Pollution in Delhi peaks in late autumn when drifting emissions from crop burning exacerbate the usual urban household, traffic and industrial sources

New science shows how air pollution triggers lung cancer, how children are the most vulnerable in Delhi’s smog, and how even small rises in PM 2.5 increase the risk of heart attacks, strokes and dementia. 

NEW DELHI – You can opt for silver, gold or platinum options for cancer-specific health insurance, according to an advertisement in India – the first group outside the health sector that has realised the country’s cancer burden is rising sharply. 

Five years ago, the number of new cancer patients was 1.15 million annually. Now it’s about 1.4 million. 

Modelling based on India’s National Cancer Registry Programme Report estimates that the incidence of cancer will increase by 12.8% between 2020 and 2025.

A series of recent studies expand our understanding of at least one major cause:  air pollution. For India, home to 39 of the world’s 50 most polluted cities, any understanding of the devastating health impact of lousy air quality is welcome. But is it enough to push the needle?

Fine particles of pollution – PM 2.5 – are known to be linked to not just cancer, particularly of the lungs, but also heart attacks, strokes, dementia and chronically diseased lungs (COPD) apart from much else. 

One of the most critical recent scientific breakthroughs comes from scientists at the Francis Crick Institute in the UK, who show how air pollution can cause lung cancer in people who have never smoked in research recently published in Nature.

“We have improved our understanding of how particulate matter air pollution can trigger cancer to start – by waking up dormant mutant cells present in the lung,” Professor William Hill, one of the lead authors, explained to Health Policy Watch.

In what should be a wake-up call to governments and lawmakers, these scientists have linked PM 2.5 air pollution and potentially fatal health risks beyond any reasonable doubt. 

In email correspondence with Health Policy Watch, Hill and colleague Emilia Lim explained: “We take a three-pronged approach, integrating epidemiology in Western and Asian cohorts, preclinical models and clinical cohorts to understand how air pollution promotes EGFR mutant lung cancer.” 

Simply, EGFR is a protein in cells that helps them grow. A mutation in the gene for EGFR can make it grow too much, which can cause cancer. 

Worryingly, they say their findings may mean that only three years of exposure to a high level of air pollution may be enough to cause lung cancer.

‘Never smokers’

The study looked at three countries, England, South Korea and Taiwan. It looked at ‘never smokers’ because they say that although smoking remains the biggest risk factor for lung cancer, outdoor air pollution causes roughly one in 10 cases of lung cancer in the UK. 

An estimated 6,000 people who have never smoked die of lung cancer every year in the UK, some of which may be due to air pollution exposure. Globally, around 300,000 lung cancer deaths in 2019 were attributed to exposure to PM 2.5. 

THE LUNG CANCER THREAT

  • Most commonly diagnosed cancer globally
  • Leading cause of cancer death
  • Highly fatal, with an overall five-year survival rate of only 18%
  • In India, in 2018, of almost 68,000 cases, mortality was over 90%
  • One in 9 people are likely to develop cancer, including of lungs

India’s official denial

Despite the recent research, the government of India maintains that there is no conclusive link between air pollution and fatal disease. In April 2023, in response to a parliamentary question on air pollution deaths, the Ministry of Environment, Forest and Climate Change stated: “There are several studies conducted by different organizations, using different methodologies, on the impact of air pollution. However, there is no conclusive data available to establish a direct correlation of death/ disease/ life expectancy exclusively with air pollution.”

The Ministry added: “Air pollution is one of the many factors affecting respiratory ailments and associated diseases. Health is impacted by a number of factors which include food habits, occupational habits, socioeconomic status, medical history, immunity, heredity, etc., of the individuals apart from the environment.”

 But even the government-run Indian Council of Medical Research (ICMR) journal has identified air pollution as offering the same attributable risk as tobacco use (43% each) for lung cancer Disability Adjusted Life Years (DALY). One DALY represents the loss of the equivalent of one year of full health either due to premature death or living with a disability due to a disease, for example, chronically diseased lungs or COPD.

The PM 2.5 threat

What the new reports show is that even small increases in pollution can increase the risks. 

One report, based on 14 studies, shows that there is as much as a 9% increase in risk for lung cancer or mortality for an increase in PM 2.5 of as little as 10 micrograms (mcg) per cubic metre. To put that into context, the WHO’s safe limit guideline is 5 mcg and Delhi averaged 105 mcg over three years between 2019-21.

Studies in dementia show similar trends. For every 2 mcg increase in average annual PM 2.5 concentration, the overall risk of dementia rose by 4%. 

According to the  BMJ journal, current estimates suggest that PM2.5 concentrations in major cities vary considerably from below 10 mcg in Toronto to more than 100 mcg in places like Delhi. However, the scientists have flagged uncertainties like the role of socio-economic status and ethnicity. 

Source: Commission for Air Quality Management, Government of India

Heart attacks and strokes

Air pollution also contributes to fatal heart attacks and strokes: A five-year study in Poland looked into almost 88,000 deaths of which over half – 48,000 – were caused by heart attacks and strokes. 

A 10 mcg increase in PM 2.5 exposure was associated with a 3% increased risk of dying from cardiovascular disease on the same day and the increased risks continued for up to two days after the polluted day. 

For strokes, the risk was far higher – an 8% increased risk. Again, to put this in context for India, there are days and weeks in parts of the north where the PM 2.5 levels shoot up from already high levels of 100 mcg to super-high levels of 700 mcg or more.  

Dr Arvind Kumar, one of India’s senior-most chest surgeons at Medanta Hospital in Gurugram, says the Poland study is well conducted and a valuable addition to existing literature. 

“The message for India is that we have even higher levels of pollution here,” said Kumar, a prominent campaigner for clean air.

“People say the economic costs are high of not building new coal power plants, of not cutting emissions. But the cost of not doing so is far higher – premature deaths are far costlier.”

Farmers burning crop stubble north of Delhi is one of the causes of the city’s air pollution.

