US Health and Human Services Secretary Robert F Kennedy Jr at the MAHA strategy launch.

 After a month-long delay, the Make America Healthy Again (MAHA) Commission’s strategy to address child health was released by the White House on Tuesday – but it offers few concrete proposals and no curbs on ultra-processed food or pesticides.

“We are now the sickest country in the world,” said US Health and Human Services (HHS)Secretary Robert F Kennedy Jr at the launch of the event, revealing that 76.4% of Americans are suffering from a chronic disease.

“We have the highest chronic disease burden of any country in the world. Yet we spend more on healthcare than any country in the world. We spend two to three times more than  European nations,” added Kennedy.

The strategy is the follow-up to MAHA’s first report, released in May, which laid out the commission’s assessment of the drivers of the ill-health of America’s children. 

While the MAHA strategy was intended to outline how to address these drivers, instead it presents a shopping list of 128 recommendations. that focus on conducting more research. This includes for nutrition, one of the key drivers of the US epidemics of obesity and non-communicable diseases (NCDs).

Ironically, the MAHA report was published on the eve of a global UNICEF report on childhood nutrition, which blames obesity in children on the increased consumption of ultra-processed food high in sugar, refined starch, salt, unhealthy fats and additives.

Noting that 21% of US children are obese, UNICEF proposes “mandatory policies to improve children’s food environments”, such as front-of-pack labelling on unhealthy products, restricting marketing to children, and higher taxes on unhealthy products.

In contrast, all that the MAHA strategy proposes is three nutrition-related recommendations: a standard definition of ultra-processed food, possible revisions to “front-of-pack nutrition information” after public comment and “potential industry guidelines to limit the direct marketing of certain unhealthy foods to children”.

‘Waffle words’

Marion Nestle, Emeritus Professor of Nutrition, Food Studies, and Public Health at New York University, said that the strategy “states intentions, but when it comes to policy, it has one strong, overall message: more research needed”.

Nestle, one of the world’s leading researchers on the influence of Big Food on health, was reacting to a leaked draft of the strategy in August, which has remained essentially the same as that released this week.

“Regulate?  Not a chance, except for the long overdue closure of the GRAS loophole (which lets corporations decide for themselves whether chemical additives are safe),” wrote Nestle.

“Everything else is waffle words: explore, coordinate, partner, prioritize, develop, or work toward.”

She also highlighted contradictions, such as prioritising “whole healthy foods” in nutrition assistance programs and promoting healthy meals in child care settings – while the Trump administration has cut the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which give food support to low-income people, pregnant women, breastfeeding mothers and mothers of children under the age of five.

“It doesn’t look like this is anything more than voluntary (and we know how voluntary works with the food industry; it doesn’t).  None of this says how or has any teeth behind it,” Nestle concluded.

Pesticides: Industry has prevailed

One of the dangers that the first MAHA report identified is children’s exposure to chemicals – including “heavy metals, PFAS [“forever chemicals”], pesticides, and phthalates”.

It also highlighted that studies of the pesticide, glyphosate (marketed as Roundup), “have noted a range of possible health effects, ranging from reproductive and developmental disorders as well as cancers, liver inflammation and metabolic disturbances”, while experimental animal studies have shown that exposure to another pesticide, atrazine, “can cause endocrine disruption and birth defects”.

The US uses more than one billion pounds of pesticides annually, which linger in the soil and groundwater. A 2021 study reported that pesticides had been found in 90% of the 442 US streams sampled by federal scientists.

However, farmers’ bodies – part of Trump’s rural support base – asserted that restricting pesticides such as atrazine and glyphosate will push up their costs and reduce yields. 

Conflict over pesticides between MAHA supporters and Trump allies is likely to have delayed the release of the report.

Ultimately, lobbying by farmers and the chemical industry has worked, as the MAHA strategy makes no mention of either atrazine or glyphosate, and simply affirms support for the Environmental Protection Agency’s (EPA) process to control pesticides. 

“EPA, partnering with food and agricultural stakeholders, will work to ensure that the public has awareness and confidence in EPA’s pesticide robust review procedures and how that relates to the limiting of risk for users and the general public and informs continual improvement,” is the report’s only statement on pesticide control.

US Environmental Protection Agency (EPA) Administrator Lee Zeldin.

However, the EPA under Administrator Lee Zeldin has systematically removed environmental regulation over industries – from pollution controls to pesticide restrictions – since Trump assumed office.

Zeldin told Tuesday’s launch that the strategy “outlines the keys to success, from pro-growth policies that advance research to driving innovation, private sector collaboration, [and] increased public awareness”.

Moms Across America, an important part of Kennedy’s MAHA alliance, said it is 

“deeply disappointed that the committee allowed the chemical companies to influence the report”, describing the reference to the EPA improving its communication of its review process as “a pathetic attempt to assuage the American people”.

“Clearly, eliminating the words ‘glyphosate and atrazine’ (that were in the first report) is not a result of new science that shows these two most widely used herbicides to be safe, but rather a tactic to appease the pesticide companies,” the group said in a statement.

“Better words on the EPA’s website WILL NOT reduce childhood chronic illness, only bans and restrictions of pesticides will.”

Farmers are satisfied

In contrast, farmers generally expressed satisfaction with the strategy, particularly the powerful American Soybean Association, with almost half a million members who are massive consumers of glyphosate and atrazine, 

“Soybean farmers are thankful the MAHA Commission recognized EPA’s approval process as the global gold standard,” said ASA President Caleb Ragland. “Between the May report and today’s strategy, the Commission was accessible and open to learning more about modern farming practices. We truly felt like we had a seat at the table, and for that, we are incredibly appreciative.”

American Farm Bureau Federation President Zippy Duvall welcomed “a renewed focus on American-grown fresh fruits, vegetables and meat, along with reintroducing whole milk into the school meal programs”.

“Prioritizing voluntary conservation efforts for farmers and ranchers and optimizing EPA’s already robust pesticide regulatory process to accelerate innovation are welcome recommendations,” added  Duvall.

Vaccine pronouncements

The strategy also promises to “ensure that America has the best childhood vaccine schedule” by “addressing vaccine injuries, modernising vaccines with transparent, gold standard science, correcting conflicts of interest and misaligned incentives” and “ensuring scientific and medical freedom”.

The American Academy of Pediatrics, which has clashed with Kennedy over changes in access to COVID-19 vaccines, said that it “cannot ignore the fact that this report is being published in the context of other recent harmful actions by the administration and Congress that undermine many of the report’s recommendations”. 

“This administration’s unprecedented cuts to Medicaid and SNAP, along with its chaotic, confusing actions restricting vaccine access are worsening – not resolving—efforts to improve children’s health,” noted AAP, which represented 67,000 paediatricians.

Professor Peter Hotez, co-director of the Texas Children’s Hospital Center for Vaccine Development, described the strategy as “more of the same wellness/influencer grift and pseudoscience that antivaccine activists have been pushing for years”.

Hotez, who is also Dean of the National School of Tropical Medicine at Baylor University, added that “medical freedom” is a “propaganda term that accelerated in the 2010s to deny kids access to life-saving vaccines, as announced in Florida last week”.

Action on medicines

The strategy has proposed a working group on prescriptions for medicines including selective serotonin reuptake inhibitors, antipsychotics and mood stabilisers.

Late Tuesday, President Donald Trump issued a presidential memorandum to ensure that “direct-to-consumer prescription drug advertisements are providing consumers with full and accurate information”.

