Particles of air pollution settle on the leaves in a south Delhi neighbourhood where the PM 2.5 is  approximately 400 micrograms/cubic metre.

New evidence shows that one in four deaths between 2009 and 2019 is linked to PM 2.5, one of the most dangerous pollutants commonly monitored. 

NEW DELHI – In November Delhi recorded its worst day of air pollution since 2019. As concerned citizens expressed outrage, authorities scrambled for answers – and it seems that the dirty air crisis may be worse than previously reported.

A new study published in The Lancet this week analyses the link between air pollution and deaths in districts (an administrative jurisdiction of a state or province) in India over 11 years from 2009. 

It shows pollution is not just a Delhi problem nor is it a recent problem, estimating that during the time period, 16.6 million deaths are attributable to PM 2.5 pollution. This is the particulate matter pollutant that is much finer than human hair that penetrates deep into the human body. 

The report is timely as the Supreme Court is now expanding the scope of its air pollution hearing from Delhi to cover all of India. 

A south Delhi neighbourhood with PM 2.5 at approximately 400 micrograms/cubic metre.

The study calls for a fundamental rethink of India’s battle against air pollution. Firstly, it shows 24.9% of deaths – almost one in four – are attributable to air pollution, more specifically PM 2.5. 

Secondly, it calls for India’s regulatory standards for air quality to be tightened. The Indian National Ambient Air Quality Standards for annual mean PM2.5 is 40 micrograms per cubic metre (µg/m³) whereas WHO’s guideline is 5 (µg/m³). 

Thirdly, the authors say this report is more relevant to policymakers than previous reports as it is based on data from India. In the past senior Indian government officials have questioned or rejected data linking deaths to air pollution, particularly from global agencies. 

More deaths than previously estimated

The Lancet report found an average of 1.5 million deaths from air pollution between 2009 and 2019, almost a quarter of all deaths.

This is a higher estimate of mortality than earlier studies. For instance, a WHO study reported an average of 830,000 deaths annually in the decade ending 2019, a conservative estimate based on secondary data sources. 

A study for 2019 by the Indian Council of Medical Reseach (ICMA), a government agency, and others estimated 1.7 million deaths. The new study tops that with 1.8 million attributable deaths for that year.

Applying the more relaxed guideline of 40 µg/m³ for PM 2.5 set by the Indian government, the number of deaths is estimated by the Lancet report to be 3.8 million over 11 years, or 300,000 every year. 

The entire population of India breathes air of a quality worse than the WHO’s guideline for an annual average.

New data is ‘more credible’ 

While there have been several large-scale studies globally on the link between PM 2.5 air pollution and deaths, this is the first such one in India which in recent years has the most polluted places. 

One of the authors, Dr Siddhartha Mandal, told Health Policy Watch that studies usually make associations between exposure to PM 2.5 and mortality. However, this report “lends more credibility” to the numbers because it uses a difference-in-difference approach to reach causal estimates. This methodology compares the changes in outcomes over time between a treatment group and a control group.

(A) Annual mean concentrations of PM2·5 in 2009. (B) Differences in annual concentrations in 2014 compared with 2009. (C) Differences in annual concentrations in 2019 compared with 2009.

“We believe that our study provides the most accurate exposure-response function and health impact assessment in India to date based on causal estimations from a state-of-the-art comprehensive exposure assessment and nationwide mortality data collected in India,” according to the authors.

It covers air pollution across 655 districts of India. The authors collected and analysed national counts of annual mortality for the 11 years, and also factored in the population and GDP per capita for each district. 

The authors say they observed stronger associations between annual PM2.5 averages and mortality in poorer districts (in terms of GDP).

Risk of death rises with pollution

In a country racked by an air pollution health crisis, there is one pressing figure for policymakers. Every 10 microgram/cubic meter increase in PM 2.5 leads to an increase in all-cause mortality rates by 8.6%, the study estimated. 

PM2·5 concentration is shown up to the 99th percentile.

While the AQI at 500 or 1,000 grab headlines, what the research points out in terms of health risks at lower levels is an eye-opener. 

“As the exposure levels increase, a plateauing effect is seen where, if you keep increasing the levels, additional increments in health are likely to be small,” says Mandal, who is affiliated with the Centre for Chronic Disease Control, New Delhi, and the Centre for Health Analytics and Trends, Ashoka University.

Simply put, that means that the risks rise from much lower levels of PM 2.5, when many thought the air quality was fine, but as the levels become extremely high, the risk may plateau or taper. 

How PM 2.5 harms humans

“Due to its size, PM 2.5 can enter the bloodstream and hence gets transported to multiple organs,” Mandal explains.

“Thereafter several common mechanisms such as inflammation and oxidative stress are triggered or exacerbated in the tissues.

“One of the major ways by which PM2.5 affects cardiovascular health is by inducing an imbalance in the autonomic nervous system, which controls several involuntary functions in humans such as cardiac rhythm. So PM2.5 contributes in multiple ways leading to exacerbation or acceleration of these conditions and subsequently death.”

A few days before this report was published, the Indian government reiterated in Parliament that “there are no conclusive data available in the country to establish direct correlation of death/disease exclusively due to air pollution.

“Health effects of air pollution are synergistic manifestation of factors which include food habits, occupational habits, socioeconomic status, medical history, immunity and heredity etc. of the individuals.” 

However, the authors say that policymakers could first take stock of all the recent work done relating air pollution and health (including mortality) using Indian data.

Experts from multiple domains, including public health, clinicians and engineering disciplines can deliberate on how to incorporate health-related evidence into designing interventions, mitigation strategies as well as revision of air quality standards. 

In parallel, there should be targeted actions backed by scientific evidence in the short and long-term, rather than reactive actions. For example, one could design and test out a public transport based intervention in certain areas within Delhi to assess how it affects pollutant levels across time. 

But they say, “most importantly, we should not wait for a perfect study to emerge and rather utilise available national as well as international evidence to take steps to improve the quality of air in the context of health.”

Image Credits: Chetan Bhattacharji, The Lancet.

Robert F Kennedy Jnr, Trump’s pick for US Health Secretary

Robert Kennedy Jr, President-elect Donald Trump’s nominee to lead the United States health system, arrived in Washington, D. C. on Monday to rally support from lawmakers for his candidacy amid fears from health experts that the anti-vaccine activist and lawyer could roll back hard-won public health gains credited with saving millions of lives and protecting more from deadly disease.

Kennedy’s campaign on Capitol Hill kicks off following revelations last week by the New York Times that Aaron Siri, his lawyer on the campaign trail who is helping him vet picks for federal health officials at the Florida white house in Mar-a-Lago, petitioned the Food and Drug Administration (FDA) to revoke its approval of the polio vaccine.

The polio vaccine, first approved over 70 years ago, has protected hundreds of millions of people in the US and around the world from the deadly disease, which primarily affects children under five, attacking the nervous system and causing paralysis and death.

“RFK Jr has spent virtually his entire career casting doubt about vaccines. This is all part of a pattern that has gone on for a decade or more,” Lawrence Gostin, a public health expert at Georgetown University, told Health Policy Watch. 

“Vaccines are among the most studied medical interventions, far safer than many medicines in people’s homes that they take regularly, such as ibuprofen.

“We need widespread vaccination coverage to protect everyone,” Gostin added.

Before the first poliovirus vaccine in 1955, children affected by polio depended on a mechanical respirator known as an “iron lung” for their survival as they had respiratory paralysis.

Prior to routine vaccinations in the 1960s, childhood illnesses like polio, measles, diphtheria, tetanus, mumps, and rubella killed and hospitalized hundreds of thousands of children annually in the US. The overwhelming success of vaccines has largely erased these memories, shifting public debate towards vaccine safety rather than the diseases they prevent. 

A reminder of how recent the dangers of polio are came from Senator Mitch McConnell, 82, who is a survivor of childhood polio, which he contracted at age two. As Kennedy hit Capitol Hill, the Republican Senate leader issued a sharp warning against any suggestion the polio vaccine’s approval should be questioned.

“Efforts to undermine public confidence in proven cures are not just uninformed – they’re dangerous,” McConnell said in a statement. “Anyone seeking the Senate’s consent to serve in the incoming administration would do well to steer clear of even the appearance of association with such efforts.”