Babies and children worst affected

 In a response to a question from Dr Amar Patnaik, a Member of Parliament, on the impact of air pollution on children, the environment ministry said in April 2023, that it had not conducted any specific studies on the mechanisms and future projections of air pollution on children’s health, education and social adaptability levels. 

 But other branches of the government have supported studies in pollution-cancer linkages. One study has explicitly stated that babies (aged three- to 21 months) and children (8-14 years of age) are more susceptible to getting fine particles’ deposited in their inner lungs (alveolar region). Alveoli are millions of tiny air sacs in your lungs that absorb oxygen. 

The study was published at the end of 2022 and looked at Delhi’s ‘severe’ smog event over two weeks in November 2017, when the PM 2.5 level crossed 700 mcg, and on average was about 29 times the WHO’s safe limit. 

The smog was largely attributed to the burning of crop residue in states north of Delhi, in addition to climatic factors like low temperatures and wind speed. 

The report looked at the toxic elements deposited in three parts of the body – head, trachea–bronchial, and pulmonary regions. It found the highest mass flux in babies and children. 

What people inhale in Delhi smog:

Doses of Toxic Elements Found to be Many Times Higher in Children Than Adults. 

  • Cr: Chromium
  • Fe: Iron
  • Zn: Zinc
  • Pb: Lead
  • Cu: Copper
  • Mn: Manganese
  • Ni: Nickel

Source: Physico-Chemical Properties and Deposition Potential of PM2.5 during Severe Smog Event in Delhi, India

 Many parents are increasingly careful about what their kids eat – and now many are also concerned about what they breathe. The science is unequivocal but there’s little they can do without the help of lawmakers, governments and courts. 

Government’s inadequate response

It’s not as though the various branches of India’s government aren’t doing anything. Millions of dollars have been allocated as part of various schemes. 

But analysts point out it is insufficient. For example, the union (federal) budget for the National Clean Air Programme has almost doubled in the last two years but it is now only a little over $90 million.

The Commission for Air Quality Management, a statutory body set up to improve air quality in and around the capital of New Delhi, one of the world’s most polluted areas, saw its budget reduced last year by about 13% to $2 million. It remains frozen at that level for the current year, and the provincial government of Delhi has marginally cut the budget for the environment. 

This is in spite of the government having set an ambitious target to cut pollution levels in cities by 40% by 2025-26. 

But even this apparently ambitious target is concerning when it is unpacked. The target only applies to PM 10, the larger particulate matter pollutant, and does not define targets for the finer and far more lethal PM 2.5. In addition, the government’s earlier target was to cut pollution by 20-30% target – but two years sooner.

Given that Delhi and its neighbourhood’s PM 2.5 levels are, on average, some 20 times higher than the WHO’s safe limits, there is a need to explicitly measure and target this. Citizens have a fundamental right to clean air. 

Image Credits: Flickr, Source: Commission for Air Quality Management, Government of India, Neil Palmer.

Mpox
Countries including the US, the UK, Spain, Belgium, and the Netherlands are seeing an increase in Mpox cases in the past few weeks.

Europe reported 22 cases of Mpox in May, prompting the World Health Organization (WHO) to urge people in high risk communities to get vaccinated if possible. 

WHO Europe director Dr Hans Kluge said that the virus is still in circulation, particularly affecting men who have sex with men. He added that people in high risk groups can also protect themselves from getting infected by following preventative measures. 

“There are things you can do – get vaccinated against Mpox if vaccines are available, limit contact with others if you have symptoms, and avoid close physical contact including sexual contact with someone who has Mpox,” Klugo told a WHO Europe briefing on Tuesday. 

In addition to the Mpox update, the Kluge addressed the health emergency situation in Ukraine after the Nova Kakhovka dam was destroyed three weeks ago, long COVID, and extreme heat in Europe. 

“Mpox resurgence not surprising”

Countries including the US, the UK, Spain, Belgium, and the Netherlands are seeing an increase in Mpox cases in the past few weeks. Health officials in Los Angeles and Colorado have issued alerts and launched vaccination campaigns to protect those in high risk groups, while London has extended the vaccination programme for Mpox due to the spike in cases in the city. 

WHO Euro
Dr Catherine Smallwood, Senior health emergency officer, WHO Europe.

Requesting those at high risk to remain vigilant and protected, Dr Catherine Smallwood, WHO Europe’s senior health emergency officer, said extreme vigilance is necessary, especially during the summer when travelling is at its peak. 

“As we enter this period of the Pride celebrations and the travel across the region, we need to remain extremely vigilant at that population level to catch early signs of disease,” she said. 

Adding that the current resurgence is not a surprise, Smallwood explained that the learnings from the outbreak in 2022, with thousands of new cases being reported every day across the continent, were immense. 

“We took a lot of time to look at why that was happening, and look at the factors that determined not only the rise in infections, but also the decline. And we understood that certainly it was linked to increased travel, particularly around June months, where there was a lot of travel to Pride events for the first time during the pandemic.”

The clear policy response to tackle Mpox, she said, is to continue investing in an elimination strategy. “We have the benefit here in Europe of not having an animal reservoir of the virus. It means stopping sustained human to human transmission is quite possible. And that’s what we implore member states, countries in the region to look into doing.”

Extreme weather events killed 16,000 in 2022

Referring to a recent report on the impact of global warming on Europe, Kluge warned that in the coming years, extreme heat in the continent will be a norm rather than an exception. 

The World Meteorological Organization (WMO) and the Copernicus Climate Change Service (C3S*) jointly released their annual State of the Climate in Europe 2022 report on 19 June. 

The report states that Europe is the fastest warming region in the world, “warming twice as much as the global average since the 1980s”. In 2022, high-impact weather and climate events have killed over 16,000 persons, of which around 99.6% were attributed to heat waves. 

WHO Euro
Dr Hans Henri P Kluge, WHO Europe Regional Director.

“Extreme heat in the summer months is becoming the norm, not the exception,” Kluge said, adding that the high temperatures greatly increase the risk of wildfires across the continent.