The memorandum directs Kennedy to ensure that prescription drug advertisements increase the amount of information regarding any risks associated with the use of prescription drugs.

UNICEF singles out the aggressive marketing of ultra-processed food as a driver of children’s rising obesity. Its research shows that retailers are more likely to display sweets and sugary cereals within children’s reach in poorer communities than in wealthier areas.

For the first time, more school children and adolescents worldwide are obese than underweight, according to a report released on Wednesday by the United Nations Children’s Fund (UNICEF).

One in five children and adolescents aged 5-19 globally are overweight (some 391 million), while one in 10 are obese – putting them at risk of life-threatening diseases such as high blood pressure and diabetes.

Only sub-Saharan Africa and South Asia have more underweight than obese children, according to the report which draws on data from over 190 countries.

The report, which is called Feeding Profit: How Food Environments are Failing Children, lays the blame for the changing shape of children on ultra-processed food that is high in sugar, refined starch, salt, unhealthy fats and additives.

“These products dominate shops and schools, while digital marketing gives the food and beverage industry powerful access to young audiences,” according to UNICEF.

UNICEF executive director Catherine Russell added that “ultra-processed food is increasingly replacing fruits, vegetables and protein at a time when nutrition plays a critical role in children’s growth, cognitive development and mental health.”

Since 2000, the prevalence of underweight children aged 5-19 has declined from nearly 13% to 9.2%, while obesity rates have more than tripled, rising from 3% to 9.4%.

Pacific Island countries have the highest global prevalence of obesity in this age group, with a 38% prevalence in Niue, 37% in Cook Islands, and 33% in Nauru. These rates have all doubled since 2000, and “ are largely driven by a shift from traditional diets to cheap, energy-dense, imported foods”, according to UNICEF.

High-income countries such as Chile (27%), United States (21%) and the United Arab Emirates (21%) also experience high obesity rates in children.

Undernutrition, including wasting and stunting, remains a significant concern among children under the age of five in most low- and middle-income countries.

“In many countries we are seeing the double burden of malnutrition – the existence of stunting and obesity. This requires targeted interventions,” said Russell. “Nutritious and affordable food must be available to every child to support their growth and development. We urgently need policies that support parents and caretakers to access nutritious and healthy foods for their children.”

Prolific junk food advertising

A UNICEF poll of 64,000 young people aged 13-24 from 170 countries found that three-quarters had seen advertisements for sugary drinks, snacks, or fast foods in the previous week.

“Even in conflict-affected countries, 68% of young people said they were exposed to these advertisements,” UNICEF noted.

In adolescents aged 15–19 years, 60% had consumed more than one sugary food or beverage during the previous day, 32% consumed a soft drink, and 25% consumed more than one salty processed food, according to data from the Global Diet Quality Project.

“Unhealthy foods and beverages, including ultra-processed foods and beverages, are widely available, inexpensive and aggressively marketed in the places where children live, learn and play. 

“The unethical business practices of the ultra-processed food and beverage industry undermine efforts to put legal measures and policies in place to protect children from unhealthy food environments.”

UNICEF’s research in Argentina, Brazil, Chile, Costa Rica and Mexico found that retailers were more likely to prominently display sweet snacks and sugary cereals at entrances and within children’s reach in poorer communities than in wealthier areas.

Meanwhile, 70% of government officials and civil society representatives polled in 24 countries identified industry influence as a major barrier to introducing government-led food marketing controls. 

“Studies have found that the industry uses a mix of political, scientific, reputational management and marketing practices to delay, weaken, block and evade government policies,” according to UNICEF.

Possible interventions

Front-of-pack warning labels in Chile

The UN agency warns that the long-term health and economic benefits will be expensive for many countries, projecting that, by 2035, the global economic impact of overweight and obesity is expected to surpass $4 trillion every year.

It proposes several possible interventions to transform food environments and ensure children have access to nutritious diets.

These include mandatory policies to improve children’s food environments, such as front-of-pack labelling, marketing restrictions, taxes and subsidies for healthy food.

It also proposes banning the provision or sale of ultra-processed and junk foods in schools and prohibiting food marketing and sponsorship in schools.
It highlights progress made by the Mexican government, which was one of the first countries to tax sugary drinks and recently banned the sale and distribution of ultra-processed foods and items high in salt, sugar and fat in public schools.

Image Credits: Health Ministry of Chile.

Traffic congestion in Nairobi is a major contributor to rising air pollution.

NAIROBI, Kenya – The sun beats down on Tom Mboya Street, where buses belch black smoke into the air and vendors shout amid the constant honking of matatus (minibus taxis). 

The air is already thick with smoke before midday. In the midst of this stands James Muro, a fruit seller whose workday is measured in dust, fumes and strained breaths.

In 2024, he began having a persistent cough. At first, he thought it was nothing serious. But as weeks went by, the symptoms worsened – chest tightness, shortness of breath and eventually a bloody cough. 

A visit to Kenyatta National Hospital revealed a lung infection aggravated by long-term exposure to polluted air. 

“It felt like the city I depend on for survival was slowly choking me,” he says. For him, the city’s fading green lungs aren’t an abstract concern, they are a daily struggle to stay healthy. Muro’s struggle reflects the growing health toll of Nairobi’s shrinking spaces and rising air pollution.

Romanus Opiyo, an environmentalist at Stockholm Environment Institute, says that urban areas block air circulation, leading to poor air quality and compromised health. 

“Lack of green spaces and built-up areas act as blockades to air circulation which actually compromises people’s health and wellbeing,” said Opiyo, who stresses the importance of addressing challenges like human capital, budget allocation and community awareness and proper implementation of the Nairobi integrated Urban Development master plan.

“If there is an adequate budget allocation, national staff who are aware and also in numbers to reinforce awareness to the community and proper implementation of plans we will be able to solve these  gaps.”

“The loss of green spaces is not just an environmental issue. It is an urban health crisis. Vegetation acts as a natural filter, absorbing harmful pollutants such as particulate matter (PM 2.5).” 

PM 2.5 is a component of air pollution that is less than 2.5 micrometers in diameter,  30 times thinner than a human hair. These microscopic particles easily bypass the body’s natural defenses, lodge deep within the lungs, and penetrate the bloodstream.

This pollutant is linked to cardiovascular diseases; chronic respiratory illnesses, particularly chronic obstructive pulmonary disease (COPD) and severe asthma and lung cancer. It also causes severe childhood conditions like pneumonia and stunted lung development.

Falling short of global standards

The Kenyan Constitution (2010, Article 42) guarantees every citizen the right to a clean and healthy environment. Yet, the disappearance of Nairobi’s green lungs shows how far reality falls short of this promise. 

WHO and UN-Habitat recommend that every resident should have access to at least 9–10 m² of green space per person, according to a 2016 WHO report on Urban Green Spaces and Health.

Nairobi, however, falls far below these thresholds.  According to the 2020 UN-Habitat Nairobi Public Space Inventory and Assessment Report, there are 826 public spaces in Nairobi City County. They occupy a combined area of 3106.4Ha – only 5.32% of the built up area – and translate to 6.56m2 per capita of public open space. 

Kenya’s Vision 2030 identifies environmental management as a pillar of sustainable development, while its National Land Use Policy calls for equitable access to urban green space. However, weak enforcement has seen Nairobi lose its green cover.

“One of the remaining indigenous urban forests in Kenya is Ngong Road Forest. However it faces repeated threats from rapid urbanization, expanding roads, encroachment for real estate and development, and installing utilities has continued to reduce the forest boundaries,” explains Wanjiru Hungi, a representative from Ngong Road Forest Association.

