Women
A major burden of collecting water falls on women and girls.

Water and sanitation crises across the world affect women and girls more than men and boys, particularly since the responsibility to collect water in seven out of 10 households without individual water supply falls on the female family members. 

This is a key message in the latest edition of the joint WHO/UNICEF report on progress on household drinking water, sanitation, and hygiene (WASH) 2000-2022 the first to provide a look at data from a gender perspective. 

The data conclusions dovetail decades of observations about the disproportionate impacts of unsafe and inaccessible water, sanitation and hygiene on women and girls.   

Globally, 1.8 billion people live in households without a source of water on the premises, the report finds. 

Women and girls, regardless of their age, bear a little over twice the burden of fetching water from sources outside their homes compared to men and boys. This leaves them with much less time to engage in education and employment, among other activities. 

In almost all the countries surveyed for the report, men and boys spent less than 10 minutes per day fetching water for such households, compared to 53 minutes per day for women and girls.  

WASH
Time spent by people fetching water.

Lack of access to sanitation and hygiene 

And if the lack of an on-site water supply eats into the time available for education or employment of women and girls, inadequate sanitation facilities makes their lives even more precarious. 

“Unsafe water, toilets, and handwashing at home robs girls of their potential, compromises their well-being, and perpetuates cycles of poverty,” said Cecilia Sharp, UNICEF director of WASH and Climate, Energy, Environment and DRR (CEED). “Every step a girl takes to collect water is a step away from learning, play, and safety.”

WASH
Proportion of world population having access to safely managed sanitation services as of 2022.

“Women and girls not only face WASH-related infectious diseases, like diarrhoea and acute respiratory infections, they face additional health risks because they are vulnerable to harassment, violence, and injury when they have to go outside the home to haul water or just to use the toilet,” said Dr Maria Neira, WHO director for Environment, Climate Change and Health, about the reports findings. 

WASH and Sustainable Development Goals 

Access to safely managed drinking water around the world has improved from 69% in 2015 to 73% in 2022, with a sizable improvement in rural areas. However, 2.2 billion people worldwide still lack access to safely managed drinking water in 2022. 

If the world is to achieve the Sustainable Development Goal (SDG) for Clean Water and Sanitation (SDG-6), it has to accelerate progress by three to six times, the report pointed out. 

Accessibility to drinking water is closely correlated with the level of income in a country, it stated. 

In a high-income country, almost all households have access to safe drinking water on site, or within a 30-minute walk. In contrast, in low-income countries, less than a third of the safe drinking water sources are located within the premises of a household. And only half of households can access a safe drinking water source within a 30-minute walk.

Sanitation even further behind 

Progress on sanitation lags even further behind. 

Around 3.4 billion people across the world still lack access to what WHO and UNICEF define as a “safely-managed” sanitation point – which they both define as an improved latrine or better.  And while access to safe sanitation sources has risen in the past seven years from 49% in 2015 to 57% in 2022 – that’s still far behind safe water access. 

Open defecation continues to be a widespread practice in some 36 countries – with rates of 5%-25%. Among 13 countries, at least one in four persons regularly defecate in the open, including Chad (63%), Niger (65%), and South Sudan (60%) . 

The practice not only increases people’s risk of exposure to disease pathogens but also makes it difficult for women and girls, in particular, to maintain privacy and dignity, as well as making them vulnerable to physical, sexual, or verbal violence. 

Image Credits: Photo by Rifath @photoripey on Unsplash, UNICEF. WHO, UNICEF, WHO.

Aspartame
Sugar crystals with aspartame in it (Round, white materials in the image).

WHO is set to release new data on Friday, 14 July on the carcinogenic risks of consuming aspartame, the artificial sweetener that is omnipresent in low-calorie soft-drinks, sweets and other processed foods, its head of nutrition, Dr Francesco Branca confirmed on Wednesday. 

A full WHO risk assessment on safe levels of exposure to the sugar substitute, which hasn’t been assessed since 1981, is due to be completed this week by the WHO and Food and Agriculture Organization’s Joint Expert Committee on Food Additives (JECFA), Branca said, speaking at a WHO press briefing on Wednesday. 

“The assessment of aspartame has been,in the first place, a hazard identification process. This has been closed. This is now followed by a full risk assessment process,” Branca said. “The two assessments will be then put together in a final release that will be completed and disseminated next week – a full risk assessment will be available next week.”

His comment came days after a Reuters report stated that aspartame is set to be declared as “possibly carcinogenic to humans”, by the International Agency for Research on Cancer (IARC), a WHO-affiliated agency that recently completed a separate assessment process on the sweetener. 

The new IARC monograph is due to be released 14 July, simultaneously with the JECFA assessment.  

IARC’s assessments looks at carcinogenicity, WHO evaluates exposure risks 

While IARC’s assessments look at whether a substance is potentially hazardous, or not, the JECFA assessments look at how much, if any, of a product is actually safe to consume, a WHO spokesperson explained, in a comment to Health Policy Watch.  

“In its Monographs Programme, IARC conducts hazard identification, which is the first fundamental step to understand carcinogenicity. Hazard identification aims to identify the specific properties of the agent and its potential to cause harm, i.e., the potential of an agent to cause cancer. 

“The classifications reflect the strength of the scientific evidence as to whether an agent can cause cancer in humans, but they do not reflect how high the risk of developing cancer is at a given exposure level.

“The JECFA Programme (Joint FAO/WHO Expert Committee on Food Additives) conducts risk assessment, which determines the probability of a specific type of harm (e.g., cancer) to occur under certain conditions and levels of exposure.  

“The evaluations are independent but complementary and are conducted one after the other in the months of June-July 2023,” the spokesperson explained. 

“Given the close collaboration between the IARC Monographs and the WHO/FAO JECFA Secretariat, we have planned to present the results of both evaluations at the same time.” This will allow to clearly communicate the different purposes of a hazard 

Aspartame’s links with health conditions

Along with cancer, aspartame has in the past been linked to a wide range of serious health conditions. A 2 July roundup by the US-based public health group, Right to Know, cites evidence around the sweetener’s links to cardiovascular disease, Alzheimer’s seizures, stroke and dementia, along with a range of head, stomach and mood disorders, and even weight gain. 

In May 2023, the World Health Organization signaled a change in its policies, advising the public not to consume non-sugar sweeteners for weight loss, including aspartame. The recommendation was based on a systematic review of the most current scientific evidence, which suggests that consumption of non-sugar sweeteners is in fact associated with increased risk of type 2 diabetes, cardiovascular diseases and all-cause mortality, as well as increased body weight.

Even so, evaluations by the US Food and Drug Administration (FDA), and the European Food Safety Authority have so far rebuffed claims that there is significant evidence of health risks. The FDA states that aspartame is “safe for the general population under certain conditions of use.

A “possibly carcinogenic to humans” IARC classification, which is the classification reportedly assigned to aspartame, is the lowest cancer classification level on the agency’s scale – other than “not classifiable at all”. 