He pointed out that parts of Spain and Portugal recorded temperatures over 40 degrees Celsius last year between June and August. “So look out for each other during the summer months by checking in on your elderly relatives and neighbours, limiting outdoor activity when it’s very warm, staying hydrated, keeping your home school, and allowing yourself time to rest alongside an increased recent risk of extreme heat.”

In addition, Kluge also mentioned that WHO Europe will be co-hosting the first Indoor Air Quality Conference in Berne, Switzerland, in September, 2023, with the Institute of Global Health. The conference will aim to make a case for monitoring and improving air quality inside buildings, in order to prevent transmission of respiratory infections.

Ukraine’s health risks compounded by dam disaster

Three weeks since Ukraine’s Nova Kakhovka dam gave in, the region remains susceptible to high risk of water borne diseases. Around one million people are without safe, clean water. 

WHO Euro
Dr Gerald Rockenschaub, WHO Europe regional emergency director.

“All kinds of communicable diseases due to the contamination of drinking water are a major public health risk there… We had already prepositioned supplies, testing kits etc which we could mobilize to provide to local authorities,” said Dr Gerald Rockenschaub, regional emergency director at WHO Europe.  

Expressing concern over the risk of leaving people behind, especially in areas like Mariupol and Donbas where the WHO still does not have access to provide healthcare services, Kluge said the agency has been calling for an international humanitarian corridor in the region for over a year to reach people living in these areas. 

“We are working together to beef up surveillance particularly for what we call ‘water borne diseases’ which include diseases like cholera, typhoid, hepatitis etc… We have been calling for an international humanitarian corridor for over a year now [to address] the lack of access to people in areas such as Mariupol and Donbass where still WHO does not have access and are very concerned that people are being left behind.”

Spotlight on Long COVID in transition plan

Although the WHO has declared an end to the pandemic, long COVID continues to remain a huge challenge to people and experts alike. According to the latest data from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, Seattle, nearly 36 million people across western European may have experienced long COVID in the first three years of the pandemic, Kluge said. 

“That’s approximately one in 30 Europeans over the past three years. That’s one in 30 who may still be finding it hard to return to normal life, one in 30 who could be suffering in silence left behind as others move on from COVID-19,” he said. 

“We are listening to the calls from long covid patients and support groups and raising awareness of their plight, but clearly much more needs to be done to understand it.”

The WHO Europe released “The transition from the acute phase of COVID-19: Working towards a paradigm shift for pandemic preparedness and response in the WHO European Region” on 12 June, detailing the regional strategy in dealing with COVID-19 and its after effects in Europe in the coming years. 

While emphasizing on the importance of individuals getting vaccinated according to their risk status, the document also outlines the structural and sustainable changes that need to be made in order to bolster up the resilience of health systems in the region. 

“Some of these measures are very, very clear, but for member states, governments, public health authorities, the real message here is that this is not the time to pack up and move away from COVID-19,” Smallwood said. 

“Right now, we have a huge opportunity to invest in and sustain the gains made…We need to right-size those COVID response operations into day-to-day public health operations, public health services.” 

Image Credits: National Institute of Allergy and Infectious Diseases (NIAID).

climate finance
The summit unlocked billions in new climate finance but failed to address spiralling the debt levels and high borrowing costs handicapping green transition efforts in developing countries.

An international summit in Paris to debate reforms of the global financial system to meet the threat of climate change was billed by UN Secretary-General Antonio Guterres as a chance for “a new Bretton Woods moment”. It was, he said, an opportunity for “governments to come together, re-examine and re-configure the global financial architecture for the 21st century”.

The Bretton Woods institutions, the World Bank and International Monetary Fund (IMF), will celebrate their eightieth birthday this year. Erected to help countries rebuild after the devastation wrought by World War II, the multilateral development banks are central cogs in a system of international finance that is increasingly viewed as unable or unwilling to address the threat of climate change by global leaders.

“Consider this: over three-quarters of today’s countries were not present at the creation of the Bretton Woods institutions … It essentially reflects, even with some changes, the political and economic power dynamics of that time,” Guterres said in his opening remarks to the delegates in Paris. “Nearly 80 years later, the global financial architecture is outdated, dysfunctional and unjust. There will be no serious solution to this crisis without serious reforms.”

In a letter published ahead of the summit, 13 world leaders, including Joe Biden, Rishi Sunak, Olaf Schulz, and Ursula von der Leyen, described the meeting as a “decisive political moment” to “forge a new consensus” on global development finance.

The Summit for a New Global Financing pact, co-hosted by French President Emmanual Macron and Barbados Prime Minister Mia Mottley in Paris last week, did not reinvent the global financial system. But it did notch several long-awaited wins on the climate finance front, leaving many delegates with a sense of optimism often absent from climate finance negotiations.

The World Bank announced it will allow countries struck by natural disasters to pause debt repayments, but only for new loans. This financial breathing room in the wake of floods, droughts and storms meets a key demand set out by Mottley in the Bridgetown Initiative – a set of development finance reforms first presented at the UN climate summit in Egypt last year that provided the impetus for Macron to host the Paris summit.

On the climate finance front, an additional $100 billion will be made available to climate-vulnerable countries through the IMF’s special drawing rights instrument (SDR), a reserve currency. The SDR funding is separate from the historic loss and damage fund agreed upon at COP27 to finance climate adaptation efforts in low- and middle-income countries, which is expected to be finalized at COP28 in Dubai later this year.

In another first, the outcome statement said the World Bank and IMF would unlock an additional $200 billion in “lending capacity” over the next ten years, subsidized by new investment by rich countries.

The conference statement also mentions the prospect of finding “new avenues for international taxation”, reflecting momentum built on the sidelines of the summit for a tax on international shipping to fund climate efforts. This tax will be debated at the International Martime Organization meetings next month.

Discussions on additional international levies to fund climate adaptation – such as taxes on wealth, aviation, and fossil fuels – remained sharply divisive.

Bringing billions to a trillion-dollar fight

Climate activist Greta Thunberg criticized the summit for failing to address fossil fuels. “If your house is on fire, the first thing you do is to stop pouring oil and gas onto the fire,” she said.