“Illegal logging and informal settlements have continually reduced the boundaries of the forest. Land grabbing and irregular allocations remain the most critical threat in the forest undermining the legal protection of the land,” she emphasises.

According to a study published in 2020 by Francis Oloo and colleagues, from approximately 6,600ha of forest land, 720 ha has been lost between 2000 and 2019, representing a loss of about 11%.  There is a clear need for Nairobi to work towards improving the amount of urban land designated, used and experienced as public space. This decline undermines Sustainable Development Goal (SDG) 11, which calls for inclusive, safe, resilient, and sustainable cities with equitable access to green spaces.

Nairobi’s green cover in 2001 (31 December).
A comparison of Nairobi over two decades shows the loss of green cover: Top: in 2001 and Bottom: 2020 (both on 31 December).                                                           

“Sometimes it feels like someone is pressing down on my chest, the pain comes suddenly and I just stop what I am doing until it passes,” says Muro. 

Steadily worsening air pollution

Air pollution is the leading risk factor for death in Nairobi. The health burden is already evident. According to the State of Global Air 2024, air pollution contributed to more than 30,000 deaths in Kenya in 2021, representing 8% of all deaths nationwide. Children, the elderly, outdoor workers such as street vendors and traffic police, and people with existing conditions like asthma or diabetes face the highest risks.

Chest tightness is a common sign of PM 2.5 damage, which inflames the lungs and reduces airflow that can strain the heart and chest muscles.  

“Once inhaled, PM 2.5 triggers inflammation and oxidative stress, weakening the lungs and making people more vulnerable to infections,” explains Dr Joseph Ndung’u,  a specialist at a local hospital. 

In Nairobi, exposure to PM 2.5 is rising at an alarming pace. The annual average PM 2.5 concentration in Nairobi, Kenya is 18.4 µg/m³ – significantly higher than the World Health Organization (WHO)’s recommended annual threshold of 5 µg/m³. 

A recent health impact assessment for Nairobi using WHO’s AirQ+ tool suggests that this level of pollution can cause 400 and 1,400 premature deaths annually in the city. 

The steady increase in air pollution over the last decade has been fueled by motor vehicle emissions, industrial activity, open burning of waste, and the continued loss of trees and green buffers that once absorbed some of these pollutants.

Trends in annual average PM 2.5 levels Kenya from 1990-2020: State of Global Air (2024)

Air Pollution and disease

Global deaths attributable PM 2.5 in 2021  (State of Global Air 2024).

Trends over the last decade show a troubling rise but, unlike infectious diseases, the effects of air pollution are hidden and cumulative, building often unnoticed over time until they manifest as chronic illness. 

Deaths from air pollution (State of Global Air 2024).

The missing link

Non-motorised transport (NMT) is often described as the backbone of sustainable urban mobility. Unlike motorized transport, it produces zero emissions, improves physical health, and reduces congestion.  

In Nairobi, however, the connection between green spaces and NMT is steadily eroding. Parks, tree-lined corridors, and public walkways that once provided shaded, safe routes for pedestrians and cyclists have been lost to urban sprawl and poor planning. 

The result is twofold: more emissions from motor vehicles as residents rely heavily on matatus and private cars, and higher risks of traffic injuries as pedestrians are forced onto unsafe, congested roads.

“Shifting even a small percentage of short trips from cars to walking and cycling can improve air quality, while also reducing greenhouse gas emissions,” says Carly Gilbert-Patrick, the UN Environment Programme’s (UNEP) team leader for active mobility, digitalisation and mode integration. 

“It’s about reclaiming space and dignity for the people who rely on walking and cycling every day. From this we can see multiple benefits including environment, air quality, road safety, equity.”

The decline of green spaces has led to a decline of safe walking and cycling routes. This loss of active transport opportunities contributes to a sedentary lifestyle, which is driving up cases of obesity, diabetes, and cardiovascular disease, illnesses that could be prevented through daily walking or cycling. 

Road traffic injuries are the leading cause of death in 15 to 29-year-olds worldwide, with Kenya amongst the hardest hit in Africa, according to the WHO. Nairobi records thousands of pedestrian and cyclist injuries annually, many of them fatal.

Kenya has recognised this gap. In 2009, the Integrated National Transport Policy stressed low-emission mobility as a national priority, and the 2017 Non-Motorized Transport Policy calls for safer walking and cycling networks. 

Yet, on the ground, progress remains slow, and Nairobi continues to expand highways while neglecting pedestrian and cycling infrastructure. 

 “I work to feed myself, but the city’s streets are slowly stealing my strength.  The air I need to survive is slowly turning against me and  everyday is a battle between survival and sickness,” Muro says.

This article was produced as part of a collaboration between Health Policy Watch and KEMRI’s Health Journalism and Public Health course.

 

Image Credits: Timon Abuna, Google Earth.

An Ebola responder in Butembo in the DRC’s North Kivu, during an outbreak in 2019.

The latest Ebola outbreak in Kasai province in southern Democratic Republic of Congo (DRC) is being hampered by lack of instructure, including roads and transport.

Samples from the index case and five other suspected cases took eight days to get to the National Public Health Laboratory (INRB) in Kinshasa, only arriving on 3 September.

The index case, a pregnant woman, died on 25 August – five days after seeking care at Bulape General Hospital in Kasai province with a high fever, bloody diarrhoea, haemorrhage and extreme weakness. 

At least 15 people, including four health workers, have died in the latest Ebola outbreak, according to the World Health Organization (WHO).

Meanwhile, some 28 suspected cases are being investigated in the Bulape health zone in Kasai province, which borders Angola.

Two of the health-care workers that had initially been in contact with the index case also developed similar symptoms and died. According to unconfirmed reports, a third health worker and lab technician in contact with the woman also died.

The DRC Health Ministry declared an outbreak on 4 September after laboratory tests confirmed the Zaire strain of Ebola Virus Disease (EVD) from the six samples.

All six samples were confirmed by GeneXpert and polymerase chain reaction (PCR) assays.

“The results obtained from whole genome sequencing suggest that the outbreak is a new zoonotic spillover event and is not directly linked to the 2007 Luebo or 2008/2009 Mweka EVD outbreaks,” according to the WHO.

The DRC’s Ministry of Health, with support from WHO and partners, is implementing public health response measures to contain the outbreak. 

The WHO has assessed the national public health risk posed by the current outbreak as high.

The virus is transmitted to humans through close contact with the blood or secretions of infected wildlife and then spreads through human-to-human transmission.

This is the sixteenth Ebola outbreak in the DRC since 1976. The last case was identified in 2022. A large outbreak in 2018-2020,  killed almost 2,300 people in North Kivu and Ituri.

Image Credits: UN Photo/Martine Perret.

Wildfires in Canada and the Amazon have substantially worsened air pollution levels in the Americas as well as parts of central Africa and Siberia.

China saw a decline in overall levels of health-harmful particulate pollution (PM 2.5) in 2024 as compared to 2023 thanks to ardent mitigation efforts of leading pollution sources.

But India remained a global air pollution hotspot, while wildfire activity led to above average PM 2.5 levels in Canada, Siberia and central Africa, according to the latest Air Quality and Climate Bulletin of the World Meteorological Organization (WMO), released on Friday.

Highest rise in the Amazon  

The biggest anomaly, however, was in the Amazon basin where dramatic increases in air pollution, as compared to 2023 levels, were driven by record wildfires and drought-fuelled fires in northern Latin America. Both wildfires and droughts are being worsened by climate change.

