Dr Garry Aslanyan and Axel R. Pries
Dr Garry Aslanyan and Axel R. Pries

Global health leaders say the world needs to rethink how it approaches health, arguing that outdated systems, narrow thinking, and lack of coordination are slowing progress at a time of growing challenges.

Speaking on the Global Health Matters podcast, Axel Pries, president of the World Health Summit, told host Dr Gary Aslanyan that improving health outcomes will require broader cooperation across sectors, stronger communication, and a shift toward prevention.

Listen to the full episode >>

Pries said it was “clear that we needed politics, civil society and also the private sector.” He argued that global health can no longer be driven by governments and medical professionals alone, and that progress depends on open collaboration between actors with different interests.

While concerns remain, especially around the private sector, he said these partnerships are key to turning research into real-world results.

He also pointed to shifting global power, saying institutions created after World War II need to adapt to a more multipolar world. Countries like India, Brazil, and those across Africa should have a bigger role in shaping global health. At the same time, he said core values, especially a shared commitment to health equity, must stay the same.

Pries also highlighted challenges in how global health is communicated. Too often, the term is misunderstood as a niche issue affecting distant regions, rather than something that directly impacts everyday life.

“It’s everything, everywhere. It’s at our doorstep,” Pries said.

Looking ahead, he called for greater engagement from finance and political leaders, and a stronger focus on prevention rather than crisis response.Without that shift, he warned, health systems will remain reactive rather than resilient.

Listen to more Global Health Matters podcasts on Health Policy Watch >>

Image Credits: Global Health Matters podcast.

“Cervical cancer has become a mirror of global health inequity:” Ambassador Leslie Ramsammy, Guyana (center). Left, UN Ambassadors Clara Delgado and Antje Leenderste of Capo Verde and Germany. Right, CeHDI CEO Haileyesus Getahun and Colin Murdoch, Organisation of Eastern Caribbean Statees (OECS).

The Human papillomavirus (HPV35), globally associated with only 2% of invasive cervical cancers (ICC), has a disproportionately higher prevalence in sub‐Saharan Africa, reaching rates of 22-30% in some countries among women with ICC lesions, according to a new study. Recently, a high-level panel called for redoubled efforts in HPV vaccination, screening and treatment to meet the WHO Global Strategy targets for 2030 – and eliminate cervical cancer by 2050 worldwide. 

Midway along the route toward the WHO 2030 targets for cervical cancer elimination, some 340,000 women a year, mostly in low-income countries, are still dying from cervical cancer – due to the dearth of simple solutions like screening, treatment off pre-cancerous cells, and low HPV vaccination coverage for adolescent girls.

Meanwhile, HPV 35—a genotype of the HPV virus that is steadily spreading throughout Africa—is not targeted by existing vaccine formulations. This highlights the urgent need to speed up research and development to create an updated vaccine.

At the same time, success stories from a handful of developing countries such as Rwanda demonstrate that the 2030 targets for 90% HPV vaccine coverage, 70% screening and 90% treatment can be attained – when political will exists. Meeting those targets would put countries on track to meeting the global elimination goal of less than 4 cervical cancer cases annually per 100 000 women as early as 2050.

Those were key messages emerging from a recent high-level seminar on a Cervical Cancer-Free Future, convened by the Center for Global Health Development and Inclusion (CeHDI) together with the UN in Geneva  ambassadors of Barbados, Germany, Guyana and Malawi.

“Although cervical cancer is both preventable and curable when detected early, it remains the fourth most common cancer and cause of cancer death among women worldwide,” said Guyana’s ambassador, Leslie Ramsammy. “In Guyana, for example, it is the number two cause of cancer deaths among women. For some countries, it’s the number one cause of cancer death among women each year.”

About 600,000 women annually are diagnosed with cervical cancer, representing 6.5% of new cancer cases and 7.7% of cancer deaths. And 94% of cervical cancer deaths occur in developing countries. As such, “cervical cancer has become a mirror of global health inequity,” he added.

The goal: global elimination of cervical cancer by 2050 

Countries must reach the WHO 2030 targets for diagnosis and treatment in order to reach the goal of cervical cancer elimination by 2050.

Most developed countries are on a trajectory to meet the WHO 2030 goals and moving on from there, to eliminate cervical cancer as a public health risk by 2050.

However, developing countries are on a much longer trajectory. And at current rates of progress, most will only reach elimination in 2120, said Ramsammy.