Climate finance, however, is an endeavour requiring trillions, not billions, of dollars.

Ahead of the Paris Summit, the International Energy Agency warned that investments in clean energy in developing countries need to triple from $770 billion in 2022 to nearly $3 trillion by the first half of the 2030s to meet climate targets. A joint report by the United Kingdom and Egypt published ahead of last year’s UN climate summit, meanwhile, found developing countries require an estimated $2.4 billion to cut emissions and build resilience to climate change.

Developed countries said at the Paris summit that they will likely pass the $100 billion climate finance pledge for the first time this year. The pledge, first agreed in 2009, was supposed to be met by 2020, and the accuracy of the figures provided by rich countries are disputed.

Earlier this month, Oxfam’s Climate Finance Shadow Report found that while donor countries claimed to provide $83.3 billion in 2020, “the real value of their spending was – at most – $24.5 billion”.

“The actual support they provide is much less than reported numbers suggest, and is coming mostly as debt that has to be repaid,” said Oxfam. “By providing loans rather than grants, these funds are even potentially harming rather than helping local communities, as they add to the debt burdens of already heavily indebted countries — even more so in this time of rising interest rates.”

The Oxfam findings spotlight the elephant in the conference room of the otherwise successful summit: debt.

The tightening financial conditions resulting from the efforts of central banks to tame inflation amid the array of recent shocks to the global economy – from the pandemic’s disruption of global supply chains to soaring energy and food prices following Russia’s invasion of Ukraine – have hit financially vulnerable countries the hardest.

The cost of debt

Low-income countries face their biggest bills for servicing foreign debts in 25 years, with a group of 91 of the world’s poorest countries paying an average of over 16% of government revenues to repay foreign debts in 2023.

The cost of borrowing for counties with C-rated credit scores has skyrocketed by nearly 15% since February 2022, forcing many to refinance already untenable loans with more expensive ones. The resulting debt spiral has forced 62 countries worldwide to spend more on refinancing foreign debt than on health care, and impeded efforts to invest in meeting development targets and adapt to climate change.

The share of emissions contributed by emerging and developing economies is growing. Their successful transition to a green economy is critical to limiting global warming.

The prohibitive borrowing costs offered to low- and middle-income countries are a major barrier to increased private climate investments, which are critical to countries suffering high debt distress, as is the case for 60% of low-income countries.

“Developing countries do not have the space on their balance sheets for the debt required even if they wished to finance [the green transition] themselves,” Advinash Persaud, a key advisor to Barbados’ Prime Minister Mia Mottley argued in a recent paper. “Recall that developing countries start from high debt levels, worsened by the pandemic, the food and fuel crisis following the Russian–Ukraine conflict, and rising loss and damage from climate change impacts.”

Building a solar field, wind farm or flood barrier in Barbados or Pakistan can incur interest rates two to three times higher than a similar project in Belgium or Germany. Persaud notes that to build a comparable solar farm, annual borrowing costs in the EU sit at an average of 4%, compared to 10.6% in developing countries. As a result of the high cost of capital, only 14% of green investment in developing countries is funded by private finance, compared to 81% in developed countries.

Europe and North America have emitted over 70% of global greenhouses gases over the past 270 years, nearly exhausting the world’s carbon budget.

“The cause of this huge spread is not project-specific risk. A solar farm is no riskier in India than Germany,” Martin Wolf, chief economics editor of the Financial Times wrote in his analysis of Persaud’s report. “More than all of the risk premium represents market estimates of macroeconomic (specifically, currency and default) risks.”

In short, off-base macroeconomic considerations are pricing private capital out of investing in the green transition of the countries most in need of funding.

“Private investors are leaving money on the table,” wrote Persaud. “But even more significant are the far greater social gains from saving the planet and boosting green growth in developing countries that are being left alongside.”

One solution proposed by Mottley is for the IMF and World Bank to provide cheap loans for climate projects. But until the spectre of growing debt and borrowing costs in low- and middle-income countries is tackled, other measures risk being limited to band-aid solutions.

“If we don’t change our institutions, the world will remain the same,” Brazilian president Luiz Inácio Lula da Silva said in his closing remarks amid parting shots at the IMF and World Bank. “The rich will go on being rich, and the poor will go on being poor.”

Image Credits: Markus Spiske/ Unsplash.

Gavi was one of the key pillars of the global COVID-19 vaccine platform, COVAX.

Six weeks before its new CEO was due to assume office, global vaccine alliance Gavi has announced that Dr Muhammad Pate is no longer available for the position.

The appointment of Pate, a former Nigerian health minister, was announced in February following a meeting of the Gavi board. He was to replace current CEO Dr Seth Berkley, who has led the alliance for the past 12 years and is stepping down in August.

However, in a short statement on Monday, Gavi said that its board had appointed Chief Operating Officer David Marlow as interim CEO, following communication from Pate that he will not be able to join Gavi. 

“Dr Pate informed the Gavi Board Chair and Vice Chair that he has taken an incredibly difficult decision to accept a request to return and contribute to his home country, Nigeria. Gavi fully respects the decision and wishes Dr Pate the very best for the future,” said Gavi.

Gavi was unable to tell Health Policy Watch what position Pate would be assuming in Nigeria. However, the Harvard-based Pate has been active in promoting primary healthcare and was well-respected as the country’s health minister between 2011 and 2013.

The announcement came as the Gavi board was meeting this week in Geneva, amidst a Reuters report that a $2.6 billion surplus remains to be spent in COVAX, the WHO co-sponsored COVID-19 vaccine platform that Gavi co-operdinates alongside the Coalition for Epidemic Preparedness Innovations (CEPI) and the World Health Organization (WHO).

While around a quarter of the funds is likely to go towards COVID-19 vaccination programmes, big decisions need to be made about whether some of the money should be poured into COVID vaccine distribution, pandemic preparedness, and bolstering vaccine production capacity in Africa.

“These are COVAX [Advanced Market Commitment] funds which have been donated to Gavi so the decision on how to spend them is ultimately for the Gavi Board and donors to make,” a CEPI spokesperson told Health Policy Watch.