Wildfires are a big contributor to particle pollution and the problem is expected to increase as the climate warms, posing growing risks for infrastructure, ecosystems and human health, warns the new WMO bulletin. It also underlines the “vicious cycle” that global warming is exacerbating.

As its title suggests, the report traces the complex interplay between air quality and climate, highlighting the role of tiny particles called aerosols in wildfires, winter fog, shipping emissions and urban pollution in climate trends – mainly warming, but some cooling as well. It stresses the need for improved atmospheric monitoring and more integrated policies to safeguard human and environmental health and reduce agricultural and economic losses.

“Climate change and air quality cannot be addressed in isolation. They go hand-in-hand and must be tackled together in order to protect the health of our planet, our communities, and our economies,” WMO Deputy Secretary-General Ko Barrett said.

A ‘complicated’ picture

Air pollution anomalies in 2024, as compared to 2023, as captured by three different sets of satellite and modelling exercises. Average annual PM2.5 levels rose in Canada, Siberia, South America, parts of Central and West Africa and India (red and orange). Levels were lower in other parts of Africa and China (blue and dark blue) than in the previous year.

WMO experts described the bulletin as presenting a “complicated” picture as there were both reasons for cheer and gloom.

The bulletin highlights the leading sources of PM2.5 releases as transport, industry, agriculture, wildfires and wind-blown desert dust. While not the only dangerous air pollutant, PM2.5 is a leading health hazard as the tiny particles, that are 1/28 of the width of a human hair, or smaller, penetrate deep into the lungs, the blood stream, and even the brain, increasing risks of heart attack, stroke, dementia and pre-natal conditions, as well as lung disease and cancers.

Both the burning fossil fuels and biomass also lead to large releases of black carbon, methane and nitrous oxide, the latter a precursor of  ground-level ozone. These “super pollutants” accelerate the effects of climate change causing the planet to even warm faster than CO2 emissions alone. The bulletin terms this as a “vicious cycle” when combined with climate change pressures.

“Climate impacts and air pollution respect no national borders – as exemplified by intense heat and drought which fuels wildfires, worsening air quality for millions of people. We need improved international monitoring and collaboration to meet this global challenge,” Barrett said.

In the Indo-Gangetic plain where nearly 900 million people live, air pollution is also worsening winter fog both in intensity and in length.

“Persistence of fog is no longer a simple, seasonal weather event – it is a symptom of escalating human impact on the environment. Addressing this requires comprehensive strategies, such as enforcing regulations on agricultural residue burning, and promoting cleaner energy for cooking, heating, lighting and public transport systems,” the WMO stated.

Spotlight on aerosols 

Lorenzo Labrador, WMO’s scientific officer, speaking at the press conference held ahead of the bulletin’s release.

The report placed special emphasis on aerosols, another term for tiny airborne particles of solids or liquids. Aerosols can have both a warming or a cooling affect depending on their composition.

Darker ones, such as the black carbon that is released from incomplete combustion of diesel fuel or biomass, can warm the atmosphere and accelerate ice and glacier melt by absorbing more radiant heat from sunlight. But the brighter aerosols such as sulphates tend to have a temporary cooling effect as they reflect solar radiation back to space before returning to the earth’s surface in the form of acid rain and snow.

In 2020, UN agency International Maritime Organization (IMO) put regulations in place capping the use of sulphur in shipping fuel. Reduced sulphur dioxide (SO2) emissions by vessels plying the world’s oceans has translated into lower atmospheric PM2.5 levels and a comparative decline in related impacts such as premature mortality as well as childhood asthma cases, particularly in South Asia and Africa, said Lorenzo Labrador, WMO’s scientific officer.

It also has had an unintended environmental consequence.

SO2 and other sulphur-containing aerosols were previously making cloud cover brighter and thus helped the clouds reflect more light into space, cooling off temperatures, Labrador explained.

“So that [reduction in SO2 emissions] results, or translates into a very slight increase in the temperature of 0.04 degrees in 2025 so what we have here, and this is very important to emphasize, is not an increase in temperature due to aerosols, but rather an unmasking of the true warming of greenhouse gasses as a result of the offset that these aerosols were having,” said Lorenzo Labrador, WMO’s scientific officer.

Bulletin underscores the importance of monitoring

The models draw on data from the European Union’s Copernicus Atmosphere Monitoring Service (CAMS), NASA’s Global Modeling and Assimilation Office (GMAO), and the Finnish-based System for Integrated Modelling of Atmospheric Composition (SILAM).

This is the first time that the WMO experts used estimates from three different amospheric models for its reporting, and while there were minor differences, all models had the same conclusion.

The Bulletin also underscored the importance of ramping up the atmospheric monitoring infrastructure, especially in developing regions. While satellites do provide critical insights for the globe, ground-based monitoring networks are also essential to validate that data. In developing countries, and particularly Africa, such infrastructure remains sparsely distributed, WMO experts said.

WMO experts also drew attention towards the positive finding of the report. “When we see that countries or regions or cities are taking measures to fight against bad air quality, it works, and we see in many areas, an improvement of the air quality,” said Paolo Laj who is the Chief of Global Atmosphere. “In regions where these measures have been taken, there is a great improvement of the air quality,” he said.

Image Credits: Mike Newbry/ Unsplash, WMO.

A healthworker takes a sample from a person suspected of having mpox – improved diagnostic capacity has helped reduce transmission.

WHO has ended its declaration of a Public Health Emergency of International Concern (PHEIC) for Mpox, announced in August 2024, saying that cases in the most affected areas of Africa had leveled off or were declining.

However, continued vigilance in testing – along with regular supplies of vaccines and drug treatments remains essential to ensure that the outbreak of a new and more deadly strains of mpox remains under control, particularly in a period of diminished donor support for African health systems, the global health agency warned.

“This decision is based on sustained declines in cases and as in the Democratic Republic of the Congo, and in other affected countries, including Burundi, Sierra, Leone and Uganda,” said WHO Director General Dr Tedros Adhanom Ghebreyesus, at a press briefing on Friday, noting that he was lifting the emergency upon the recommendation of WHO’s Mpox Emergency Committee of experts, that had met Thursday.

“We also have a better understanding of the drivers of transmission, the risk factors for severity and the most affected countries have developed a sustained response capacity,” Tedros said.

But  “lifting the emergency declaration does not mean the threat is over, nor that our response will stop,” Tedros added, noting that only yesterday, Africa Centers for Disease Control had met and declared that mpox remains a “continental health emergency.”

“We note…the possibility of continued flare ups and new outbreaks remains requiring adequate surveillance and response capacity. Ongoing efforts are needed to protect the most vulnerable groups, particularly young children and people living with HIV.”

Mpox affected 29 African states – as well as Asia, Europe and Americas

Overview of mpox cases in Africa as of end August.

The global health emergency was first declared after the deadly Clade 1 mpox, which has a fatality rate as high as 10%, surged in the Democratic Republic of Congo, followed by a less virulent but more contagious Clade 1b variant, as well as Clade 2. The variants spread across some 29 African ,member states as well as to other far flung countries from China to the Philippines. Unlike the previous global mpox outbreak of 2022-2023, which primarily affected men who have sex with men, the new Clade 1b variant raced through communities infecting  women and children as well.

In recent months, however, cases on the continent, the epicenter of the outbreak, have tailed off, with a 28% decline in new cases between June and July according to a recent Africa CDC update. Cases in the Americas and Europe both declined by 31% – prompting the Mpox Emergency Committee to recommend that the international health emergency alert could be lifted.

