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

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

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

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

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

Multilateral mechanisms

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

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

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

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

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

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

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

Tight process

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

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

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

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

Image Credits: Wikimedia Commons.

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

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

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

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

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

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

Dr Tedros and African Development Bank Group President Dr Akinwumi Adesina

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

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

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

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

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

European Investment Bank president Dr Werner Hoyer

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

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

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

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

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

European Union offices in Brussels.

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

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

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

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

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

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

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

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

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

Pandemic products as public good

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

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

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

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

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

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

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

Emerging divisions between EU members

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Heat wave warning from Indian’s Metereological Department

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

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

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

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

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

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

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

Early warning 

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

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

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

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

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

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

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

 

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

Climate change worsening heat waves

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

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

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

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

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

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

The air pollution connection

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

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

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

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

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

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

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

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

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

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

Marketing claims made by commercial formula milk companies (brand names have been changed).

As representatives of 130 countries meet in Geneva this week to discuss how to counteract the tactics of baby formula manufacturers, the World Health Organization (WHO) has urged member states to update their laws to prevent the marketing of baby formula in the wake of increasing industry sophistication.  

The meeting is aimed at beefing up the International Code of Marketing of Breastmilk Substitutes, adopted in 1981 as a means to encourage exclusive breastfeeding, which was being undermined by the aggressive promotion of baby formula.

Since the code was adopted, almost three-quarters of countries have enacted legislation that puts in place at least some of the code’s provisions. As a result, exclusive breastfeeding feeding has increased globally by 10%, reaching 48% of children under six months – the highest level since the 1980s, said WHO Director-General Dr Tedros Adhanom Ghebreyesus. 

The International Code of Marketing of Breastmilk Substitutes is making an impact

“But little progress has been made in high-income countries where the code has not been made into effective legislation and, as a result, exclusive breastfeeding rates are stagnating,” Tedros told a media briefing on Wednesday.

“Manufacturers of breast milk substitutes are also using increasingly sophisticated marketing tactics, including targeted ads on pregnant mothers’ mobile phones, clandestine participation in online baby clips, or coaxing mothers to market formula to one another,” he added.

High-income countries have “the lowest rates of exclusive breastfeeding in children under six months”, according to Dr Francesco Branca, WHO Director of Nutrition.

Meanwhile, only 32 countries are fully compliant with the code and many others needed to update their legislation to address the “new forms of marketing”, including digital outreach and donations to professional societies, added Branca.

“Definitely WHO is recommending that member states… have much greater and stricter legislation because we have seen that that is associated with increased rates of breastfeeding,” added Branca, commending countries in South Asia and Africa for “producing legislation which is closest to the implementation of the code”. 

Behind closed doors

But two days of the three-day talks are taking place behind closed doors at WHO’s Geneva headquarters. Media access to the proceedings has been limited to the opening statements  – with no virtual press access granted even to that portion.

Asked why the forum was closed to the public, and only open to Geneva media, WHO said only: “The meeting is really geared towards countries, as we hope to provide an opportunity for member states to make plans on how they can improve the implementation of the code.” 

Rates of exclusive breastfeeding are 20% higher in countries that have legislation substantially aligned with the code, noted WHO’s Director General Dr Tedros Adhanom Ghebreyesus at the start of the meeting.

Continuation of breastfeeding in the first two years of life is more than twice as high when the legislation is substantially aligned with the code. “Let’s put a stop to the commercialization of our children’s health. It’s time to end exploitative marketing,” said the WHO Director General. 

“Inadequate breastfeeding increases the risks of childhood obesity, sudden, unexplained unexplained infant death, leukaemia and other cancers,” Tedros told the media briefing. “WHO recommends exclusive breastfeeding for the first six months of life and continued breastfeeding for two years or beyond.”

A Nestle advertisement from 1911 undermines breastfeeding.

The World Health Assembly (WHA) adopted the code in 1981, when global awareness about the health impacts of infant formula reliance, particularly in developing countries with unsafe water, first emerged. While there has been “clear progress” in the 42 years since it was adopted, formula milk manufacturing companies have sharpened their marketing tools, using “exploitative” practices on new digital platforms to market milk formula, according to WHO. 

A report released in April 2022 revealed what WHO described as the “shocking” extent of such practices, used by the baby formula industry, estimated to earn some $55 billion a year. 

The report detailed how formula milk companies are paying social media platforms and influencers to access and influence pregnant women and new mothers using personalized social media content that is often not recognizable as advertising. 