It means that there is some limited evidence that the additive causes cancer in humans. 

“Probably carcinogenic” is the next step in the scale – in which red meat belongs along with glyphosate, the widely used weedkiller, first marketed by Monsanto and now controlled by Bayer. 

Substances with the most robust evidence receive the highest classification – “carcinogenic”.  Those range from outdoor air pollution and diesel exhaust to processed meat and asbestos. All have convincing evidence showing they cause cancer, IARC says.

National regulatory agencies have not always followed IARC’s recommendations.  For instance, the US Environmental Protection Agency still considers glyphosate to be “not likely to be carcinogenic in humans.”

Image Credits: Maxwildcat, CC BY-SA 4.0.

Malaria
A resident of Tanzania tucked into a mosquito net, to protect himself from mosquito bites.

Twenty-two months after the world’s first malaria vaccine RTS,S was approved by the World Health Organization (WHO), 12 countries in Africa will soon receive 18 million doses. A second, arguably more efficient, vaccine against malaria is currently in the queue for WHO approval. 

Meanwhile, distribution of the 18 million RTS,S doses is to be carried out jointly by WHO, Gavi and UNICEF, according to WHO Director-General Dr Tedros Adhanom Ghebreyesus, speaking at a media briefing Wednesday from WHO’s Geneva headquarters.  

“At least 28 African countries have expressed interest in receiving the RTS,S vaccine,” Tedros said. “The second vaccine is currently under review for prequalification, and if successful, provides additional supply in the short term.”

At the briefing, the WHO Director General also condemned the rising incidents of gender-based violence in Sudan, including conflict-related sexual violence against women and girls who have been internally displaced due to the clashes. 

“I’m appalled by attacks on healthcare as well as increasing gender-based violence in the country,” Tedros said. 

His comments coincided with a joint statement, several UN agencies called for an immediate end to the use of such instances of gender-based violence as tactics to terrorize people.

The malaria vaccine race

Tedros said that the RTS,S vaccine has already been administered to over 1.6 million children in Ghana, Kenya, and Malawi and has proven to be safe and effective. The initial shipment of RTS,S vaccines will go to Benin, Burkina Faso, Burundi, Cameroon, Democratic Republic of the Congo, Liberia, Niger, Sierra Leone and Uganda, in addition to Ghana, Kenya, and Malawi, according to a WHO statement.

Developed by GlaxoSmithKline (GSK), the vaccine was initially tested between 2019-2021 in a pilot study in Ghana, Kenya, and Malawi, in which 800,000 children aged 5-17 months received the vaccine. The study found that severe malaria infections were reduced by 30% and hospitalizations 21%, while mortality declined by 10% among children receiving the vaccine. 

The other vaccine, R21/MM, developed by Oxford University, has achieved much higher rates of efficacy – as much as 75%. But that was in smaller Phase 2B trials, while a larger Phase 3 trial is still underway. 

Even so, the vaccine was recently approved by Ghana and Nigeria, which hope to begin manufacturing the vaccine soon. However, it has not yet been approved by WHO under its “Prequalification programme” insofar as the trials performed so far were notably smaller in comparison to the massive real-world trials conducted on the GSK vaccine. 

Already, more than 1.5 million children in these countries have received over 4.5 million doses of the GSK vaccine, according to Dr Kate O’Brien, head of WHO’s Immunization Department. 

She flagged the lack of adequate supply of the GSK vaccine, however, saying that the time is ripe for a second malaria vaccine. 

“We’re very much looking forward to the review of the second malaria vaccine through both our regulatory processes and our policy processes,” O’Brien said. “And, if that review of the evidence leads to recommendations, we would expect a significant increase in the supply in the short term.”

Sudan conflict: increase in sexual violence

Since April 2023, the UN Human Rights office in Sudan has received credible reports of 21 incidents of conflict-related sexual violence against at least 57 women and girls. The victims include at least 10 girls. In one case, as many as 20 women were reportedly raped in the same attack, the statement revealed. 

The office added that Sudan’s ministry of social development also has received at least 42 alleged cases of conflict-related sexual violence in the capital Khartoum, and 46 such cases in the Darfur region. Given that sexual violence is severely underreported, it is feared that the actual number of cases is much higher.

“I’m appalled by attacks on healthcare as well as increasing gender-based violence in the country,” Tedros remarked, adding that the ongoing violence is preventing survivors of gender-based violence from accessing much-needed healthcare services. 

“Women and girls must have unhindered access to the care they need, particularly survivors of sexual violence and women that need support through pregnancy and birth health.”

There have been 50 attacks on healthcare infrastructure in Sudan, in which 10 people were killed and 21 injured since April 2023, when clashes erupted in Khartoum. 

The current conflict in Sudan has internally displaced over 800,000 people, and over 220,000 more have fled the country. 

On Monday, violence escalated in Sudan’s Darfur region, where a group of armed forces and the Rapid Support Forces (RSF) clashed with each other. The region borders Chad, and the recent clashes have resulted in thousands of people fleeing to Sudan’s western neighbor seeking refuge in camps. 

This situation has made providing health support to the affected persons difficult, according to Dr Olivier le Polain, WHO’s incident manager for Sudan. He said that the flow of information from the region to the WHO is limited due to the security situation currently in place. 

“We are very concerned about the situation in Darfur which, by all accounts, is very dire. We also have very limited information in Darfur given the security situation at the moment… We know that conflict is intensifying, some of which is along ethnic lines,” he said, adding that the agency along with its partners is trying to provide the necessary medical and healthcare support to people on either side of the border – Chad and Darfur. 

Image Credits: Peter Mgongo.

Air pollution
Air pollution is the 10th leading cause of death in the European Union.

Ministers of Health and Environment from WHO’s European Region, meeting this week in Budapest, are poised to adopt a Declaration pledging to tackle climate, pollution and biodiversity risks that account for about 15% of disease burden in the 53-nation region.

Health and environment ministers from WHO’s 53-member strong WHO European Region are meeting in Budapest this week to agree on an agenda that aims to redouble action on health challenges related to climate change, pollution and biodiversity loss. 

A ‘Budapest Declaration’, set to be adopted on Friday, contains a set of new commitments by countries to tackle the environmental causes of ill health, which lead to  some 1.4 million deaths annually, according to a new WHO report released Wednesday on the opening day of the three-day conference. 

“Everyone has the right to a clean, healthy and sustainable environment. Yet the triple environmental crisis – climate change, pollution, and biodiversity loss – threatens our very existence and that of our planet, our home,” said Dr Hans Henri P. Kluge, WHO Regional Director for Europe, at a press conference announcing the commitments at the Budapest event. 

“The Budapest Declaration offers concrete actions to improve the environments people live in, decrease the disease burden, reduce health inequalities, relieve pressured health systems and enhance our collective resilience to future pandemics,” he added.

Air pollution tops list of pollution-related deaths

Press conference on the first day of the ministerial conference of WHO’s European Region to discuss policies to tackle the health impacts of environmental and climate issues.