Sustained decline – but ….

Dimie Ogoina, Niger Delta University Nigeria

“There have been a sustained decline in the number of cases of mpox in the African continent overall, and also in the most affected countries of Uganda, DRC, Sierra, Leone and Burundi, there has also been a remarkable decline in the case fatality rate,” said the head of WHO’s Mpox Emergency Committee, Professor Dimie Ogoina, of Niger Delta University, speaking from Nigeria.

“There has also been a remarkable decline in the case fatality rate, in the DRC endemic regions from 3.6% to about 1% over the period of one year,” he added, along with a big increase in testing capacity – from only 30% to around 60% of suspected cases – and 54% for the conflict-ridden DRC.

“We know, of course, this is still very suboptimal, but many of the countries, have improved the ability to to diagnose and case findings, search for impacts, and also there have been local investment from the ministries,” Ogoina added.

Meanwhile, nearly 6 million vaccines have been pledged to African communities, said Tedros, with more than 3 million doses delivered to 12 countries – although just under 1 million vaccine doses have in fact been administered to date.

“So we have made much progress, but we still face significant challenges,” Tedros said. “Mpox clades continue to circulate surveillance and access to diagnostics remains patchy. Response capacities are under strain from limited funding and community engagement requires sustained investment and local partner coordination, who and our partners are working to mitigate these risks and sustain support to countries. Financial resources are still very much needed to support this work.”

New Ebola outbreak in DRC

Ebola health worker in protective gear.

Meanwhile, just as mpox is winding down, DRC health authorities are rushing to contain a new outbreak of the even more deadly Ebola virus, in Kasai province, a small and isolated area in the southwest of the country, WHO said.

The index case is a 34-year-old pregnant woman admitted to hospital last month with symptoms including high fever and repeated vomiting. Laboratory tests have confirmed the Zaire strain of Ebola. Investigations are ongoing to determine the source of exposure.

Kasai province last reported an Ebola outbreak in 2008, while nearby Equateur province experienced one in 2022.

The virus has already led to the deaths of some 15 people, with another 28 suspected cases, four of them among health workers. WHO surge teams and vaccine supplies are being mobilized from Kinshasa to cope with the outbreak, said WHO and Africa CDC officials in separate statements.

Image Credits: Katson Maliro/ WHO, Africa CDC , Africa CDC .

A new generation of obesity drugs has reached sky-high popularity and costs. Can WHO’s recommendation for wider use help lower prices and increase access?

WHO’s 2025 Essential Medicines Lists (EML), published Friday, has included the active ingredients in popular weight loss drugs like Ozempic and Wegovy –  semaglutide or other comparable  GLP-1 receptor agonists – in a recommendation that recognizes the growing importance of the drugs in clinical treatment of diabetes worldwide. 

These drugs, as well as new PD-1/PD-L1 cancer therapies, notably pembrolizumab and two other therapeutic alternatives, were also among the 20 new medicines added to the 2025 WHO EML. 

The EML also includes rapid acting insulin analogues to the list for the first time.  Longer-acting synthetic insulin formulas were first included in the list in 2021, as an alternative to human-derived insulin products.

WHO EML additions for adults (2025)

Another 15 drugs were added to a separate Essential Medicines List for children (EMLc) in this year’s listing, which is published every two years. The new list includes new drugs for cystic fibrosis and haemophilia, as well as recently approved vaccines for malaria and mpox. Also on Friday, WHO removed its declaration of an mpox Public Health Emergency of International Concern (PHEIC), noting that cases in Africa, which had been most affected by the recent emergency, had stabilized.  

The EML lists are used by over 150 countries, as well as insurance and health care providers, to guide decisions about procurement and provision of critical medicines for virtually every infectious and non-communicable disease condition. 

The 24th edition of the EML includes  about critical medicines for 563 drugs, on the adult list, and 361 treatments on the children’s listing.  

WHO EML additions for children (2025).

Short-acting insulin completes the package

This latest insulin addition rounds out the package of recommended insulin treatments, said WHO’s Deus Mubangizi.

“These are complementary; there those conditions where it’s more appropriate to use long-acting but also we need have conditions where we need short acting,” he said at a Friday press briefing.   

The inclusion of pembrolizumab and its counterparts follows on evidence demonstrating that the drugs, used in treatment of metastatic cervical, colorectal and lung cancer, prolong survival by at least four to six months, added WHO’s Lorenzo Moja, also at the briefing.

In comparison, trials in some of the newer, and also pricier, breast cancer drugs submitted for inclusion in the list, “are still maturing so the follow up of these patients is not yet consolidated,” Moja said, adding:  “The expert committee had a preference for those results in which we had long term follow up data and we are sure about the effect on overall survival and quality of life.” 

Short-acting insulin rounds out the balance of WHO recommendations: WHO’s Deus Mubangizi, at Friday’s briefing

Inclusion of new insulin analogues and GLP-1 agonist drugs welcomed by access advocates

Elizabeth Jarman, of Médecins Sans Frontières ACCESS initiative welcomed the WHO’s inclusion of the insulin analogues and GLP-1 agonists as a “critical milestone” – but called upon countries to make the treatments more affordable as well. 

“We welcome the inclusion of rapid-acting insulin analogues and GLP-1 agonists to the World Health Organization’s (WHO) Model List of Essential Medicines (EML) as a critical milestone on the path towards increasing access to diabetes treatment,” said Jarman.  

“In our experience of providing diabetes care in low-resource settings and humanitarian emergencies, rapid-acting insulins and GLP-1s are unaffordable and often unavailable. Current prices are unacceptably high, with rapid-acting insulin analogues priced as much as 75 times and GLP-1 agonists 400 times higher than what they can be profitably produced for, according to a recent MSF study. 

“We call on countries to take urgent steps to update their national EMLs, begin procurement planning, and – alongside the WHO – demand pharmaceutical corporations make these key diabetes treatments available in-country by immediately registering them and – critically – making them affordable.” ​ 

While gaining greater fame for obesity control, WHO has in fact recommended GLP-1 agonists as glucose-lowering therapy for adults with type 2 diabetes mellitus  “with established cardiovascular disease or chronic kidney disease, as well as obesity, defined as body mass index (BMI) ≥ 30kg/m2,” according to the EML.

The EML did not explicitly recommend the drugs for weight loss per se, but it contains guidance on “who can most benefit from the new drugs”, WHO said. 

GLP-1 agonists work by mimicking the body’s natural GLP-1 hormone to regulate blood sugar. They stimulate the pancreas to release insulin, reduce the liver’s sugar production, and slow down digestion. The medications also act on the brain to suppress appetite and have been shown to yield other benefits for heart and kidney health.

Exclusion of drug for spinal muscular atrophy decried

However, another medicines access group, Knowledge Ecology International (KEI) decried the exclusion, for the second time, of risdiplam, a drug that can significantly reduce the symptoms of spinal muscular atrophy, a rare genetic condition.

“The second rejection of risdiplam is appalling,” said director Jamie Love, of the drug, which is currently produced by the Swiss-based Roche.

Risdiplam, produced by Roche, was rejected by the EML expert group.

“This is exactly the type of drug for a rare disease the EML should embrace. It works and it’s easy and cheap to make and distribute generic versions. The consequences of no access are terrible for many children.”

The proposal for including the drug was apparently discarded by the EML expert group, Love said, because results of an ongoing trial on pre-symptomatic infants had not yet been published in a peer-reviewed journal at the time the group made its decisions. A study published in mid-August in the New England Journal of Medicine showed a very high rate of infants reaching key milestones for sitting, walking and other motorskills after 12 months of treatment, in comparison to untreated infants.