Through tools like apps, virtual support groups or ‘baby clubs’, and with the support of paid social media influencers, formula milk companies offer women competitions, advice forums or services – buying and collecting their personal data to further hone down their promotions. 

The report summarizes findings of research that sampled and analyzed four million social media posts about infant feeding published between January and June 2021, reaching some  2.47 billion people.

Meanwhile, experts said last year said that infant formula companies have “pathologised” normal baby behaviour to promote their products, and there should be “an international, legal treaty” to prevent their marketing, and that political lobbying by milk formula companies to influence public policy should be sharply curtailed.

These comments were contained in a three-part series published in The Lancet, in which the authors said that formula milk companies “exploit parents’ emotions and manipulate scientific information to generate sales at the expense of the health and rights of families, women, and children”.

“The sale of commercial milk formula is a multi-billion-dollar industry which uses political lobbying alongside a sophisticated and highly effective marketing playbook to turn the care and concern of parents and caregivers into a business opportunity. It is time for this to end,” says series co-author, Professor Nigel Rollins from WHO’s Department of Maternal, Newborn, Child and Adolescent Health.

Image Credits: WHO.

The climate crisis is creating a new generation of refugees.

There are more displaced people in the world today than at any other time in history. A record 110 million people have been forcibly displaced worldwide as of May 2023. Last year, 19.1 million people fled their homes as conflicts, climate shocks and hunger swept across the world, the largest single year increase ever recorded. 

Russia’s full-scale invasion of Ukraine caused the largest forced movement of people since World War II – the conflict that spurred the ratification of the UN Refugee convention 70 years ago. 

Record droughts in the Horn of Africa, a renewed war in Sudan and the growing severity and frequency of natural disasters have only added to the growing list of causes for the ever-growing surge. 

“It’s quite an indictment on the state of our world,” said UN Refugee agency head Filippo Grandi. “Unfortunately, in today’s divided world, long-term solutions for people forced to flee remain pitifully scarce.”

The number of refugees has more than doubled in the past decade, rising to 35 million from 15 million in 2011. Seven in ten refugees flee across just a single border to neighboring countries in hopes of eventually returning home. More than half of refugees come from just three countries: Syria, Ukraine and Afghanistan.

“The prevailing rhetoric is still that all the refugees go to rich countries,” said Grandi. “This is actually wrong. It’s quite the opposite.”

Around 76% of forcibly displaced people are hosted in low- and middle-income countries, while 70% of refugees are hosted in countries neighbouring their country of origin. 

Turkey is home to the most refugees in the world. It hosts 3.8 million people, the majority of whom are Syrians who fled the civil war. Iran is second, with 3.4 million refugees, mostly Afghans. Columbia, Germany and Pakistan round out of the top five. 

“These are not numbers on a page,” said UN Secretary General Antonio Guterres, who served as the UN High Commissioner for Refugees for a decade before taking over leadership of the UN. “These are individual women, children, and men making difficult journeys – often facing violence, exploitation, discrimination and abuse. Four in ten people forced to flee are children. They deserve a home, a childhood and a future just as much as anyone else.”

The week leading up to World Refugee Day, celebrated on June 20 every year, served as a stirring reminder of the dangers faced by people who leave their countries to find safety for themselves and their families.

Last Tuesday, on what would have been the dawn of World Refugee Day had it been a week later, the Greek coastguard was notified of a vessel carrying hundreds of migrants en route to Italy. Dozens of pleas for help from the dilapidated shipping trawler were recorded by humanitarian search-and-rescue groups over the ensuing hours. 

The ship sank mere meters from a coast guard vessel 18 hours after authorities were made aware of its existence. The wreck claimed the lives of up to 700 men, women and children on board. 

Survivors say as many as 100 children may have been in the hold of the ship when it sank. Yiva Johansson, the EU Commissioner for Home Affairs, said the incident may be “the most tragic ever in the Mediterranean”. Greek officials continue to contest the chain of events that led to the disaster. 

The Mediterranean Sea, despite its proximity to the European Union, the world’s wealthiest economic bloc, is the deadliest route for refugees in the world. The International Organization for Migration (IOM) has recorded over 20,000 deaths on the route since 2014, and another 7,000 people reported missing along the route have never been found.

After years of innumerable tragic headlines reaching the notification screens of people around the world, observers worry the extent of their plight has become normalized. 

