Civil society organisations held a protest outside the European Parliament in Brussels last week, urging the EU to support a fair and equitable PABS Annex.

A snail would have a faster passage than the Pandemic Agreement talks currently underway in Geneva, according to a briefing on Wednesday by civil society observers – some of whom mooted the possibility of World Health Organization (WHO) member states voting on the outstanding annex to break the deadlock.

Only one portion of a single paragraph has been “greened” – fully agreed – since the sixth meeting of the Intergovernmental Working Group (IGWG) started on Monday, according to Third World Network’s KM Gopakumar.

At the opening session, African countries rejected the latest draft text proposed by the IGWG Bureau, and a closed session of the meeting finally agreed to revert to the text of IGWG 5, reported Professor Lauren Paremoer, a member of the People’s Health Movement.

Member states are negotiating the one outstanding piece of the Pandemic Agreement – the Pathogen Access and Benefit Sharing (PABS) system, which will govern how dangerous pathogens should be shared and how any benefits that accrue from this information are also shared. 

Numerous countries, particularly in Africa, want the assurance that if they share pathogen information, they will be able to benefit from any vaccines, therapeutics or diagnostics (VTD) that are developed as a result.

They also want the PABS Annex to include standard contracts with pharmaceutical companies, setting out the terms of access and benefit-sharing.

Several European countries – notably those with powerful pharmaceutical industries – argue that compulsory benefit-sharing will stifle research and development. 

They are also against set contracts, giving companies “a lot of wriggle room” to negotiate terms of benefit-sharing, said Gopakumar.

Some European countries also favour allowing parties to use pathogen information without registration as a PABS user – something that the civil society representatives said would enable them to bypass any obligations to share benefits.

There is also a dispute over when countries will receive a share of the benefits. According to the current draft, the WHO will receive a donation of 10% of vaccines or medicines produced by the pharmaceutical companies that sign up to PABS during a pandemic only, not a public health emergency of international concern (PHEIC).

Voting to break deadlock?

Pedro Villardi, representing Public Services International – a trade union federation with over 30 million members, more than half of whom are health and care workers – warned that a binding benefit-sharing system is essential to protect frontline health workers.

“If we don’t have a benefit-sharing system that truly works with binding commitments, the risk is that, when we face the next pandemic, frontline workers will not receive priority access to [VTDs] and we will have the same tragedy that we had during the COVID-19 pandemic.”

“Some delegations are framing the non-conclusion of these negotiations as a failure of multilateralism,” said Villardi.

But he warned that a weak PABS system would undermine the global solidarity that multilateralism was supposed to build.

“So if we need [to reach an agreement], why don’t we vote? We have a majority of countries pushing for equitable provisions… and we have a few countries that are opposing these measures and defending the position of the pharmaceutical industry and other big corporations.”

Villardi said that voting had happened on other issues, including a recent vote at the WHO Executive Board meeting in February on an Israeli proposal on Palestine.

Although Villardi initially told the briefing that the WHO Essential Medicines List was created through a vote, he later qualified this, saying that member states had voted on a resolution to give the WHO a mandate to set up an expert group on essential medicines.

“In the 1970s, the WHO was highly polarised, both in terms of East and West, and developed ‘versus’ developing nations. Developed countries [termed First World at the time] opposed the concept of essential medicines, and the creation of a WHO Essential Medicines list itself,” Villardi explained.
“Developing nations did not back down because the First World countries wouldn’t agree with the WHO working on an equity-driven agenda. In other words, developing countries and the WHO itself took the agenda forward even without consensus. So consensus cannot be used as a veto power. The WHO did important things, such as the essential medicines list, even without consensus. And since developing countries are the majority, why not vote?”

 

Civil society briefing (clockwise from top left): Rajnia Rodrigues, Lauren Paremoer, Alessandra Tisi, Guilherme Faviero, KM Gopakumar and Pedro Villardi.

Pressure to adopt ‘stripped down’ Annex

Guilherme Faviero, director of the AIDS Healthcare Foundation Global Public Health Institute, warned that member states are under mounting pressure to “accept a stripped-down annex that is devoid of meaningful benefit-sharing provisions and adequate legal guarantees”. 

However, the PABS Annex is supposed to address the “deep structural inequities within the global health system” exposed by the COVID-19 pandemic, said Faviero. 

“Pathogen samples and genomics sequence data moved quickly across borders, but life-saving technology did not and this is precisely what this Annex must solve,” said Faviero.

“Despite months of good faith efforts by delegations to advance text-based negotiations, the European bloc and key developed countries have been resistant to commonsense proposals to operationalise equity and ensure that these commitments, that are set forth in Article 12 of the Pandemic Agreement can be implemented successfully on an equal footing.”

He blamed the “delaying tactics of the European bloc” for the current impasse, adding that “civil society organisations have coalesced around very clear principles that should be reflected in the agreement”.

‘Europe to blame’

Alessandra Tisi, executive secretary of the Geneva Global Health Hub (G2H2), agreed: “The biggest threat to the successful outcome of this negotiation is the position of the European Union and other developed countries. Basically, they just keep rejecting key proposals from developing countries, and we have now arrived at this deadlock.”

Tisi said that some of the positions of the European Union contradicted its own internal regulations and other international agreements.

“The European Union was a very vocal, if not the main proponent, of the creation of a WHO Pandemic Agreement back in 2020. So it’s very hard to understand why, rather than advancing health for all and trying to build a more equitable and resilient healthcare architecture, it actually reinforces the very same status quo which has caused the pandemic in the first place.”

This article was updated with a new quote from Villardi.

WHO Deputy Representative to Sudan, Dr Hala Khudari, addresses the UN press briefing in Geneva following the deadly hospital attack.
WHO Deputy Representative to Sudan, Dr Hala Khudari, addresses the UN press briefing in Geneva following the deadly hospital attack.

Millions of civilians in Sudan have lost their primary access to medical care following a lethal drone attack on the Al Daein Teaching Hospital in East Darfur on the evening of Eid al-Fitr.

The death toll from the 20 March assault has risen to 70, with 146 people now documented as injured, according to the World Health Organization (WHO), which updated casualty figures on Tuesday.

“An attack on a hospital is not only an attack on a building, it’s an attack on people seeking care, on health workers risking their lives to save others, and on the very possibility of survival at times of crisis,” said Dr Hala Khudari, WHO Deputy Representative to Sudan, during a UN press briefing in Geneva.

Among the casualties from this latest strike were seven women, 13 children, one doctor, and two nurses. Eight other health workers sustained injuries.

This hospital attack exacerbates a widening humanitarian catastrophe fuelled by the lethal use of drones, widespread starvation, and severe violations of international law as the country approaches its third year of armed conflict.

The medical centre served as a critical referral hub for more than two million residents across East Darfur and nine surrounding localities. With the facility entirely out of service following the attack, critically ill patients must now undertake a perilous 160-kilometre journey to reach the nearest functioning specialised clinic, WHO pointed out.

UN demands accountability for hospital attack

WHO Director-General Tedros Adhanom Ghebreyesus shared these images of the Al Daein Teaching Hospital in East Darfur, showing the extensive structural destruction.
WHO Director-General Tedros Adhanom Ghebreyesus shared these images of the Al Daein Teaching Hospital in East Darfur, showing the extensive structural destruction.

While the perpetrators of the attack remain unidentified, both the Sudanese Armed Forces (SAF) and the Rapid Support Forces (RSF) extensively deploy relatively cheap, high-tech drones.

The hospital is in territory held by the RSF, but the SAF has denied attacking the hospital in the rebel-held area.

According to the UN Human Rights Office, these lethal weapons had already killed over 500 civilians. primarily in the Kordofan region, between 1 January and 15 March, even before the recent deadly strike in Darfur.

This widening drone warfare is now spiralling across Sudan’s borders into neighbouring Chad, severely endangering refugee populations in border towns like Tine. By repeatedly bombing protected clinics, the warring factions are directly defying international humanitarian law.

“Continued patterns of such attacks striking civilians and destroying civilian infrastructures… may amount to war crimes,” UN Human Rights Office spokesperson Marta Hurtado said on Tuesday during the press briefing in Geneva.

Attacks on Healthcare: Devastating New Norm as Hotspots Like Sudan Are Overlooked

Medical facilities benefit from strict legal protection and only lose this status under exceptional circumstances. Disregarding these global norms severely damages health systems and completely paralyses local medical infrastructure.

The destruction of the Al Daein Teaching Hospital reflects a grim global trend, where hospital attacks are increasingly becoming a hallmark of present-day armed conflict.

Violence decimates healthcare system, compounds suffering

Since the civil war in Sudan erupted in 2023, hundreds of healthcare facilities have been damaged, and health workers killed, kidnapped, or arrested.
Since the civil war in Sudan erupted in 2023, hundreds of healthcare facilities have been damaged, and health workers killed, kidnapped, or arrested.

The violence further strains a health system that has been systematically dismantled over nearly three years of fighting. Since the civil war first erupted in April 2023, the WHO has verified over 200 attacks on medical facilities, leaving only 60% of the nation’s clinics operational.

These relentless assaults have claimed the lives of more than 2,000 individuals, effectively dismantling the nation’s fragile healthcare system.

Medical professionals have paid a devastating price, with independent tracking data from Insecurity Insight documenting that at least 186 health workers have been killed, 112 medical staff arrested and another 15 kidnapped during the ongoing conflict.

The collapse of medical care compounds an unprecedented humanitarian emergency. According to the latest Integrated Food Security Phase Classification (IPC) analysis, 21.2 million Sudanese currently face high levels of acute food insecurity.