Extensive testing of vaccines

The first polio vaccine, invented by Dr Jonas Salk in 1955, underwent extensive testing against placebos in nearly two million American children before its rollout. The modern-day vaccine, manufactured by French pharmaceutical firm Sanofi, did not undergo placebo trials but is very similar to the original Salk vaccine.

 Siri, Kennedy’s lawyer who has been involved in extensive efforts to fight vaccines of all kinds nationwide, pointed in his legal filings to this lack of a placebo control trial, arguing the vaccine should be suspended until this happens. 

That would mean depriving children of a vaccine that will protect them against a potential death, however, which the overwhelming majority of health experts consider unethical. Salk himself opposed the placebo trial conducted on his original vaccine for this same reason.

“Randomized control trials are unethical in the context of vaccines because vaccines are so effective – we can’t give a person a placebo knowing that he or she is susceptible to potentially serious or deadly infectious diseases,” Gostin said. “Since we know vaccines are highly protective, we can’t withhold the treatment.”

Sanofi notes that the vaccine has been used by nearly 300 million people worldwide. More than 300 studies, including trials with follow-up periods of up to six months, have been conducted since the vaccine’s development began in 1977.

“From the age of two, normal life without paralysis was only possible for me because of the miraculous combination of modern medicine and a mother’s love,” McConnell said. “But for millions who came after me, the real miracle was the saving power of the polio vaccine.”

Today, wild polio remains endemic in just two countries: Afghanistan and Pakistan. Forty-six nations across Africa and the Asia Pacific are listed as outbreak countries by the Polio Eradication Initiative.

Global efforts led by the Rotary Club, the global vaccine platform Gavi, the Global Fund, the Gates Foundation and the Polio Eradication Initiative aim to eradicate polio. This would make it only the second disease ever to be fully eradicated after smallpox, considered the largest global health victory in history.

A health worker administers a polio vaccination in Pakistan’s northwestern region.

US childhood vaccination rates are falling

In statements to legacy media outlets, congress and cable networks, Kennedy has been careful to craft a moderate image on vaccines. Katie Miller, a spokeswoman for his office, said in response to the New York Times report on Siri’s efforts to revoke polio vaccine approval that Kennedy “has long said that he wants transparency in vaccines and to give people choice.”

Yet Kennedy and Siri are key players in a profitable industry of anti-vaccine activism that flourished during the COVID-19 pandemic, which killed over 1.2 million Americans. Their ascent coincides with reports from the Centers for Disease Control and Prevention (CDC) of falling childhood vaccination rates for all available vaccines.

Earlier this year, measles outbreaks were reported in 15 US states, coinciding with the lowest child immunisation rates the country has seen in 10 years, according to the CDC.

Kennedy has repeatedly stated he believes vaccines cause autism and “neurodevelopmental disorders.” Asked whether he would support a move to end childhood vaccination programs if Kennedy passes the Senate, Donald Trump told Time magazine: “We’re going to have a big discussion. The autism rate is at a level that nobody ever believed possible. If you look at the things that are happening, there’s something causing it.”

Long anti-vax history

Kennedy was a key figure in the anti-vaccine world long before the COVID-19 pandemic shut down the world in 2019. 

He took over the flailing World Mercury Project in 2015, a non-profit named after the belief that mercury in vaccines causes autism in children. He rebranded the organisation as Children’s Health Defense (CHD) in 2018 and has shepherded it into a global anti-vaccine juggernaut.

CHD,  which Kennedy led until stepping down for his presidential run, is one of the top medical disinformation sites on the internet. This week, the most-read story on the Defender, CHD’s news arm, covers a study led by Peter McCollough, another leader in the anti-vaccine movement, who argues that COVID-19 vaccines should be suspended by the FDA. The study appears to be based on a misuse of VAERS, a federal database that records unverified reports of adverse events.

The “peer-reviewed study” is published in the misleadingly titled Journal of American Physicians and Surgeons, the publication of a conservative non-profit that has also published studies on the “health benefits of firearms,” which calls gun research sponsored by the CDC “junk science.”

It has also published articles claiming that tobacco taxes and indoor smoking bans harm public health and that there are links between abortion and breast cancer. It is not listed in academic literature databases such as MEDLINE, PubMed or Web of Science.

CHD, whose revenue skyrocketed from $1.1 million in 2018 to $23.5 million in 2022, the last year for which tax disclosures are available, is part of a constellation of “medical freedom” groups that include the Informed Consent Action Network (ICAN), led by Kennedy’s presidential campaign’s director of communications, Del Bigtree. 

In 2022, ICAN paid Siri’s law firm $5.3 million for its legal efforts to fight vaccine approvals and mandates across the US, including polio and hepatitis B.

Kennedy made $510,000 in executive compensation for his role as director of CHD in 2022; ICAN paid out $880,000 in executive compensation from its $13.4 million in revenue that same year, public filings show.

“It’s difficult to understand the motivations behind RFK Jr and his organization and staff,” Dr Peter Hotez, a vaccine expert, told Health Policy Watch.

“I could only speculate, and that wouldn’t be helpful, but I can say his anti-vaccine [stance] is very damaging for global public health,” added Hotez, who has an autistic child, has been introduced to Kennedy by colleagues at the National Institutes of Health in an attempt to persuade him that vaccines do not cause autism.

Kennedy has other fringe views including that AIDS is not caused by HIV, that antidepressants are responsible for mass school shootings, and that atrazine, a widely used herbicide, triggers gender dysphoria and has led to increases in young people identifying as transgender. 

https://x.com/PeterHotez/status/1868848477054419408

“Vaccines [are] our most impactful public health/scientific successes for the last 50 years, saving 154 million pediatric lives,” Hotez argues. “We also have overwhelming evidence for vaccine safety and knowledge vaccines don’t/cannot cause autism. I hope to say this every chance I get.”

Image Credits: Paul Palmer/ WHO, Pakistan Polio Eradication Program .

Lenacapavir, packaged as Sunlenca in the US, where is sellas for $42,250 for two injections.

Some two million people may get access to lenacapavir, the twice-yearly antiretroviral injection that prevents HIV injection, within the next three years, thanks to the Global Fund and United States President’s Emergency Plan for AIDS Relief (PEPFAR).

The initiative is contingent upon regulatory approval from the US Food and Drug Administration (FDA), national pharmaceutical regulators, and a recommendation from the World Health Organization (WHO).

It is being supported by the Children’s Investment Fund Foundation (CIFF) and the Bill & Melinda Gates Foundation (BMGF) 

At present, lenacapavir is licensed in the US and other countries as a treatment for adults with drug-resistant HIV. 

However, in two clinical trials it has shown to almost completely block HIV when used as pre-exposure prophylaxis (PrEP).

Not a single one of the 2,138 women in PURPOSE 1 trial who received lenacapavir contracted HIV. In the PURPOSE 2 trial involving men and gender-diverse people, only two of the 2,179 participants became infected during the trial – a success rate of over 99%.

In both trials, lenacapavir was tested alongside oral PrEP and found to be superior as the twice-a-year injection is much easier to adher to than taking daily pills.

“We cannot reach a sustainable HIV response without rapidly reducing the 1.3 million new HIV infections that occur worldwide every year,” said Ambassador Dr John Nkengasong, US Global AIDS Coordinator head of PEPFAR in a statement on Tuesday.

“Lenacapavir offers a potentially tremendous opportunity to transform the impact of HIV programs to ensure adolescent girls and young women, key populations, and others who could benefit have access to highly effective HIV prevention, testing and treatment services and to end HIV/AIDS as a public health threat by 2030.”

In October the medicine’s manufacturer, Gilead, announced that it had signed non-exclusive, voluntary licensing agreements with six pharmaceutical companies to manufacture and supply generic versions of lenacapavir for 120 primarily low- and lower-middle-income countries.

Global regulatory filings

“Data from both PURPOSE 1 and PURPOSE 2 will support a series of global regulatory filings for lenacapavir for PrEP that will begin by the end of 2024,” Gilead announced.