“I am struck by the alarming level of tolerance to serious human rights violations against refugees, asylum seekers and migrants that has developed across Europe,” said Dunja Mijatović, the Commissioner for Human Rights of the Council of Europe. “Reports of human rights violations against refugees, asylum seekers and migrants are now so frequent that they hardly register in the public consciousness.” 

António Vitorino, who leads the International Organization for Migration that runs the Missing Migrants Project, echoed similar concerns: “I fear that these deaths have been normalized.”

Climate threatens to force unprecedented numbers of people to seek safer ground

If the world can limit warming to 1.5C, the number of people living outside the livable “climate niche” will be reduced by 80% compared to the current 2.7C trajectory.

Weather-related disasters triggered 32.6 million internal displacements in 2022, the highest number in a decade and 41% over the annual average of the last ten years. Unpredictable rainfall and intense droughts across Southeast Asia have already led to over eight million people moving to more hospitable climates in the Middle East, Europe and North America, according to the World Bank. 

Millions have already been made climate refugees by the current 1.2C in global temperatures. In Bangladesh, 10 million people have fled their homes as a result of flooding and drought. An estimated 2,000 people move to the capital, Dhaka, every day – 70% of them due to weather-related events. But as migrants move to Dhaka in search of safer ground, the city itself is sinking, threatening the livelihoods of its 168 million residents. 

And with the world on track for 2.7C of global heating, these numbers may be just a drop in the bucket by 2050. As the IPCC projects worse fires, longer droughts, and increased flooding, the World Bank estimates 143 million people could be climate migrants by 2050 – four times the record-setting number of refugees in the world today. And some scientific projections make the World Bank estimate look like a best-case scenario. 

If the world continues to warm at the current pace, two billion people will be driven out of the “climate niche” humans have thrived in for thousands of years. The extreme temperatures and weather patterns that result from the warming could lead up to one billion people to leave their homes in search of safer weather, a recent study in Nature Sustainability found. 

An earlier study, published in the journal Proceedings of the National Academy of Sciences in 2020, estimated that 19% of land currently inhabited by people could turn into uninhabitable hot zones by 2070, placing one in every three people in climates that will force them to leave.

The consequences of climate change place people living in conflict-affected and politically fragile regions in particular danger. An estimated 70% of refugees and 80% of internally displaced people today come from countries that are also highly vulnerable to climate change, while 40% of refugees worldwide are hosted in climate vulnerable countries. In 2021, nine in ten refugees who returned home returned to highly climate vulnerable countries. 

“Climate shocks are throwing fuel on the fire of persistent cycles of crisis and displacement,” the UN Refugee Agency told delegates ahead of the UN Climate Summit, COP27, in Egypt last year. “Loss and damage from the impacts of climate change is already a devastating reality for millions of people as climate-fueled crises, food and water insecurity and loss of habitable territory drive new displacement and make life harder for people already uprooted from their homes.”

The Ecological Threat Register, a project run by the Institute for Economics & Peace, estimates that by 2040, more than half of the world’s projected population – 5.4 billion people – will live in countries experiencing water stress. Meanwhile, 3.5 billion people may suffer from food insecurity by 2050, 1.5 billion more than today.

With the prospect of millions of climate refugees on the horizon, the world will need to adjust. Yet for now, the world is moving in the opposite direction. 

“We see pushbacks. We see tougher and tougher immigration or refugee admission rules. We see in many countries a criminalization of immigrants and refugees, blaming them for everything,” said Grandi. “It cannot be just about controlling your borders.

“Leadership is about convincing your public opinion that there are people that deserve international protection.”

Two-thirds of the world’s oceans are unregulated and subject to overfishing and pollution.

After almost 20 years of negotiations, the United Nations has adopted a legally binding treaty to protect the marine biodiversity of sea outside national borders known as the high seas, which cover two-thirds of the world’s oceans.

The High Seas Treaty was adopted by consensus at the Intergovernmental Conference on Marine Biodiversity of Areas Beyond National Jurisdiction on Monday. 

It will come into force once ratified by 60 of the 193 UN member states.

“The ocean is the lifeblood of our planet, and today, you have pumped new life and hope to give the ocean a fighting chance,” the UN Secretary-General António Guterres told delegates.

The treaty, an international legally binding instrument under the 1982 United Nations Convention on the Law of the Sea, aims to “ensure the conservation and sustainable use of marine biological diversity of areas beyond national jurisdiction, for the present and in the long term”.