“Today’s High-Level dialog is a call to change the trajectory for elimination from 2120 to earlier… closer to 2050 when many European countries and North America would have achieved elimination.”

Said Ramsammy, “The question is no longer whether cervical cancer can be eliminated, but when and whether the world will mobilize the political will and resources needed to ensure that no woman dies from a preventable disease. Just as international collaboration led to the eradication of smallpox, the global community can work together to end cervical cancer.”

Incidence rates in African countries 10–20 times higher than 2030 goal

Cervical cancer incidence and mortality are heavily concentrated in low-and middle-incomee countries of Asia, Africa and Latin America.

Most developed countries already have a cervical cancer incidence of between 10-4 cases annually per 100 000 women – with 4/100 000 being the elimination threshold.

But many countries in Africa have cervical cancer incidence of 60-70 or even eighty cases annually per 100 000 women, said Nathalie Broutet, of the University of Sydney, Australia, citing Malawi and Eswatini as examples. As a former WHO staff member, Broutet helped draft the WHO cervical cancer elimination strategy, which was approved by the World Health Assembly in 2020.

To get on course for elimination “we need to reach the 2030 targets, which are 90% HPV vaccination coverage; 70% of women screened with a high performance, twice in a lifetime; and 90% of women detected with a cervical disease treated,” she said.

In terms of vaccination, for instance, apart from the region of the Americas, which has almost reached 80% coverage, all other WHO regions remain far behind the 90% goal for 2030. “So, the work that we have to do to reach 90% is enormous,” said Broutet.

Better adapted vaccines – the missing HPV 35 genotype 

Nathalie Broutet, University of Sydney aand former WHO cervical cancer specialist.

However, along with more uptake of HPV vaccination, HPV vaccines need to be better adapted to the needs of girls and women in low- and middle–income populations. And recent research undertaken by CeHDI together with the International Agency for Research on Cancer (IARC) is pointing to a big gap in Africa.

That is the lack of vaccine coverage for the HPV 35 genotype, which now a common subtype of the virus in Africa, in comparison to the rest of the world.

“This is a genotype which is very common in African countries, which is responsible for around even more than 4% of cervical cancer cases in Africa,” said Broutet. “Yet this genotype is not included in the current HPV vaccine.”

One brand-new study points to an even higher incidence, said Haileyesus Getahun, CEO of CeHDI, citing a new review of the “Burden of HPV 35 in African Cervical Pathologies” in the journal Medical Virology.

That peer-reviewed study published this month, cites HPV35 prevalence of 19-30% in Mozambique, 22-26% in Kenya, 17% in South Africa and 11% in Zimbabwe and Tanzania among women with ICC lesions. In women with pre-cancerous lesions, rates of 20-26% were found in Botswana and Tanzania.

In sharp contrast, studies from China, Canada, Sweden and Europe pointed to a prevalence of less than 1%. Globally, the prevalence among women with ICC lesions was only 2%.

“Specifically, HPV35 has been more frequently associated with precancerous cervical lesions and accounts for a significant proportion of ICC [invasive cervical carcinoma] (4%–10%) in these populations, with a higher fraction than that observed in other regions,” concludes the authors from the University of Cape Town, South Africa; as well as medical research faculties in Tanzania, Botswana and Zimbabwe.

HPV genotypes covered by current vaccines and percentage contribution in invasive cervical cancer.

Overcoming the key problems in service delivery 

For cervical cancer, school-based HPV vaccination delivery is critical.

There are cited three key problems in service delivery, vaccination gaps, lack of access to low-cost HPV testing and related laboratory services; and lack of access to cancer treatments, such as radiation therapy, which are out of reach in most rural clinics and in the public health systems of many urban centres.

To overcome the challenges, global experts recommend the following:

School-based vaccination – This is the first time a vaccine must be delivered to an adolescent population, leading to challenges with both disinformation as well as the need to put new systems in place.

“We know in countries that use school- based delivery has been quite a success,” said Broutet. “Gender-neutral vaccination can improve the coverage and lift barriers that we see regarding the HPV vaccination of girls-only; and strong community engagement – communication needs to be in place.

In Dwazark Community, Freetown, Sierra Leone, students at St. Augustine School receive the HPV vaccine to protect against cervical cancer.