New cystic fibrosis drug addition hailed as a breakthrough 

Meanwhile, a leading cystic fibrosis patient advocate group hailed the inclusion of the new drug ivacaftor and its therapeutic alternatives, as a “historic breakthrough in the fight for global access to lifesaving cystic fibrosis treatment.”

The elexacaftor/tezacaftor/ivacaftor (ETI) trio –  better known as Trikafta/Kaftrio, was included in the EML for both adults and children.  

“This decision is a turning point. For the first time, a medicine specifically aimed at treating CF has been included on the EML and the world’s leading health authority has recognised that Trikafta is not a luxury drug, but an essential medicine – and that every child and adult living with CF should have the right to access it,” stated the group Right to Breathe.

“This is a powerful statement from the WHO: not only is Trikafta recognised as essential, but its inclusion is about breaking down barriers to access and ensuring patients everywhere – not just in the richest countries – can benefit from its lifesaving impact.” 

David Reddy, director-general of the International Federation of Pharmaceutical Manufacturers and Associations, hailed the addition of multiple new, cutting-edge treatments on the updated EML, saying their inclusion,”highlights how scientific advances are transforming how we prevent, treat and cure disease, and reinforces the importance of ensuring patients everywhere can benefit from them.”

While the EML expert group that vets new drugs has also held back, at times, on recommending cutting edge treatments specifically because of their high costs, “tiered pricing, voluntary licensing and value-based healthcare models” can help expand access, Reddy stressed.

Healthcare system strengthening is also a critical, and often overlooked, part of the equation, he added, noting “healthcare systems need to be strengthened with the right infrastructure, diagnostics and trained professionals in place, alongside effective regulatory pathways and sustainable procurement, to help ensure these innovations can achieve greatest impact for patients. “

Image Credits: Chemist4u.

Carrying drinking water supplies in Srinagar where supplies have been contaminated by heavy flooding across Jammu and Kashmir, India.

SRINAGAR, INDIA – When record-breaking rains, landslides and cloudbursts lashed northern India in late August — across Jammu and Kashmir, Punjab and Himachal Pradesh — highways turned into rivers, homes collapsed and death tolls mounted. But beneath the visible destruction lies a quieter emergency: public health systems buckling under the strain.

In Kashmir, the Jhelum River, a lifeline for the region, swelled dangerously after days of relentless downpours. By the night of Aug. 26–27, its waters entered neighbourhoods in Srinagar, the largest city in Jammu and Kashmir, and a popular summer tourism destination known for its stunning lake and riverfront visages and houseboats.  Earlier in the month, on Aug. 14, a devastating cloudburst near Chisoti — the last motorable village en route to the Machail Mata temple in Jammu — had already triggered flash floods that killed at least 64 people.

Health experts warn these floods are not isolated disasters but part of a worsening cycle of extreme weather events that India remains ill-prepared to handle. From Kashmir to Punjab to Himachal, disrupted medical care, contaminated water, and surges in mosquito-borne disease are exposing how fragile India’s public health safety nets are in the face of weather extremes driven by climate change. Unless resilience is built into the health system, each new flood risks compounding existing crises — from mental health to infectious disease.

Life cut off, treatment interrupted

Maliha Zehra – her medicines were inaccessible due to flooding.

In Srinagar’s flooded Rajbagh neighborhood, 22-year-old student Maliha Zehra from Baramulla faced a harrowing wait for her psychiatric medication after landslides blocked the Srinagar–Jammu National Highway, delaying essential supplies from reaching the Valley.

“My mental health medicines were delayed,” she told Health Policy Watch. “Without them, the flooding felt even more suffocating.”

Normally, winter highway closures meant she could at least call her doctor or request an ambulance. But this time, there was no lifeline. For three days, mobile networks and internet services across much of Kashmir were down after flood damage, severing communication between patients and providers.

“I tried to go to a nearby hospital, but it was overcrowded, and without a phone I couldn’t contact the private clinic where my psychiatrist sees me,” Zehra said. “At least in the snow you can call for help. With the floods, there was nothing.”

Mental health needs in Kashmir are staggering. As Health Policy Watch reported earlier this year, a 2015 survey by Médecins Sans Frontières (MSF) found that 1.8 million adults in the Kashmir Valley — about 45% of the population — experience significant mental distress. Almost one in five showed symptoms of post-traumatic stress disorder. Meanwhile, 41% of women and 26% of men showed signs of depression.

Yet the system is woefully underprepared to cope with chronic disease conditions during a disaster. According to the 2011 Census, there were just 41 psychiatrists for Jammu and Kashmir’s 12.5 million people. Experts say that number has only modestly increased since, leaving much of the population without specialized care. Flood-related disruption, even for a few days, becomes catastrophic in this context.

Contaminated waters, sick communities

Aadil Dar a community science educator: flooding brought illness in its wake.

The health toll was not limited to delayed prescriptions. Aadil Dar, a science educator at a community education centre in southern Kashmir’s Anantnag district, said the flooding brought illness in its wake.

“After these floods, many people in my area fell sick with diarrhoea because of contaminated drinking water,” he said.

Such outbreaks are common.  Epidemiologist Dr. Shailesh told The Tribune that “stagnant and contaminated water becomes the primary source of infections in flood-affected areas.” He warned that diseases like cholera, diarrhoea, typhoid, hepatitis A and gastroenteritis are “very common after floods,” while stagnant pools also fuel malaria, dengue and chikungunya outbreaks. 

Flood-linked disease is not hypothetical. In the aftermath of the 2014 Kashmir floods, clusters of jaundice and diarrheal illness were documented within days of the waters rising 

This year, Punjab is already seeing a surge in dengue cases since 2023 ,  in  2023 11,000 infections were reported by mid-november). Flooding has only worsened mosquito breeding conditions.

Arshdeep Singh, 22, from central Kashmir, said his family has resorted to buying bottled water after past illnesses. “My elder sister and I both developed jaundice earlier. It took me months to recover, so now we don’t take risks,” he said. “But packaged water is expensive. Not everyone can afford it.”

Collapsing infrastructure

Srinagar is a popular summer tourism area due to its lake and river visages – but extreme weather is making the area more flood prone during monsoon season.

Health facilities themselves were not spared. Landslides cut off access to several district hospitals in Jammu and Kashmir. In Punjab’s flood prone  24  districts, floodwaters inundated primary health centres, forcing patients to travel long distances. Himachal Pradesh, already battered by landslides, reported damaged subcentres and stockouts of critical drugs.

According to the Indian Meteorological Department Jammu and Kashmir registered 612 mm of rain  in the last week of August. That is 726% above normal rainfall in the region during for this time of the year. 

“It is the highest rainfall in the region since 1950,” Mukhtar Ahmad, Director at the India Meteorological Department in Srinagar, told Reuters. 

Roads, bridges and power lines collapsed under the onslaught, crippling emergency services. Ambulances struggled to reach rural patients, especially pregnant women and children. Telemedicine, which proved vital during the COVID-19 pandemic, was rendered useless in Kashmir due to the communications blackout.

A broader and recurring pattern

Satellite derived map shows scale and intensity of 2025 monsoon floods in neighbouring Pakistan.

