Deceptively, this is not an immobile population,” Dr Leonardo Martinez, an epidemiologist at BUSPH and lead author of the study said in an interview. “If around 50% of cases are undiagnosed in prison, and then people are released, they are spreading TB to the general population.”

In Ciudad del Este and Asunción, Paraguay, a recent study found that around 30% of non-incarcerated individuals in both cities were culture-positive for the strain of TB circulating in each city’s prisons. Another study conducted in Brazil found that 50.6% of individuals with no incarceration history were part of infection clusters that included recently incarcerated people.

“It’s really important to show that mass incarceration has an impact on infectious diseases and health in general,” said Martinez.

Squeezed for space

prison
Inmates crammed together in an El Salvador prison during a cell check at the height of the COVID-19 pandemic.

As an airborne disease that spreads through close contact, TB is right at home in crowded, poorly ventilated prison cells. This is reflected in the numbers of the BUSPH study, which show that countries whose prisons are overcrowded also have the highest rates of TB incidence for incarcerated people.

The story of mass incarceration’s relationship to TB incidence in prisons is legible everywhere. The Philippines prison system is the most overcrowded in the world, jailing over five times its official capacity.

The country’s TB incidence in prisons – 3,829 cases per 100,000 people – is the highest in the world as a result, coming in at 30 times the rate observed in the general population and over three times the rate in prisons globally.

In Brazil, the prison population has skyrocketed in recent decades to over 800,000 people, up from just 230,000 in 2002. The country led the world in prison TB cases in 2019.

“The incarcerated population is increasing, crowding is increasing, and as a consequence TB rates are increasing as well,” said Martinez, who spent years working in Brazilian prisons. “There is a really strong relationship between the two.”

The South African prison system has one of the highest TB incidence rates in the world, clocking in at 20 times the risk faced by the global general population. This comes as no surprise to Rafube.

“Whether it was in the cells or the trucks on the way to trial, there was no space,” he said. “I was coughing on people when I was sick.”

Prisoners in Africa were twice as likely to contract tuberculosis than prisoners in other parts of the world in 2019. The Americas region had the largest total number of tuberculosis cases in prison that year, driven by the recent surge in mass incarceration in Central and South America.

“Our hope is that this data is the first step in saying: this is a huge problem, this is the amount of undiagnosed cases we have,” said Martinez. “Larger global health organizations should be collecting this data systematically, every year. I shouldn’t be doing this.”

Sentenced to tuberculosis

The constitution of the World Health Organization recognizes the right to the “highest attainable standard of health” as a fundamental human right.

Life behind bars can be excruciating for the 50% of prisoners who never receive a TB diagnosis. To the people behind the numbers, the high rates of tuberculosis in prisons raise an ethical question: Do we have the same right to health as everyone else?

Rafube is certain the nurse who oversaw his diagnosis saved his life.

“When I started to take my treatment, my life started to change,” said Rafube. “I was picking up strength, I was gaining weight.

“If it wasn’t for this woman, I wouldn’t be speaking with you now,” he said. “If she had arrived a month later, I would be gone.”

Today, Rafube is a “TB teacher” in South African prisons. He makes regular visits to the correctional facilities he almost died in to convince those suffering from TB that life is still worth living.

“Irrespective of your criminal record, irrespective of what you have done, make sure your health is okay, and you can be okay,” Rafube tells inmates on his visits.

He emphasizes the importance of sticking to the six-month medical schedule, as many prisoners choose to crush their medications into powder to sell or smoke.

The COVID-19 pandemic hit TB prevention efforts like a wrecking ball, leaving people suffering from TB more vulnerable than at any time in the last decade.

Deaths from TB jumped by over 100,000 worldwide in 2021 – the first increase in fatal TB cases since 2005 – and the World Health Organization estimated that disruptions to TB treatment may have caused an additional half a million deaths that year.

The BUSPH study data is limited to the pre-pandemic era. The impact of the pandemic on people suffering from TB behind bars is not yet known.

“We can’t end TB without treating everyone,” said Rafube. “That includes prisoners.”

Image Credits: Ye Jinghan, CC, CC, CC.