While this reflects a slight improvement – declining by 3.4 million people in the previous months due to gradual stabilisation and improved humanitarian access in states like Khartoum, Al Jazirah, and Sennar – the overall crisis remains catastrophic. Restricted access and the destruction of agricultural capacity continue to transform the former regional breadbasket into an epicentre of starvation.

Relief efforts persist amid devastation

Over 14 million people have been forced to flee their homes in Sudan, creating one of the world's largest displacement crises.
Over 14 million people have been forced to flee their homes in Sudan, creating one of the world’s largest displacement crises.

The civil war has triggered a widespread displacement crisis, forcing over 14 million people to flee their homes, with nearly 9.6 million internally displaced and almost 4.5 million seeking shelter in neighbouring countries. Heavy rains and severe flooding have further exacerbated this public health crisis by accelerating major outbreaks of cholera, malaria, and dengue fever across the nation.

The suffering of these vulnerable populations is continually prolonged by external actors who fuel the underlying conflict. While international aid agencies struggle to deliver relief, foreign powers complicate the crisis by continuing to supply weapons to both sides despite a UN arms embargo on Darfur.

Despite the hospital attack and the ongoing violence, international health organisations and local volunteers continue to secure vital victories on the ground. Together with health authorities, UN agencies and humanitarian NGOs are actively working to sustain and revitalise remaining facilities.

Following the recent strike, WHO and partners coordinated alternative healthcare sites and utilised pre-positioned medical supplies sufficient to support approximately 40,000 people over three months. Teams are currently moving additional trauma kits from warehouses in Abéché, Chad, to support rapid-response medical teams.

Image Credits: @DrTedros/WHO, Felix Sassmannshausen/HPW, Insecurity Insight.

A laboratory technician examines a bacterial culture as part of a global effort to resolve the undetected tuberculosis crisis and curb the transmission of tuberculosis.
A laboratory technician examines a bacterial culture. New tools are rolled out to counter the undetected tuberculosis crisis.

Widespread undetected tuberculosis is leaving one in five patients across the European region without crucial care, as health services fail to identify a vast number of infections.

This critical diagnostic gap was highlighted in a joint surveillance report published by the World Health Organization (WHO) European Region and the European Centre for Disease Prevention and Control (ECDC) ahead of this year’s World Tuberculosis Day on 24 March.

“It is a missed chance to treat earlier, prevent suffering and stop further transmission,” said Dr Hans Kluge, WHO Regional Director for Europe.

According to the WHO data, this diagnostic crisis is exacting a particularly heavy toll on vulnerable groups, including children. To combat these massive shortfalls and curb transmission, the WHO is rolling out novel, low-cost diagnostic tools.

Eastern European nations drive regional epidemic

Only 79% of estimated tuberculosis infections in the European region were diagnosed in 2024, leaving one in five patients without crucial care.
Only 79% of estimated tuberculosis infections in the European region were diagnosed in 2024, leaving one in five patients without crucial care.

The WHO European region recorded 161,569 newly diagnosed cases in 2024, representing only 79% of the estimated actual infections. The disease predominantly strikes vulnerable groups, disproportionately affecting seasonal migrants, people living with HIV, and prisoners.

Driving the WHO European Region’s epidemic are Russia, Ukraine, Uzbekistan, Türkiye, and Romania, which all faced estimated burdens of over 10,000 new tuberculosis infections in 2024. Persistent structural limitations in healthcare systems and a lack of integrated, patient-centred care are the primary drivers behind the region’s diagnostic struggles.

When cases remain hidden from health systems, the delay routinely leads to severe illness and ongoing transmission within communities. TB is highly contagious and is transmitted from person to person when an individual with a pulmonary infection expels bacteria into the air by coughing or spitting.

Furthermore, incomplete treatments and undetected tuberculosis act as catalysts for drug-resistant bacterial mutations, which are compounded by the displacement of populations in crises like the ongoing war in Ukraine.

With 23% of new cases showing resistance to standard medications, the European region’s rate exceeds the global average sevenfold.

Protecting children from undetected TB

43% of the 1.2 million global childhood infections went undiagnosed, with children under 15 accounting for 4.2% of all new and relapse cases in the EU/EEA.
43% of the 1.2 million global childhood infections went undiagnosed, with children under 15 accounting for 4.2% of all new and relapse cases in the EU/EEA.

Children bear a particularly heavy burden due to these massive diagnostic gaps, underscoring the continued need for vigilant paediatric surveillance. While the broader WHO European Region encompasses 54 nations across Europe and Central Asia, localized datasets tracking the 30 countries of the European Union and Economic Area (EU/EEA) show that children under 15 accounted for 4.2% of all new and relapse cases in 2024.

Citing WHO estimates, the medical charity Médecins Sans Frontières (MSF) warned that 43% of the 1.2 million children who contracted the disease globally in 2024 were never diagnosed.

“The tools to diagnose and treat children with tuberculosis may not be perfect, but they exist. Despite this, only half of the sick children receive a diagnosis or treatment,” explained Dr Cathy Hewison, head of the MSF international tuberculosis working group, in a press statement.

To combat the undetected tuberculosis crisis in younger demographics, MSF is advocating for the wider implementation of a 2022 clinical algorithm that enables doctors to diagnose children based on clinical symptoms when laboratory tests are unavailable.

Initial studies across five African nations showed this method doubled the number of children successfully diagnosed and treated.

Decentralising care in high-burden regions

A global map of estimated 2024 tuberculosis incidence rates, with the highest burdens concentrated across the Western Pacific and in sub-Saharan Africa.
A global map of estimated 2024 tuberculosis incidence rates, with the highest burdens concentrated across the Western Pacific and in sub-Saharan Africa.

In 2024, an estimated 10.7 million people fell ill with the disease worldwide, resulting in 1.23 million deaths. The overwhelming majority of these new infections remain concentrated in South-East Asia, sub-Saharan Africa, and the Western Pacific.

The latter region alone recorded an estimated 2.9 million cases, and it is home to three of the world’s top five high-burden countries: Indonesia, the Philippines, and China. Furthermore, these same nations are driving the global drug-resistance crisis, as China and the Philippines alone account for over 14% of the world’s multidrug-resistant infections.

Huge Risk of Drug-Resistant Tuberculosis in Wake of Abrupt US Funding Cuts 

“Ending TB in the Western Pacific Region is achievable – if we transform care, decentralise services, and act with ever greater urgency,” emphasised Dr Saia Ma’u Piukala, the WHO Regional Director in a press statement.

To combat these high numbers, health leaders are actively pushing for decentralised care to bring diagnostic tools directly to marginalised communities. Integrated primary care and the rapid rollout of new tests are seen as essential steps to reduce transmission and reach vulnerable populations.

Transformative tools to eliminate tuberculosis

WHO recommends portable, low-cost NPOC-NAAT diagnostic tools as the primary catalyst for achieving the End TB goals.
WHO recommends portable, low-cost NPOC-NAAT diagnostic tools as the primary catalyst for achieving the End TB goals.

To address the global undetected tuberculosis crisis, WHO has now recommended near point-of-care nucleic acid amplification tests (NPOC-NAATs) alongside the use of tongue swabs for patients who cannot produce sputum. These portable, battery-operated devices deliver results in under an hour at a fraction of current costs, representing a major technological breakthrough for peripheral health clinics.

As global health programs face critical funding shortages in 2026, these newly recommended tests offer a vital economic lifeline, delivering rapid results at a fraction of current costs. ”

These new tools could be truly transformative for tuberculosis, by bringing fast, accurate diagnosis closer to people, saving lives, curbing transmission and reducing costs,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, in a press statement marking World Tuberculosis Day 2026.

Despite the grim reality of diagnostic gaps, long-term surveillance data offers genuine reasons for optimism, as general incidence rates across the European region have fallen by 39% since 2015. Furthermore, worldwide tuberculosis deaths have declined by 29% since 2015, while the global treatment success rate for non-resistant infections remains robust at 88%.

By scaling up rapid, oral treatment regimens and investing in the newly recommended point-of-care molecular tests, health experts emphasise that countries still have a vital window to eliminate the epidemic entirely. Doing so is critical to meeting the UN Sustainable Development Goals and the WHO End TB Strategy, which aim for an 80% reduction in TB incidence and a 90% reduction in deaths by 2030.

Image Credits: European Union, Felix Sassmannshausen/HPW, World Health Organization.

A run leader (right) holds up a portable air quality sensor during the UrbanBetter air quality awareness walk in Lagos.

On a Saturday morning in Lagos, several volunteers in white “Run Lagos” t-shirts gathered for an air pollution awareness walk. They split into small groups and filed through the narrow streets, placards in hand. One read, “Air Is Free But Polluted Air Leads To Health And Climate Change Expenses.”

The walk coordinators carried portable air quality sensors, logging particulate matter (PM)2.5 (fine particles) and PM10 (coarse particles), nitrogen dioxide (NO2), humidity and temperature readings in real time. 

By the time the walk ended, the sensors had recorded a PM2.5 reading of 14 µg/m³ – a moderate morning by Lagos standards, where readings typically average between 30 to 50 μg/m³ (over 35.5μg/m³ is considered unhealthy while a reading of 12 and under is considered good).

This walk is part of a wider air quality monitoring effort in Lagos led by UrbanBetter, one of the implementing partners of the World Athletics’ Running for Clean Air initiative, which leverages city marathons and existing running communities to collect air pollution data in urban areas. Lagos is the second city to host the project after Warsaw, Poland.