Shift from Pap smears to HPV testing  – In high income countries with high rates of cervical cancer screening, the most used test remains the Pap smear – a cytology-based test. In low income countries BIA or bioimpedance screening, which uses electrical signals to detect abnormal cells, has been widely used as well due to its low–cost and rapid results.

But WHO as well as many national health systems are now recommending a shift to HPV testing, widely regarded as more accurate and ultimately more cost-efficient. That involves  testing specifically for the human papillomavirus genotypes that are the most common cause of cancer.

“Even in countries that we think reach 70% coverage, there is a lot of work to be done to switch out the existing technology, which is basically cytology, and in low-income countries, BIA. Instead, all countries need to switch toward HPV testing,” says Broutet. “And we need also to ensure that innovation is available, and one of them is self-sampling, so self-collection and also urine samples. We need to ensure that all countries have access to this technology.”

Self-screening and community-based treatment  – Treatment immediately following screening is the third basic tool needed to reach elimination targets. Such treatment can remove pre-cancerous cells before they develop further.

“Mobile screening clinics can be an option to increase coverage, task shifting to community health workers,” said Broutet. “This expands coverage. And finally, digital registry [of screening results]. We need to follow up and track women who have been screened to ensure those with a positive test have been treated.”

Improving vaccine composition   

HPV 35 is one of five highly invasive genotypes not now covered by vaccines, responsible for an outsized proportion of cancers in Africa.

Improving vaccine composition is also a critical mission, said Getahun. Together with IARC, CeHDI is supporting an even more thorough African and global review of the evidence on the HPV 35 genotype and its burden.

“Our collaboration with IARC will help generate the evidence needed to inform the development of next-generation HPV vaccines that better reflect regional disease patterns, including the burden of HPV 35 in sub-Saharan Africa,” he observed.

“Going forward we hope this will stimulate dialogue with the manufacturers, countries, WHO and global procurement partners such as Gavi and Unitaid to ensure that this genotype is included in the next generation of vaccines, particularly those deployed in Africa.”

Currently, none of the main HPV vaccine manufacturers, which include the UK- and USA-based GSK and MSD(Merck), as well as the Serum Institute of India and two Chinese firms include HPV 35 in their vaccine formulations.

However, a 14-valent vaccine by another leading Chinese pharma innovator, Sinocelltech, has a 14-valent vaccine SCT1000 in Phase 3 trials with some 18,000 women, which includes the HPV 35 genotype.

“Especially in regions with high HIV prevalence, such as sub-Saharan Africa, the application of polyvalent HPV vaccines (including HPV 35) is essential, as people living with HIV are more prone to multiple HPV infections requiring broader protection,” state an October 2025 review by Chiara Paternostro and Elmar Joura, of the Medical University of Vienna.

Gavi board: approved inclusion of improved vaccines once available 

HPV vaccine – Gavi has approved inclusion of improved formulations to protect against more genotypes once available.

Asked by Health Policy Watch about the need and potential to update existing vaccines to include the HPV 35 genotype, Gavi, the Vaccine Alliance, said its board had in 2025 approved the inclusion of improved vaccines covering more virus genotypes in its portfolio as soon as they become available:

“Current HPV vaccines are designed to protect against the large majority (70%) of cervical cancers. The importance of this evolving research is that we now have a better understanding of the disease burden of HPV-35 in countries across Africa, which Gavi supports – as well as how that burden is expected to increase over time as other types decrease due to improved vaccine coverage,” a Gavi spokesperson said.

“While there are currently no licensed vaccines that provide protection against HPV‑35, the Gavi Board in December 2025 approved, based on WHO and SAGE guidance, an expansion of Gavi’s portfolio so that higher-valent vaccines can be made available to countries as and when they come available. We encourage our manufacturing partners to work with us in helping bring this about.”

WHO pointed to a recent systematic review by WHO/IARC  (Wei et al. 2024) confirming that  HPV35  is part of  the remaining known 10 HPV causal genotypes, it causes only about 5% of cases worldwide, “but with some notable regional variations, including a higher proportion (~4%) for HPV 35 in Africa than in other regions.”

“Currently, HPV35 is not among the types covered in the two existing, licensed (highest valency)  HPV9 vaccines that contain the same  7 oncogenic types (16,18, 31, 33, 45, 52, and 58),” a spokesperson said. “We are aware additional work is being done on HPV35 that may provide more information on this strain and its contribution to cervical cancer burden– in particular, in the African region. In future that may inform vaccine developers in their choice for additional HPV type to be included in ‘even higher valency’.”