The Gavi COVAX AMC is the innovative financing instrument that supported the participation of 92 low- and middle-income economies in the COVAX Facility.

“Our understanding is that no decision has been made to repurpose the COVAX AMC funds as yet,” added the CEPI spokesperson.

Even though the WHO has declared that COVID-19 no longer is a public health emergency of international concern, thereby acknowledging that the worst and most deadly phase of the pandemic is over, it is important to recognize that we will all be living with COVID-19 and its effects for a long time to come so it is prudent to remain prepared to respond quickly should the COVID-19 situation deteriorate.

“One of the key learnings from the COVID-19 pandemic is that predictable and sustainable end-to-end financing and flexible surge financing – including for R&D and manufacturing – that is readily available in the event of a new outbreak with pandemic potential are key to enabling equitable access to vaccines and other medical countermeasures.

“CEPI is advocating for such financing mechanisms to be established through our engagement with the Pandemic Accord process and the G20 and G7, and we would welcome leftover COVAX funds contributing towards them if the Gavi Board and donors chose to pursue that option.”

Gavi is the biggest vaccine procurement group in the world and is currently responsible for vaccinating almost half the world’s children.  It had not responded to queries about the COVAX surplus funds at the time of publication.

UN Special Rapporteur on the right to health, Dr Tlaleng Mofokeng submits her report on digital health to the UN Human Rights Council (HRC)

Real challenges exist in improving human rights within the digital world of health, according to the UN Special Rapporteur on the right to health, Dr Tlaleng Mofokeng, addressing a UN Human Rights Council (HRC) side event on Friday. 

Shortly after submitting her report on “Digital innovation, technologies and the right to health” to the HRC, Mofokeng said: “We will need to ensure that rights holders know their rights. They understand that digital technologies are not just a safe space.”

The COVID-19 pandemic brought to the fore the use of digital systems and artificial intelligence in healthcare. For many, health care was only provided through online appointments with health professionals. 

Meanwhile, the use of the track-and-trace applications used by many governments worldwide raised legal and ethical questions about people’s private and personal human rights. 

Due to the speed at which the pandemic hit, new rules were often introduced speedily, without the necessary guarantees to protect human rights that other regular frameworks would include. 

The Special Rapporteur’s report analysed the impact of digital technologies on privacy and data protection, and these issues were brought up several times during Friday’s event. 

Allan Maleche, KELIN Executive Director; Timothy Wafula Makokha, KELIN; Timothy Fish Hodgson, ICJ (Africa); Dr Tlaleng Mofokeng, UN Special Rapporteur on the Right to Health; Joyce Ouma, Y+ Global; Dr Mandeep Dhaliwal, UNDP.

“Companies such as Facebook have been quietly amassing health data for years,” Mandeep Dhaliwal, director at the HIV and Health Group, Bureau of Policy and Programme Support, United Nations Development Programme, stated. “Now is the time to make sure that we put that on the table so that people understand that they own their data. That, for me, is fundamental to the rights-based approach to this.”

Timothy Fish Hodgson, a legal advisor on economic, social, and cultural rights at the International Commission of Jurists (ICJ), agreed, telling the audience, “The issue here is that big corporations that are operating in the space of technology and on technological platforms have control over what we do and do not share all over the world. They need to be held responsible.

“To regulate these companies is very difficult for any country because they operate on a global scale, and we need to improve that. Secondly, we need to make very clear specific guidelines for these companies.”

Aside from corporate access to private health data, a second central area of concern related to the impact of growing digital use in countries, particularly in the Global South, where medical data could help perpetuate racism, sexism, or other forms of discrimination – such as countries where abortion is illegal or LGBTQ+ rights are infringed upon. 

One example explained how a woman who approaches a doctor about abortion in a state where abortion is criminalised may risk repercussions for herself and her doctor unless safeguards protecting her right to privacy are maintained. 

Documentation and criminalisation

“There is a direct line between documentation and criminalisation of marginalised groups all around the world, which needs to be taken seriously in this process,” Fish Hodgson said. 

The report concludes with 23 recommendations for the HRC, stating, “Vulnerable groups who face multiple forms of discrimination and oppression in some cases lack access to digital technology and face criminalization, stigmatization, and state surveillance.”

“If we are not thinking properly and thinking through, we run the risk of actually further marginalizing people because the issues of privacy data breaches are heightened,” Mofokeng said.

“Some states have used data searches on your phone, which leave a digital footprint. They can then go and ask the police to trace your search history or retrieve your search history. If you find that it is related to abortion or contraception, they may charge you, and you may end up in prison.”

Mofokeng’s report reiterates the need for state actors to ensure their responsibilities are fulfilled, affirming: “States must embed human rights principles of equality, non-discrimination, participation, transparency and accountability in implementation, in order to meet their obligations to respect, protect and fulfil the right to health in relation to digital innovation and technologies.”

Joyce Ouma, Advocacy and Campaigns Officer at the Global Network of Young People living with HIV (Y+ Global), was optimistic about digital healthcare. 

“Digital technologies and digital health are bringing us closer to Universal Health Coverage. They are bringing us closer to self-care, to taking self-care where we, as young people, can take control of our own lives and our own health,” said Ouma.

As the report maintains, digital innovation and technologies can be an asset when used appropriately to realize the right to health. However, it is up to the HRC to implement the Special Rappoteur’s recommendations as best they can and ensure states and companies protect the rights of all. 

The event was organized by the Kenya Legal and Ethical Issues Network on HIV and AIDS (KELIN) in collaboration with the Permanent Mission of Brazil in Geneva, the Permanent Mission of the Federal Republic of Germany in Geneva, Global Network of People Living with HIV (GNP+), Privacy International, STOPAIDS, the Global Health Centre of the Graduate Institute, International Commission of Jurists (Africa), the Global Governance Centre at Geneva Graduate Institute, and the Centre for Interdisciplinary Methodologies at University of Warwick.