Last week, the athletics governing body announced the second phase of the initiative. In partnership with the Clean Air Fund, the program is expanding its monitoring network to cover upcoming athletics events in Botswana, Thailand, and Spain.

“’Running for Clean Air’ phase two marks a defining moment: for the first time, a major sports federation is systematically monitoring air quality across multiple continents and competition types,” says World Athletics President Sebastian Coe.

Mapping the marathon route

In 2025, during the first phase in Lagos, sensors were deployed along the route of the annual Lagos City marathon.  

“The data we gathered was not surprising to us,” says Waziri Abubakar, UrbanBetter Hub Liaison Officer.

The heatmap of the PM10 levels on the route of the 2025 Lagos City Marathon shows the highest concentration on the Lagos Mainland (upper region), while Lagos Island (lowest region) showed better air quality because it is within a restricted residential area.

Heatmap of the PM10 levels on the route of the 2025 Lagos City Marathon. Its concentration was highest on the Lagos Mainland (upper region), while Lagos Island (lowest region).

The readings showed consistently elevated pollution at major intersections and across the Lagos Mainland, where activities like fish smoking and poor waste management drive localised spikes. 

The levels of the greenhouse gas, NO2, followed a similar pattern to PM10, with the highest readings in the upper region. However, readings were also high towards the end of the race. NO2 is a traffic-related air pollutant associated with cardiovascular and respiratory mortality following short-term exposure.

UrbanBetter now integrates these findings into the state’s regulatory framework by sharing data with the Lagos State Environmental Protection Agency (LASEPA), the state’s primary environmental regulator.

“A primary outcome of this data was the decision to reroute the 2026 marathon to Lagos Island to leverage its superior air quality,” says Abubakar. 

Heatmap of the NO2 levels on the route of the 2025 Lagos City Marathon. The highest NO2 concentration is observed on the Lagos Mainland (upper region).

While the air quality data supported this shift, the race organisers’ official statement omitted environmental factors, instead framing the change as an evolution and a commitment to their values of “excellence, safety, and world-class delivery.”

Following the end of the first phase, World Athletics gifted the air-monitoring device to LASEPA, with the agency committing to using the data for policy decisions. According to Abubakar, the agency is also looking at setting up low-emission zones in Lagos, with the data helping determine where those zones would be located.

Three monitors for 20 million people

Sub-Saharan Africa averages one ground-level air quality monitor per 16 million people. Lagos now has three reference-grade monitors and several low-cost sensors for its 20 million residents. 

“What was missing and is still missing is that for a population of over 20 million, that is not enough,” says Abubakar.  

One of the three reference monitors in Lagos is a United States Embassy station with an uncertain future amid shifting American environmental policies.

Air pollution continues to be a leading risk factor for early death, surpassed only by high blood pressure, and 90% of the burden falls on low- and middle-income countries, according to the State of Global Air 2025 report.

The report attributes around 200,000 deaths in Nigeria to air pollution annually, making it the country’s third leading risk factor for premature death.

Waziri Abubakar (right), UrbanBetter Hub Liaison Officer, at the 2026 Lagos City Marathon, Nigeria.

Grassroots data, government-sized gaps

In the absence of government monitoring, low-cost sensors have become an important source of data in resource-constrained places like Nigeria. 

The 2023 IQAir World Air Quality Report found that more than half of the world’s air quality data came from grassroots community efforts.

The second phase of the World Athletics’ Running for Clean Air initiative will kick off at the World Athletics Relays in Gaborone, Botswana, a country whose primary air quality legislation dates back to 1971. 

The WHO’s Health and Environment Scorecard gives Botswana a policy score of 24 out of 100, reflecting weak adoption and implementation of national plans to address environmental health threats. 

“The data we generate across Gaborone, Bangkok and Valencia will be transformative for World Athletics, for our member federations, and for the broader sports community,” says Dr Stéphane Bermon, Director of the Health and Science Department at World Athletics.

The closest precedent to the sport’s body approach is India’s System of Air Quality Forecasting and Research (SAFAR). It was built for the 2010 Delhi Commonwealth Games and now a permanent national forecasting network covering five Indian cities. But SAFAR was designed from the start as a government project with sustained public funding.

When the runners go home

Lagos State has expanded its sensor network roughly fivefold between 2024 and 2025 to 114 units, with a target of 200 sensors by late 2026. But that growth has been driven in part by foreign donations and partnerships.

The fiscal picture remains unclear as its air quality commitments are buried within a broad environmental budget with no public breakdown. 

While the overall state budget grew by 32% in 2026, the specific allocation for the environment sector decreased by nearly 18% compared to 2025, falling to 235.96 billion Naira (roughly $174 million).

The initiative has shown it can collect data in places that lack it. What is yet to be seen is if this data creates a lasting system or remains a snapshot from race day.

“It would require political will and sensitisation of key stakeholders on how air quality affects the health of people living in their cities to get the buy-in of the government and citizens,” says Abubakar.

Image Credits: UrbanBetter, Wold Athletics, World Athletics, Ekuma Barnabas.

Punjab environmental officers put out fires set by Pakistani farmers in Province – an annual ritual on both sides of the border that leaves the entire Indo-Gangetic Plain shrouded in smoke during late fall and early winter – contributing to the world’s highest average air pollution levels overall.

Pakistan had the most polluted air in the world overall in 2025, and Delhi was the most polluted capital for the seventh time in the last eight years of reporting by the Swiss-based IQAir.  A town bordering India’s capital is the world’s most polluted place. Despite covering nearly 9,500 cities, pollution data gaps leave millions of people exposed to unhealthy air out of the count.

Air pollution worsened in 2025, with the share of cities globally that met the World Health Organisation’s guideline of safe air quality falling to 14% from 17% the previous year. Progress on air quality progress stalled as wildfire smoke and climate change intensified air pollution concentrations, accordinig to the latest global ranking report by IQAir, released today. 

The report by the Swiss-based air quality technology firm ranked 143 countries and territories, as well as almost 9,500 cities by annual average PM2.5 levels, drawn from a continuous real-time data base, accessible to users worldwide.  

It also flags vast data gaps, especially in Africa and West Asia, which saw setbacks in air quality monitoring coverage last year. One particular blow was the Trump administration’s decision to halt the public reporting on air quality from US Embassy and Consulate locations worlwide in March 2025, depriving many cities of their trusted primary data source. As a result, monitoring efforts in 44 countries were weakened, and six were left without any monitoring, according to the new IQAir report.

South Asia remains world’s most polluted region 

Most polluted countries in the world in 2025 – Pakistan topped the list with India in sixth place. Other hotspots were in Africa and central Asia.

The five most polluted countries in 2025 were Pakistan with an annual average PM2.5 of 67.3 micrograms per cubic metre (µg/m³), Bangladesh with 66.1, Tajikistan at 57.3, Chad at 53.6 and the Democratic Republic of the Congo at 50.2. 

India is sixth, having dropped out of the top five for the first time since the rankings began eight years ago. Its average PM2.5 level dipped by 3% to below 50 μg/m³ as an annual average across the country still nearly 10 times the WHO’s recommended annual average for PM2.5 of 5 μg/m³. 

South Asia remains the world’s most polluted region. Not only are Pakistan, Bangladesh and India ranked 1st, 2nd and 6th as countries, but 83 cities from these three countries as well as Nepal are among the 100 most polluted cities in the world. 

Given how transboundary pollution from neighbouring jurisdictions contributes significantly to the air quality of any country, province or city, the report underscores the need for regional cooperation to tackle this public health crisis. As the report also points out, for children, the impact of air pollution exposure can last a lifetime; the respiratory damage sustained during developmental years is often irreversible.  

Wildfires severely impacted North American regions with historically low air pollution

Wildfires in North America substantially worsened air pollution levels around the continent in 2025 – IQ Air.

“Globally, just 13 countries, regions, and territories saw annual average PM2.5 concentrations meeting the WHO annual PM2.5 guideline of 5 μg/m³, with the majority located in the Latin
America and Caribbean region,” the report notes.

The 2025 data serves as a “critical reminder that air quality is not a static achievement, but a fragile asset,” it adds, noting that in 2025, “wildfire activity severely impacted regions that have historically experienced relatively low PM2.5 levels. As a result, only 14% of global cities met the WHO annual PM2.5 guideline in 2025, compared to 17% in 2024. ”

India: ‘victim of its own success in monitoring’

Air pollution levels in Pakistani and Indian Punjab and across the Indo-Gangetic plain in December 2024 at the peak of crop-fire season; 2025 saw the same pattern.

Sixty-six of the most polluted 100 cities are from India, and just 15 are from Pakistan. But the comparison is not as straightforward as it seems. The more monitoring there is, the more air pollution is revealed. There was data from 259 Indian cities and 18 Pakistani cities. That means one in four Indian cities monitored is in the top 100, while almost all Pakistani cities are included. 

“India is a victim of its success in monitoring,” Frank Hammes, IQAir’s CEO, told Health Policy Watch. It’s one of the better monitored countries. “India is now discovering that air pollution is a very widely distributed problem. This is maybe one of the reasons too that India may be falling in the listing as more and more countries (monitor).” IQAir is a Swiss air quality technology firm. 

In fact, the list of the top 20 most polluted places is almost equally divided between India and Pakistan, nine from India and eight from Pakistan, the remaining three being in China. 