However, after its adoption Venezuela’s delegate pointed out that his country is not a party to the convention, so is not bound by the treaty. Meanwhile, Russia also distanced itself from the consensus, claiming that it feared the agreement would be politicised.

The new agreement contains 75 articles to protect and ensure the responsible use of the marine environment including provisions based on the polluter-pays principle.

This is particularly important to contain toxic chemicals and plastic waste. More than 17 million tons of plastic entered the world’s oceans in 2021, and this is expected to double or triple each year by 2040, according to the latest Sustainable Development Goals (SDG) report.

The treaty intends to establish new marine protected areas, to conserve and sustainably manage vital habitats and species in the high seas and the international seabed area.

The treaty also considers the special circumstances facing small-island and landlocked developing nations.

The treaty also underlines the importance of capacity building, including collaboration among regional seas organisations and regional fisheries management organisations to regulate the high seas.

The treaty also offers guidance on tackling the adverse effects of climate change and ocean acidification, and maintains and restores ecosystem integrity, including carbon cycling services.

“We have a new tool,” UN General Assembly President Csaba Kőrösi told the Intergovernmental Conference delegates on Monday. “This landmark achievement bears witness to your collective commitment to the conservation and sustainable use of marine biological diversity in areas beyond national jurisdiction. Together, you laid the foundation for a better stewardship of our seas, ensuring their survival for generations to come.

Image Credits: Julia Goralski/ Unsplash.

A child with HIV takes a paediatric dose of antiretroviral medication.

One of the most successful US aid programmes, the US President’s Emergency Plan for AIDS Relief (PEPFAR) – which has saved 25 million lives in its 20 years of existence – is facing a right-wing backlash based on misinformation.

PEPFAR’s five-year budget is due for re-funding by the US Senate and Congress by 30 September, but there has been unprecedented right-wing mobilisation against it over the past few months by both US and African groups. 

Twenty million people living with HIV are currently on antiretroviral medication thanks to PEPFAR, which also channels the US contribution to the Global Fund for AIDS, Tuberculosis and Malaria.

PEPFAR’s key achievements in 2022

PEPFAR was started by Republican president George W Bush in 2003 and has enjoyed bipartisan support from both Republicans and Democrats.

But a group of US right-wing groups claimed in a recent letter sent to Senate and Congress leaders that PEPFAR grantees  “are using taxpayer funds to promote a radical sexual and reproductive health agenda”. Signatories include the Center for Family and Human Rights (C-FAM), Heritage Foundation and the Dr James Dobson Family Institute.

A similar letter was sent on 6 June to the same US Senate and Congress leaders by African politicians and religious leaders claiming that PEPFAR “is supporting so-called family planning and reproductive health principles and practices, including abortion, that violate our core beliefs concerning life, family, and religion”.

US Representative Chris Smith, who co-sponsored PEPFAR’s refinancing in 2018, has also joined its critics by recently claiming that the programme is being used to “promote abortion on demand”. 

Illegal for PEPFAR to fund abortion

However, it is illegal for PEPFAR to fund or support abortion, and abortion is illegal in most of the  African countries where it operates.

“PEPFAR has never, will not ever, use that platform in supporting abortion,” said Dr John Nkengasong, who heads PEPAR as the US Global AIDS Co-ordinator, as reported by Devex.

One of the PEPFAR grantees that have been singled out is DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe), which targets teenage girls in 16 African countries. 

Girls and young women are up to five times more likely to contract HIV than boys and men their age, and DREAMS offered HIV prevention services to 2.9 million adolescent girls and young women in 2022.

However, a C-FAM report claims that “in Malawi the program focused on young girls 12-14 years providing access to sexual and reproductive health services, which according to the Biden administration includes abortion”. 

Abortion is illegal in Malawi so this simply isn’t possible.

The group also singles out the Anova Health Institute, a respected South African organisation that works largely with government departments on HIV prevention, treatment and care and health systems strengthening.

It claims that Anova “promotes abortions to teens as young as 14” and had condemned ”laws enacted in US states that designate bathroom use based on biological sex”.

However, Anova CEO Dr Helen Struthers, told Health Policy Watch that her organisation “has always worked within the South African legal framework and within the terms and conditions of our grant agreements”.