The new WHO report, “A healthy environment in the WHO European Region” provides a breakdown of the estimated 1.4 million environment-related deaths in the WHO European Region – which extends from the United Kingdom to the borders of China.  Air pollution tops the list with an estimated 570,000 deaths. Other key quantifiable risks include: 

  • 269,500 deaths from toxic chemicals exposure
  • 150 000+ deaths due to household air pollution from smokey coal, kerosene and biomass cookstoves;
  • 33,500 deaths from unsafe water, sanitation and hygiene amongst the more than 77 million people lacking access to safely managed drinking water;
  • 24,600 deaths from lung cancer caused by emissions of radon, a naturally-occuring radioactive gas leaking into homes.

Global warming, biodiversity and greenspace loss are growing factors 

People crowded in a fountain in central Berlin during a heatwave in summer 2018.

The report also points to climate change and biodiversity as growing factors in disease risks – whose health impacts have not yet been fully assessed. 

However, in 2022 alone, at least 20 000 people died from extreme heat in what was the hottest summer ever recorded in Europe, the new WHO report states. 

And over the past 50 years, some 148 000 lives were lost from extreme temperatures – comprising most of the 159 000 deaths attributable to climate-related storms, floods and extreme weather.

In urban areas, almost two-thirds of populations lack adequate access to green space close to their homes.  By providing shade for cooling and filtering the air, green spaces have a protective health effect that can reduce natural-cause mortality by nearly 1%, the report notes.

Roadmap of actions

A tram stopped in front of Budapest central station in 1988.

As part of the Budapest Declaration, countries will be pledging to take a series of actions to reduce harmful pollution emissions and mitigate climate impacts.

The actions range from safer waste management and switching to zero-emission transport systems to greener and healthier built environments. Actions in the health sector, including decarbonizing health systems and improving the climate literacy of health workers. 

There is a special emphasis on including youth voices and empowering youth organizations.

The 10 million disability adjusted life years in 2019 caused by ambient air pollution in Europe every year.

“The [Budapest] declaration is accompanied by a roadmap of actions. Member states can choose which things to focus on but we actually are urgently asking every country: Please take all actions aboard as much as you can,” said Brigit Staatsen, Chair of the European Environment and Health Task Force, at the briefing.

“The current and future generations are and will be affected by the triple crisis (climate change, biodiversity loss and pollution) and the effects of climate change on physical and mental health,” said Sara Cozzone, youth representative, Associazione A Sud – Ecologia e Cooperazione (Association South – Ecology and Cooperation). 

She added that tackling climate and eco-anxiety, which is increasingly being felt by young people, has to be a matter of urgency on the agenda of European institutions.

Environment and Health Process Partnerships for knowledge sharing

A new mechanism – Environment and Health Process Partnerships – will also be launched to facilitate collaborations and share knowledge on specific environmental and health challenges.  

Apart from challenges due to the changing climate, European countries are also facing a rapidly aging population, rising chronic diseases, and health workforce shortages as well as energy, cost of living, and geopolitical crises. Together the issues are exerting tremendous pressure on the healthcare systems. 

This week’s meeting in Budapest is the seventh such environment and health ministerial conference, whose aim is to devise and promote innovative policies to support long-term health and well-being of people in the WHO European Region.

The Conference was convened by the WHO Regional Office for Europe in collaboration with the United Nations Economic Commission for Europe (UNECE) and the United Nations Environment Programme (UNEP). 

Image Credits: Mariordo, CC, CC.

tuberculosis
The entrance of Sun City Prison in Johannesburg, South Africa.

Karabo Rafube was born to a single mother in 1982 in Soweto, a sprawling township south of Johannesburg, South Africa. His mother abandoned him three months later, and Rafube was taken to live with his father.

In the final years of apartheid, Soweto was a harsh place to grow up. His father already had an existing family, and Rafube says he was never welcome in his new home.

“About fifteen people lived under the same roof,” Rafube recalled in an interview with Health Policy Watch. “There were two bedrooms, one kitchen, and one TV room. It was very crowded.”

His father and stepmother had both died of diabetes by the time he turned fourteen. After his stepmother passed away, Rafube was adopted by a prominent local businesswoman who ran a fish and chip spot, a neighbourhood liquor store and a butcher shop. 

“My life started to change,” Rafube said. “Even in school I was able to concentrate.”

But one winter’s day in July 2001, after returning home from playing football in Pretoria, Rafube was arrested. He was accused of providing information on how to access the businesswomen’s house to two people who had been caught breaking in earlier that day. Rafube denies knowing the two individuals involved.

Soweto
Soweto Township was established by South Africa’s apartheid government in the 1930s to separate blacks from the white population of Johannesburg. Today, it is the largest black urban settlement in Africa, home to over 2 million people.

At 19 years old, Rafube was taken to prison to await trial. His bail was set at 3000 Rand, worth around $500 today. With no family to turn to for help, Rafube awaited trial in prison for the next two years.

“I was all alone,” he recalled. “Awaiting trial, that’s when hell broke loose.”

Rafube was squeezed for space from the moment he entered the transport van that first carried him to Sun City Prison on the outskirts of Johannesburg. He was placed in a cell with 150 other inmates on arrival at the prison.

“Our cell was overcrowded, it was packed. There was one shower, one toilet, it was so small,” said Rafube. “We were not screened for anything.”

A few months into his incarceration, still awaiting trial, Rafube started to feel weak.

“I saw myself losing weight dramatically, and suddenly I had sores all over my body from head to toe,” said Rafube. “I didn’t know what was going on.”

Rafube sought help from the prison nurse, but he was turned away. His condition worsened over the coming months, and several of his cellmates started to develop symptoms. As their health deteriorated and numbers climbed, the prison hired a new nurse who would change the course of their lives.

“She made sure that I was screened for TB and HIV,” said Rafube. “She actually cared about me.”

When the test results arrived, Rafube was finally diagnosed: he had TB. After months of suffering, he was put on a six-month treatment course that set him on the road to recovery.

New Study First to Track Prison TB Globally

tuberculosis
Estimated tuberculosis incidence in prisons by country in 2019.

Prisons have been associated with tuberculosis for decades. But unlike other high-risk groups such as people with HIV, global and regional data on the incidence of TB in prisoners has never been systematically collected – until now.

In a sprawling global study of TB in prisons in 193 countries published in the Lancet last week, researchers from the Boston University School of Public Health (BUSPH) found prisoners are nearly ten times more likely to contract TB than people living on the outside.

Around 125,000 of the 11 million incarcerated people worldwide developed TB in 2019. Nearly half of all cases in prisons are undiagnosed.

“Prisons are closed settings where we should be detecting 100% of those with TB,” said Anthony Harries, senior advisor at the International Union Against Tuberculosis and Lung Disease. “If you go to prison, you should not also have to contend with a high risk of getting TB.”

tuberculosis
Estimated new tuberculosis cases and notifications among incarcerated individuals in 2019 for countries with the highest number of incarcerated people.