The world’s most polluted place is Loni, India in Uttar Pradesh, which borders north-east Delhi. Altogether, the Indian cities in the most polluted top 20 span about 2,000 km across the northern part of the country, from Punjab to Assam, which suffers sharp seasonal pollution peaks due to weather conditions and crop waste burning along with chronic problems with traffic and power production. 

World’s most polluted capital

Delhi is the world’s most polluted capital and fourth among the most polluted cities in the world, concentrated in Asia and particularly in South Asia.

Delhi, home to over 30 million people, remains the world’s most polluted capital. Its average PM2.5 was 99.6 micrograms, 20 times the WHO’s safe guideline of 5. This is despite an 8% fall in the annual concentration of the pollutant. This is Delhi’s seventh time at the top in eight editions of the IQAir world ranking report. 

The report also notes that India’s capital saw “rare” public protests in November 2025 when the daily average pollution peaked near 460 micrograms of PM2.5. Fueled by seasonal crop burning, vehicular emissions, and stagnant winter air, the poor air quality corresponded to a rise in hospital patients dealing with asthma, cardiac issues, and difficulty breathing. Authorities responded by closing schools, encouraging online work and classes, banning construction, and restricting diesel generators, but did not immediately respond to demands for long-term emission cuts.

Gulf war and air pollution

Tehran covered by toxic smoke at 8 a.m. on 8 March after a hit on its main oil storage facility.

The war launched by the US and Israel against Iran also has affected air pollution, but data is patchy.

In Israel, IQAir’s researchers noticed a “very quick spike” on government sensors there. But in Tehran, where the city was covered by billowing clouds of smoke after a missile attack on the city’s oil storage facilities, “we currently don’t have any data, but we usually have data embassies putting up sensors out there. Currently that data is down. We hope it’ll come up very soon again,” Hammes says.

The impact of war on air pollution was first observed by an IQAir team tracking the Russia-Ukraine war. Many civilians have used the firm’s app to track the attacks by monitoring the plumes and spikes of air pollution, and then report on real time levels. Formal analysis of the data and its implications is managed in-house.    

Air pollution data gaps

Global distribution of air pollution monitoring stations captured by the IQAir database, which monitors pollution in real time around the globe.

Hammes responded to the pushback received from some governments on the global rankings noting that IQAir uses a dataset larger than most governments. 

IQAir bases its 2025 report on data from about 50,000 reference-grade air quality monitors and low-cost sensors. The online air quality platform aggregates, validates and calibrates air quality data from a wide variety of sources, including governments, private citizens and organizations using a range of lower-cost monitoring devices. 

Data that is not deemed reliable is weeded out; thanks to a “data cleaning”. For instance, this year’s report is based on analysis of about 33,000 data points out of the 50,000. 

The more data you have, the more that less sensitive low-cost monitoring systems can be included because they validate each other, Hammes explained, saying: “The more data you have, the less relevant it is if one or two sensors with questionable accuracy are in one place.”

Even so, expanding pollution data coverage remains a challenge. Despite some regional improvements, major data gaps remain, with only a fraction of the global population having access to hyper-local, real-time air quality information. 

Africa’s representation in the data has expanded significantly this year with the inclusion of seven countries and territories not present in last year’s report: Guinea, Eswatini, Tanzania, Benin, Morocco, the Canary Islands, and Réunion. 

But Africa and West Asia remain significantly underrepresented in terms of station density, despite being home to some of the world’s most polluted cities. 

French Polynesia and Nieuvoudtville South Africa –  the least polluted places

The least polluted cities in the world are concentrated in the USA, Finaland and Australia, as well as Barbados, French Polynesia and South Africa.

Globally, just 13 countries and territories saw annual average PM2.5 concentrations meeting the WHO annual PM2.5 guideline of 5 μg/m³, with the majority located in the Latin America and Caribbean region. 

The countries where pollution rose include the United States, due to smoke generated by wildfires across North America, as well as Switzerland and Greece which experienced smog days due to the drift of Saharan dust from Africa.

French Polynesia – in the middle of the Pacific Ocean – was the cleanest territory in 2025 with a PM2.5 concentration of just 1.8 micrograms. The single least polluted  place identified by the available data was Nieuwoudtville, South Africa, a town of 2000 people in the country’s northern Cape Province, with average annual PM2.5 of just 1 microgram/cubic meter of air.

Image Credits: IQ Air , Punjab Enviornment Department, IQAir, Mike Newbry/ Unsplash, X/Mohamed Safa@mhdksafa, IQ Air.

 

Namibia, speaking for the Africa region, at IGWG6.

Tension was palpable at the start of the sixth – and supposedly final – round of talks on an annex to the Pandemic Agreement, with the African region rejecting the latest draft PABS Annex text.

Pakistan also asserted that an agreement on the Pathogen Access and Benefit-sharing (PABS) annex should not be rushed simply to “manufacture a multilateral success”.

The World Health Organization’s (WHO) Intergovernmental Working Group (IGWG) aims to conclude talks on how to share information about dangerous pathogens – and any vaccines, therapeutics and diagnostics that are developed as a result – by Saturday night. 

This would enable the PABS annex to be presented to the World Health Assembly (WHA) in May for ratification.

But while IGWG’s agenda for the final six days of talks runs until 11pm each night, this may not be enough time given the lack of trust and an unwillingness to compromise that was evident at the opening session.

The message from one African country after another was that they would not allow a repeat of the inequity seen during the COVID-19 pandemic, and would not compromise on certain key issues. These include that the countries sharing pathogens need guaranteed benefits, and that the PABS annex needs “legal certainty”, including contracts for commercial users of pathogen information.

Burkina Faso, speaking for the WHO Africa and Egypt, Sudan, Libya and Somalia, noted that registration should be mandatory for all users of the PABS system, benefit-sharing obligations should be clearer, and there should be more capcity-building –including technology transfer – for developing countries.

Return to earlier draft?

IGWG co-chairs, Brazil’s Ambassador Tovar da Silva Nunes and the UK’s Matthew Harpur.

Leading Africa’s position, South Africa and Namibia proposed that the draft text circulated by the IGWG Bureau on 9 March should be disregarded in favour of the on-screen text considered at the end of the fifth IGWG meeting on 14 February.

African regional ambassadors had resolved to stick to this text as they had not had time to consult their capitals on the new draft, Namibia reported.

But an exasperated Ambassador Tovar da Silva Nunes, co-chair of IGWG, accused the African countries of attempting to “curtail the possibility of the Bureau to actually fulfil the mandate that it was given by the membership”.

“We will obviously proceed to use all of the contributions that have been put forward, including the [IGWG 5] text,” said Tovar.

“We cannot say that we will only use that [IGWG 5] text because we have so many enriching contributions, including, for example, the contracts that were put forward, including the terms of reference for labs and database that were produced by the secretariat. 

“So I think there, we are not allowed to impoverish our deliberations by just promising that we will solely see and focus on one text,” he asserted, later asking Namibia if it mistrusted the process.

Eventually, Namibia proposed retaining the Bureau’s version as a “reference” while using the IGWG5 text for actual negotiations.

Meanwhile, Nigeria said that the IGWG5 text is “contested”, reflecting “genuine disagreement between delegations on fundamental questions about sovereignty, about binding obligations, about who bears the cost of pandemic equity and who receives its benefits”. 

“That disagreement is real, and this session must resolve its honesty, rather than paper over it with language that creates an appearance of agreement while delivering on none of its substance.”

Nigeria proposed prioritising key issues during the negotiations: sovereignty safeguards during public health emergencies; legal accountability for laboratories and sequence databases, and technology transfer that “directly enables African pharmaceutical manufacturing”.

Changing the status quo

Indonesia at IGWG 6, speaking for the Group for Equity

Indonesia, speaking on behalf of the regionally diverse Group for Equity, asserted that “multilateralism is not simply about reaching an outcome. It is about producing an outcome that significantly changes the status quo”. 

Indonesia said that some “multilateral outcomes may appear to show progress on paper, but underlying inequities remain insufficiently addressed.

“We are asking for a higher standard. We recognize the pressure of the timeline, but some of the sticky issues are not about time but the willingness to find meaningful solutions. The time pressure alone should not lead us toward weak design, diluted commitments, or lowered expectations,” said Indonesia.

Pakistan, which is also part of the Group for Equity, said: “The PABS Annex must not be turned into a face-saving exercise for a strained multilateral system. A weak or unbalanced outcome will not strengthen the system; it will undermine it.”

Pakistan warned IGWG6 not to adopt a symbolic agreement that won’t ensure equity.

The European Union reminded IGWG that the PABS annex “is intended to create a system for rapidly sharing pandemic pathogen samples and genetic data while significantly improving equitable access to vaccines, treatments and diagnostics for parties and better equipping the WHO and the international community to respond to future pandemics”.

“Without this annex, the Pandemic Agreement will not be open for signature, and ultimately, our collective capacity to effectively prevent, prepare and respond to future pandemics will be significantly reduced and limited,” said the EU representative, on behalf of the 27 EU member states.

He stressed the need for “an open, collaborative and multilateral approach for pandemic prevention, preparedness and response”. and called on all delegations to “muster the necessary result to overcome our remaining differences in the time we have left for this process”.

More time won’t bring agreement

WHO Director-General Dr Tedros Adhanom Ghebreyesus, wearing green to encourage consensus, warned member states that more time will not buy more agreement.

However, WHO Director-General Dr Tedros Adhanom Ghebreyesus warned that “there is a dangerous temptation to think more time might mean a better outcome”.