“We have abided by the United States Government’s Various Codes of Federal Regulation and other restraints placed on the use of PEPFAR funds. Anova has never performed any abortions, nor has it actively promoted abortion as a method of family planning with PEPFAR or any other funds,” Struthers stressed, adding that Anova had supporting the South African government to put 400,000 more people on antiretroviral treatment in the past four years.

“These people are all playing with fire, and they’re playing with people’s lives, and there can only be one reason: political motivation to kill PEPFAR,” Mark Dybul, former US global AIDS coordinator, told Devex.

Monica Geingos, co-chair of the Global Council on Inequality.

Meanwhile, Namibian First Lady Monica Geingos, co-chair of the newly formed UNAIDS Global Council on Inequality, said that “PEPFAR has been an incredibly effective partner for Namibia, and has really contributed to some of our remarkable gains” against HIV. 

“Unfortunately, as the US moves into a political season, and as many countries move to political seasons, things like this tend to happen. And it’s a reminder again, for many countries to become more self-reliant when it comes to health financing,” Geingkos said in response to a Health Policy Watch question at a webinar on Tuesday organised by UNAIDS and the Financial Times.

However, Geingos added that misinformation “is not something that the Global Council can ignore” as it “can exacerbate and prolong pandemics when people don’t believe in science, when politicians behave and speak irresponsibly and when this starts to impact where money flows to.”

* Story updated to include Anova comment.

Image Credits: Paul Kamau/ DNDi.

refugees
A doctor providing essential health services to children in a refugee camp in northwest Syria during the COVID-19 pandemic.

Thirty countries signed a political declaration at an international meeting in Morocco last week calling for the health of refugees and migrants to be included in national health systems and universal health coverage. A total of 50 UN member and observer states attended the talks.

The Rabat Declaration, signed on Friday, is the first official outcome document on the health of refugees to emerge from a series of Global Consultations on the Health of Refugees and Migrants that began in Istanbul in March last year. 

“Universal health coverage is only truly universal if it includes refugees and migrants,” the declaration states. 

The World Health Organization (WHO), UN High Commissioner for Refugees (UNHCR), International Organization for Migration (IOM) and UN Refugee Agency called the declaration “groundbreaking”.

“Member States today have pledged that no one will be left behind when addressing the health needs of those forcibly displaced,” said Raouf Mazou, Assistant High Commissioner for Operations at UNHCR, in a joint press release. 

“Their commitment to not only include refugees, migrants and their hosting communities in national health policies and plans, but to also include them meaningfully in policy health discussions is a significant momentum towards universal health coverage and worthy of global support,” he said.

The declaration also calls for increased international efforts for “the protection of refugees, stateless persons, asylum-seekers and other forcibly displaced persons”, recognizes the “positive role and contributions of migrants and refugees for inclusive growth and sustainable development”, and emphasises the need for regional and national health strategies that “include measures to reach refugees and migrants … with the aim of leaving no one behind”. 

“Refugees and migrants face significant threats to health, and significant barriers to accessing the health services they need,” said WHO Director-General Tedros Adhanom Ghebreyesus. “Protecting the health and dignity of refugees and migrants during their often-dangerous journeys, and in the countries hosting them, is a matter of human rights, and human decency.”

Two previous rounds of international meetings on “migrant health” — concluded in Madrid in 2010 and Colombo in 2017 — did not include “refugees” in their official scope. The Colombo statement, signed by 19 countries at the conclusion of the 2017 round of talks, makes no reference to refugees in its guiding principles. 

WHO spotlights refugee health challenges

People receiving food assistance at the Oruchinga refugee settlement in Uganda.

A WHO spokesperson described the declaration as the latest in a series of WHO and international actions to recognize refugees’ unique health challenges:

“The declaration comes at a crucial moment after the adoption of the Global Compact for Safe, Orderly and Regular Migration (GCM) and the Global Compact on Refugees (GCR) in 2018, the adoption of the WHO Global Action Plan on Promoting the Health of Refugees and Migrants in 2019 and its extension until 2030 just adopted by the World Health Assembly in May this year, the International Migration Review Forum in 2022 and prior to the Global Refugee Forum in December 2023,” the spokesperson said.

“In the declaration Member States commit to stronger global coordination and collaboration for better health outcomes of refugees and migrants, as well as actions that improve the health of these populations, such as sustainable Universal Health Coverage (UHC) financing mechanisms or health system strengthening; the development of high-quality global research on the health of refugees and migrants; investments in data to develop a monitoring framework; the participation of refugees and migrants in health policy discussions; and cooperation and financial mechanisms to assist the efforts of host countries at the national and local levels.”