The FDA has granted lenacapavir for PrEP “breakthrough therapy designation”, which is intended to expedite the development and review of new drugs that may demonstrate substantial improvement over available therapy.

The FDA has also granted a “rolling review” for lenacapavir for PrEP, which allows the FDA to fast-track the review of a drug application by allowing a company to submit sections of the application for review as they are completed.

In September, WHO announced that it is “working rapidly to convene a guideline development group with experts, ministries, partners and communities”.

This group will develop and issue guidelines based on a “rigorous assessment of the potential of lenacapavir for HIV prevention, evaluating key aspects such as efficacy, safety, cost-effectiveness, values and preferences from stakeholders and communities, and global scalability, among others”.

A WHO spokesperson told Health Policy Watch on Tuesday that the Guideline Group meeting will be held from 28-30 January and would have a recommendation by July 2025, at the latest.

“WHO has already listed lenacapavir on the Expression of Interest list (EOI) and has provided guidance on bioequivalence,” the spokesperson added.

It is also working to ensure rapid regulatory approval via the FDA and European Medicines Agency EMA Medicines4All pathways.

Once a Stringent Regulatory Authority (SRA) approval is obtained, the manufacturer can apply for pre-qualification using the abridged pathway.

“WHO is working with potential early adopter countries to anticipate and prepare for guidelines and country regulatory approvals,” the spokersperon said.

Excited by the promise

“At the Global Fund, we are incredibly excited by the promise of lenacapavir and its potential to help us achieve a further significant reduction in new infections among individuals at high risk of acquiring HIV,” said Peter Sands, Executive Director of the Global Fund. 

“As part of this coordinated effort, the Global Fund, PEPFAR, CIFF, and BMGF will work with Gilead and the voluntary licensing manufacturers to accelerate affordable and equitable access, so that more people can benefit from this powerful innovation from day one.”

CIFF founder and chair Sir Chris Hohn, said that innovations like lenacapavir can profoundly impact the lives of millions.

“It will be a travesty if the communities who need it most don’t have access. That is why this collaboration is so essential to ensure that lenacapavir is available as soon as possible for those who need it the most,” said Hohn.

Image Credits: Gilead.

Médecins sans frontières (MSF) teams prepare to distribute mosquito nets to protect against mosquito bites during a health fair in vulnerable communities in Anzoátegui state, Venezuela.

Climate change, unplanned urbanization, sprawling cities, and the El Nino effect all converged to make 2024 a “historic” year for dengue transmission. With increased opportunities for Aedes aegypti mosquitoes–the insects that carry dengue– to breed, cases reached a record 12.7 million cases in the WHO’s Americas Region, nearly three times more than in 2023.

This translates to roughly 21,000 severe cases and over 7700 deaths across northern, central and southern regions of the continent.  And more than a third of the severe cases occurred in children, warned Dr Jarbos Barbosa, Pan-American Health Organization (PAHO) Director, in a press conference last week. 

“In countries like Guatemala, 70% of dengue-related deaths have occurred in children,” Barbosa noted. Barbosa’s home country of Brazil accounted for nearly 80% of cases in the Americas, followed by Argentina, Colombia, and Mexico. 88% of deaths from dengue occurred in these four countries.

At the close of this historic dengue season, Pan-American Health Organization (PAHO) leadership discussed reasons for the surge in cases, and the tools to combat next season’s caseload. Of concern is the geographic expansion of dengue-susceptible regions into countries like Argentina, Uruguay, and the United States. “This increase in cases is directly associated with climate events, including droughts, floods, and warmer climates that favour the proliferation of mosquito breeding sites,” said Barbosa. The director also cited population growth, unplanned urbanization, poor living conditions, and inadequate water supply and waste disposal as major drivers of dengue transmission. 

“Despite these challenges, we are not defenseless,” argued Barbosa. Vector surveillance, improved case management, community engagement, and the rollout of dengue vaccines in targeted populations have meant PAHO is optimistic about next year’s season. “We don’t have a crystal ball,” said Dr Sylvian Aldighieri, PAHO director of the Department of Prevention, Control, and Elimination of Transmissible Diseases, referring to 2025 projections. But because 2024 had such high transmission rates, much of the population has now acquired immunity to the most prevalent serotypes, he noted. 

Migrants at risk of dengue and other diseases – gaps in data and health care coverage are challenges

Migrants in Darien Gap Panama
Over half a million migrants passed through the Darien Gap in 2023. “A vulnerable population” according to PAHO, migrants face a host of health challenges.

While dengue is typically characterized as an urban disease–where mosquitoes breed in discarded plastic bottles and sidewalk puddles, the large migrant population moving through central America to southern and central Mexico [Mesoamerica] towards the United States, is also especially vulnerable to infectious diseases.

“This is a big throughway for persons,” noted Dr Thais dos Santos, Regional Advisor on Surveillance and Control of Arboviral Diseases, in response to a Health Policy Watch query. “Dengue surveillance has a long tradition in the region of the America, but as it evolves, we realize that there are some data gaps.” Healthcare facilities do not typically collect information on a patient’s migrant status, meaning there is limited data to understand the burden of dengue in migrants. Dos Santos cautioned, thus, that PAHO has limited data to understand the scope of migrant health statuses, especially with regard to vector-borne diseases.

Dengue is not the only communicable disease of concern for migrants. “We are assisting countries in preventing any reintroduction of malaria that can be spread through the flow of migrants,” said Dr Andrea Vicari, PAHO Head of the Infectious Hazard Management Unit. “It’s a population at risk, living in very vulnerable conditions,” Vicari noted. 

Strengthening migrant health remains a PAHO priority, as record-breaking numbers of asylum-seeking migrants traverse the Darien Gap through Panama. The year 2023 saw more than half a million people transit through Mesoamerica en route to the United States. This population is burdened by a host of health threats, including sexual and gender-based violence, food insecurity, HIV, and malaria. PAHO’s November 2024 migrant health report called for increased access to emergency, maternal, pre and postnatal, and mental health services. 

Oropouche, avian flu emerge as new threats in 2024

PAHO leadership arboviruses
PAHO Arbovirus Panel (From left): Dr Andrea Vicari, Dr Sylvain Aldighieri, Dr Jarbas Barbosa, Dr Thais dos Santos.

While dengue contributed to the largest burden of mosquito-borne diseases, PAHO leadership also brought attention to Oropouche, a rare but increasingly circulating virus in the Americas. The year 2024 saw nearly 12,000 cases, mostly in Brazil, representing a dramatic increase since last year. The virus, an arbovirus like dengue, Zika, and chikungunya, is spread through bites by certain midge mosquitos. Oropouche symptoms are similar to these other arboviruses with fever, rashes, muscle aches, and headaches common. Symptoms typically last 5 to 7 days, but more recently, the virus has been linked to severe fetal outcomes, including congenital abnormalities and death. 

Notably, cases were seen in regions not typically associated with the disease, mirroring dengue’s march into new geographic areas.  Brazil also reported several instances of transmission from mother to child earlier this year, with 8 cases of infant microcephaly and fetal death, causing the US Centers for Disease Prevention and Control (CDC) to issue travel warnings for pregnant women to the affected regions in the country. 

PAHO leadership also provided an updated report on the ongoing H5N1, or avian flu, outbreak in North America. The United States has already reported 58 human cases, mostly poultry and dairy workers, while in Canada a teenager with no known contact with infected birds or cattle also fell ill recently – reviving longstanding concerns about new virus mutations that could facilitate more human-to-human transmission.

“Surveillance, including genomic characterization, is crucial to track the virus across species, understand its evolution and risks to humans, and guide our actions,” said Barbosa. The director argued that intersectoral collaboration with a One Health approach is critical – as this influenza strain has now jumped to dairy cows for the first time, meaning that measures to reduce animal exposures as well as to protect people must be addressed together.

Also among the longstanding WHO recommendations is the pasteurization of milk to contain the public health risk. “The pasteurization of the milk has been described and used for the last 150 years. This is one of the great achievements of the public health sector…with pasteurized milk, we should not have any major issues of transmission of this disease to people,” mentioned Dr Vicari.

“Countries must strengthen their surveillance and continue sharing information. We must work across borders to monitor new cases and support health systems to respond,” emphasized Barbosa.