He cautioned: “We must be realistic: more time will not change fundamental positions, and it will not enable every detail of the PABS system to be set in stone in the treaty. More time would mean trying to continue negotiations in an increasingly unfavourable climate – this will get harder, not easier.”

Instead, Tedros told delegates that “this week, is the best chance – and probably the only chance – to secure an outcome on PABS…. Now is the time to bring solutions, not to reinsert text that will not help to build consensus.”

Tedros also warned: “The conflict in the Middle East and crises elsewhere in our world are reminders that health emergencies can erupt suddenly and affect multiple countries, increasing the risk of disease outbreaks.

“A commitment to upholding international law, multilateral solutions and strong international collaboration to shared threats has never been more needed.”

Civil society questions WHO commitment

Over 100 civil society organisations wrote to Tedros before the meeting, raising the need for the WHO to adher to “access and benefit-sharing (ABS) principles”.

Research indicates that “there are at least 15 WHO coordinated networks engaged in pathogen sample or digital sequence information sharing” without any regard for ABS, they noted, “facilitating biopiracy, including digital biopiracy and increasing biosecurity risks”. 

“Critically, WHO has failed to mandate user registration, identity verification, and data access agreements as baseline requirements,” they added.

Anonymous access “means that genetic resources originating in developing countries can be accessed, commercialised, and exploited with complete impunity, and with WHO’s implicit endorsement”, they noted.

Meanwhile, a range of non-state actors addressed the PABS 6 opening, stressing issues such as the need for equitable access to pandemic countermeasures, enforceable benefit-sharing terms,  transparency and legally binding obligations. 

Pharma calls for ‘precise parameters’

The International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) appealed for a “workable PABS”.

“Companies need clear, science-based definitions of scope that should focus on pandemic emergencies. If inclusion depends on broad or evolving interpretations rather than precise parameters, it risks capturing routine research operations and creating uncertainty that could negatively impact R&D efforts.

“Experience shows that voluntary, collaborative approaches deliver the strongest outcomes. PABS should support open scientific exchange, rather than condition access to pathogens on contractual arrangements that may limit collaboration.

“In this regard, treating pathogens as sovereign or monetizable resources, or linking access to financial obligations, risks creating barriers to rapid sharing that are inconsistent with global health security objectives,” the IFPMA warned.

 

Ukraine war
A severely ill COVID-19 patient in Ukraine. The Pandemic Agreement’s Pathogen Access and Benefit-sharing (PABS) system seeks to address the unequal access to vaccines, medicines and tests that became evident during the pandemic.

Final talks on the Pathogen Access and Benefit-Sharing (PABS) system, the last outstanding piece of the Pandemic Agreement, are being held in Geneva this week.

The Pandemic Agreement, being negotiated in Geneva, emerged to address the unacceptable inequities that defined the COVID-19 global health disaster. During this pandemic, delayed and inequitable access to vaccines may have cost more than one million lives, the majority of which could have been averted through earlier vaccine sharing with lower-income countries.

While initially guided by noble objectives, to ensure universal and equitable access to build a more resilient and equitable global health architecture, the EU’s negotiating position has hardly reflected these commitments to date. At the center of the remaining political disputes within the Pandemic Agreement negotiations is the Pathogen Access and Benefit-Sharing (PABS) system.

The PABS System is the mechanism through which the Agreement seeks to give concrete meaning to equity. It aims to establish clear obligations on manufacturers and other commercial entities that access and utilize pathogen samples or their genetic sequence for the development of life-saving technology like vaccines, therapeutics, and diagnostics.

It requires them to commit a portion of such commercialized products as shared benefits through the World Health Organization (WHO), so that the countries whose biological materials made those products possible are not last in line to receive them in the event of a serious health emergency.

The PABS system is predicted to house the largest collection of pathogens with pandemic potential and their sequences. By replacing the burden of negotiating access to these resources on a country-by-country basis with a single multilateral framework, the system is designed to attract researchers and industry into a global pooling arrangement in exchange for accepting equitable benefit-sharing obligations.

Developing countries, which will supply much of the pathogen materials and genomic sequence data for the system, have been calling for the PABS System to include adequate assurances that obligations to share these valuable resources will be matched by fair, equitable, and enforceable benefit-sharing. 

EU can choose better

The European Union is being accused of blocking attempts to operationalise equity.

Despite months of good-faith efforts by many delegations to advance text-based negotiations, the European bloc has been resistant to common-sense proposals to operationalize equity and ensure that the commitments set forth in Article 12 of the Pandemic Agreement can be implemented on an equal footing. 

With time now running short, pressure has been mounting on developing countries to accept a stripped-down annex that is devoid of adequate benefit-sharing provisions and legal guarantees. As was the case in May 2025, the WHO – namely the Director General’s (DG) Office and Secretariat – has reportedly been applying pressure on developing countries to accept a deal while bearing the full burden of making multilateralism succeed at any cost, even at the expense of their own negotiating priorities.

Should a deal on the PABS annex not be reached, it should be clear to all that it is because the European bloc has chosen to act in opposition to basic health equity provisions rather than align its negotiating stance with its (now empty) rhetoric that “no one is safe until everyone is safe.” The bloc’s credibility, however, is not yet beyond recovery.

Mandatory benefit-sharing 

Access to COVID-19 vaccines was initially confined to wealthy nations. The Pandemic Agreement is supposed to address the imbalance in access to medicines during public health emergencies.

The PABS System rests on two interconnected pillars: the rapid and timely sharing of PABS materials and sequence information, and, on an equal footing, the rapid, timely, fair and equitable sharing of benefits arising from the sharing or utilization of the PABS materials and sequence information for public health purposes, especially vaccines, therapeutics and diagnostics (VTDs). 

While minimal percentages have been guaranteed in the text of the agreement with respect to pandemic emergencies, the 9 March Bureau’s text appears to abandon the critical minimum percentage of VTD supplies to prevent or respond to Public Health Emergencies of International Concern (PHEICS). The text instead relies on undefined “options”, which may be left to be determined by WHO and pharmaceutical manufacturers through bilateral negotiations. 

Deferring critical benefit-sharing negotiations to a bilateral process would represent a significant tactical loss for developing countries, as it is predicted to increase the leverage of commercial entities while stripping provider countries of bargaining power and legal certainty. 

Earlier draft proposals by developing countries tabled their preference for more concrete and standardized benefit-sharing obligations during PHEICs – proposals that the Bureau’s clean text has since removed.

Departure from existing practice

This approach also marks a significant departure from existing practice in access and benefit sharing. Under the Pandemic Influenza Preparedness Framework, for example, standardized material transfer agreements with defined benefit-sharing options have been applied to manufacturers accessing PIP biological materials for fifteen years. 

Moreover, the PABS Annex creates obligations on states to share pathogen materials and sequence information, but manufacturers, commercial users, laboratories, and databases are not signatories to the treaty – and the Annex cannot bind them. The only mechanism to do so is through contracts. 

During the Annex negotiations, many countries have stressed the need to agree on clear, binding terms for both participating manufacturers and non-commercial users. But now that time is running out, countries are being rushed into glossing over important contract term discussions that should be settled before the Agreement is adopted.

Even if full standard contracts cannot be finalized before May 2026, the Annex should, at a minimum, contain all essential elements that must govern access, utilization, benefit-sharing, intellectual property, onward transfer, dispute resolution, and consequences for non-compliance in these contracts.

If obligations to share pathogen materials and sequence information are mandatory and enforceable on states, while benefit-sharing commitments for industry remain ill-defined or optional, and subject to bilateral negotiation, the PABS system no longer operates on the “equal footing” required by Article 12.

Such a system cannot provide legal certainty that critical, life-saving access to vaccines, diagnostics, or therapeutics will reach vulnerable populations in developing countries when they are needed most. This risks condemning developing countries, once again, to the back of the queue – the very inequity the Pandemic Agreement was negotiated to correct.

European nations still have the opportunity to demonstrate that their commitment to equity is more than rhetoric by supporting a transparent, accountable, and enforceable system that ensures that benefit-sharing obligations are as enforceable as the duty to share pathogen samples and genetic sequence information.

How to share the benefits that come from sharing pathogen information is a key stumbling block at the PABS negotiations.

No user registration, no accountability

Developing countries have proposed that WHO-recognized sequence databases be required to implement user registration, identity verification, and data-access agreements, and that they enter into binding contractual relationships with WHO, rather than merely agreeing to non-binding terms and conditions. Without the identification and registration of users accessing PABS Sequence Information, there is no practical mechanism to promote transparency and accountability. 

In the negotiations, many European countries have resisted these conditions, arguing they would impede open science or render the system inoperable.

This reasoning, however, is not supported by evidence. As Campos and Sylvester explain in a recent analysis, many widely used genomic repositories already require user registration, identity verification, and data-access agreements – all the while serving tens of thousands of researchers across nearly every country, all of whom routinely accept terms of use while still conducting time-sensitive, large-scale analyses. The resistance, they note, isn’t technical but political.

Justifications behind such resistance become even more difficult to swallow when one considers the EU’s own internal policies. Within the European Health Data Space, adopted in February of 2025 last year, researchers accessing health data, including pathogen genomic data, must register, specify their purpose, operate under supervision, and remain traceable. The system is sophisticated, enforceable, and deliberately so.

The EU position also favors private entities and externally governed databases over WHO Member States collectively as custodians of critical pathogen data infrastructure, and this carries significant implications for the sovereign control that states exercise over the system.

When pathogen sequence data flows into databases whose governance, access policies, and terms of use are set by host institutions and private funders rather than by member states collectively, the countries that provide the raw material lose meaningful control over their genetic resources and oversight over how their contributions are stored, accessed, or used.