Undiagnosed TB in prisons can have serious health consequences for both prisoners and the communities they return to, as prisoners who are unable to access medication or diagnosis may spread the disease to others when they are released.

Incarceration periods can be very short, and many people frequently cycle between prison and the general population. Incarcerated people can also be transferred between prisons, increasing the risk of infections spreading to new communities beyond their walls.

“Deceptively, this is not an immobile population,” Dr Leonardo Martinez, an epidemiologist at BUSPH and lead author of the study said in an interview. “If around 50% of cases are undiagnosed in prison, and then people are released, they are spreading TB to the general population.”

In Ciudad del Este and Asunción, Paraguay, a recent study found that around 30% of non-incarcerated individuals in both cities were culture-positive for the strain of TB circulating in each city’s prisons. Another study conducted in Brazil found that 50.6% of individuals with no incarceration history were part of infection clusters that included recently incarcerated people.

“It’s really important to show that mass incarceration has an impact on infectious diseases and health in general,” said Martinez.

Squeezed for space

prison
Inmates crammed together in an El Salvador prison during a cell check at the height of the COVID-19 pandemic.

As an airborne disease that spreads through close contact, TB is right at home in crowded, poorly ventilated prison cells. This is reflected in the numbers of the BUSPH study, which show that countries whose prisons are overcrowded also have the highest rates of TB incidence for incarcerated people.

The story of mass incarceration’s relationship to TB incidence in prisons is legible everywhere. The Philippines prison system is the most overcrowded in the world, jailing over five times its official capacity.

The country’s TB incidence in prisons – 3,829 cases per 100,000 people – is the highest in the world as a result, coming in at 30 times the rate observed in the general population and over three times the rate in prisons globally.

In Brazil, the prison population has skyrocketed in recent decades to over 800,000 people, up from just 230,000 in 2002. The country led the world in prison TB cases in 2019.

“The incarcerated population is increasing, crowding is increasing, and as a consequence TB rates are increasing as well,” said Martinez, who spent years working in Brazilian prisons. “There is a really strong relationship between the two.”

The South African prison system has one of the highest TB incidence rates in the world, clocking in at 20 times the risk faced by the global general population. This comes as no surprise to Rafube.

“Whether it was in the cells or the trucks on the way to trial, there was no space,” he said. “I was coughing on people when I was sick.”

Prisoners in Africa were twice as likely to contract tuberculosis than prisoners in other parts of the world in 2019. The Americas region had the largest total number of tuberculosis cases in prison that year, driven by the recent surge in mass incarceration in Central and South America.

“Our hope is that this data is the first step in saying: this is a huge problem, this is the amount of undiagnosed cases we have,” said Martinez. “Larger global health organizations should be collecting this data systematically, every year. I shouldn’t be doing this.”

Sentenced to tuberculosis

The constitution of the World Health Organization recognizes the right to the “highest attainable standard of health” as a fundamental human right.

Life behind bars can be excruciating for the 50% of prisoners who never receive a TB diagnosis. To the people behind the numbers, the high rates of tuberculosis in prisons raise an ethical question: Do we have the same right to health as everyone else?

Rafube is certain the nurse who oversaw his diagnosis saved his life.

“When I started to take my treatment, my life started to change,” said Rafube. “I was picking up strength, I was gaining weight.

“If it wasn’t for this woman, I wouldn’t be speaking with you now,” he said. “If she had arrived a month later, I would be gone.”

Today, Rafube is a “TB teacher” in South African prisons. He makes regular visits to the correctional facilities he almost died in to convince those suffering from TB that life is still worth living.

“Irrespective of your criminal record, irrespective of what you have done, make sure your health is okay, and you can be okay,” Rafube tells inmates on his visits.

He emphasizes the importance of sticking to the six-month medical schedule, as many prisoners choose to crush their medications into powder to sell or smoke.

The COVID-19 pandemic hit TB prevention efforts like a wrecking ball, leaving people suffering from TB more vulnerable than at any time in the last decade.

Deaths from TB jumped by over 100,000 worldwide in 2021 – the first increase in fatal TB cases since 2005 – and the World Health Organization estimated that disruptions to TB treatment may have caused an additional half a million deaths that year.

The BUSPH study data is limited to the pre-pandemic era. The impact of the pandemic on people suffering from TB behind bars is not yet known.

“We can’t end TB without treating everyone,” said Rafube. “That includes prisoners.”

Image Credits: Ye Jinghan, CC, CC, CC.

COP
UN Climate Change Conference, June 2023, Bonn, Germany.

The United Arab Emirates, hosts of the upcoming UN Climate Conference (COP28), have promised to deliver the first COP with a health focus. In addition to focusing attention on the existential human health risks of climate change, it is vital that a “Health COP” delivers commitments that maximize the health gains that can be obtained from more aggressive mitigation and adaptation. However, stalemates on finance and mitigation negotiations during the recent COP28 preparatory talks in Bonn (SB58) have left this December’s conference with a mountain to climb. 

The annual June UN climate meeting in Bonn in preparation for COP28 stalled, with tensions stemming from the failure of wealthy countries to deliver on their commitment to provide $100 billion per year to support low-income countries’ action on climate change. Meanwhile, major fossil fuel-producing countries took advantage of this impasse to oppose constructive discussion on climate change mitigation, and to block progress towards phase-out of the fossil fuels responsible for dangerous warming trends. 

In Bonn, governments came close to failing to agree even on the proposed agenda for the Bonn meeting itself. When finally set, the agenda omitted any mention of the crucial Mitigation Work Programme, where agreement is urgently needed on more rapid reductions of emissions of CO2, as well as short-lived, but powerful, climate change drivers like methane. 

In order to ensure the necessary time and attention is directed to negotiating solutions to the monumental threats our planet faces at COP28, these same delays cannot occur in Dubai at COP 28 (30 November-12 December). Willingness to meet commitments on climate finance, and to enter constructive discussions on mitigation, will be prerequisites for the talks to begin in earnest. 

Worsening trends 

These political developments are all the more worrisome in light of recent trends. 

A recent report from the World Health Organization noted that if our high emissions trajectory continues, nine million people per year will die annually from climate-related causes by the end of the century.

People around the world are already enduring climate impacts, from heatwaves, wildfires and air pollution, to floods and extreme storms. Climate change is also exacerbating crop losses and the spread of infectious diseases, as well as migration. The extraction and use of oil, gas, and coal harms people’s health, and is incompatible with a healthy climate future. That’s all the more reason that COP28 must deliver a commitment to phase out all fossil fuels, and a just transition to renewable energy for all.

Health considerations gaining more traction

Due to warmer climates, international travel and urbanization, one or more of the leading arboviruses are now present in most countries of the world.

While Bonn has left COP28 with plenty to do, the United Arab Emirates, host of this year’s climate negotiations, has committed to elevate attention to health. The country will deliver an official, Presidency-level health programme, including an official “Health Day” for the first time ever, as well as an inter-ministerial meeting on climate and health.