Across the wider Himalayan arc and Gangetic plain, severe monsoon flooding has hammered neighboring countries this year too. In Pakistan, hundreds of deaths and mass displacement have been reported this season, with national  and UN flash updates detailing widespread damage along the Indus River basin. Regional weather and climate agencies  warn the Hindu Kush mountain range west of the Himalayas, which extends from Afghanistan into northwestern Pakistan, is also facing increasingly frequent, intense rain events that heighten risks of floods and landslides across borders. Afghanistan has thus also seen repeated flash floods across its northern and eastern provinces.

In Afghanistan, this season’s floods were compounded by another disaster. On Aug. 31, a 6.0-magnitude earthquake struck Afghanistan’s eastern region, killing more than 1,457 people and injuring over 3,394, according to the World Health Organization (WHO). 

Afghanistan is dealing with the combined impacts of a recent earthquake as well as heavy seasonal Monsoon flooding.

More than 6,700 homes were destroyed, leaving thousands homeless and exposed to harsh conditions just as monsoon floods were already battering the country. Hospitals in Kunar, Nangarhar, Laghman and Nuristan provinces have been overwhelmed by trauma cases, while overcrowded shelters and limited sanitation are raising fears of cholera, diarrhoea and other post-disaster outbreaks.

“When we speak of casualties, we are speaking of families and communities in crisis,” said Dr. Mukta Sharma, deputy representative in  Afghanistan, which has launched a flash emergency aid appeal for $4 million. “Our teams are working around the clock to deliver lifesaving care in areas devastated by the earthquake. The needs are immense. We urgently require more resources to sustain our operations and prevent further losses.”

Kashmir’s 2014 floods were a historic benchmark 

Flooded homestead in some of the worst flooding seen since 2014.

In 2014, India-administered Jammu and Kashmir saw its worst flooding in sixty years: more than 500 lives were lost and tens of thousands displaced. Hospitals, water and power infrastructure, and communications were crippled, leaving health systems paralyzed. Outbreaks of diarrhoeal disease, jaundice and other waterborne illnesses were reported within days of the waters rising, compounding the humanitarian emergency.

A spatial analysis of the 2014 floods found that the provincial capital of Srinagar, which has nearly 1.7 million residents, also had one of the highest “Relief Deprivation Index” scores — showing that access to timely rescue and aid was uneven, and the poorest households were often last in line for assistance.

A decade later, the pattern is repeating in Jammu Kashmir and beyond, with increasing frequency.  Almost every year in the past ten years has seen significant flood events. The neighbouring State of Himachal Pradesh also has endured successive monsoon-triggered landslides and floods over the past five years. Punjab continues to battle back-to-back dengue waves, related to more rainfall.

Climate scientists link this to a warming atmosphere fueling increased rainfall, more intense rainfall and sudden cloudburst events.  A Srinagar based climate scientist told Health Policy Watch  that the Himalayan region recorded a 33% increase in extreme weather events compared to the previous decade. In addition, glacial lakes are expanding as glaciers shrink. Rapid urbanization and deforestation have undermined natural watershed drainage, while urban flood drainage is often deficient or non-existent.

Public health experts say that while disaster relief often focuses on food and shelter, health systems remain the weakest link.

Building resilience – what needs to change

WHO has repeatedly warned that health crises following floods can cause more deaths than the flooding itself if not addressed promptly.

Flood preparedness in India still centers on evacuation and rescue, but public health preparedness continues to lag.

“Health is always the weakest link in disaster planning,” said a senior official from a Srinagar-based NGO who asked not to be named. “We have evacuation drills, but no real disease surveillance system to catch cholera, hepatitis or dengue outbreaks early.”

Another challenge is ensuring medicines don’t run out. “We need emergency stockpiles of essential drugs — psychiatric medicines, insulin, oral rehydration salts, antibiotics,” said the official. “When the highway closes or communication lines are down, the delay becomes life-threatening.”

Health workers also stressed the need to strengthen facilities themselves. “Flood-proofing primary health centers and keeping backup power and communications should be non-negotiable,” said Shazia Bhat, a community volunteer in Anantnag. “Right now, one storm can knock out the only health unit for an entire district.”

Clean water remains an urgent priority. “Mobile water treatment units should be deployed within hours, not weeks,” said Arshdeep Singh, the young resident from central Kashmir who earlier described his family’s struggle with jaundice. “Boiling water is not enough when sewage has already entered the supply.”

“We Can’t Afford to Wait”

As floodwaters recede in parts of Jammu and Kashmir, Punjab and Himachal Pradesh, communities are left to confront not just destroyed homes, but the lingering health fallout.

“The government talks about roads and bridges,” said Aadil Dar from Anantnag. “But people are falling sick. We can’t afford to wait for medicines and clean water next time.”

For Maliha Zehra in Srinagar, the disruption felt deeply personal. “Even after the water goes,” she said, “the anxiety stays.”

Image Credits: Arshdeep Singh, Al Jazeera/Creative Commons Licensing, European Commission .

Patients undergoing chemotherapy for cancer.

ISLAMABAD – Cancer cases in Pakistan are on the increase, but patients and health advocates are caught in a struggle for access to life-saving treatment amid concerns about the quality of generic drugs and the rising cost of medicine.

Tahmeena Kausar Parveen, a 45-year-old resident of Islamabad, was shocked by the news that she needs to see an oncologist about a lump in her breast after a screening at the Breast Cancer Hospital at Pakistan Institute of Medical Sciences.

Although she knows that early diagnosis makes this disease treatable, she has many anxieties. She is wrestling with the challenges of finding a reliable oncologist, covering the cost of treatment, and accessing quality medicines.

“I have the courage to fight this disease, but I fear that the difficult journey to get treatment may wear me down,” said Parveen.

The shadow of substandard drugs

Pakistan faces an estimated burden of 185,748 new cancer cases annually, according to the latest data from the World Health Organization (WHO).

But the fight against this disease extends far beyond the hospital ward – it is a battle fought on the supply chain, in regulatory offices, and in the courts, where the integrity and affordability of essential drugs hang in the balance.

The country’s cancer crisis is multifaceted, with access to cancer medication being one of the most complex problems.

There are fears about the quality of generic drugs, particularly following a report on failures in generic chemotherapy drugs published in The Lancet in late July.

The report, which involved testing various generic versions of seven key cancer drugs distributed in four African countries, found that around 20% failed various tests, most commonly over their active pharmaceutical ingredients (API). 

Many of these generic drugs are distributed worldwide, including in Pakistan.

Dr Maqbool Ahmed, an oncologist at Deaconess Hospital in Evansville in Indiana in the United States, says that the stakes could not be higher.

“Patients may not get the correct dose in a timely fashion, allowing their cancer to progress,” he warned. Medicines with lower APIs may be ineffective, while those with too high doses could have “toxic side effects”, said Ahmed.

Ahmed said that Pakistan “does not apparently have the know-how to test the drugs and no political desire to open this can of worms.”

Regulation of medicine

There are fears that sub-standard generic cancer medicine may be being distributed in the country.

However, Dr Akhtar Abbas, a representative from the  Drug Regulatory Authority of Pakistan (DRAP) disputes this.

While DRAP has not had any specific complaints about failed generic cancer treatments, Abbas confirmed that, in the wake of the report on failed generics elsewhere, the authority has initiated “proactive sampling and laboratory testing of suspect products already in the market.”

Initial tests on samples of Doxorubicin and Methotrexate performed successfully, said Abbas, adding that DRAP’s mandate is to ensure quality through strict regulatory mechanisms, including a detailed evaluation of safety, efficacy, and quality before a drug can be registered.

The authority also regulates the storage and distribution of anti-cancer medicines at the manufacturer and importers level and this includes mandatory adherence to Good Distribution Practices (GDP).