At this late stage of negotiations, European countries would be wise not to lose sight of the forest for the trees. If source countries come to see the PABS system as one in which their resources are extracted while governance and benefits remain elsewhere, the likely result is not greater openness but restricted sharing, bilateral workarounds, and a fragmented framework that fails all.

If any single element can collapse the PABS system, it is anonymous access to PABS sequence information because it facilitates and legitimizes biopiracy through digital means. The EU would therefore do well to withdraw its resistance to user registration, a meaningful step toward restoring goodwill.

Call for equity in the European Bloc

We do not write this as adversaries of European governments. As civil society members, we believe it is important to make EU governments fully conscious of the choices they are making and the implications of the demands they put forward.

We take the EU’s stated values seriously – its commitment to multilateralism, to the Convention on Biological Diversity, to the Pandemic Agreement, and to health emergency preparedness. It is precisely because we take those commitments at face value that we urge the EU to align its negotiating positions with the values that it claims to uphold.

The 23-28 March session is the last scheduled round before the PABS Annex goes to the World Health Assembly. The decisions made at IGWG6 will determine whether the Pandemic Agreement delivers on its promise of equity or institutionalizes the very asymmetries it was designed to correct

The EU has the standing and the influence to shift the trajectory of these negotiations—by withdrawing its resistance to standard benefit-sharing provisions, enforceable contracts, and user registration. We urge it to do so.

Guilherme Faviero is a Director at the AHF Global Public Health Institute and represents AHF Brasil, a relevant civil society stakeholder in the WHO Pandemic Agreement and PABS Annex negotiations.

Nithin Ramakrishnan is a Senior Researcher at Third World Network (TWN), and represents TWN—a relevant civil society stakeholder in the WHO Pandemic Agreement and PABS Annex negotiations. The views are personal. 

 

 

 

Image Credits: Alexandre Lalleman/ Upslash, Mstyslav Chernov/ Wikimedia Commons, Carl Campbell/ Unsplash, International Monetary Fund/Ernesto Benavides, Marco Verch.

The Caribbean is still recovering from the damage caused by Hurricane MelissaExtreme weather events affected almost every region in the world in 2025.

Hurricane Melissa’s $60 billion path of destruction through the Caribbean. Cyclones in Mozambique. Typhoons in the Philippines. Floods in Nigeria, the United States, India and Viet Nam. Wildfires in California and Korea. Heatwaves from Europe to East Asia.

These are some of the extreme weather events captured by the World Meteorological Organization’s (WMO) State of Global Climate Report for 2025 – a grim read as the globe reels from the cumulative effect of 11 of the hottest years ever recorded.

“Extreme events, including intense heat, heavy rainfall and tropical cyclones, created challenges for virtually every continent, and are a key way that societies are experiencing a changing climate,” Ko Barrett, WMO Deputy Secretary-General, said at the launch of the report.

“Planet Earth is being pushed beyond its limits. Every key climate indicator is flashing red,” said United Nations Secretary-General Antonio Guterres in a recorded message at the launch.

“The Earth’s energy imbalance, the gap between heat absorbed and heat released, is the highest on record. In other words, our planet is trapping heat faster than it can shed it,” Guterres warned.

Some of the key extreme weather events for 2025.

“Greenhouse gas concentrations are higher than at any point in hundreds of thousands of years. Global temperatures continue to rise, and humanity has just endured the 11 hottest years on record. 

“Oceans are absorbing epic levels of heat, fuelling ever stronger storms. Glaciers and sea ice are vanishing and sea levels are relentlessly rising.”

Guterres added that these findings are not confined to charts and graphs: “They are written into the daily lives of people in families struggling as droughts and storms drive up food prices. 

“In workers pushed to the brink by extreme heat, in farmers watching crops wither; in communities and homes swept away by floods.”

Ko Barret, WMO Deputy Secretary-General.

Greenhouse gases reach reord levels

“Concentrations of three key greenhouse gases, carbon dioxide, methane and nitrous oxide, reached record levels in 2024, which is the last year for which we have consolidated global numbers,” said WMO scientist John Kennedy.

Carbon dioxide levels were 152% higher than the pre-industrial base, methane was 266% higher and nitrous oxide was 125% higher.

The year 2024 also showed the single biggest one-year increase on record, with data from individual sites around the world indicating that levels of these greenhouse gases continued to increase in 2025.

Greenhouse gas increases in 2024.

Energy imbalance

Global energy imbalance 2025

The WMO has introduced a new measure: the Earth’s energy imbalance, which “measures the rate at which energy enters and leaves the Earth’s system”. 

Kennedy explained that, in a stable climate, the energy coming in from the sun is balanced by the energy going out from the climate system. 

“However, in the current climate, there is an imbalance. We have the same amounts of incoming energy, but there’s less outgoing energy due to the increased concentrations of greenhouse gases.

This positive imbalance, with energy accumulating in the Earth’s system, means the Earth is warming. Although it has been warming since 1960, the rate at which it is warming is speeding up – initially from around 0.13 watts to 0.3 watts in 2025.

“That energy is not accumulating evenly,” said Kennedy, with the oceans absorbing 91% of that accumulating energy, 3% going into melting and warming ice, 5% being absorbed by the land, and 1% warming the atmosphere. 

Hottest oceans on record

“Over three billion people depend on marine and coastal resources for their livelihoods. They’re living off the ocean. Nearly 11% of the global population lives on low-lying coasts directly exposed to coastal hazards, so they’re very vulnerable to things like sea level rise,” said Kennedy.

The oceans are warming, with 2025 recording the highest ocean heat on record. And the rate of ocean warming is speeding up, with the rate between 2005 and 2025 more than twice that observed between 1960 and 2005

As ocean water warms, it expands. This, melting ice and the transfer of water from the oceans to land, is causing the sea level rise to rise. Like with hear, the rate of sea level rise is faster from 2012 to present than fbetween 1993 and 2012.

The ocean continues to absorb carbon dioxide, playing a fundamental role in the climate system. 

It is estimated that the ocean has absorbed around 29% of the carbon dioxide emitted by human activities in the past decade, but this has reduced the ocean’s pH, making it more acidic and harming coral reefs and other sensitive areas that provide food and shelter for marine life. 

Glaciers melting faster

Around 3% of the energy trapped in the Earth system is melting ice, both ice sheets and glaciers. WMO has tracked glacier melt since 1970, and it has continuous records for a set of reference glaciers across 19 global mountain regions.

Like with other climate trends, the ice has started melting faster over the past few years.

“In 2025, our glaciers continued to retreat, and ice continued to melt. The warming ocean and melting land-based ice are driving the long-term rise in global mean sea level,” said Kennedy.

Global mean temperature

Despite 2025 being in a La Niña weather cycle, where cooler air is expected in contrast to the hotter El Niño cycle of  2024, it was “the second or third hottest year on record, depending on the data set used”, said Barrett.

“In 2025, global mean temperature was about 1.43º C above the 1850-1900 [pre-industrial] baseline. Between 2015 and 2025, we experienced the hottest 11 years on record,” she said, adding that this had been corroborated by nine different data sets.

“The past 11 years, in all nine of these datasets, are the warmest years on record, and the past three years are the three warmest.”

Greenland, northern Canada, western Europe, Fennoscandia, the Mediterranean and many parts of Asia experienced significant warm anomalies in comparison to other regions, according to the report.

Referring to the  last 11 years, the hottest on record, Guterres said that “when history repeats itself 11 times, it is no longer a coincidence, it’s a call to act.”

“Climate stress is also exposing another truth. Our addiction to fossil fuels is destabilising both the climate and global security. Now more than ever, we must accelerate the just transition to renewable energy,” said Guterres.

Image Credits: WMO.

From left to right, panelists Sylvain Perron (MSF), Stéphanie Rinaldi (University of Manchester), Karl Blanchet (Geneva Centre of Humanitarian Studies), and Supriya Rao (ICRC) lead a discussion on attacks on healthcare.
From left to right, panellists Sylvain Perron (MSF), Stéphanie Rinaldi (University of Manchester), Karl Blanchet (Geneva Centre of Humanitarian Studies), and Supriya Rao (ICRC) discussed attacks on healthcare.

The year 2025 saw significant declines in the number of attacks on healthcare worldwide asa compared to 2024, but events still remain at record high levels in comparison to previous years, said a leading civil society group that tracks incidents last week in Geneva.

This grim reality took centre stage at a seminar organized by the Geneva Health Forum at a session of the UN-sponsored Humanitarian Networks and Partnerships Week (HNPW). The event on Strengthening the Application of International Humanitarian Law brought together civil society and academic experts from around the world.

According to tracking data of attacks on health facilities published by the leading civil society coalition Insecurity Insight, and highlighted at the event, there were 2,723 recorded conflict-related attacks on medical facilities, transport, and personnel in 2025.

Conflict-related attacks on healthcare in 2025. Tracking includes militia and criminal attacks, but violent government or regime attacks are categorized separately.

While this marks a welcome decrease from the 3,921 incidents documented by the Health Map in 2024, it still represents a trend of escalation, in comparison to the 2,238 recorded cases in 2022 and 1,600 in 2021, said Manchester University researcher Stéphanie Rinaldi who presented the data.