 

United Nations member states meet in New York on Monday and Tuesday (26-27 June) to discuss the latest draft of the Political Declaration on Pandemic Prevention, Preparedness, and Response, ahead of the high-level meeting in September.

The 58-page behemoth compilation draft sent to member states this week is a mass of red, indicating country additions and edits to the zero draft.

Notable are new clauses on the impact of COVID-19, and the inclusion of more references to climate change and the sustainable development goals.

But the mass of contradictory red text on a number of contentious issues, including research and development for vaccines and medicines, indicates that the negotiations have some way to go before consensus is achieved.

Extract from the Political Declaration on HLM on pandemics (compilation draft 1)

Multilateral mechanisms

More attention is also directed a developing “adequately funded multilateral response mechanisms” to address future pandemics.

One clause calls for the UN to “establish, as soon as possible, a mechanism for a coordinated and powerful response in the event of future pandemics”.

Norway wants the WHO to host “an accountable multi-stakeholder coordination mechanism for pandemic-related medical countermeasures” that is “ready when pandemic emergencies hit” but can be scaled back to “essential operational coordination capacity in inter-pandemic periods”.

The EU wants an “interim coordination mechanism for medical countermeasures” that builds on the ACT-Accelerator model to feed into the pandemic accord negotiations. This “will be the legal underpinning for a permanent medical countermeasures platform, and will be adjusted to the outcomes” of those negotiations.

In a new section on global governance, Costa Rica, Canada, Australia, New Zealand (CANZ) and the EU all call for independent monitoring of countries’ implementation of pandemic governance obligations.

In another new section headed “scientific research and development”, the EU wants a reference to “promoting” innovative incentives removed, along with the deletion of R&D “financing mechanisms” for vaccines, therapeutics, diagnostics and other health technologies.

Meanwhile, the US encourages the development of “voluntary patent pools” to develop pandemic products. 

Tight process

June and July are crunch times for the political declaration negotiations. The deadline for the revised text after negotiations on 26-27 June is 30 June.

The third reading of the declaration is set for 5-6 July, with the final reading on 24-25 July.

On 26 July, the final text will be placed under “silence procedure”. This refers to the period at the end of negotiations when tentative agreement has been reached, but delegations may need to get final approval from their governments. 

The final resolution will be debated at the high-level meeting on 20 September.

Image Credits: Wikimedia Commons.

French Health Minister François Braun (left) at an event to introduce HIIP.

Three multilateral development banks and the World Health Organization (WHO) announced the launch of an investment platform on Thursday aimed at supporting low and middle-income countries to build their primary healthcare (PHC) services via grants and concessional loans.

PHC is widely recognised as the most effective way to improve health and well-being, and the recent World Health Assembly recognised it as the driver of universal health coverage, one of the United Nations Sustainable Development Goals (SDGs).

The Health Impact Investment Platform (HIIP), launched during the Summit for a New Global Financing Pact in Paris, will make an initial €1.5 billion available to LICs and LMICs in concessional loans and grants to expand the reach and scope of their PHC services.

HIIP’s founding members are the African Development Bank (AfDB), European Investment Bank (EIB), Islamic Development Bank (IsDB) and WHO. The Inter-American Development Bank (IDB) is also considering joining this partnership, which would extend this initiative to Latin America and the Caribbean region.

“Around 90% of essential health services can be delivered through PHC – on the ground, in communities, via health professionals, doctors and nurses, in local clinics. The broad spectrum of services that PHC provides can promote health and prevent disease, avoid and delay the need for more costly secondary and tertiary services, and deliver rehabilitation,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus at the launch in Paris.

Dr Tedros and African Development Bank Group President Dr Akinwumi Adesina

WHO will act as the platform’s policy coordinator, ensuring the alignment of financing decisions with national health priorities and strategies. HIIP’s secretariat will support governments to develop national health and prioritize PHC investment plans. 

“The COVID-19 pandemic showed significant gaps in health systems around the world, and this is particularly true in primary healthcare,” French Health Minister François Braun told the launch.

“Our world urgently needs a more coordinated financing approach, which bridges the gap between health system investment needs and the challenge of domestic funding.”

European Investment Bank president Dr Werner Hoyer said the platform will “ensure countries in need are better able to build resilient primary health care services that can withstand the shocks of future health crises, and safeguard communities and economies for the future.” 

“The platform will facilitate access to crucial international financing for the most vulnerable. It is a concrete deliverable of President Macron’s call to increase international financial solidarity with the Global South,” he added.

European Investment Bank president Dr Werner Hoyer

The new platform builds on experience gained during the pandemic when countries worked with multilateral organizations and development banks to strengthen their health systems. 

For example, WHO, the EIB and the European Commission worked closely with Angola, Ethiopia and Rwanda to strengthen their health systems. These interventions mobilized technical assistance, grants and investments with advantageous terms to build up PHC.

Rwandan Prime Minister Édouard Ngirente said that his country had worked with several partners for over a decade to build its PHC, resulting in improved life expectancy and other health indicators.

“We believe in partnerships. You can’t build your health system alone,” Ngirente stressed.

African Development Bank Group President Dr Akinwumi Adesina said the bank “will work with countries individually to identify gaps in national health systems, design interventions and investment strategies, find funding, implement projects and monitor their impact”.

European Union offices in Brussels.

The European Union’s proposals to strengthen the pharmaceutical ecosystem are not ambitious enough to address health inequities

The recent meeting of the European Union’s (EU) Employment, Social Policy, Health and Consumer Affairs Council on 13 June, was an opportunity for Health Ministers make proposals to  strengthen the pharmaceutical ecosystem in support of competitiveness and equitable access to medicines. 

The discussion resulted from the Commission’s recently released proposal for the revision of pharmaceutical legislation.

The COVID-19 crisis showed that there are many issues to be resolved regarding the accessibility and availability of lifesaving medicines and the need for effective incentives to produce medicines that truly respond to medical needs, particularly during global public health emergencies.

While it is challenging to improve the pharmaceutical legislation and address the concerns of different stakeholders,  we urge the EU to do better. 