Rwanda: on track to beat 2050 global elimination target    

Two girls sit together after receiving their HPV vaccinations at their primary school in Masaka, Rwanda, a country that is on track to reach the 2050 goal for cervical cancer elimination.

But vaccination is not in itself an answer. It must be part of a multi-pronged approach.

“Over the next 50 years, scaling up screening and treatment could avert up to 14.6 million deaths, three times more than vaccination alone,” noted Cabo Verde’s UN Ambassador in Geneva Clara Delgado and a member of the Unitaid Executive Board.

Since 2019, Unitaid has introduced HPV testing, self-sampling methods and portable thermal ablation treatment devices (for removal of precancerous lesions) across approximately 50  low- and middle income countries, driving down costs significantly.”

Bulk procurement has reduced HPV test prices by 40% and the costs of thermal ablation by 45% “making these lifesaving tools affordable where they are needed most.”

But just as important are country models that work, she stressed, citing Rwanda, South Africa, Malawi and the Philippines as “champion” examples.

“For example, in Rwanda with Unitaid’s partnership since 2019, a national screen and treat program now operates in over half of the country. Women in rural communities are being reached through HPV self-collection kits, a simple, dignified approach that brings services closer to home, breaking barriers of distance, stigma and cost.

As a result of the partnership, Rwanda is on track to beat the 2030 elimination targets by three years, “proving that elimination is not just possible, but achievable.”

Repeating the success of smallpox eradication  

“Just as international collaboration led to the eradication of smallpox, the global community can work together to end cervical cancer by 2050,” said Ramsammy, “Today we have an opportunity to elevate cervical cancer elimination on the multilateral agenda as a matter of equity, gender justice and the right to health.”

Said Getahun, “At a time when global solidarity and multilateralism are under strain, health diplomacy is more important than ever in strengthening North–South and South–South cooperation and advancing the global effort to eliminate cervical cancer.”

Adds Broutet, “We have a generation to end cervical cancer, and we have the tools,” citing  national elimination targets; sustainable financing; regional cooperation to decrease the price of the tools and investing in treatment infrastructure as key political levers.

“The science exists, the roadmap exists, but the inequity persists. Political will determines the outcome.”

Most important is the need to address gender inequities.

“Each country of the world needs to understand, what are these drivers of inequity in their own country?” she said, citing the late WHO director Mahmoud Fathalla, who once said: “women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.”

Image Credits: UNICEF, WHO , N. Broutet/WHO, ecancer.org, Murahwa et al, Reviews in Medical Virology, 33 March 2026, Broutet, Gavi, HPV World .

US President Donald Trump shocked partners when he announced an immediate freezing of all international health aid shortly after assuming power in January 2025.

The rapid withdrawal of international health aid by the United States (US) constitutes a public health emergency of international concern (PHEIC), according to Professor Matthew Herder and colleagues writing in the BMJ this week.

According to the World Health Organization’s (WHO) International Health Regulations, a PHEIC is “an extraordinary event which is determined to constitute a public health risk to other states through the international spread of disease and to potentially require a coordinated international response”. 

“Multiple estimates predict reduced US funding will lead to millions of deaths by 2030,” argue Herder, from the Dalhousie University’s school of law in Canada, Professor Roojin Habibi from Ottawa University, Fatima Hassan, director of Health Justice Initiative in South Africa, and Andrew Hill, visiting research fellow at the University of Liverpool in the UK.

The Trump administration’s funding freeze on the US President’s Emergency Plan for AIDS Relief (PEPFAR), resulted in “the sudden closure of treatment services for thousands of people with HIV/AIDS”, while the stop-work orders imposed on the US Agency for International Development (USAID) “immediately reduced HIV testing and treatment”.

If this aid is not resumed, UNAIDS estimates that there could be six million HIV-related deaths – a 10-fold increase on 2023 mortality – and nine million new HIV infections by 2030.

Meanwhile, cuts in funding for malaria, tuberculosis and other diseases are expected to “risk millions more deaths in the coming years”, they argue.

“If the Trump administration follows through on its threat to halt funding for Gavi, the Vaccine Alliance, alter the US childhood vaccination schedule, and fundamentally change its approach to pandemic preparedness as part of its America First global health strategy, vaccine preventable diseases and deaths are likely to resurge, both in the US and abroad,” they note.