This is welcome. For years, the health community has hammered at the door of climate summits, exhorting delegations to acknowledge how health and climate are intertwined, and to protect people’s health from the impacts of a warming climate. 

The 2015 Paris Agreement invoked the “right to health” as a fundamental rationale for climate action. Even so, language about the “right to a clean, healthy and sustainable environment,” was nearly deleted from the final outcome text of COP27, only to be reinstated at the last minute.  

Despite these kinds of setbacks, it was clear at the Bonn meeting that health is at last penetrating deeper into the global climate negotiations. Country delegates integrated health references into discussions on the Global Stocktake, the Global Goal on Adaptation, and Loss and Damage in meaningful ways. This is unprecedented. 

We have argued that health and climate are connected, and must be addressed together. Our persistence is bearing fruit: we are now seeing the beginning of a crucial cross-pollination between the climate and health worlds – good news for people, and for the planet.

Health needs to be a driver for meaningful action, including mitigation and finance

However, as health gets further integrated into climate talks, it is essential that it serves as a driver for faster, more collective, and more meaningful action – including on critical mitigation and finance elements – as action in both of these areas is essential to protect and support people’s health in this era of multiplying climate crises. Greater investment in health systems and health adaptation, both vitally important steps, are not by themselves enough to protect people’s health.

If COP28 is to be the Health COP, it must do better than Bonn

The COP28 negotiations, and all those to follow, must go further than Health Days if people are truly to be at the centre of the climate agenda.

Most of all,  for COP28 to really achieve “Health COP” status, it must steer us away from dangerous tipping points and catastrophic levels of warming. Concretely this means a number of things, all of which must be supported by adequate finance and means of implementation: phase-out of fossil fuels; a just transition to renewable energy; and maximizing health gains of ambitious climate actions across sectors, spanning mitigation, adaptation and loss and damage.

Full phase-out of fossil fuels

COP28 must deliver the full phase-out of fossil fuels, and a just energy transition that does not saddle developing countries with outdated energy technologies and health-harming pollution. And it must deliver climate finance that enables all countries to make the necessary transitions to have clean energy access for all, and adapt and respond to climate impacts. 

Oil and gas projects in Africa are set to quadruple; projects in the Congo Basin, the world´s second largest rainforest, pose a major risk to regional and global climate stability.

Energy access is essential for health: governments must incentivize, invest in, and support a just clean energy transition, rapidly ramping up renewables to expand energy access, even while we simultaneously kick our fossil fuel addiction. Renewable energy can help overcome the lack of electricity access currently experienced by over 750 million people worldwide, positively influencing social determinants of health with reliable and clean cooking, heating, lighting, healthcare services, and education-related technology.

Governments must also take fast action to cut methane emissions – a short-lived super-pollutant with more than 80 times the warming effect of CO2 (in the short term) – as part of the swift energy, food system, and waste system transitions needed to limit warming.

Fossil fuel lobbyists have no place at COP 

Delegates at COP27 included over 600 corporate lobbyists from fossil fuel companies. Fossil fuel corporate lobbyists have no place at COP28 or in the climate policy-making space. 

Fossil fuel companies with the highest overshoot of the IEA’s net zero emissions scenario, in terms of planned oil and gas extraction.

For decades, these same fossil fuel companies have sown doubt and hidden evidence about climate change, and reaped massive profits, while people around the world have paid the price with our health and our lives. Governments banned the tobacco industry from involvement in decision-making on controls to protect people from the health harms of tobacco; they should just as firmly not allow the fossil fuel industry to dictate our climate and health policies. In response to growing concerns, the UNFCCC will, for the first time this year, require all participants – including lobbyists at COP28 –  to disclose their affiliation. This is a small step in the right direction.

Addressing “co-morbidities of climate change”

COP28 should also address the many “comorbidities of climate change”, such as unsustainable agriculture, urban sprawl, biodiversity loss, and air pollution. The recent forest fires in Canada are but one example of the vicious cycle we are in: climate change drives extreme events, which in turn both contribute to worsening climate change and intersect with and aggravate other serious environmental and health impacts.

Climate change is impacting people’s health now. At COP28, governments must invest in adaptation measures, including building greater resilience of healthcare and public health systems, and in integrating health considerations into adaptation across other sectors. Leaders must also grasp that while adaptation is essential, adapting to a world that has warmed by 2.8°C will prove well nigh impossible – so they must hold fast to their commitments to limit warming to as close to 1.5°C as possible.

Integrating health into finance for adaptation and mitigation

COP28 must integrate health into financing for adaptation, mitigation and loss and damage, with substantial new and additional funding across these areas. Between 2018 and 2020, only 0.3% (14 million USD) of climate adaptation finance was allocated to health sector adaptation, though 13.9% of adaptation was allocated to sectors benefiting health. Meanwhile, according to donor tracking, approximately 7% of bilateral health Official Development Assistance, (ODA) (US$1.58 billion) contributes to climate adaptation, though figures may be lower in reality due to misreporting. Very little synergistic investment is made in health and climate mitigation. 

Finance and technical assistance for low-income countries are critical for protecting people’s health through climate preparation and response, and to make the system transformations required for a healthy, sustainable future. It’s unclear whether or not the recent Summit for a New Global Financing Pact in Paris made meaningful progress in this direction. 

Within the health sector, health civil society and ministries of health are increasingly discussing climate action, from local and national to regional and global levels. With a health focus at COP28, we hope to witness a record number of health ministers in attendance. 

The health community is working to make health systems low-carbon and climate-resilient and to integrate climate change into health professional and health worker education and training. We must go further, divesting health associations and organizations from fossil fuels, and addressing climate change in global health investments and programmes. We are also using our influence to push for effective climate action that protects people’s health, and for climate solutions that secure a stable, livable, and equitable future for humanity.

We need a true Health COP

What should world leaders do to make COP28 a true Health COP? It’s a welcome start to have a Health Day and an inter-ministerial meeting that brings health ministers to COP as part of their national delegations. To be a true Health COP, however, COP28 must deliver an end to the fossil fuel era, deliver financial and technical support to countries most impacted and least responsible for climate change, and bring climate progress centred on people’s health and well-being. 

Dr Jeni Miller is the Executive Director of the Global Climate and Health Alliance, an alliance of more than 150 health professional and health civil society organizations addressing climate change.
Jess Beagley is the Policy Lead of the Global Climate and Health Alliance, an alliance of more than 150 health professional and health civil society organizations addressing climate change.

 

 

 

 

 

 

 

 

 

 

Image Credits: Pixabay, Jess Beagley, Rainforest Foundation and Earth Insight, 2022.

Countries increased their spending on health during the pandemic. Building interest for investing in pandemic preparedness is proving more difficult.