Image Credits: Matias Delacroix/MSF, PAHO/WHO, PAHO/WHO/David Spitz.

A Mexican study has found that younger people are more vulnerable to heat, possibly because they spend more time working outside.

Some 75% of heat-related deaths occurred amongst people under the age of 35 , and one-third of such deaths were young adults between the ages of 18 to 35, according to a new study on heat mortality in Mexico.

This contradicts previous assumptions that the elderly are the most vulnerable to heat.

“We project, as the climate warms, heat-related deaths are going to go up, and the young will suffer the most,” said R. Daniel Bressler, a PhD candidate in Columbia’s Sustainable Development program and co-lead author of the study, published in Science Advances.

“It’s a surprise. These are physiologically the most robust people in the population,” said the study’s co-author Jeffrey Shrader  from the Center for Environmental Economics and Policy, an affiliate of Columbia University’s Climate School in New York City. “I would love to know why this is so.”

The researchers speculate that several factors may be at work. Young adults are more likely to be engaged in outdoor labour including farming and construction, and thus more exposed to dehydration and heat stroke. Young adults are also more likely to participate in strenuous outdoor sports, the researchers pointed out.

Infants and children under the age of five are also particularly vulnerable to heat as their bodies are not yet efficient in regulating temperature. Deaths of infants and young children, together with those aged 18-35, made for 75% of all heat-related deaths.

Meanwhile, people in the 50 to 70 age bracket suffered the least amount of heat-related mortality to the surprise of researchers.

Using the same daily temperature and mortality data, the researchers found that elderly people were at a higher risk of dying from modest cold, as compared to heat, at least in the Mexican context. Mexico is mainly tropical and subtropical country, but it has many climate zones including high-elevation areas that can get relatively chilly.

Younger people do most manual, outdoor labour

The new study has global implications, said the team of researchers, who along with Shrader, are mostly affiliated with Columbia, as well as Boston University, Stanford and the University of California. Many poor, hot countries, mainly in Africa and Asia, have young populations, with a large proportion working in manual and outdoor labour.

The retrospective analysis assessed heat-related deaths over a twenty-year period, from 1998 to 2019. For individuals under 35, heat causes 2.6 times more deaths than cold whereas for individuals 35 and older, cold causes 56 times more deaths than heat.

Children under five, especially infants, also had a disproportionate number of heat-related deaths, although not as large. Overall, people under 35 years accounted for 75% of historical, heat-related deaths, the researchers found.

Historical and projected annual deaths due to heat and cold exposure by age group in Mexico. Among adults, people aged 18-35 had by far the highest risk of death from heat exposure (top), with infants and children under 5 close behind.

A previous separate analysis by primarily Mexican researchers showed that death certificates of working-age men were also more likely to list extreme weather as a cause than those of other groups.

“These are the more junior people, low on the totem pole, who probably do the lion’s share of hard work, with inflexible work arrangements,” said Shrader.

The vulnerability of infants and small children came as somewhat less of a surprise. It is already known that their bodies absorb heat quickly, and their ability to sweat, and therefore cool off, is not fully developed. So exposure to temperatures that exceed their body temperature can be rapidly fatal.

Their immune systems are also still developing, which put them at higher risk of ailments that become more common with humid heat, including vector-borne and diarrhoeal diseases.

The researchers reached their conclusions by correlating excess mortality or the number of deaths above or below the average, with average temperatures in the same period, on the “wet-bulb scale” that reflects he magnified effects of heat when combined with high levels of humidity.

Despite being based mostly in the USA, the researchers y chose Mexico for the study because it collects highly granular geographical data on both mortality and daily temperatures.

Older people more likely to die of cold

Older people tend to have lower core temperatures, making them more sensitive to cold. In response, they may be prone to staying indoors, where infectious diseases spread more easily.

Despite all the attention given to the dangers of global warming, other extensive research has generally suggested that to date, excessive cold exposures, not heat, are currently the world’s number one cause of temperature-related mortality, including in Mexico. However, the proportion of heat-related deaths has been climbing since at least 2000, and this trend is expected to continue.

Around 4.1 billion people or roughly half the world’s population has experienced unusually hot temperatures between June and August this year, according to a report from US-based non-profit Climate Central.

Deaths occurred at lower-than-expected heat levels

There is a widespread recognition that temperatures alone are not a good measure of the impact of heat but “wet bulb temperatures” that also factors in humidity, are. Essentially, the same temperature level in conditions of high humidity is more dangerous than at low-humidity because humid conditions reduce the absorption of sweat, which cools off the body.

Wet bulb temperatures are often referred to as the “real-feel” heat indexes where numbers can vary depending on the exact combination of heat and humidity.

Previous research has suggested that workers begin to struggle when wet-bulb temperatures reach about 27°C, which would equate to 86 to 105°F, depending on humidity. However, the new study found that the largest number of deaths occurred at wet-bulb temperatures of just 23 or 24°C, in part because those temperatures occurred far more frequently than higher ones, and thus cumulatively exposed more people to dangerous conditions.

A study published last year showed that farm workers in many poor countries are already planting and harvesting amid increasingly oppressive heat and humidity.

Bressler, the report’s lead author, said the team is now looking to firm up its conclusions by expanding its research into other countries, including the United States and Brazil.

Image Credits: Unsplash, Study: Heat disproportionately kills young people: Evidence from wet-bulb temperature in Mexico.

The International Court of Justice in the Hague heard arguments from the WHO Director-General on Friday in a landmark case on climate justice.

Climate change poses an immediate and catastrophic threat to human health worldwide, the World Health Organization (WHO) chief warned the UN’s highest court on Friday as it considers a landmark case that could establish fresh legal obligations for nations to cut emissions and pay for climate damages.

WHO director-general Dr Tedros Adhanom Ghebreyesus testified to the International Court of Justice (ICJ) that climate change is “fundamentally a health crisis” that is already “wreaking havoc” on human health, societies, economies, and overwhelming healthcare systems worldwide.

The case, brought by the Pacific island nation of Vanuatu, represents the largest in ICJ history, with nearly 100 countries and organizations participating. While the court’s advisory opinion, expected next year, will not be binding, legal experts say the ruling could strengthen climate litigation worldwide. For small island nations, the stakes are existential – climate models predict many will disappear beneath Pacific waters without dramatic cuts to global emissions.

“The climate crisis is among the most significant health challenges facing humanity today,” Tedros told the court. “It is not a hypothetical crisis in the future. It is here and now. Without immediate action, climate-related increases in disease prevalence, destruction of health infrastructure, and growing societal burdens could overwhelm already over-burdened health systems around the world.”

The UN health chief highlighted how climate change is already altering disease transmission patterns for infections like malaria, dengue and cholera, while extreme weather events are destroying health infrastructure and claiming thousands of lives. Tedros also emphasized that noncommunicable diseases, including cancers and cardiovascular conditions, are linked to climate change and air pollution.

An estimated 920 million children currently face water scarcity, a situation he warned would worsen as climate change intensifies droughts and contaminates water supplies. Rising temperatures are also increasing heat-related deaths and illnesses. Tedros further articulated fears of massive population displacement and projected that over 130 million people could be pushed into extreme poverty by 2030, with devastating impacts on health.

“Millions are expected to be pushed into poverty. This will dramatically increase health burdens and disparities,” he said. “Not enough is being done…to avoid the most catastrophic impacts related to climate change.”

‘Health at the centre’

Iririki Island, Vanuatu.

The WHO chief criticised “massive fossil fuel subsidies,” citing International Monetary Fund projections that appropriate fossil fuel pricing that includes health and environmental costs could prevent 1.2 million air pollution deaths annually. The UN health agency estimated last month ahead of COP29 in Baku meeting climate targets could save two million lives a year.

“The value of health improvements from mitigation significantly outweighs the costs,” Tedros said. “The failure to respond to climate change is undoubtedly the most costly approach.”

WHO’s chief legal counsel Derek Walton urged the court to place health considerations at the center of its advisory opinion, emphasizing that “science and technical evidence should be at the heart of the court’s consideration.”