COP
UN Climate Change Conference, June 2023, Bonn, Germany.

The United Arab Emirates, hosts of the upcoming UN Climate Conference (COP28), have promised to deliver the first COP with a health focus. In addition to focusing attention on the existential human health risks of climate change, it is vital that a “Health COP” delivers commitments that maximize the health gains that can be obtained from more aggressive mitigation and adaptation. However, stalemates on finance and mitigation negotiations during the recent COP28 preparatory talks in Bonn (SB58) have left this December’s conference with a mountain to climb. 

The annual June UN climate meeting in Bonn in preparation for COP28 stalled, with tensions stemming from the failure of wealthy countries to deliver on their commitment to provide $100 billion per year to support low-income countries’ action on climate change. Meanwhile, major fossil fuel-producing countries took advantage of this impasse to oppose constructive discussion on climate change mitigation, and to block progress towards phase-out of the fossil fuels responsible for dangerous warming trends. 

In Bonn, governments came close to failing to agree even on the proposed agenda for the Bonn meeting itself. When finally set, the agenda omitted any mention of the crucial Mitigation Work Programme, where agreement is urgently needed on more rapid reductions of emissions of CO2, as well as short-lived, but powerful, climate change drivers like methane. 

In order to ensure the necessary time and attention is directed to negotiating solutions to the monumental threats our planet faces at COP28, these same delays cannot occur in Dubai at COP 28 (30 November-12 December). Willingness to meet commitments on climate finance, and to enter constructive discussions on mitigation, will be prerequisites for the talks to begin in earnest. 

Worsening trends 

These political developments are all the more worrisome in light of recent trends. 

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

People around the world are already enduring climate impacts, from heatwaves, wildfires and air pollution, to floods and extreme storms. Climate change is also exacerbating crop losses and the spread of infectious diseases, as well as migration. The extraction and use of oil, gas, and coal harms people’s health, and is incompatible with a healthy climate future. That’s all the more reason that COP28 must deliver a commitment to phase out all fossil fuels, and a just transition to renewable energy for all.

Health considerations gaining more traction

Due to warmer climates, international travel and urbanization, one or more of the leading arboviruses are now present in most countries of the world.

While Bonn has left COP28 with plenty to do, the United Arab Emirates, host of this year’s climate negotiations, has committed to elevate attention to health. The country will deliver an official, Presidency-level health programme, including an official “Health Day” for the first time ever, as well as an inter-ministerial meeting on climate and health.

This is welcome. For years, the health community has hammered at the door of climate summits, exhorting delegations to acknowledge how health and climate are intertwined, and to protect people’s health from the impacts of a warming climate. 

The 2015 Paris Agreement invoked the “right to health” as a fundamental rationale for climate action. Even so, language about the “right to a clean, healthy and sustainable environment,” was nearly deleted from the final outcome text of COP27, only to be reinstated at the last minute.  

Despite these kinds of setbacks, it was clear at the Bonn meeting that health is at last penetrating deeper into the global climate negotiations. Country delegates integrated health references into discussions on the Global Stocktake, the Global Goal on Adaptation, and Loss and Damage in meaningful ways. This is unprecedented. 

We have argued that health and climate are connected, and must be addressed together. Our persistence is bearing fruit: we are now seeing the beginning of a crucial cross-pollination between the climate and health worlds – good news for people, and for the planet.

Health needs to be a driver for meaningful action, including mitigation and finance

However, as health gets further integrated into climate talks, it is essential that it serves as a driver for faster, more collective, and more meaningful action – including on critical mitigation and finance elements – as action in both of these areas is essential to protect and support people’s health in this era of multiplying climate crises. Greater investment in health systems and health adaptation, both vitally important steps, are not by themselves enough to protect people’s health.

If COP28 is to be the Health COP, it must do better than Bonn

The COP28 negotiations, and all those to follow, must go further than Health Days if people are truly to be at the centre of the climate agenda.