He said cold chain compliance, storage conditions, batch tracking, and recall procedures are routinely checked through inspections and audits.

DRAP is also scaling up its post-marketing surveillance activities including risk-based sampling, increased coordination with provincial drug control units, digital pharmacovigilance platforms, and a National Quality Control Surveillance Plan, added Abbas.

“DRAP also works with WHO and other global partners to track international alerts and trace counterfeit or substandard drugs entering the supply chain and is also going to introduce a bar code reader app in near future for detection of Spurious and counterfeit medicines,” said Abbas.

Underlying anxiety

However, the assurances from the regulator have done little to end the underlying anxiety.

For institutions like the Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC), which treat a significant portion of Pakistan’s cancer patients, the reliance on a national regulatory body is not enough.

“We, at SKMCH, have strong institutional mechanisms to ensure the quality of the products we get,” said CEO Dr Faisal Sultan.

He detailed the hospital’s own rigorous process of comprehensive pre-qualification assessments, review of quality documentation, and, when necessary, chemical equivalency tests and facility inspections.

According to Sultan, breast cancer is the most common cancer in Pakistani women, accounting for 31.3% of all new cases. Ovarian cancer ranks third with 4,987 new cases and 3,492 deaths annually.

Manufacturing success, pricing failure

Alongside concerns over drug quality and regulation, a significant success story has been unfolding in Pakistan’s pharmaceutical landscape: the rise of local anti-cancer drug manufacturing.

Noor Mahar, a pharmacist and president Pakistan Pharmacist Lawyers Forum (PPLF), points out that companies like Pharmasol, Oncogen Pharma, and BF Biosciences are now producing a range of essential oncology medications locally.

These include drugs to treat breast and ovarian cancer, as well as leukemia, said Mahar, marking a “major milestone for public health” by reducing the nation’s reliance on foreign imports, mitigating supply chain risks, and potentially lowering costs.

It is also a testament to the country’s growing industrial capabilities and represents a critical step towards achieving self-sufficiency in a highly specialized field.

However, Mahar warned that this progress is being undermined by an unwelcome policy called “price decontrol”.

In 2024, the country’s caretaker government enacted a policy to remove the maximum retail price (MRP) cap on non-essential medicines, allowing pharmaceutical companies to set their own prices. This has resulted in huge price hikes for certain medicines.

This decision is currently being challenged in the Lahore High Court.

Mahar argued that decontrol is a “clear violation of the Drug Act 1976,” which mandates strict regulation of life-saving medicines. 

He described the government’s stance as one of deep insensitivity towards patients and warns that the unchecked increase in drug prices will render essential cancer treatments “unaffordable for the common man”.

However, DRAP’s Abbas said that “the prices of the anti-cancer drugs included in Essential Medicine List are fixed and regulated”.

System under strain

The struggle with drug quality and pricing is compounded by a larger, systemic problem, namely the lack of a cohesive national framework for cancer care.

While the number of women presenting with breast cancer in early stages has increased at Shaukat Khanum Hospital, CEO Sultan notes that many women still present late and there is not enough understanding about why this is.

A functional national cancer registry would provide the data necessary for informed policy and resource allocation.

The supply chain is also under significant stress with several essential cancer medications not locally registered, making timely procurement a challenge, added Sultan.

Several multinational pharmaceutical companies have scaled down activities in Pakistan, which has contributed to the scarcity of essential cancer medications, creating additional challenges in ensuring consistent and timely patient care.

“This precarious environment puts immense pressure on healthcare providers,” said Sultan.

His hospital procures drugs from approved sources that comply with international standards.

“However, institutions like SKMCH&RC can only do so much. The core problems – the lack of political will, the absence of comprehensive data, and the recent dismantling of price controls – require a national-level solution,” he said.

Image Credits: Roche, WHO.

Delegates at World Health Assembly’s Committee A after it adopted the pandemic agreement by vote in May.

Regulating pharmaceutical companies that manufacture essential health products during a public health emergency is a key flashpoint between developed and developing countries ahead of the final round of talks on the pandemic agreement.

This is evident in some of the 17 submissions made to the Intergovernmental Negotiating Working Group (IGWG), which is coordinating the final phase of the talks. These talks begin on 15 September and focus on an annex to the pandemic agreement adopted at the World Health Assembly (WHA) in May. 

The annex deals with a pathogen access and benefit-sharing (PABS) system. It will outline how information about pathogens with pandemic potential is shared in a safe, transparent, and accountable manner, and how those who share information will benefit from products that are developed as a result.

Many countries in the global South want any sharing that they do to be on condition that they get benefits from products made as a result. It stems from the bitter experience of these countries during the COVID-19 pandemic, when countries like South Africa shared details of the Omicron variant only to face travel sanctions rather than access to vaccines.

Hours and hours of negotiations failed to secure agreement on PABS, which was then kicked down the road in an annex, enabling the WHA to adopt the deal. However, with less than nine months until the next WHA, it remains unclear whether member states will be able to reach a compromise.

The IGWG only has about seven months of negotiating time as the PABS annex has to be completed by 17 April 2026 to meet the deadline of submission to the World Health Assembly in May 2026, according to WHO legal officer Steven Solomon.

Group of Equity submission

The recent submission by the Group for Equity, a powerhouse interest group of 33 developing countries, wants manufacturers that are part of the PABS system to grant the World Health Organization (WHO) “non-exclusive licenses that can be sub-licensed to manufacturers in developing countries” during a public health emergency of international concern (PHEIC) and a pandemic. This would enable them to make vaccines, diagnostics and therapeutic products.

The Group believes that manufacturers in developing countries that provide pathogen materials and sequencing information should be the primary beneficiaries of such licenses.

They also want such a license to “include provision of the full regulatory dossier, technical know-how, and any necessary materials”. 

Two diseases – polio and mpox – are currently designated as PHEICs by the World Health Organization (WHO). 

If the Group’s proposal were adopted, it would mean that manufacturers in mpox hotspot countries that share information – such as the sequencing of the new mpox clades – could obtain licenses to produce any vaccines and therapeutics that develop as a result.

The Group of Equity includes countries with significant capacity to produce pharmaceutical products, including Bangladesh, Brazil, China, India, Indonesia, Malaysia, Thailand, Mexico, South Africa, Ethiopia and Egypt.

Voluntary contracts

Wealthier countries, primarily in Europe, now that the US is no longer part of the WHO, have sought to protect the intellectual property rights of their pharmaceutical companies and provide wide access to affordable medical products.

However, the European Union’s submission to the IGWG, a mere three pages, mainly summarises what the annex should cover, rather than proposals. But it does state that the key instrument for benefit-sharing should be “contracts with participating manufacturers (which are both legally-binding and voluntarily concluded)”.

Meanwhile, China has suggested that the access pharmaceutical manufacturers get to the PABS system should be “contingent” on their home country being a party to the Pandemic Agreement, as previously reported by Health Policy Watch. 

This would exclude US manufacturers, as the US withdrew from the WHO when the Trump administration assumed office on 20 January.

According to China,  the annex should “specify qualification criteria, boundaries of liability, and both financial and technical benchmarks” for manufacturers, and “make these contingent on whether their home state is a party to the Pandemic Agreement”.

Aside from deciding on PABS, the IGWG will prepare the ground for the Conference of the Parties that will govern the pandemic agreement, and the terms of reference for a coordinating financial mechanism, which will help defend countries against outbreaks and pandemics.

Image Credits: WHO.