“WHO respectfully requests the court to place health at the center of its advisory opinion, and in this regard, to give full effect to the fundamental right of every human being to the highest attainable standard of health,” Walton said.

Walton further cited precedents in ICJ rulings that consider health as a human right, pointing to the court’s 1996 ruling on nuclear weapons.

“As the court stated nearly three decades ago in its advisory opinion on nuclear weapons, the environment is not an abstraction, but represents the living space, the quality of life and the very health of Human beings, including generations unborn,” Walton said. “We respectfully ask you to allow the science and the technical evidence to guide your analysis.”

Out of the COPs and to the courts

COP 29 in Baku, Azerbaijan

The proceedings come just weeks after December’s UN climate summit in Baku ended without meaningful commitments on emissions cuts or climate finance, even as global carbon dioxide emissions hit record highs and 2024 is confirmed as the hottest year on record.

Throughout the two-week proceedings in the Hague, which concluded on Friday, major emitters pushed back against the ICJ’s jurisdiction in the case. China urged the court to defer to existing UN climate mechanisms as “the primary channel for global climate governance,” while Saudi Arabia insisted national climate pledges represent only “an obligation of best efforts, not of results.” The United States and several EU members similarly argued existing treaties should be sufficient.

Low-lying islands, several of which called the outcome at COP29 a death sentence, argued the failure of current UN climate instruments is precisely why this case is before the court.

“We’ve heard much about the Paris Agreement as being the solution, but the reason why the climate-vulnerable states have come before the court is that the Paris Agreement has failed,” said Payam Akhavan, counsel for small island states, pointing to projections of 3.1C warming by century’s end.

Small islands represent just 1% of the global population, economy and emissions, but face existential threats from rising seas. In his remarks, Tedros recounted meeting a boy, Falou, on the island of Tuvalu five years ago who shared discussions with friends about what they would do if their island disappeared.

“They worry about the survival of their island homes due to the emissions produced by distant nations,” he said. “This reality weighs heavily on their young shoulders.”

Falou’s island home is projected to be the first nation to disappear beneath the waves. “Tuvalu will not go quietly into the rising sea,” its representative Philippa Webb told the court on Friday.

The court’s opinion, which small island states and developing countries hope to leverage in climate lawsuits worldwide, is expected in 2025. Though not legally binding, the ruling will carry significant moral and legal weight, legal experts say.

“States’ long-standing duties to prevent transboundary environmental harm and human rights violations, including from climate change, did not begin with the UNFCCC or the Paris Agreement, and they do not end with any COP deal,” said Nikki Reisch, director of the Climate and Energy Program at the Center for International Environmental Law (CIEL).

“The ICJ can and must make clear that when States breach their climate obligations, and harm ensues — as it so evidently has — they must right the wrongs,” Reisch said.

Kathmandu has introduced air sensors to monitor pollution.

More than one-third of countries worldwide lack government-level air quality monitoring, leaving nearly one billion people in the dark about one of the greatest risks to their health, a new report showed on Friday.

The assessment by non-profit OpenAQ, which maintains the largest open-source database of air quality measurements, found significant gaps in government tracking and sharing of air quality data, particularly in low and middle-income countries. The biennial report is the only global assessment of whether and how national governments are producing and sharing air quality data with the public.

Thirty-six per cent of countries provide no government monitoring of air quality, with 90% of people in nations without monitoring programs living in low and lower-middle-income countries, where the World Health Organization (WHO) says higher pollution levels and disease rates make populations especially vulnerable. A further 9% of countries do collect government air quality data but do not share it publicly, widening the gap of public access to this critical health threat even further.

Air pollution ranks as a leading cause of death and disability in all the most populated countries without monitoring, including the Democratic Republic of Congo, Tanzania, Afghanistan and Iran. Progress in expanding monitoring remains slow, with only a 3% increase in countries conducting national or subnational air quality monitoring since 2022.

“In order to deliver clean air for all, governments need to not only track air quality, but also offer an accessible, quality data set,” said Dr Colleen Rosales, OpenAQ’s Strategic Partnership Director. “Billions of people do not know what they are breathing and could benefit from greater data transparency.”

Air pollution, mainly from fossil fuel emissions, kills more than eight million people annually and costs over $8 trillion worldwide, making it the largest environmental health risk. Its impact on life expectancy matches that of smoking and exceeds that of alcohol use, transport injuries and HIV/AIDS.

Exposure to pollutants in the air affects health from birth, causing respiratory diseases, cardiovascular problems and developmental issues, with babies, young children and low-income communities facing the greatest risks. WHO data shows 99% of people worldwide breathe unhealthy air every day.

Transparent data would benefit billions 

While NGOs, academic institutions and private companies monitor air quality, government data provides unique value through continuous, comprehensive measurements. Unlike time-limited studies, government monitoring tracks a wider range of pollutants, supporting regulatory compliance, legal proceedings, health research, pollution tracking and air quality forecasting.

Only 55% of governments share their air quality data publicly, with just 27% providing it in a fully transparent and accessible format, the report found. Countries facing major air pollution crises that continue to lack transparency include China, Russia, India, Pakistan, and seven other major nations with populations of at least 70 million people.

“While many populous countries have partially shared their air quality data, an increase in transparency could benefit over 4.5 billion people,” the report said. “Barely over one-quarter of countries provide full and easy public access to data detailed enough to inform scientific inquiry and pollution reduction policies.”

Air Quality Indexes (AQI) vary widely between countries, leading to inconsistent messaging to the public about the risks of pollution levels.

Countries lacking transparent reporting frequently rely on Air Quality Index (AQI) systems that vary widely between nations, often triggering different health warnings for the same pollution levels and confusing communication with the public. While these help with daily decision-making, they lack the detailed measurements scientists and policymakers need for research and regulation.

India and Pakistan illustrate the data transparency challenges, even as their cities rank among the world’s most polluted. Both countries share air quality data only in “static, non-machine-readable formats” like PDFs and graphics rather than analysable datasets, the report said. Last month, Delhi suspended schools and construction as pollution reached twenty times WHO’s safe limit, while Lahore recorded its highest-ever levels. The severity of the crisis has forced long-time rivals toward cooperation, with Pakistan’s Punjab province seeking unprecedented talks with India.

“Although sharing data as a PDF or graphic is a good first step, when data are provided in a machine-readable, analysis-ready and standardized form, many more use cases—and ultimately, impact—can be derived from the data,” the report found. “In the quest for clean air for all, we appeal to all governments to offer data-transparent air quality monitoring versus only the 27% that do so today.”

Some nations have made progress, with 30 countries improving their monitoring or transparency since 2022. Eleven countries, including Japan, Italy and Kenya, achieved full transparency in that period.

Barriers to monitoring

Three-wheelers trapped in smog in Lahore, Pakistan in late November, 2024

Nearly one billion people live in countries without air quality monitoring, but government inaction isn’t always the cause. Many nations, particularly low- and middle-income countries, lack the financing and technical expertise to implement monitoring systems. A 2022 Clean Air Fund survey found one-third of 119 countries could not establish monitoring networks due to these constraints.

The report suggests increased investment could quickly expand monitoring, but funding remains scarce. Only 0.5% of development aid and 0.1% of philanthropic funding targets clean air initiatives. Health programs linked to climate change – a key driver of mounting air pollution deaths – receive just 2% of adaptation funds and 0.5% of multilateral climate funding.

War and civil conflict have also disrupted monitoring efforts. Air quality monitoring systems have collapsed amid wars in Ukraine and Palestine, while ongoing civil conflict in Sudan has prevented any progress on building air surveillance infrastructure.

Beyond disrupting measurement systems, warfare itself creates severe pollution. Millions of bullets, grenades, bombs and missiles detonated in Ukraine during Russia’s ongoing assault led to an abrupt spike in air pollution across Europe, with around a 10% increase in harmful pollutants such as PM2.5 and NO2 in cities near the fighting.

The health impacts of air pollution in war zones are also likely underestimated, according to research from the International Union Against Tuberculosis and Lung Disease. Even small increases in pollutants significantly raise hospitalization risks for cardiovascular and respiratory conditions, while war zones face multiple simultaneous pollution sources and populations under extreme stress, weakening their response to environmental hazards.