Most of all,  for COP28 to really achieve “Health COP” status, it must steer us away from dangerous tipping points and catastrophic levels of warming. Concretely this means a number of things, all of which must be supported by adequate finance and means of implementation: phase-out of fossil fuels; a just transition to renewable energy; and maximizing health gains of ambitious climate actions across sectors, spanning mitigation, adaptation and loss and damage.

Full phase-out of fossil fuels

COP28 must deliver the full phase-out of fossil fuels, and a just energy transition that does not saddle developing countries with outdated energy technologies and health-harming pollution. And it must deliver climate finance that enables all countries to make the necessary transitions to have clean energy access for all, and adapt and respond to climate impacts. 

Oil and gas projects in Africa are set to quadruple; projects in the Congo Basin, the world´s second largest rainforest, pose a major risk to regional and global climate stability.

Energy access is essential for health: governments must incentivize, invest in, and support a just clean energy transition, rapidly ramping up renewables to expand energy access, even while we simultaneously kick our fossil fuel addiction. Renewable energy can help overcome the lack of electricity access currently experienced by over 750 million people worldwide, positively influencing social determinants of health with reliable and clean cooking, heating, lighting, healthcare services, and education-related technology.

Governments must also take fast action to cut methane emissions – a short-lived super-pollutant with more than 80 times the warming effect of CO2 (in the short term) – as part of the swift energy, food system, and waste system transitions needed to limit warming.

Fossil fuel lobbyists have no place at COP 

Delegates at COP27 included over 600 corporate lobbyists from fossil fuel companies. Fossil fuel corporate lobbyists have no place at COP28 or in the climate policy-making space. 

Fossil fuel companies with the highest overshoot of the IEA’s net zero emissions scenario, in terms of planned oil and gas extraction.

For decades, these same fossil fuel companies have sown doubt and hidden evidence about climate change, and reaped massive profits, while people around the world have paid the price with our health and our lives. Governments banned the tobacco industry from involvement in decision-making on controls to protect people from the health harms of tobacco; they should just as firmly not allow the fossil fuel industry to dictate our climate and health policies. In response to growing concerns, the UNFCCC will, for the first time this year, require all participants – including lobbyists at COP28 –  to disclose their affiliation. This is a small step in the right direction.

Addressing “co-morbidities of climate change”

COP28 should also address the many “comorbidities of climate change”, such as unsustainable agriculture, urban sprawl, biodiversity loss, and air pollution. The recent forest fires in Canada are but one example of the vicious cycle we are in: climate change drives extreme events, which in turn both contribute to worsening climate change and intersect with and aggravate other serious environmental and health impacts.

Climate change is impacting people’s health now. At COP28, governments must invest in adaptation measures, including building greater resilience of healthcare and public health systems, and in integrating health considerations into adaptation across other sectors. Leaders must also grasp that while adaptation is essential, adapting to a world that has warmed by 2.8°C will prove well nigh impossible – so they must hold fast to their commitments to limit warming to as close to 1.5°C as possible.

Integrating health into finance for adaptation and mitigation

COP28 must integrate health into financing for adaptation, mitigation and loss and damage, with substantial new and additional funding across these areas. Between 2018 and 2020, only 0.3% (14 million USD) of climate adaptation finance was allocated to health sector adaptation, though 13.9% of adaptation was allocated to sectors benefiting health. Meanwhile, according to donor tracking, approximately 7% of bilateral health Official Development Assistance, (ODA) (US$1.58 billion) contributes to climate adaptation, though figures may be lower in reality due to misreporting. Very little synergistic investment is made in health and climate mitigation. 

Finance and technical assistance for low-income countries are critical for protecting people’s health through climate preparation and response, and to make the system transformations required for a healthy, sustainable future. It’s unclear whether or not the recent Summit for a New Global Financing Pact in Paris made meaningful progress in this direction. 

Within the health sector, health civil society and ministries of health are increasingly discussing climate action, from local and national to regional and global levels. With a health focus at COP28, we hope to witness a record number of health ministers in attendance. 

The health community is working to make health systems low-carbon and climate-resilient and to integrate climate change into health professional and health worker education and training. We must go further, divesting health associations and organizations from fossil fuels, and addressing climate change in global health investments and programmes. We are also using our influence to push for effective climate action that protects people’s health, and for climate solutions that secure a stable, livable, and equitable future for humanity.