With a drop in government spending on preparedness and woefully inadequate donor pledges, how can the ambitious new commitments envisioned for a WHO Pandemic Accord ever be financed? This second issue of Governing Pandemics Snapshot, looks at this conundrum and possible solutions, including creative forms of debt relief for low-income nations. 

This issue also provides updates on negotiations over the WHO Pandemic Accord and parallel talks on amendments to the International Health Regulations. Finally, it provides fascinating insights into the thorny question of how “medical countermeasures” might be handled in either accord, where North-South divides persist. In addition there are questions about who might manage a new global countermeasures platform – the G7, G20 or WHO? 

Later this month, the Pandemic Fund Governing Board is due to meet in Washington D.C. to make the first round of decisions on disbursement of some $300-350 million in initial funding for pandemic preparedness. However, due to a woeful shortfall in funds so far raised for the fund, hosted by the World Bank, most of the requests submitted by some 129 low- and middle-income countries will likely be denied.

The first two years of the pandemic saw a sharp rise in government spending for health while the general government expenditure trends remained mostly constant, indicating a great political will at country level to fund a response to an urgent health crisis. 

However, in 2022 as inflation drove increased costs of living in energy and food, trends shifted, with a decline in governments’ health spending – over which the World Bank has expressed concerns.

That has once more left health systems vulnerable, and unable to plan for future crises. Although pandemics and their governance continue to attract attention in Geneva, in relation to the ongoing negotiations over for a pandemic treaty and amendments to the International Health Regulations, recent developments suggest that countries are perhaps not as committed to Pandemic Prevention, Preparedness and Response (PPPR) financing as they initially seemed.

The Pandemic fund – status today  

G7 leaders in Hiroshima, Japan.

The ambitious Pandemic Fund, created late last year within the World Bank, has so far raised around $2 billion including the recently pledged $250 million by the United States, announced at the recent G7 Leaders Summit in Hiroshima. 

But this is far short of the $10.5 billion estimated annual gap in PPPR donor requirement. After the first round of calls for proposals, requests for funding amounting to $2.5 billion have been submitted in some 180 applications from 129 low- and middle-income countries.

All of these requests are competing for the relatively minuscule $300-350 million that the Fund currently has to disperse – meaning that most countries will likely not receive any funding at all – or very minimal funding at best.

Although the Fund may be able to raise more money through replenishment rounds, one recent study by the US-based Center for Policy Impact and University of Leeds, has concluded that “total donor funding requirement is closer to US$ 15.5 billion, rather than US$ 10.5 billion; WHO and WB assume that donors are already providing 100% and 60% of the LIC and LMIC PPR costs respectively, which we believe does not hold outside of pandemic times.” 

Nonetheless, even sticking with the US$ 10.5 billion and under the most favorable scenario of donors increasing the percentage of their GNI given to ODA by 2.5% each year – a mean of US$ 213 billion over 6 years, the PPPR donor requirement gap could not be filled.

PPPR funding in draft treaty – heavily referenced with few real commitments  

WHO member states discuss new pandemic convention or treaty, 18 July 2022.

PPPR financing represents a significant theme in negotiations over a pandemic accord.  In the latest text released by the Bureau guiding the negotiations of the Intergovernmental Negotiation Body, Article 19.3(a) on “financing” refers to a fund  “to be funded, inter alia, through the following sources: i. Annual contributions by Parties to the CA+, within their respective means and resources; ii. Contributions from pandemic-related product manufacturers; iii. Voluntary contribution by Parties and other stakeholders”.  

Additionally, the draft Article 19.3(b) calls for the creation of a second separate “voluntary fund”, which would rely entirely on voluntary contributions by “all relevant sectors that benefit from good public health (travel, trade, tourism, transport)” foreseeing a considerable role of both public and private actors.

Article 19 also seems to privilege voluntary options over binding financing obligations, so it’s unclear whether this fund could realistically be filled. Additionally, it remains unclear if the disbursement of monies from the two funds foreseen by the Bureau’s text would be somehow linked with another key set of issues raised by developing country demands – for example, the sharing of “benefits” derived by pharma from their sharing of data on new and emerging pathogens. 

National and ODA commitments to fund PPPR also watered down 

Furthermore, the Bureau’s text has significantly diluted certain States’ obligations included in the previous Zero Draft text. 

For instance, following the suggestion of more than 60 countries, the document no longer includes the commitment by state parties to allocate a certain proportion of their domestic resources to PPPR. In fact, the obligation to dedicate 5% of their “current health expenditure” to PPPR (art. 19.1.c) was deleted from the most recent version of the text. 

Likewise, more than 30 -mostly high-income- countries successfully lobbied for the removal of language on a parallel obligation by countries to allocate a specific percentage of GDP to international cooperation and assistance for PPPR (art. 19.1.d).

Converting debt repayments into pandemic preparedness investments 

Barbados Prime Minister Mia Mottley.

A new, promising financing option that has been included for consideration in the Bureau’s text is the conversion of a portion of countries’ debt repayment installments into PPPR investments. 

A clause referring to this, Option A in Article 19.6 would establish a programme to “convert debt re-payment into pandemic prevention, preparedness, response, and recovery investments in health”. 

Creative refinancing of developing country debt has become a rallying cry of Barbados Prime Minister Mia Mottley in her Bridgetown Initiative. Speaking at a recent conference on Noncommunicable Diseases in Small Island Developing States, Mottley stressed that the approach should be used to make badly needed investments in health as well as in climate mitigation and adaptation. 

According to the World Bank’s International Debt Statistics 2022, low-income countries’ debt rose by 12% in two years (2020-2022) as a result of the pandemic. 

Debt burdens hinder the ability of countries to recover and rebuild capacities and further distract resources away from the health sector. A recent OXFAM report revealed how development finance channeled billions into expensive for-profit hospitals in lower-income countries that deny access to healthcare to patients who cannot afford to pay.

WHO budget boost is one optimistic signal 

WHO
The World Health Organization operates on a shoe-string budget relative to its mandate.

Against this worrisome context, one optimistic note was sounded at the recently concluded 76th World Health Assembly in May that approved the organization’s programme budget for 2024-2025, including a historic 20% increase in member states’ assessed contributions to the agency’s budget. Although these funds will not be specifically for PPPR, they lay the ground for a more predictable and sustainable WHO’s financial model which will hopefully strengthen its role and capacities in, inter alia, the PPPR domain. 

In conclusion, the landscape for PPPR financing remains unclear and, to some extent, worrisome. There is no guarantee that the Pandemic Fund will be able to secure significantly more resources and the current options inside the pandemic instrument lack strong national and international commitments, while inflation and debt continue to rise. 

As such, financing PPPR is faced with a multiplicity of challenges and risks of being underfunded once again. It takes strong political will and innovative thinking to raise sufficient resources and use them in the most efficient manner.

For more coverage of the negotiation over WHO Pandemic Accord and parallel talks on amendments to the International Health Regulations, see the complete  Governing Pandemics Snapshot.

Image Credits: US Mission Geneva.

Covax
A COVAX vaccine delivery to Africa in April 2021. 