Lack of broader country support 

refugees

Countries hosting large numbers of refugees were among the leading signatories of the new statement. These include Turkey, Jordan, Morocco, Lebanon and Iran in the Middle East; Libya, Chad, Somalia, and Algeria and Ethiopia in Africa; Guatemala, Honduras and Mexico in Latin America; and India, the Philippines and Thailand in Asia.  

Notably, the USA, Italy, Greece, Romania, Slovakia, and Portugal also supported the declaration. Canada, the United Kingdom, Germany, Norway, Sweden and other countries in Europe that play host to large numbers of refugees were not among the signatories. 

IOM and UNHCR could not be reached for further comment on the implications of the declaration or its political supporters, in time for publication.

In response to the relatively low number of signatories, WHO said that the increased attendance, which has more than doubled since the second consultation in 2017, reflects increased “interest in commitment to improving the health of refugees and migrants and addressing the root causes of poor health outcomes”. 

“This positive trend is very much aligned with the adoption of a resolution to extend the WHO Global Action Plan on Promoting the Health of Refugees and Migrants until 2030, which was put forward by almost 30 governmental co-sponsors,” WHO said. “With the resolution, Member States have seven more years to continue to address the health needs of refugees and migrants, integrate refugee and migrant health in global, regional, and national initiatives, and identify and share challenges, lessons learned, and best practices related to implementing the global action plan.”

WHO’s European Region is currently negotiating a new regional action plan on the health of refugees and migrants, with the participation of the countries of the region, the spokesperson added.

In a landmark WHO report in 2022, the agency noted that migrants and refugees face big hurdles in accessing health services in two-thirds of their host countries. 

The report called for more active integration of migrants and refugees into the national health system schemes of their host countries – saying that their inclusion is critical to meeting 2030 Universal Health Coverage goals. A United Nations High Level Meeting on Universal Health Coverage, is scheduled for September. 

Algeria opposes registration of refugees in health system

Tens of thousands of Sahrawi refugees have been stranded in the aftermath of the conflict between Morocco and the Polisario Front over the former Spanish colony of Western Sahara following Spain’s withdrawal in 1975.

During three days of negotiations over the statement in Rabat, Morocco last week (13-15 May), Algeria stirred up controversy when its delegation came out in opposition to a key section of the declaration, which notes the international legal obligation of host countries to register refugees in order for them to access national health systems. 

Algeria is home to an estimated 111,500 refugees from Sub-Saharan Africa and Syria. Around 90,000 of these are Sahrawi refugees who live in five camps near the Saharan desert town of Tindouf, which borders the disputed region of the Western Sahara, Morocco and Mauritania. The Sahrawi are considered by UNHCR to be the “most vulnerable” of the region’s refugees.

The Saharawi region is claimed by Morocco. It is recognized as an independent state known as the Sahrawi Arab Democratic Republic by the Africa Union but not by the United Nations. 

While Algeria did not publicly provide a rationale for its opposition to registration, this is typically seen by many host countries as a step towards the granting of legal refugee asylum status, which they want to discourage.  

Even so, refugees and asylum seekers in Algiers are allowed free access to the national health system, with around 86% of such people in the capital being treated primarily by its public health system, according to UNHCR.

In the harsh deserts of Tindouf, however, Saharawi refugees rely almost entirely on humanitarian assistance. In 2022, UNHCR provided 70% of required medical equipment and supplies in addition to funding training programmes for doctors, nurses and midwives within the camp. The World Food Programme is also responsible for providing essential food supplies across the five camps.  

The UNHCR describes the predicament of Sahrawi refugees as “one of the most protracted refugee situations in the world”, with many Sahrawi having lived in Tindouf for over 45 years.  

Over 150,000 Sahrawi were displaced in a 16-year war with Morocco and Mauritania following Spain’s retreat from its colonial territories in the Western Sahara in 1975 – some of which was the Sahrawi homeland. 

Sahrawi claims are supported by a 1975 International Court of Justice ruling recognizing their claims to self-determination, and a ceasefire agreement negotiated by the UN in 1991 on the condition that a referendum on Sahrawi independence be held. However, the referendum has never been held and the conflict remains unresolved.

See also the WHO Global Health Matters series: How can we ensure that health is a reality for migrants and refugees

Image Credits: International Rescue Committee, Flickr – USAID, Leiv Meir Clancy, European Commission.