Meanwhile, ceasing US funding for United Nations agencies, including UN Women and the UN Population Fund, “threatens to end services that support sexual rights and reproductive health in more than 150 countries.”

Mobilise resources

In response, they want the World Health Organization (WHO) to declare a PHEIC in order to galvanise resources to address the US actions.

They argue that the US actions amount to an “extraordinary event” within the definition of the IHR, and that an “event” is not limited to the “manifestation of disease” but extends to any “occurrence that creates a potential for disease.” 

“The main interpretive issue in this case is whether the political actions of the US amount to a public health risk through the ‘international spread of disease’,” they acknowledge.

While the “spread of disease” hasn’t fully materialised yet, “we are in a state of anticipation that numerous outbreaks of infectious diseases will occur as treatment and public health programmes reliant on US funding shut down around the globe”.

They argue that, while a PHEIC “has never been declared because of the political actions of a single country, risk is the paramount consideration, and the US’s recent decisions have greatly amplified the risk of multiple international outbreaks of disease”.

However, should the WHO declare a PHEIC, this can help to “mobilise collaboration, assistance, and financing across member states” and also enable countries to issue “compulsory licences, overriding the patent rights of pharmaceutical companies, to improve access to essential medicines to treat HIV, malaria, tuberculosis, and other diseases.”

Social media giants are liable for harming young users, according to two landmark court rulings in the United States this week that order Meta and YouTube to pay millions in damages.

On Wednesday, a Los Angeles jury found that Meta (parent company of Facebook and Instagram) and YouTube were liable for creating addictive products that had led to a young user developing depression and anxiety.

The court ordered Meta to pay $4.2 million and YouTube $1.8 million in compensation to the woman identified only as KGM, now aged 20.

KGM’s lawyers accused the companies of creating products as addictive as cigarettes and online gambling, using features like infinite scrolling and algorithm-based recommendations.

On Monday, a New Mexico jury found that Meta had misled its social media users into thinking its platforms were safe, yet sexual predators were able to contact and exploit children.

It ordered Meta to pay $375 million in damages for violating state consumer protection laws in the case, which was brought ​​by New Mexico Attorney General Raúl Torrez.

“Meta executives knew their products harmed children, disregarded warnings from their own employees, and lied to the public about what they knew,” Torrez told The Guardian after the ruling.

A two-year Guardian investigation revealing how Facebook and Instagram had become “marketplaces for child sex trafficking” was cited several times in the complaint.

Big Soda, alcohol companies ‘flood’ social media

Vital Strategies accuses Coca-Cola of “sportswashing” their sugary drinks via sponsorships.

Meanwhile, soda and alcohol companies are flooding social media platforms with a “constant stream of content” that evades outdated advertising regulations, according to Vital Strategies, a global public health organisation.

The consumption of sugary drinks and alcohol is linked to several noncommunicable diseases, including diabetes, cancer and cardiovascular disease. 

By embedding their brands in “sports highlights, influencer content and viral moments” rather than traditional advertising, these industries are generating billions of impressions, according to Vital.

Using its digital media monitoring tool, Canary, Vital’s researchers tracked how Coca-Cola’s sponsorship of the FIFA World Cup and alcohol companies’ use of festivals, cultural events and celebrities in Brazil, Mexico, the Philippines, and South Africa “integrated brand promotion into people’s everyday online experiences”.

“Companies are using culture, entertainment and social media to make harmful products – like alcohol, tobacco and sugary drinks – seem normal and unavoidable,” said Sandra Mullin, senior vice president at Vital.

“This undermines critically important policies to reduce consumption, like curbing marketing to kids and taxing these products. Governments cannot rely on social media to self-regulate: We need to implement proven policies that protect health.” 

Vital Strategies called on governments to implement comprehensive marketing policies that span both digital and physical environments, particularly youth spaces where exposure is highest. 

It also called on governments to ban harmful industries from sponsoring sports events, and increase taxes on alcohol, tobacco and sweetened beverages to reduce consumption.

“One moment in a stadium can become millions of online impressions,” said Vital vice president Nandita Murukutla and Canary lead. “That’s how today’s marketing machines work: amplifying exposure across digital platforms where young people are constantly engaged. This isn’t passive advertising; it shapes behaviour. Governments must respond with urgency.”

Image Credits: Unsplash, Vital Strategies.

Image Credits: Pete Lewis/ UK Department for International Development, Abdirahman Ahmed Aden.

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.