Some of the $2.6 billion that remains in a COVID-19 vaccine delivery scheme, COVAX, could be redirected into investment into investigational vaccine candidates for Marburg Virus Disease (MVD) and Ebola Sudan strain virus, as well as over half a dozen other vaccine programmes that were suspended due to the pandemic or delays in product development, a spokesperson for the Global Vaccine Alliance (Gavi) told Health Policy Watch. COVAX is a COVID vaccine initiative jointly run by Gavi, the World Health Organization (WHO), and the Coalition for Epidemic Preparedness Innovations (CEPI) co-sponsored by WHO and financed by donations from high-income countries. 92 low- and middle-income countries can participate through COVAX Advanced Market Commitment [AMC], a financing instrument launched by Gavi.

Pilot trials for new MVD and Ebola vaccines were among a series of new investments  approved by the Gavi Board last week, in part with the support of the surplus funds from unused COVID vaccine delivery to low-income countries. 

The board also approved new investments into a hexavalent vaccine which will offer protection against six diseases–- diphtheria, tetanus, pertussis (whooping cough), hepatitis B and Haemophilus influenzae type b, and the inactivated polio vaccine (IPV). However, the Board remains committed to making COVID-19 vaccines available to high-risk groups in eligible low-income countries until 2025, a Gavi press statement underlined. 

Restarting programmes in new vaccinations 

The agency is also taking advantage of the lull in COVID vaccine demand to restart programmes introducing approved vaccines against hepatitis B, DTP boosters, a post-exposure prophylaxis for rabies, maternal RSV, and a multivalent meningococcal conjugate vaccine. 

“Decisions taken by our Board will help countries fight disease more cost-effectively, be better equipped to fight back against emerging threats and continue to protect those most at risk from COVID-19,” said Professor José Manuel Barroso, chair of the Gavi Board. He said the decisions will bolster Gavi’s record as “an innovator and a disrupter in global health.”

“The next steps in this process are to continue working with Alliance partners, particularly the WHO, UNICEF and countries to create timelines, technical guidance for introduction of these new products, and outline the parameters of these new programmes,” the press statement added. 

In its meeting, the Board also approved a long list of vaccines to be considered in the agency’s next vaccine investment strategy, which is expected to be finalized in 2024.

Those include licensed or pipeline products against hepatitis E, Mpox, dengue, COVID-19, tuberculosis, group B streptococcus, chikungunya and shigella. 

Investment in the global stockpile of vaccines

The Gavi board described its allocation to global stockpiles of vaccine candidates against MVD and Ebola Sudan virus as a  “time-limited investment”, pending recommendations by “scientific expert groups”.  

“The concept of Global Virtual Pool Inventories (GVPIs) is to establish small reserves of investigational vaccine candidates, which would be ready for use [condition] in the event of an outbreak,” the press statement said.

Opportunities to jumpstart a clinical trial of vaccine candidates for Ebola Sudan Virus were missed late last year because it took time to get the vaccines into place in Uganda, at which point the outbreak was already in decline, and was finally declared over in early 2023.

In early 2023, 2000 doses of MVD vaccine candidates were made available for administration as part of a planned “ring trial” among those diagnosed with the disease during the recent outbreak in Africa. 

However, the WHO couldn’t proceed with the trials due to lack of sufficient participants, followed by the eventual declaration that the MVD outbreak was over in late March. 

There are no global stockpiles of vaccines for MVD and Ebola Sudan virus at present, partly because the vaccines have not been approved by regulators. But experts have emphasized that having stockpiles available and ready for more rapid deployment could facilitate trials that demonstrate vaccine efficacy – or lack thereof. 

Image Credits: WHO.

The World Health Organization (WHO) launched a new guideline on Monday in a bid to push governments to adopt more stringent regulations on the marketing of unhealthy foods high in saturated fatty acids, trans-fatty acids, free sugars or salt (HFSS) to children. 

The UN health body has hardened its stance on what it describes as predatory practices used by fast food companies. This is the first time the WHO has advised countries that only mandatory regulations to curb the industry’s ability to target children will address the problem. WHO added that the ubiquity of advertising means the measures must also “go beyond children’s media”.

“Marketing is done to promote products, and promoting products is done to improve profits,” Francesco Branca, WHO Director of Nutrition and Food Safety told reporters on Monday. “This is a classic situation where there is a conflict between the objectives of private entities and the interests of public health.” 

The updated guidance follows over a decade of stalled progress since the World Health Assembly first endorsed recommendations to protect children from harmful food marketing in 2010. Thirteen years on, policy coverage around the world remains poor, with just 60 countries worldwide adopting policies restricting food marketing to children. Only 20 of them have passed mandatory legislation. 

And the laws that are in place often have holes. For example, policies currently in place often only protect young children under the age of five, and many do not cover digital marketing, the main source of ad exposure for children in a digitized world.

“It is an increasing worry for all of us that children are now exposed to harmful food marketing in digital spaces,” said Dr Ailan Li, Assistant Director-General for Healthier Populations at WHO. “Digital marketing is the most important now, and for the future.” 

Guideline’s goal is to stem childhood obesity

Almost no progress has been made in reducing childhood obesity in two decades.

WHO’s drive to limit the power of unhealthy foods marketing to children is grounded in concern around the childhood obesity epidemic gripping the world, especially low- and middle-income countries. Almost no progress has been made in batting back childhood obesity rates in over two decades.

Nearly 40 million children under the age of 5 were estimated to be overweight or obese in 2020 – 41% them living in low- and lower-middle-income countries – and another 337 million children aged 5-19 suffered the same conditions in 2016, the most recent year for which data is available. 

Efforts by industry to address the negative health effects of their food products exist, but continue to fall short. Interference in policymaking by the food industry through lobby groups remains commonplace, Li said, often resulting in “weakened, delayed or defeated policies”.

With no sign industry will voluntarily restrict itself in more meaningful ways, WHO officials say it is time to accept the market realities and impose regulations from the top down.

“The obligation of commercial actors is to continue practices that prioritize profit over health unless required to do otherwise,” said Juliette McHardy, a legal expert consulting on the commercial determinants of health at WHO. 

“Certain health-harming industries are by the very nature of their business models misaligned with the public health interests … including those segments of the food industry whose product portfolio largely comprises unhealthy options,” she said.  “The principal profit generating products and services of these industries require they grow their markets by shaping our preferences and knowledge in favour of harmful products and behaviours.”

Children’s right to health threatened

Mother and son in Usolanga, Tanzania. Childhood fat is traditionally seen as a sign of abundance, but too much of it can lead to obesity and related diseases later in life.

Marketing harmful foods to children is not just a question of healthy diets: it is a question of children’s rights. 

This is the conclusion arrived at by WHO based on the nearly 200 studies of children’s exposure to food marketing and its influence on eating-related attitudes, beliefs, and behaviors in children reviewed to estblish its updated guidance. 