The pharmaceutical package should take into account the impact of quality service provision, make clear the most suitable drugs for particular patients, and enhance inter-agency cooperation – not only at EU-national level, but also within the EU (for example, Directorates General for Trade, International Partnerships, Health Emergency Preparedness and Response Authority, European Centre for Disease Prevention and Control, European Health and Digital Executive Agency).

New measures should be created to control and survey the modification of medicines that may extend patent protection inappropriately. Pharmaceutical companies must prove that the modifications they make are bringing additional value to the patients versus simply extending patents to prevent access to cheaper versions of their drugs.

We also recommend more transparency in R&D-related costs to bring benefits for health use and imply innovation, allowing a better understanding of the medicines landscape and tracking needs overall. 

The pay and bonuses of pharmaceutical company CEOs should also be directly linked to the impact on positive public health outcomes and access to medicines, especially in developing countries.

Pandemic products as public good

 Recognizing pandemic-related products as a public good during health emergencies and limiting the profit margins is the logical step to improve responses to crises.  It should become binding, not only in the pharmaceutical package, but also in the future pandemic accord.

In addition, the legislation under negotiation should bring more equity among EU member states by harmonizing marketing approvals and distribution of new products in all national markets. 

Finding the balance between national, private, and patients’ interests is hard, and taking sides may be inevitable. We strongly believe that the EU must, first and foremost, support the population, the community, and the patients – all who bear the brunt of a lack of access to affordable medicines.

The revision of the pharmaceutical legislation is also an opportunity to reflect on where we want our health systems to be in the future and the kind of care we can provide to people. 

Do we want to continue to incentivise the high salaries and profits for big pharmaceutical companies, with $19,2 million pay packages, while many struggle to access basic medicines and other health commodities? 

Can we allow companies to make $5.6 billion in sales while still in the pandemic period, while countries are operating in emergency mode and struggling to keep their respective responses going?

Customers queuing in Toulouse, France, as part of social distancing measures taken to reduce crowding in supermarkets during the COVID-19 pandemic.

Emerging divisions between EU members

Since the publication of the revised pharmaceutical legislation on 26 April,  divisions between member states are emerging. 

One group (Austria, Estonia, Hungary, the Netherlands, Poland, Slovakia) is pushing for more flexibility for the generic market and requiring new products to respond to unmet medical needs allowing profits from incentives. 

The other group (Germany, Italy, Denmark) is pushing for more protection of private industries, including a more predictable regulatory framework, voluntary commitments for companies, and the safeguarding of intellectual property rights.

The revision of the World Trade Organization (WTO) Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) is also closely linked with equal access to medicines and the revision of pharmaceutical legislation. 

The EU is strongly promoting its own vision of voluntary and compulsory licensing, leading to complicated negotiations at the WTO. Several patient advocacy associations have pointed to the need for revisions to TRIPS Agreement since voluntary licenses are often difficult to implement, have limited scope of distribution, exclude many middle-income countries, and sometimes do not even allow the sales of active pharmaceutical ingredients. 

As authorities leave the market unregulated, the profit-seeking nature of private companies often makes it  difficult access to lifesaving medicines, including for treatable conditions such as HIV and hepatitis C.

Patent evergreening, whereby pharmaceutical companies are able to extend patents by making small changes to the formulations that do not constitute a major innovation, and re-patenting them as new and improved drugs, also needs to be addressed by the EU.

 Patent evergreening creates barriers to affordable, generic medicines and keeps them from reaching low- and middle-income countries. It also carries societal costs and often deviates research from truly necessary medical needs, keeping costs higher and undermining access.

There is a danger that even the innovative incentives to produce medicines responding to unmet medical needs, such as exclusivity vouchers, risk the distortion and monopolization of markets of public interest. One year of market exclusivity is estimated to cost  around €500 million by the European Commission.

We echo the sentiments of other like-minded advocates like Dimitri Eynikel of Médecins Sans Frontières who states, “We urge EU member states and the European Parliament to not forsake this opportunity to legally safeguard public health interests and remain vigilant up until this new proposal is adopted as legislation: there must be no watering down of the provisions on transparency and compulsory licenses, and if access to affordable medicines in the EU is a priority, any inclusion of transferable exclusivity vouchers should be seriously challenged.” 

Only by taking responsibility and accepting accountability for people’s health now can the EU better prepare for future health crises and establish an innovative, fair, and inclusive health system that works for all.

AIDS Healthcare Foundation Europe is the European branch of world’s largest non-governmental HIV service provider, AIDS Healthcare Foundation (AHF). AHF Europe is active in nine European countries: Estonia, Georgia, Lithuania, Poland, Ukraine, UK, the Netherlands, Greece and Portugal;  supporting HIV/AIDS prevention, testing and treatment services. AHF Europe advocates for inclusive health care services, equal access to medicine, comprehensive prevention initiatives and multisectoral approach to health at national, regional and international levels.  For further information, contact Indre Karciauskaite, Europe Policy Director, indre.karciauskaite@ahf.org 

Image Credits: Carl Campbell/ Unsplash, Wikimedia Commons: Alteo31300.

The World Health Organization (WHO) has published its first global research agenda to combat antimicrobial resistance (AMR) that outlines 40 research priorities.

An estimated 4.95 million deaths were associated with bacterial AMR in 2019. AMR occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to antimicrobial medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death.

Drug-resistant tuberculosis is particularly pervasive, with an estimated 450 000 new cases of rifampicin- and multidrug-resistant tuberculosis in 2021.

The research agenda was developed after a review of over 3,000 documents published over the past decade and is divided into prevention, diagnosis, treatment and care, as well as cross-cutting issues. 

Prevention includes basic issues such as improved access to clean water and sanitation. Diagnosis identifies a long list of tests needed to fast-track the identification of drug resistance. Treatment and care focus on encouraging stewardship of antibiotics by pharmacists and health workers.

“To help preserve antimicrobials and save lives and livelihoods, this research agenda is a crucial tool for researchers and funders to prioritize research questions, and promptly and efficiently generate evidence that informs policy,” said Dr Hanan Balkhy, WHO Assistant Director-General for AMR. 