We need a true Health COP

What should world leaders do to make COP28 a true Health COP? It’s a welcome start to have a Health Day and an inter-ministerial meeting that brings health ministers to COP as part of their national delegations. To be a true Health COP, however, COP28 must deliver an end to the fossil fuel era, deliver financial and technical support to countries most impacted and least responsible for climate change, and bring climate progress centred on people’s health and well-being. 

Dr Jeni Miller is the Executive Director of the Global Climate and Health Alliance, an alliance of more than 150 health professional and health civil society organizations addressing climate change.
Jess Beagley is the Policy Lead of the Global Climate and Health Alliance, an alliance of more than 150 health professional and health civil society organizations addressing climate change.

 

 

 

 

 

 

 

 

 

 

Image Credits: Pixabay, Jess Beagley, Rainforest Foundation and Earth Insight, 2022.

Countries increased their spending on health during the pandemic. Building interest for investing in pandemic preparedness is proving more difficult.

With a drop in government spending on preparedness and woefully inadequate donor pledges, how can the ambitious new commitments envisioned for a WHO Pandemic Accord ever be financed? This second issue of Governing Pandemics Snapshot, looks at this conundrum and possible solutions, including creative forms of debt relief for low-income nations. 

This issue also provides updates on negotiations over the WHO Pandemic Accord and parallel talks on amendments to the International Health Regulations. Finally, it provides fascinating insights into the thorny question of how “medical countermeasures” might be handled in either accord, where North-South divides persist. In addition there are questions about who might manage a new global countermeasures platform – the G7, G20 or WHO? 

Later this month, the Pandemic Fund Governing Board is due to meet in Washington D.C. to make the first round of decisions on disbursement of some $300-350 million in initial funding for pandemic preparedness. However, due to a woeful shortfall in funds so far raised for the fund, hosted by the World Bank, most of the requests submitted by some 129 low- and middle-income countries will likely be denied.

The first two years of the pandemic saw a sharp rise in government spending for health while the general government expenditure trends remained mostly constant, indicating a great political will at country level to fund a response to an urgent health crisis. 

However, in 2022 as inflation drove increased costs of living in energy and food, trends shifted, with a decline in governments’ health spending – over which the World Bank has expressed concerns.

That has once more left health systems vulnerable, and unable to plan for future crises. Although pandemics and their governance continue to attract attention in Geneva, in relation to the ongoing negotiations over for a pandemic treaty and amendments to the International Health Regulations, recent developments suggest that countries are perhaps not as committed to Pandemic Prevention, Preparedness and Response (PPPR) financing as they initially seemed.

The Pandemic fund – status today  

G7 leaders in Hiroshima, Japan.

The ambitious Pandemic Fund, created late last year within the World Bank, has so far raised around $2 billion including the recently pledged $250 million by the United States, announced at the recent G7 Leaders Summit in Hiroshima. 

But this is far short of the $10.5 billion estimated annual gap in PPPR donor requirement. After the first round of calls for proposals, requests for funding amounting to $2.5 billion have been submitted in some 180 applications from 129 low- and middle-income countries.

All of these requests are competing for the relatively minuscule $300-350 million that the Fund currently has to disperse – meaning that most countries will likely not receive any funding at all – or very minimal funding at best.

Although the Fund may be able to raise more money through replenishment rounds, one recent study by the US-based Center for Policy Impact and University of Leeds, has concluded that “total donor funding requirement is closer to US$ 15.5 billion, rather than US$ 10.5 billion; WHO and WB assume that donors are already providing 100% and 60% of the LIC and LMIC PPR costs respectively, which we believe does not hold outside of pandemic times.” 

Nonetheless, even sticking with the US$ 10.5 billion and under the most favorable scenario of donors increasing the percentage of their GNI given to ODA by 2.5% each year – a mean of US$ 213 billion over 6 years, the PPPR donor requirement gap could not be filled.

PPPR funding in draft treaty – heavily referenced with few real commitments  

WHO member states discuss new pandemic convention or treaty, 18 July 2022.