“In a war zone, air pollution is likely to result in more deaths than bombs,” the Union found.

Image Credits: Partnership for Health Cities.

Members of the trade union, PSLink, protesting outside the Philippines Supreme Court. The union petitoned the court to win increases for nurses.

Countries are most likely to have laws about health workers’ pay and least likely to provide them with mental health services and protection against discrimination.

There is also little correlation between a country’s wealth and the protection it offers its health workers.

These are some of the findings of a study of over 1,200 laws relating to health and care workers from 182 countries led by the O’Neill Institute for National and International Health Law and the World Health Organization (WHO).

Researchers examined the countries’ laws to see how well they aligned with the Global Health and Care Worker Compact adopted by the World Health Assembly in 2021.

The Compact was introduced to provide countries with guidelines to protect their health and care workers – a response both to the huge price health workers paid during COVID-19 and the growing shortages of health workers.

Over 115,000 health workers were estimated to have died from the virus by the time the Compact was adopted, while there is a global shortage of over 10 million health workers.

Significant gaps

The research identifies key areas where governments can use law and policy to safeguard health workers’ rights, promote and ensure decent work free from discrimination, and a safe and enabling working environment.

Around 62% of the laws were aligned with the Compact, according to Matt Kavanagh, Director of the Center for Global Health Policy and Politics at the O’Neill Institute.

“Our analysis shows significant gaps. Nearly every country has multiple areas where national laws are not yet aligned with the Care Compact, although alignment is feasible,” Kavanagh told a media briefing on Tuesday. 

The findings were published in Plos Global Health on Monday and details about the countries’ laws are available on a dedicated website that will serve as a baseline 

“While 69% of countries have some form of health services guaranteed for health workers, only 20% of those ensure that mental health and well-being are covered,” Kavanagh noted.  Twelve percent of countries had zero provision for health for healthcare workers.

“This analysis highlights the need for, and opportunity of, law reform in countries throughout the world to elevate and protect the rights and well-being of health and care workers and, in doing so, improve health systems,” noted Kavanagh.

With 105 countries aligned to half of more of the Compact’s recommendations, Kavanagh  described the report as “half-full”.

“Law reform is a key piece of what might drive us toward better retention and better effectiveness of our health and care workforces.”

One of th biggest gaps is that community health workers are usually not protected and often do not earn even the minimum wage.

Speakers at the launch of research on the protection of healthworkers (L to R): Atul Gawande, Matt Kavanagh, Catherine Kane (moderator), Laetitia Rispel, Jillian Roque and Jim Campbell

Health workers ‘are the health system’

Dr Atul Gawande, Assistant Administrator for Global Health at USAID, described the research as “transformative” as it provides both a baseline for countries to assess themselves against the Compact as well as the capacity to track progress.

“When we are talking about plans for strengthening systems, what we’re really talking about are plans for strengthening health workers. ‘Systems’ is abstract. Health workers are the system,” said Gawande. USAID assisted in funding the research.

Jim Campbell, Director of the WHO’s Health Workforce department, said the research marked a move “beyond political will into evidence-based policy”.

“Health systems are under huge challenges – population, ageing, conflict, humanitarian disasters, climate disasters. These are being transferred to the health and care workers worldwide,” he added.

With an estimated shortage of around 11 million health workers, “health systems will not have the capacity to respond to the demand, transferring a burden onto the workers that we seek to protect,” said Campbell.

“The first action has to be to invest in today’s workforce to seek those protections.”

Sub-optimal working conditions

Professor Laetitia Rispel from the School of Public Health at the University of the Witwatersrand in South Africa noted that slightly more than half of African countries had laws aligned with the Compact.

Yet Africa is going to be one of the worst affected by health worker shortages, Rispel noted.

“Sub-optimal working conditions, which are often most acute in the region, often serve as a push factor for health workers to migrate,” she warned.

Trade unionist Jillian Roque, Chief of Staff at the Public Services Labor Independent Confederation (PSLink) in the Philippines, also decried the “persistent gaps” in the protection of healthcare workers’ rights.

“In many areas, public health care workers are denied their fundamental rights to freedom of association and collective bargaining,” Roque said.

PSLink is part of the global federation of public sector workers, Public Services International (PS), which is fighting for “fair pay, decent work, equality and non-discrimination” through organising unions, said Roque. 

In the Philippines, unionists have been killed, harassed and “red-tagged” [labelled as communists], making it one of the 10 worst countries for workers in the world, she added.

Despite this, PSLink has successfully ensured the ratification of important conventions on occupational health and safety, the elimination of violence and harassment in the workplace and compelled the government to raise the salaries of nurses after filing a petition at the Supreme Court. 

Campbell noted that two-thirds of the global health workforce (67%) is women and this is often linked to the lack of protections.

Image Credits: Sophie Mautle/HeDPAC , PSLink.

Purchasing drugs at a pharmacy in Johannesburg, South Africa, in May 2020; out of pocket health expenses have soared in many low- and middle-income countries.

After an early surge of spending during the COVID pandemic, public health layouts by countries at all income levels declined in 2022, on average, as compared to 2021.

Meanwhile, there was a 60% increase overall in per-capita health expenditures between 2000 and 2022 – but in low income countries this was largely driven by a sharp rise in out-of-pocket spending (OOP), according to WHO’s 2024 report on global health expenditures, released on the eve of Universal Health Coverage Day, 12 December.  

In low income countries, public spending on health has in fact stagnated since the turn of the millennium, with governments de-prioritizing health spending in national budgets while international donor aid made up for an increasing share of the shortfall. 

40 x 40: Only 40% of spending covered with just $40 per person by public health authorities

By the end of 2022, as countries emerged from the COVID pandemic, out-of-pocket spending, per capita, in low-income countries stood at slightly more than 40% of health expenditures. And  overall spending averaged $40 per person annually – less than half of the minimal baseline WHO estimates is needed to run a health care system. 

Per capita health spending all sources – grew but not always for the right reasons.

The report emphasizes the urgent need for increased domestic health spending to meet  2030 Universal Health Coverage goals, said WHO’s Director General Dr Tedros Adhanom Ghebreyesus in a launch of the report this week at WHO’s Geneva Headquarters. 

“Between 2000 and 2022 global spending per capita grew by more than 60% outpacing GDP,” Tedros said. 

On the plus side, that increase is critically correlated with significant improvements in life expectancy, including lower maternal and child mortality. But there is a big minus as well: 

 “Over the same period, governments in low income countries consistently deprioritized health in national budgets,” Tedros observed. “So while the increase in health spending is welcome, the trends in the sources of that spending are concerning…. Out of pocket health spending is the most inequitable type of spending, while aid is volatile and dependency is a major issue for low income countries. 

“Increasing domestic health spending must therefore be a policy priority for all countries to reduce financial hardship caused by out of pocket spending and aid reliance.”

Report accompanied by launch of the world’s largest global health spending database 

Dr Tedros Adhanom Ghebreyesus – spending trends pose obstacle to UHC.

The report’s publication coincided with the launch of a new WHO global health expenditure  database – also marking 25 years since WHO began tracking health finance systematically.  

Billed as “the world’s largest global health spending database,” it covers spending by more than 190 countries since the year 2000, covering health expenditures by governments, donors and households. 

“These products are not just numbers,” Tedros stressed.  “They are used widely by governments, development partners, international organizations, academia and civil society to monitor financial trends, to assess equity and efficiency in health spending and to guide evidence based health financing decisions nationally and globally. 

“This is especially important in a time of increasingly tight budgets with many competing demands.”

Insights into how countries responded to the COVID pandemic – and afterwards

Post-pandemic decline in spending seen in countries of all income levels.

While most countries increased public health spending for a while during the pandemic, the across-the-board decline seen as countries emerged from COVID, reflects a worrisome trend, he added. This is particularly in light of the big gap between present day spending and the aims of the 2030 Sustainable Development goal for UHC. 

“In 2022, domestic public health spending per capita actually decreased for the first time since 2010,” Tedros observed, “Although it did increase significantly during the COVID 19 pandemic, it’s too soon to tell which direction spending on health will go. It could return to pre pandemic levels, or it could continue on a declining trend, putting us even further off track. 