The tracking, which also includes criminal, cartel, and militia attacks, highlights Ukraine, DR Congo, Myanmar, Sudan, and Syria as the leading hotspots last year, with high concentrations of attacks on healthcare in Mexico and Colombia, Yemen, Gaza and parts of central and West Africa as well. Government or regime attacks on health workers and facilities, such as those seen in Iran during the January “Dey” civil uprising, are also tracked in the “political” category.

The tracking data is more detailed than the World Health Organization’s dashboard on healthcare attacks, also drawing from a wider range of civil society sources. Data is collected in collaboration with Physicians for Human Rights, the International Council of Nurses, Johns Hopkins University and other academic institutions, and supported by the Swiss Confederation, UK AID, and German Humanitarian Assistance.

International norms not strong enough

ICRC legal adviser Supriya Rao argues for the domestic prosecution of those who target medical facilities during a 2026 humanitarian debate in Geneva.
ICRC legal adviser Supriya Rao: what’s needed, and too rare, is national prosecution of military crimes.

The discussion brought together key voices from the frontlines, including Médecins Sans Frontières (MSF) Sudan programme manager Sylvain Perron, and International Committee of the Red Cross (ICRC) legal adviser Supriya Rao. Driven by the mounting toll of attacks on healthcare on medical professionals, the panellists moved beyond mere condemnation to explore concrete mechanisms to fight impunity.

As belligerents increasingly violate the laws of war and armed conflict, the disregard for international norms inflicts severe, long-term impacts on health systems that are already destabilised by crises, participants noted.

“Healthcare workers are worried about international norms not being strong enough to protect them,” warned Professor Karl Blanchet, director of the Geneva Centre of Humanitarian Studies and moderator of the panel.

More national prosecution is needed

While international humanitarian law explicitly shields civilian medical staff operating inside health facilities, ICRC’s Rao stressed that active prosecutions of war crimes at the national level are necessary to successfully hold perpetrators to account. But this is precisely the kind of action that is rare or non-existent in many of the world’s worst hotspots today.

Even when legal mechanisms are in place, “accountability can often become an alibi,” Rao charged, noting that formal commissions and investigations frequently lead nowhere. Rather than relying solely on post-incident prosecutions, she argued that the primary focus must be on generating the necessary political will to prevent these violations from happening in the first place.

At the same time, hospital assaults have increasingly become a hallmark of modern warfare, with facilities raided, bombed, or occupied in conflict zones worldwide.

Recent media reports have highlighted the severe damage to healthcare in Ukraine and Gaza, where more than half of the enclave’s hospitals were put out of service during the two-year Israel-Hamas war. Less in the spotlight, but equally devastating, have been the attacks on health care in DRC, Sudan and Myanmar – where an earthquake last year compounded the civil war’s impacts.

Situation in Sudan is especially dire

Sudanese refugees receive critical medical care at an MSF-run health centre in the Adré refugee camp, Chad (2024).
Sudanese refugees receive critical medical care at an MSF-run health centre in the Adré refugee camp, Chad (2024).

The current situation in Sudan is especially dire while remaining overlooked, panellists stressed. The civil war between the Sudanese Armed Forces and the Rapid Support Forces (RSF) has triggered a widespread displacement crisis, forcing roughly 12 million people to flee their homes.

The widespread displacement, meanwhile, has contributed to the collapse of the country’s medical infrastructure and fuelled disease outbreaks. “We stopped being doctors and became survivors,” said MSF’s Perron, sharing a stark testimony from a Sudanese health worker.

According to the Health Map data published by Insecurity Insight, a total of 141 reported incidents of conflict violence affected health care in Sudan during 2025, with at least 53 health workers killed and nine kidnapped.

Data from Insecurity Insight’s Health Map shows that Sudan faced 141 reported incidents of conflict violence affecting healthcare in 2025.
Data from Insecurity Insight’s Health Map shows that Sudan faced 141 reported incidents of conflict violence affecting healthcare in 2025.

This dynamic reached a brutal peak in an October 2025 attack on the Saudi Maternity Hospital in El Fasher, where RSF gunmen reportedly stormed the facility and killed more than 460 patients and their companions, while abducting six health workers. Most recently, a 24-year-old Sudanese Red Crescent volunteer was killed while on duty in the maternity ward of Al-Dilling hospital when the health facility was attacked in March.

“International humanitarian law is dead there; we have seen it in the past three years”, concluded MSF’s Perron, explaining that medical teams are now forced to rely on dangerous pragmatism rather than international legal frameworks just to continue operating.

First Vaccines in Three Years Reach Besieged Sudanese State

Additionally, aid workers reported systematic blockades in the capital, Khartoum, and indiscriminate, ethnically targeted violence in regions like West Darfur. Maintaining neutrality is exceedingly difficult due to increased efforts of instrumentalising aid and health organisations by conflict parties, Perron pointed out.

The violent incidents not only force essential health workers to flee. Attacks on healthcare also damage or destroy facilities, transports and supply routes, which can completely paralyse local health systems, exacerbating humanitarian crises.

International law mandates strict protection of healthcare

The Nasser Medical Complex in Gaza in the aftermath of military operations.
The Nasser Medical Complex in Gaza in the aftermath of military operations during the Israel–Gaza war. In February 2026 MSF withdrew its staff from most parts of the hospital, stating that armed men operating from the facility jeopardized health care activities.

As wars and civil wars increasingly involve densely populated urban areas and civilian infrastructure, health care facilities also are increasingly at the nexus of the maelstrom.

The Israel Defense Forces, for instance, justified its attacks in Gaza with documentation that armed Hamas forces were operating from inside and around hospitals, as well as from tunnel networks underneath facilities, turning them into military targets.

Human rights lawyers, meanwhile, argued that under international humanitarian law, medical facilities benefit from specific protection and only lose this status under strict, exceptional circumstances. Even if a facility is misused for military purposes, attacking forces are obligated to issue a timely warning and allow sufficient time for the act to cease before any operation can proceed.

“Any loss of protection is an absolute exception,” stated ICRC expert Rao.

Legal scholars argue that rules of “proportionality”, properly applied, would still forbid assault in cases where the risks of harm to civilians and particularly patients, outweighed the military threat. Also, legal experts assert that international humanitarian law requires parties to conflict to facilitate safe and unimpeded passage for medical personnel and supplies.

Beyond direct violence, the tightening of supply routes frequently deprives hospitals of the medicines, equipment, and basic services they need to function. The denial of these vital resources compromises medical services, weakens entire health systems, and also places civilian lives at risk.

Divergence in leading data sets tracking attacks 

A significant gap of documented incidents exists between official WHO reports and independent monitoring due to differing methodologies.
A significant gap of documented incidents exists between official WHO reports and independent monitoring due to differing methodologies.

Gathering accurate evidence of attacks on healthcare is highly complex because data collection is frequently hindered by active insecurity, communication blockages, and the severe risks local health professionals face if they publicly report incidents.

The challenges are also highlighted by the stark discrepancies in data collected by different international monitoring systems. Most notably, the World Health Organization’s Surveillance System for Attacks on Health Care (WHO SSA) and the independent database of Insecurity Insight, highlight considerable inconsistencies in their datasets, said Blanchet, citing the results of a recent comparative exercise.

This discrepancy is most glaring in the 2024 figures. While the WHO SSA recorded 1,645 attacks across 16 countries, Insecurity Insight and the Safeguarding Health in Conflict Coalition (SHCC) documented nearly 4,000 such attacks across 36 countries.

Researcher Stéphanie Rinaldi of the University of Manchester presented data on the escalating attacks on healthcare in conflict zones.
Stéphanie Rinaldi of the University of Manchester presented data on the escalating attacks on healthcare in conflict zones.

The gap stems from differing methodologies. The WHO SSA relies heavily on reports from country offices and local partners, which can capture vital confidential information but may be hindered by political barriers, communications blackouts, or a fear of reprisals. In contrast, Insecurity Insight casts a wider net using an event-based approach, utilizing AI technology to scrape open-source media alongside partner contributions.

A previous detailed assessment comparing the two systems with data from 2017 found only a 12.9% overlap in reported incidents. The divergence suggests that considerable under-reporting remains, Blanchet said.

Rather than viewing these datasets as competing, experts stress the need for collaboration. Rinaldi emphasized that researchers are actively in dialogue with WHO to share data, aiming to collate existing information into a format that supplements official channels and remains as open and accessible as possible.

Iran’s civil uprising – 6 incidents or 48? 

Data from Insecurity Insight's Health Map illustrates the toll of political volatility in Iran between late 2025 and early 2026.
Data from Insecurity Insight’s Health Map illustrates the toll of political volatility in Iran between late 2025 and early 2026.

The discrepancies are further highlighted by Insecurity Insight’s data on regime assaults on health workers and health care centres during the Iranian civil uprising that began in late 2025 and continued into February 2026. Security forces systematically targeted medical professionals for treating injured protesters during the nationwide uprising, according to multiple reports.

Tracking these incidents under “political volatility,” Insecurity Insight documented 48 incidents of violence against healthcare in Iran between 27 December 2025 and 27 February 2026. During this brief two-month window, state military and police forces were responsible for the arrest of 43 health workers and the killing of 8 health workers, with further arrests and attacks following during the war.

For the same period, up to the start of the US-Israeli attacks on Iran on 28 February, the WHO’s SSA recorded 6 attacks on healthcare resulting in one death and 54 injuries, with impacts on medical facilities, personnel, and supplies.

Closing reporting gaps is critical because accurate data collection is the essential first step in identifying perpetrators and fighting impunity. “Accountability… is about documenting the crimes that our teams witness everywhere in the world,” MSF’s Perron stressed during the expert panel in Geneva.