“This first research agenda from WHO will provide the world’s AMR researchers and funders with the most important topics to focus on and give the world its best chance to combat AMR,” added Dr Silvia Bertagnolio, Head of the WHO AMR Division.

Heat wave warning from Indian’s Metereological Department

PUNE, India – Close to 200 people have died in Central India as a result of a severe heat wave in the region with temperatures in the range of 40-43 degrees Celsius, according to India’s Meteorological Department. 

While there has been no official confirmation of the death toll, Associated Press has estimated that close to 200 people have died so far in the states of Uttar Pradesh and Bihar alone. The heat wave is affecting seven states.

Heat-related deaths are notoriously hard to pin down and overwhelmed hospitals are often not able to dedicate the time to clinically establish it in the middle of a heat wave, which gives authorities the alibi to easily downplay the numbers.

Heatwave map shows temperatures in Central India, 21 June 2023.

Earlier, heat wave warnings were also issued for the months of April and May. Last year, large parts of South Asia experienced the hottest March in 132 years. This was unusual as April and May are usually the hottest months India. 

The current heatwave is also unusual for June when monsoon showers usually cool down the subcontinent. Human-caused climate change doubled the likelihood of the three-day extreme heat wave over India’s most populous state, Uttar Pradesh, between 14- 16 June, according to a new analysis by researchers at climate communication group Climate Central.

With climate change, such anomalies are expected to rise, according to scientists, but heat-related deaths are easily preventable, they say.

Early warning 

India has adequate early warning system in place, Abhiyant Tiwari, the lead of health and climate resilience at NRDC-India, told Health Policy Watch. His organisation works with governments on improving climate resiliency. 

Heat-related deaths can be prevented by improving coordination between weather and city officials, said Tiwari, something his team helped set up in Ahmedabad city in 2013, making it the first city in South Asia to have a heat action plan in place that remains functional to date. 

India’s weather department already releases alerts ahead of heat waves and other extreme weather events. In Ahmedabad, a local officer was charged with coordinating with the weather department and other health and civic officials to kickstart a response in the event of a heat wave. 

Such plans have worked to drastically reduce deaths by simply warning the communities to stay indoors ahead of time, and asking them to keep hydrated. Hospitals too are warned to brace up for additional patients.

“The best part is that it is a low-hanging fruit. Heat-related deaths are easily averted and there are no major costs involved at least in implementing the early warning systems. I’m not talking about the long-term mitigation measures, but at least these short-term measures during summer which can save lives by proper messaging, proper preparedness, proper response,” Tiwari said.

In the past few days, both day and night time temperatures have been high in Central India leading to a high “heat load,” he said. As average global temperatures continue to rise, night-time heat waves are set to worsen, according to studies.

India’s health minister Dr Mansukh Mandaviya interacts with senior officers of the seven states affected by severe heat waves.

 

India’s central government has advised affected states to ensure uninterrupted electricity supply and improve the collection of data from the ground on heat wave deaths to improve response, as hours’ long power cuts are still common in the country’s rural areas.

Climate change worsening heat waves

Summers in India are always hot and a time when schools shut down for the annual break. But rising global temperatures linked to the changing climate have significantly worsened the heat, according to scientists.   

An analysis released in May this year by a team of international climate scientists at the  World Weather Attribution initiative, based at Imperial College, London, found that climate change had made the April heat wave over parts of India, Bangladesh, Laos and Thailand 30 times more likely.

“We see again and again that climate change dramatically increases the frequency and intensity of heat waves, one of the deadliest weather events that exist. Our most recent WWA study has shown that this has been recognized in India, but the implementation of heat action plans is slow. It needs to be an absolute priority adaptation action everywhere,” said Dr Friederike Otto, a researcher at Imperial College London and co-lead of World Weather Attribution (WWA).

While many Indian cities and states have developed heat wave action plans in recent years, their implementation remains weak. This week the country’s central government asked all states to develop a plan with the summers increasingly turning deadly.

Images from news reports from the ground in Central India showed collapsed old and young people being carried to the hospital by family members, overcrowded hospital beds, and family member performing the last rites of the dead.

High temperatures also mean increased demand for electricity and higher carbon emissions as roughly half of India’s electricity is primarily generated by burning coal, despite the ongoing attempts to scale up access to solar electricity.

The air pollution connection

India’s toxic air is also making matters worse. High temperatures generally also worsen air pollution levels.

“During heat waves, levels of ozone, and in some cases, production of particulate matter pollution can increase,” said Pallavi Pant, who is the head of global health at the Boston-based Health Effects Institute.

Ozone pollution can damage tissues of the respiratory tract and worsen asthma symptoms, while persistent exposure to particulate matter can cause strokes, heart disease, lung disease, lower respiratory diseases (such as pneumonia), and cancer, according to the UN Environment Programme. High levels of fine particles also contribute to other illnesses, like diabetes, can hinder cognitive development in children and also cause mental health problems.

“This problem is also not unique to India. Cities and regions around the world are experiencing a higher intensity of heat waves and deterioration of air quality.  In California, one study found that exposure to high heat and air pollution at the same time led to nearly three times higher risk of death compared to air pollution or heat alone,” Pant said.   

High heat and air pollution are linked to respiratory diseases and together, they can increase the risk of poor health, especially for people living with chronic lung or heart diseases. In some cases, exposure to high heat and pollution can also lead to death. Older people and outdoor workers are particularly vulnerable.

Central India is already home to a majority of the world’s most polluted cities and an analysis from Delhi by the Centre for Science and Environment confirmed that ozone pollution spikes in summers.

Ozone exposure is already high across India, according to the State of the Global Air report. 

India has one of the highest levels of ozone pollution in the world.

While short-term measures like heat wave plans can reduce deaths, scientists are clear that unless global carbon emissions are brought down and fossil fuels are phased out, such extreme weather events are only going to get worse. 

But on that front, there isn’t enough largescale movement yet and the world is currently headed to an average global temperature rise of 2.8 degrees Celsius by the turn of the century, according to the United Nations.