“Arguments in defense of marketing fade when the marketed products harm health and when marketing poses a threat to children’s rights,” WHO said. “Marketing is a recognized means to promote products that are harmful to health.”

The UN Convention on the Rights of the Child, ratified in 1989, recognizes the right of children to health, the achievement of their full developmental potential, privacy and freedom from exploitation. 

The omnipresence of marketing for unhealthy foods in the day to day lives of children – whether on television, at school, on social media or at sports clubs – violates those rights, as does the non-consensual exposure of children to advertisements that have the power to dictate health outcomes for them when they are adults, WHO said.

“Countries that are State Parties to the Convention are obliged to take action toward the fulfilment and realization of children’s rights,” said WHO. “This should include actions to protect children from marketing of HFSS foods as such marketing negatively affects children’s rights, such as the rights to health, adequate and nutritious food, privacy and freedom from exploitation.”

Dietary risks caused nearly 8 million deaths and over 10% of all disability-adjusted life years lost to NCDs in 2019. The evidence conclusively shows that marketing foods high in saturated fats, sugars and salt can influence children’s dietary preferences, and governments must do what they can to prevent children from becoming one of those statistics, WHO experts said. 

“A core part of regulating health-harming markets and market segments is narrowing in on the core business models of relevant commercial actors and reducing their ability to use marketing and other tactics to shape public preferences and undermine public knowledge of harms,” said McHardy.

“Building up public sector capacity in this way reduces those asymmetries in power which undermine political will and capacity to effectively devise, adopt and enforce marketing and other regulations,” she said. 

For the younger generations accustomed to seeing their futures overlooked for the sake of profit in the climate debate, the financial motive behind the marketing of unhealthy foods strikes a personal chord.

“By allowing predatory marketing to infiltrate our schools, our media and our communities, we are really jeopardising the rights of our children to grow, learn and develop free from exploitation,” said Pierre Cook Jr., Technical Advisor for Youth Voices at the Healthy Caribbean Coalition. “Profit often trumps the well-being of our children. We need to be steadfast in our resolve to challenge this pervasive culture of exploitation.” 

Image Credits: World Obesity, Jen Wen Luoh.

South Africa’s Economic Freedom Fighters’ party protests against Uganda’s Anti-Homosexuality Act in Pretoria, South Africa.

As Pride month celebrations wind down in parts of the world that recognise LGBTQ rights, Ugandan human rights organisations have recorded a record number of abuses against that community following the introduction of the Anti-Homosexuality Act in that country one month ago.

Meanwhile, the World Bank sent a fact-finding mission to Uganda last week following an international appeal by over 170 organisations to suspend future lending to Uganda following the enactment of the law.

Beating, kidnapping and evictions of LGBTQ people have been recorded by the Human Rights Awareness and Promotion Forum (HRAPF) b y people who have come to its legal aid clinic for help.

A consortium of civil society groups called the Strategic Response Team (SRT) has estimated that the number of attacks on the LGBTQ community in the past month is around 300 – 10 every day.

In the three weeks (30 May-20 June) following the introduction of the Act, the HRAPF’s legal aid clinic attended to 30 cases involving discrimination against LGBTQI people based on their sexual orientation or gender identity – in contrast to 10 cases over the same period last year.

In one case, a man was attacked in his home by a group of men one night. He was beaten and some of his property burnt by the mob, which accused him of being a homosexual.

In a similar incident, a lesbian was attacked by two men in her home. She had been evicted by her landlord on the grounds of homosexuality but did not have the resources to move.

“Most of the violations are by non-state actors, who use the prevalent homophobic environment to carry out attacks and threats knowing that LGBTQ persons will not have recourse to the police for fear of being arrested,” according to HRAPF.

“Indeed, most of the cases were not reported to the police for fear of arrest under the Act. The law is therefore promoting an environment of lawlessness to the detriment of real or suspected LGBTQ persons in Uganda, without any recourse to the law for remedies.”

The forum noted that its report is not comprehensive as it only reflects clients that have sought its help, whereas there are other legal aid providers.

The attacks are being documented to support the court petition to get the Anti-Homosexuality Act overturned for being in contravention of the country’s Constitution.

World Bank under pressure

During last week’s fact-finding mission to Uganda, World Bank delegates met human rights organisations but have yet to act against Uganda.

When that country introduced a similar law in 2014 – referred to as the “kill the gays” law, – then-World Bank President Jim Yong Kim postponed a $90 million loan to the Ugandan government in response. The current law goes even further as it contains the death penalty as well as potential prison terms for minors.

However, aside from issuing a statement on May 31 stating that Uganda’s Anti-Homosexuality Act is “not consistent with the values of non-discrimination and inclusion that the institution upholds”, the Bank has yet to take action.

Numerous attempts by Health Policy Watch to get comment from the World Bank about its visit to Uganda and any action they intend to take went unheeded, although the Bank finally acknowledged receipt of the queries on Thursday.

HIV programmes under threat

Meanwhile, Uganda’s Ministry of Health sent a circular to health facilities recently urging them to continue to assist all citizens seeking healthcare. 

This is likely to be in response to pressure from international health agencies, including the US President’s Emergency Plan for AIDS Relief (PEFAR), which is concerned that the Act will prevent LGBTQ people from getting access to health services.

PEPFAR has suspended meetings with the Ugandan government to discuss the adoption of its Country Operational Plan for 2023, citing the Anti-Homosexuality Bill as the reason. PEPFAR spends around $400 million in the country annually.

PEPFAR has “invested over $5 billion in HIV prevention, care, and treatment services in Uganda” over the past 20 years, including the massive scale-up of its antiretroviral therapy (ART) programme, which is estimated to have averted almost 600,000 HIV-related deaths and 500,000 new HIV infections, according to a statement from the US Embassy in Uganda earlier this year.

“The first person in the world to receive PEPFAR-supported HIV treatment almost 20 years ago is a Ugandan who is alive and thriving, further demonstrating the success of this lifesaving program,” the US Embassy added.

According to UNAIDS data, 1.4 million Ugandans are estimated to be living with HIV, and over 1.3 million are currently receiving PEPFAR-supported HIV treatment. 

However, a cornerstone of the HIV/AIDS sector’s approach to HIV globally is targetting “key populations” who are most vulnerable to HIV – including men who have sex with men (referred to as such as many do not identify as gay, particularly in countries where they would face persecution if they did).

PEPFAR head Dr John Nkengasong recently said that the “passage of the Anti-homosexuality Act jeopardizes efforts to end HIV/AIDS, achieve health equity, and risks the lives of LGBTQI+ individuals and other key populations that need lifesaving treatment and prevention services.”

A petition challenging the constitutionality of the Act has been filed, as well as a notice of motion to suspend its enforcement pending the determination of the petition. The notice of motion was filed by eight people including Fox Odoi-Oywelowo, the only Member of Parliament to oppose the law.

Uganda’s Attorney General has responded to the petition, and Odoi-Oywelowo and others are in the process of responding to his letter, according to a civil society report.