Strengthening protections

Key 2026 global milestones for the protection of healthcare in conflict.
Key 2026 global milestones for the protection of healthcare in conflict.

Despite the bleak landscape, dedicated efforts are underway to reaffirm the protective status of medical facilities, ICRC legal adviser Rao asserted. The ICRC has spearheaded a “Global Initiative to Galvanize Political Commitment to International Humanitarian Law”, which now includes 103 states, committed to improving implementation of existing legal frameworks.

To drive this agenda, the ICRC has hosted a series of expert exchanges and state consultations, with fourth and fifth rounds scheduled for May and June, announced Rao. These consultations aim to generate political will and gather good practices to translate international norms into practical domestic frameworks and military doctrines.

Following these rounds, the initiative will conclude with a final high-level meeting in November, where a dedicated report outlining specific legal recommendations will be published.

Beyond reinforcing political will to prevent attacks on healthcare, the initiative focuses on integrating specific protections into domestic legislation, military field manuals, and standing orders. Practical measures include establishing coordination platforms to map out essential water and electricity systems, securing alternative resupply routes, and ensuring curfews do not hinder medical personnel.

Looking ahead, stakeholders are preparing for the 10th anniversary of UN Security Council Resolution 2286 in May 2026, viewing it as a pivotal moment to shift from rhetoric to concrete action. The resolution, originally adopted historically in May 2016, strongly condemned targeted assaults on medical personnel and demanded an end to impunity for perpetrators.

“It is absolutely possible to protect hospitals in armed conflicts,” stated legal expert Rao.

Image Credits: WHO/Nicolò Filippo Rosso, Felix Sassmannshausen/HPW, Insecurity Insight, Health Map/Insecurity Insight, WHO.

physical activity heat climate change egypt
A community gym for women in a church in Upper Egypt is empty during a heatwave.

Climate-change related temperature increases are making physical exercise more uncomfortable and dangerous, especially for people in lower-and-middle income countries. A new study from The Lancet estimates this could lead to half a million more premature deaths and aboout $2.5 billion dollars a year in lost economic productivity.

In a village in Upper Egypt, a women’s-only gym complex remained empty and idle as temperatures soared past 40℃ last summer. The women were instead mostly home, sheltering from the intense heat and sun. Their doctors had told them to keep active to stave off the many chronic diseases that plague the village. But in this heat, not even leisure walking through the village where I was a guest and volunteer in July 2025 was an option.

Rising temperatures due to climate change could put routine physical activity out of reach for millions of adults by 2050 – resulting in a about 500,000 more premature deaths and $2.5 billion in lost productivity annually, according to a study just published in The Lancet Global Health.

The study builds on evidence linking climate change-related exposures to a host of poor health outcomes, from direct health impacts like heatstrokes and kidney damage, to the spread of infectious diseases and worsening air quality.

Countries in already warm regions like the Middle East, Central America and the Caribbean, Sub-Saharan Africa, and South-East Asia, are likely to experience the brunt of declining physical activity rates, predicts the study, authored by researchers in Argentina, Chile, Colombia and Ecuador.

‘Profoundly inequitable’

 

The WHO recommends at least 150 minutes of moderate-intensity activity, 75 minutes of vigorous-intensity activity, or an equivalent combination per week.

“Because these exposures co-occur disproportionately in tropical LMICs,” wrote the authors, “where air-conditioning penetration, shaded public infrastructure, and discretionary leisure time are scarce—the resulting burden is profoundly inequitable.” 

As is, a third of adults worldwide fail to meet the World Health Organization physical activity guidelines. The WHO recommends a minimum of 150 minutes of moderate intensity or 75 minutes of vigorous intensity physical activity on a weekly basis. Declining physical activity rates are linked to cardiovascular diseases, cancer and diabetes, poor mental and brain health, and an estimated 5% of all adult deaths.

“Lives are becoming increasingly sedentary through the use of motorized transport and the increased use of screens for work, education and recreation,” says the WHO.

Heat drastically affects how active people can be, according to the group of Latin American-based researchers. That includes not only leisurely activity, like playing a sport or running, but also occupational physical activity and active transport like walking or cycling.

The researchers analyzed self-reported data from 156 countries between 2000 and 2022 to predict how rising temperatures could affect physical activity in the coming decades.

The implications of fewer opportunities for physical activity due to heat translates to a estimated 470,000-700,000 more premature deaths annually and between $2.40 and $3.68 billion in productivity losses, depending on the scenario of temperature increase. 

Lower- and middle – income countries hardest hit

Climate change “hotspots” are expected to see the largest declines in physical activity. Change in physical inactivity under the most extreme of three climate warming scenario.

The burden of reduced exercise falls most heavily on already warmer equatorial regions, where physical activity is projected to decline 4% for each month spent over 27.8℃ (82℉). Globally, that number is 1.4%, while in lower-and-middle income countries (LMICs), the study authors estimated a 1.85% decline. 

Those living in the climate change “hotspots” of Central America, the Caribbean, eastern sub-Saharan Africa, and equatorial southeast Asia are more susceptible to increases in physical inactivity, the authors found.

A hazy day in an Upper Egyptian village. High temperatures combined with poor air quality make outdoor exertion difficult-and dangerous.

“Outdoor labourers, street vendors, and subsistence farmers cannot easily shift physical exertion to cooler hours,” wrote Dr Christian García-Witulski of the Pontificia Universidad Católica Argentina, the lead study author. 

Furthermore, women and adolescents in LMICs face additional barriers to exercise, he noted and already have lower rates of exercise. “[They] often lack access to climate-controlled recreational spaces; and public health budgets in these settings are least able to absorb downstream cardiometabolic costs.

In higher-income countries, where adaptation to rising temperatures such as indoor gyms and air conditioning is perhaps more accessible, the authors projected no statistically significant change.

A ‘feedback loop’ between heat and sedentary behavior

Map of physical inactivity for women
Women already have a higher prevalence of physical inactivity, per a 2024 Lancet Report.

The connection between temperature and the decline in physical activity has several pathways, the authors note.

Physiologically, “heat elevates skin blood flow and sweating, increasing cardiovascular strain, dehydration risk, and perceived exertion.” In addition, high vapour pressure and poorer air quality from smog make breathing uncomfortable, pushing people to avoid outdoor movement – perhaps taking the bus or driving instead of walking to work or school – and staying inside air conditioning.

Globally, the share of households with residential AC is projected to grow from 27% to 41% by 2050, according to a 2024 Nature modeling study. This could further exacerbate sedentary behavior, as air conditioned spaces provide cool refuge but do little to encourage being active. 

This “reinforces a feedback loop between heat and physical inactivity,” García-Witulski wrote.

Rise in premature deaths, lost productivity

Outdoor workers are often exposed to disproportionate amount of heat. The study did not differentiate between occupational, leisurly, or transporation-related physical activity.

Because measures of physical activity also include occupational settings – like agriculture, construction, and other outdoor jobs – heat-driven physical inactivity also threatens economic output. 

Higher temperatures are linked to reduced muscular strength, impaired cognition, and poor sleep – all translating into lower on-the-job performance and higher absenteeism, the authors note.

“Outdoor labourers, street vendors, and subsistence farmers cannot easily shift physical exertion to cooler hours,” García-Witulski and colleagues wrote.

This all means that the model estimated between $2.4 and 3.7 billion in economic losses attributable to rising temperatures, depending on the warming scenario; the study looked at three. Along with that are the projected premature deaths linked to inactivity – 470,000 to 700,000 additional deaths globally. 

Lancet physical activity climate change table
Mortality attributable to physical inactivity by region.

“Physical inactivity is a silent threat to global health, contributing significantly to the burden of chronic diseases,” said Dr Rüdiger Krech, Director of Health Promotion at WHO during the release of WHO data on the topic last year.

García-Witulski and her colleagues undertook this research as part of the Lancet Countdown project tracking progress on health and climate change in Latin America. And though they found that warming temperatures will intensify sedentary behaviors, the authors noted that their modeling had several limitations.

For one, the study relied on self-reported physical activity from its 5.7 million participants, instead of measurement devices, potentially leading people to over-or-under report their activity levels. They also examined only annual, national physical activity averages – and did not differentiate between the kind of physical activity such as leisure, occupational, or transport.

And lastly, the authors only examined temperature, and not any other metric of climate change such as extreme weather events. 

Building heat resilience in cities

Regardless, the authors strongly argued for policies that would make cities heat resilient: “Without stronger mitigation, rising temperatures alone could undermine—or even reverse—a substantial share of WHO’s target of cutting global physical inactivity by 15% by 2030,” they wrote.

Interventions such as expanding shade and tree cover, expanding access to cooling centers, and walking and cycling-friendly roads are all part of creating more resilient cities. 

Adding in air conditioning to the women’s gym in the Upper Egyptian village could also encourage more users in peak summer heat. “They still need the exercise,” said the volunteer who runs the facility. 

The study authors echoed this sentiment: “[T]reating physical activity as a climate-sensitive necessity—rather than a discretionary lifestyle choice—will be essential to prevent a heat-driven sedentary transition and its accompanying surge in cardiometabolic diseases and economic losses.”

 

Sophia Samantaroy spent seven months in Egypt as a research fellow with the non-profit Coptic Orphans in 2025. She also contributes to Health Policy Watch as a reporter covering environmental health, chronic and infectious diseases, and US public health policy.

Image Credits: S. Samantaroy/HPW, WHO, The Lancet, The Lancet Global Health, Mario Spencer/Unsplash, The Lancet.