“We therefore are at a time of uncertainty as countries emerge from the pandemic. Enormous challenges remain.” 

Among those, about one half of the world’s population still lacks access to one or more essential UHC services, such as primary health care. And over two billion people face financial hardship due to out-of pocket spending strains. 

In many low-income countries, public health spending is a fraction of minimum health system needs

Kalipso Chalkidou, WHO

In 42 low-income countries, mainly in Africa and South Asia, domestic public spending, per capita, on health remains below $30 per person per year, pointed out Kalipso Chalkidou, Director of WHO’s Department on Health Financing and Economics. 

“And that’s way lower than the $80 to $90 that we estimate is needed to support necessary workforce and essential commodities in low income countries,” she said. 

In some 35 low- and lower-middle income countries government health spending, or the share of government budget allocated to health, actually declined during the COVID-19 pandemic response and recovery of 2019-2023, the report also points out.

“Gandhi said that it’s not just words, but actions that express priorities,” Chalkidou said. “These are not just numbers, and the time for action is now.” 

Gap between low income countries and everyone else is growing larger 

WHO’s Xu Ke: Public health expenditure (blue line)  stagnated, while donor aid (green) rose and out of pocket spending (red line) grew fastest in the poorest countries.

“Government spending from domestic sources is absolutely essential for moving towards UHC,” added Ke Xu, senior health finance analyst, who led the work on the 2024 report, “Out of pocket payments are the most inequitable way to finance health services.”

And the gap between overall spending in low income countries and all other nations is only growing. 

Between 2000 and 2022, overall spending on health in low-income countries – from out of pocket, public and donor sources, grew from about $25 to about $30 on average.

“But even that is lower than what lower-middle income countries spent on health 20 years ago,” she pointed out. “So you can see the magnitude of the differences across income level. 

Out of pocket spending increased less, in upper and high income countries, as compared to middle and low-income ones.

“And in upper middle income countries, we’re now around $600 per capita, while in high income countries spending is about $3000 per person. So it’s not difficult to imagine the differences in the countries across income levels, in terms of the availability of the services, the quality of the services, and also the financial accessibility of the services.”  

While in lower income countries, out-of-pocket spending represents the biggest part of national health expenditures, in all other income groups, public spending by the government plays the leading role.

Out of pocket spending also increased significantly in lower-middle income countries, while more gradually in upper middle-income ones. It is in the high income countries, therefore, where financing trends are healthiest, with out of pocket spending almost flat over the past 20 years.

“In the high income countries, it is very clearly, is the domestic government spending that has driven all the [spending], while the out of pocket (OOP) is very stable and at the lower level,” Ke said. 

Interest in tracking health spending grew over time 

Health finance reporting developed over past several decades.

While tracking patterns of health spending is a critical core task at WHO today, it wasn’t always that way. 

It was only in the 1980s that the Organization of Economic Cooperation and Development (OECD) first began to consolidate and report on member states’ health spending at annual meetings. 

In 1993, the World Bank’s publication of the a milestone World Development Report ‘Investing in Health’, sharpened interest in the issue, underlining the importance of public health expenditure  to development overall. 

In 1999, WHO established its health finance program. But it wasn’t until 2011 that WHO’s first global health expenditure database was published, with the inaugural health expenditure report published in 2017.  Overtime, the scope and scale of the data has been expanded in collaboration with countries and other partners, Ke said, with primary health care indicators first added in 2018. In 2022, data on vaccine spending was added, reflecting the concerns raised by the pandemic with access. 

“Data matters, because data drives transparency. “It’s important for equity purposes, because that’s the only way we can see who’s left behind – who is benefiting and who is not from the investments, and also we can understand who’s bearing the growing burden of out-of-pocket expenses,” Chalkidou said.

In 2022 and 2023, the issue was also the focus of a series of Future of Global Health Initiatives consultations, led by Kenya and Norway. The consultations, involving several dozen countries, bilateral and international partner agencies, culminated in a meeting in Zambia in November 2023, with a “Lusaka Agenda” etching a way forward to strengthen domestic public health spending in low-income countries.

Adding spending data on emergency preparedness, pharma spending and more 

Pharmaceutical spending can drive out-of-pocket health costs for households which lack insurance, or have plans that fail to cover drug costs.

The WHO data repository is expected to continue growing, Chalkidou said, citing national budget data as one planned feature: “to see how countries do or do not execute this budget [in their spending].” 

Spending on emergency preparedness and response, is another expanding point of interest, Chalkidou noted, to help track how countries are planning for possible future pandemics. 

“We’re also working to improve the tracking of primary health care spending,” she added. “The latest data from OECD shows a reduction in spending on WASH and on primary health care – whilst at the same time, ODA (overseas development aid) has been growing towards pandemic preparedness and response. But these are really unacceptable trade-offs.” 

“Finally, we’re keen to do more and better tracking of pharmaceutical spending, because we know that spending on drugs is driving out of pocket spending and poverty in many places.”

Ensuring countries routinely capture spending data efficiently

More systematic data collection on health spending by countries is critical to tracking gaps and challenges.

The WHO thrust also aims to push countries to routinely collect, and efficiently report on their own health expenditure data – rather than relying upon donors or multilateral agencies to perform that task on their behalf. 

“We want to move away from expensive, manual, retrospective and consultant-led, data extraction exercises, more to routine, prospective and automated solutions,” Chaldikou said.

“Where we can, we want to work with countries to integrate financial information with health data and link to financial management information systems.

“These systems are used by the Ministries of Finance to routinely capture budgets and expenditures in the standard format, typically aligned to countries on accounting standards,” she pointed out – although the same processes and standards are not always are not always used in health ministries’ own accountancy. 

“We need sustainable investments by WHO, by partners and by member states themselves to institutionalize these processes.”

Forthcoming WHA resolution by Nigeria on health finance aims to raise ambition

Victor Nwaoba Itumo: Nigeria’s WHA resolution aims to raise ambition on health spending.

While the threat to low-income families from out-of-pocket spending is obvious, the gap between insurance coverage and healthcare costs can be a threat to financial stability even in higher income countries and households, observed Victor Nwaoba Itumo, Minister at Nigeria’s UN Mission in Geneva. 

“Countries need to do more when it has to do with health financing,” he said. “In the most advanced global economies, the cost of health [services] for households is on the high side.  Even the middle class in most societies find there’s a threat to their finances due to health challenges.”

With that in mind, Nigeria is leading the development of a new World Health Assembly resolution on health finance, due to be presented at the May 2025 meeting, which will appeal to countries and international partners to increase health spending.

It remains to be seen exactly what targets WHA member states might agree to support on domestic outlays, if any. A 2019 report by WHO recommended that at least 1% of GDP should be spent on primary health care, a target recalled in the September 2023 UN High Level Declaration on UHC. Other WHO and expert assessments have cited a figure of 5% of GDP as a better goal for overall public health expenditures. Internally, some professionals question the extent to which one-size-fits-all targets negotiated at WHA can in fact usefully motivate action – or not. 

“There are three major areas, relating to solutions being tabled by Nigeria,” Itumo said of the draft resolution. Those include provisions for: “strengthening and providing some support for health financing of households within countries; for what countries can do at international level together to make sure they create support for health financing; and what multilateral institutions, including financial institutions, can do to support health finance.”  

Building up other parts of the health ecosystems, such as domestic R&D and medicines manufacture, can also make healthcare more affordable while supporting development, he added.  

Can’t achieve UHC by 2030 without addressing these trends

Bruce Aylward, Assistant Director General for UHC.

“We’ve said public health spending is a priority, but government spend isn’t showing that,” said Bruce Aylward, Assistant Director General for WHO’s UHC Division, of the report’s findings.

“Domestic spending in low income countries is flat and stagnant – that’s hugely alarming in the current environment. And …out-of-pocket spending is going the wrong direction.

Health- it’s on the government – is the theme of this year’s UHC day.

“We cannot achieve UHC by 2030 without addressing these things. And as we look forward, we also face three big challenges: economic headwinds are going to be worse for countries for this next period. The debt burden – debt servicing burden – is huge. Some 3 billion people live in countries where they’re spending more on debt than they are on these kind of [health] services, which are crucial.