PPPR financing represents a significant theme in negotiations over a pandemic accord.  In the latest text released by the Bureau guiding the negotiations of the Intergovernmental Negotiation Body, Article 19.3(a) on “financing” refers to a fund  “to be funded, inter alia, through the following sources: i. Annual contributions by Parties to the CA+, within their respective means and resources; ii. Contributions from pandemic-related product manufacturers; iii. Voluntary contribution by Parties and other stakeholders”.  

Additionally, the draft Article 19.3(b) calls for the creation of a second separate “voluntary fund”, which would rely entirely on voluntary contributions by “all relevant sectors that benefit from good public health (travel, trade, tourism, transport)” foreseeing a considerable role of both public and private actors.

Article 19 also seems to privilege voluntary options over binding financing obligations, so it’s unclear whether this fund could realistically be filled. Additionally, it remains unclear if the disbursement of monies from the two funds foreseen by the Bureau’s text would be somehow linked with another key set of issues raised by developing country demands – for example, the sharing of “benefits” derived by pharma from their sharing of data on new and emerging pathogens. 

National and ODA commitments to fund PPPR also watered down 

Furthermore, the Bureau’s text has significantly diluted certain States’ obligations included in the previous Zero Draft text. 

For instance, following the suggestion of more than 60 countries, the document no longer includes the commitment by state parties to allocate a certain proportion of their domestic resources to PPPR. In fact, the obligation to dedicate 5% of their “current health expenditure” to PPPR (art. 19.1.c) was deleted from the most recent version of the text. 

Likewise, more than 30 -mostly high-income- countries successfully lobbied for the removal of language on a parallel obligation by countries to allocate a specific percentage of GDP to international cooperation and assistance for PPPR (art. 19.1.d).

Converting debt repayments into pandemic preparedness investments 

Barbados Prime Minister Mia Mottley.

A new, promising financing option that has been included for consideration in the Bureau’s text is the conversion of a portion of countries’ debt repayment installments into PPPR investments. 

A clause referring to this, Option A in Article 19.6 would establish a programme to “convert debt re-payment into pandemic prevention, preparedness, response, and recovery investments in health”. 

Creative refinancing of developing country debt has become a rallying cry of Barbados Prime Minister Mia Mottley in her Bridgetown Initiative. Speaking at a recent conference on Noncommunicable Diseases in Small Island Developing States, Mottley stressed that the approach should be used to make badly needed investments in health as well as in climate mitigation and adaptation. 

According to the World Bank’s International Debt Statistics 2022, low-income countries’ debt rose by 12% in two years (2020-2022) as a result of the pandemic. 

Debt burdens hinder the ability of countries to recover and rebuild capacities and further distract resources away from the health sector. A recent OXFAM report revealed how development finance channeled billions into expensive for-profit hospitals in lower-income countries that deny access to healthcare to patients who cannot afford to pay.

WHO budget boost is one optimistic signal 

WHO
The World Health Organization operates on a shoe-string budget relative to its mandate.

Against this worrisome context, one optimistic note was sounded at the recently concluded 76th World Health Assembly in May that approved the organization’s programme budget for 2024-2025, including a historic 20% increase in member states’ assessed contributions to the agency’s budget. Although these funds will not be specifically for PPPR, they lay the ground for a more predictable and sustainable WHO’s financial model which will hopefully strengthen its role and capacities in, inter alia, the PPPR domain. 

In conclusion, the landscape for PPPR financing remains unclear and, to some extent, worrisome. There is no guarantee that the Pandemic Fund will be able to secure significantly more resources and the current options inside the pandemic instrument lack strong national and international commitments, while inflation and debt continue to rise. 

As such, financing PPPR is faced with a multiplicity of challenges and risks of being underfunded once again. It takes strong political will and innovative thinking to raise sufficient resources and use them in the most efficient manner.

For more coverage of the negotiation over WHO Pandemic Accord and parallel talks on amendments to the International Health Regulations, see the complete  Governing Pandemics Snapshot.

Image Credits: US Mission Geneva.