“And of course, there are other priorities emerging post pandemic for countries. So what are we going to do with this report? Well, the very first thing who is going to do is act on it, and we’re hoping all member states, all partners, will do the same thing. On UHC day [Thursday], the theme this year is ‘Health- it’s on the government’ and that’s a wonderful theme.”

–Updated 25.12.2024 

Image Credits: WHO Global Health Expenditure Database0, Health Policy Watch , WHO Global Health Expenditure Repository, WHO GLobal Health Expenditure Data Repository, HP Watch, Flickr: SteFou!, HP Watch , WHO.

A Ghanaian child receives a  malaria vaccine, which has been credited with reducing deaths in children since its introduction.

New WHO Global Malaria Report points to funding shortfalls, climate change, and antimicrobial resistance as key challenges to control.

Last year saw 263 million new malaria cases and 597,000 deaths in 83 countries worldwide, an increase of almost 11 million cases from the prior year, according to the World Health Organization’s (WHO) newly-released Global Malaria Report. The vast majority of cases occurred in the African continent, with children under five bearing the greatest burden of malaria mortality. 

Targeted interventions like insecticide-treated bed nets and integrated vector management, alongside factors such as improved nutrition, housing, and urbanization, have all reduced malaria transmission and disease in the past decades. More than 177 million cases and 1 million deaths were averted globally in 2023, and Egypt was declared malaria free, a significant milestone for Africa’s third-most populous country, according to the WHO.

Yet despite progress made in reducing the spread of the ancient disease, challenges like climate change, humanitarian crises, drug resistance, and persistent disparities all threaten global malaria progress. 

“Instead of dying, mosquitoes are dancing on the treated bed nets,” said Dr Michael Charles, CEO of RBM Partnership to End Malaria, referring to the growing number of mosquitoes resistant to commonly-used insecticides. 

Malaria burden per country in 2023

The number of new malaria cases actually increased in the past years, the report notes. Malaria case incidence – the number of new cases while accounting for population growth – grew from 58 to 60.4 cases per 1000 between 2015 and 2023. Five countries accounted for the majority of this increase in cases: Ethiopia (+4.5M), Madagascar (+2.7M), Pakistan (+1.6M), Nigeria (+1.4M) and Democratic Republic of Congo (600K). 

The WHO presented its newly-released report on the global state of malaria as a combination of both hard-fought victories, and obstinate and emerging challenges ahead of key replenishment rounds next year.

“No one should die of malaria; yet the disease continues to disproportionately harm people living in the African region, especially young children and pregnant women,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

“An expanded package of lifesaving tools now offers better protection against the disease, but stepped-up investments and action in high-burden African countries are needed to curb the threat.”

 

Africa ‘not on pace’ to meet WHO target

The Africa region bears the brunt of the global malaria burden – both in the number of cases and deaths – with 11 countries accounting for two-thirds of cases worldwide. Nearly half of these deaths occurred in just four countries: Nigeria (30.9%), Democratic Republic of the Congo (11.3%), Niger (5.9%), and United Republic of Tanzania (4.3%). 

Over 75% of deaths in the African region were among children under the age of five. Progress to reduce malaria mortality has barely budged in the past decade. The 2023 malaria mortality rate of 13.7 deaths per 100,000 people at risk was more than twice the WHO global strategy target of 5.5. 

While these rates remain high, many African countries have either stabilized or reduced their mortality rates. Dr Mary Hamel, WHO Team Lead for Malaria Vaccines, credits this to vaccinations for children in conjunction with bed nets and other interventions. 

“The vaccine is recommended by the WHO from five months of age, and during the pilot implementations where the governments of Ghana, Kenya, and Malawi introduced the vaccine …we saw high impact from these young age periods, with reduction in all cause mortality in these young children by 13% in all cause mortality.”

Seventeen countries have since introduced the malaria vaccine alongside childhood immunizations, with supply so far sufficient to meet demand.

WHO goals for malaria mortality rates (green) and projected rates under the status quo (blue).

Climate change, conflict, biological threats undermine progress

The many climate change-related disruptions in rising temperatures and changing weather patterns favor the quick-adapting and anthropophilic mosquito species that transmit malaria. The report warns that these changes are impacting the “health, security, and livelihoods of people around the world,” particularly in the hardest hit African region. 

But climate change is threatening malaria control in other parts of the world, like Pakistan. The devastating floods that submerged a third of the country in 2022 also left pools of standing water – “ideal breeding grounds for mosquitoes” and leading to an 8-fold increase in malaria cases between 2021 and 2023, the report notes.

Cases rose from about half a million to more than four million. The increasing frequency of extreme weather events is expected to increase the burden of malaria in the long term, especially because the mosquitoes that transmit malaria are “highly sensitive” to environmental changes, noted Dr Arnaud Le Menach, Unit Head, Strategic Information for Response, WHO Global Malaria Progamme. 

Conflict and ensuing humanitarian crises are impeding efforts to curb malaria. “In some countries, their conflict is also stopping people from getting the needed health access and the needed commodities,” said Charles. Internally displaced peoples often lack access to malaria prevention and treatment, leaving them “highly vulnerable to the disease,” said Le Menach. The report highlights these additional drivers of malaria transmission, noting that more than 80 million people in malaria-affected countries are internally displaced or refugees in 2023.

Biological threats in the form of resistant mosquitoes and antimicrobial resistance make it increasingly difficult to control vectors and treat patients. Resistance to pyrethroids, a common insecticide, was reported in nearly every country it was monitored, while resistance to artemisinin, the most effective malaria treatment, was reported in four African countries. 

Better global, regional, and country coordination is a key solution, according to Charles, to bring together stakeholders. This includes involving civil society organizations and resource optimization to overcome the above challenges. 

Reaching vulnerable populations

The global report features for the first time highlights the significant disparities in malaria burden, with a particular emphasis on gender equality.

“[W]e need to keep in mind the issue of poverty, poverty being a significant risk factor,” said Alia El-Yassir, director of the WHO Department for Gender Equality. “Malaria takes the heaviest toll on those who are poorest and are the most disenfranchised segments of a society. The data shows that children under the age of five who are living in low income households have the highest prevalence of malaria, and as their socioeconomic status improves, the risk of malaria and the prevalence will decrease.”

A host of biological, environmental, social, structural, and economic factors converge to increase a person’s vulnerability to malaria, “disproportionately” impacting those living in poverty, refugees, migrants, and indigenous peoples, notes the report.

“Poverty is very much gendered…gender norms become so deeply entrenched and institutionalized that they will place many women and girls at a disadvantage, and that affects their risk of malaria and also their access to treatment,” said El-Yassir. To address these challenges, the report urges health system strengthening to collect disaggregated data because current averages “are not giving us the true picture in terms of who is being affected.”

Calls for funding ahead of replenishment rounds

Several panelists made calls for funding at a recent WHO press conference in Geneva given the current “shortfalls” in funding. In 2023, less than half of the target $8.3 billion was invested in malaria response. This gap has widened in the past several years from $2.6 billion in 2019 to $4.3 billion in 2023. The vast majority of these funds come from international sources, with endemic countries contributing 33% in the past decade.

“Next year is a very, very big year for all of us in the malaria world,” noted Dr Charles. “We have two replenishments. We have the GAVI replenishment, and we also have the Global Fund replenishment…The mosquito is so unrelentless and so smart that the longer we wait, the harder it is.”

Even with malaria vaccines available, GAVI, the Global Fund, and the President’s Malaria Initiative all need replenishment “to realize the promise of the vaccine and other interventions,” argued Dr Hamel.

The Global Fund also released a statement urging funding to meet targets, making the argument that “investing more in the fight to end malaria not only has the potential to save millions of lives, but it can also help rebalance global economic power and stimulate trade.

“This, in turn, can unlock additional funding to strengthen health systems and enhance health security both in Africa and around the world. Malaria investment is not just a health imperative—it is a strategic driver of broader, far-reaching economic and social benefits,” said Peter Sands, Global Fund executive director, in a press release.

Image Credits: Fanjan Combrink / WHO.