A healthworker administers polio vaccination in Pakistan’s sensitive northwestern region.

ISLAMABAD – Pakistan’s last countrywide anti-polio drive of 2024 is set to conclude on 22 December but eradicating polio remains a challenge for the government, and this year’s surge in cases has resulted in calls for an independent audit of the program.

Pakistan and Afghanistan are the last two countries in the world battling to eliminate polio. In Pakistan, 63 polio cases have emerged this year in comparison to six in 2023, raising eyebrows about the strategies adopted by the government and international organizations working on polio eradication.

Shahzaib Khan, a health worker from the northern district of Mansehra in Pakistan’s Khyber Pakhtunkhwa province, is one of those grappling with these concerns.

Shahzaib, who works as a vaccinator in the health department, participated in the countrywide anti-polio drive with the target of vaccinating 44 million children five and under. Around 260,000 frontline workers are involved in the campaign.

As a frontline polio worker, he believes that the check-and-balance system at the district level has weakened, resulting in rising polio cases.

According to Khan, while the number of polio vaccination teams in each district has increased, there has been a reduction in those monitoring their performance at the district level. 

“Previously, these teams numbered up to 80 per district, but now the minimum has reduced to around eight, which has affected the standard of monitoring field teams,” Khan said.

Moreover, the long gaps between national polio campaigns allows the crippling disease to strengthen its roots, he added. For instance, in Naran, Khyber Pakhtunkhwa, the recent campaign was conducted after a seven-month hiatus.

Increase in cases

Aside from the, 63 cases have been reported this year, positive polio samples from 27 districts indicate a potential increase in cases in the coming days.

The highest number of cases has been reported in Balochistan, Pakistan’s southwestern province, with 26 cases, followed by Khyber Pakhtunkhwa with 18, Sindh with 17 and one case each from Punjab and the federal capital, Islamabad.

The polio elimination program faces major challenges from population migration, cross-border movement with Afghanistan and the refusal from some tribal communities and ultra-conservative groups in remote areas to allow vaccinations.

These communities, where the government also struggles to establish its writ, consider anti-polio drives as a ‘Western conspiracy’ against their children, allegedly believing it will harm the children’s fertility.

Polio teams in these areas are sometimes subject to armed attacks. During the recent seven-day national anti-polio campaign, two security personnel and five children were killed in such attacks in Balochistan and Khyber Pakhtunkhwa.

Conspiracy theories

Abdul Basit, a health department official from southern province of Sindh, noted that mistrust about the polio program exists among some communities and parents who either see the polio vaccine as a conspiracy or believe it is harmful to their children’s health.

In areas where security threats hinder polio teams, incidents of fake vaccination marking and data are common, he added. There is no national or provincial law to deal with parents who refuse polio drops for their children or those involved in falsifying data. 

Basit believes paediatricians can play a crucial role in educating parents about the positive effects of the vaccine, as they are often the first to be consulted when children fall ill. He would like to see a comprehensive strategy involving pediatricians at primary health centers to educate parents about the importance of the polio vaccine for their child’s future.

Prime Minister’s intervention 

Prime Minister Shahbaz Sharif, during a high-level meeting on polio, expressed confidence that the country would soon be free of polio, but he has also ordered a third-party audit of the polio campaign.

He has also directed top health officials to form a comprehensive strategy to reduce the immunity gap.

The Prime Minister’s Office in its statement reiterated its commitment to eradicating polio from the country through concerted efforts.

Meanwhile, former federal minister and public health expert Dr Nadeem Jan believes that the current immunity gap can be reduced within two years if there are changes in the polio program.

Jan said that while the high number of polio cases in a single year is concerning, the virus’s spread can be contained with a new approach. He proposes that Pakistan integrate the polio program with the routine immunization program.

“Routine immunization is already accepted within communities and does not face the same level of resistance as the polio program, therefore, the polio program should also be managed under the Expanded Program on Immunization (EPI),” said Jan.

Jan also stressed the need for a third-party audit of the program to ensure its effectiveness.

‘Significant failure’

However, Dr Abdul Ghafoor Shoro, general secretary of the Pakistan Medical Association (PMA), the country’s largest body representing physicians, has described the rise in cases as a failure of the program.

“This alarming trend indicates a significant failure in the polio eradication efforts, and PMA calls on the government to take immediate and decisive action to address this critical situation,” said Shoro.

He claims that the current approach, which appears reliant on a bureaucratic and foreign-funded system, has failed to contain the virus.

The PMA has demanded a comprehensive and transparent investigation into the reasons behind the resurgence of polio, including a thorough assessment of the existing polio eradication program, the role of the government, and the effectiveness of the current strategies.

The PMA also urged the government to immediately implement a robust and effective polio eradication strategy, increase public awareness campaigns and strengthen the surveillance system to ensure timely detection and response to new cases.

It also emphasized that adequate resources and support need to be provided to the polio eradication program, and those responsible for the failure to control the spread of the virus need to be held accountable.

Militancy and insecurity

Door-to-door campaigns, a critical part of the polio eradication strategy, are difficult in districts with high insecurity.

The World Health Organization’s (WHO) regional polio eradication director Dr Hamid Jafari, told a webinar hosted by Global Polio Eradication Program that the current polio resurgence in Pakistan and Afghanistan is not comparable to the catastrophic levels witnessed decades ago, when over 20,000 children were paralyzed annually in Pakistan alone.

“By 2021 to 2022, Pakistan reported just one case of wild poliovirus, while Afghanistan recorded two. This is a dramatic improvement compared to the 176 cases reported in 2019 across both countries,” Jafari noted.

However, he explained that resurgence in polio is a predictable pattern in eradication efforts. “Until you completely eliminate the virus, it will resurge and come back,” he remarked.

Jafari highlighted several immediate causes for the recent rise in polio cases. These include the large-scale repatriation of Afghan nationals which triggered unpredictable population movements within Pakistan and across Afghanistan. 

Challenges such as militant insurgencies and insecurity have hindered vaccination campaigns in certain regions as “children in these insecure areas cannot be consistently vaccinated,” he explained.

Jafari also pointed to vaccine hesitancy and community boycotts driven by unmet expectations for broader services as significant obstacles.

Despite these setbacks, both Pakistan and Afghanistan are actively working to counter the polio resurgence using measures such as remapping and identifying children who missed vaccinations, particularly among migrant and mobile populations, he added. 

Strategies also address vaccine fatigue and hesitancy by rebuilding community trust and confidence. Pakistan and Afghanistan are collaborating with their respective security forces to access children in insecure regions, he added.

“In Afghanistan, where door-to-door vaccination campaigns are not feasible, WHO is working closely with local authorities and communities to ensure children are mobilized for vaccination,” he said.

 Jafari expressed optimism about the future, stating that the current resurgence does not signify a return to high case levels: “Next year, we are confident we will come very close to elimination.”

He emphasized the importance of overcoming challenges in the virus’s remaining safe havens – insecure areas, mobile populations, and vaccine-hesitant communities.

National priority

The Prime Minister’s health coordinator,  Dr Mukhtar Ahmed Bharath said polio eradication is our first national priority under the leadership of the Prime Minister of Pakistan.

He said necessary measures are being taken on an emergency basis for the complete eradication of polio and an effective road map has been laid out for the success of the upcoming polio campaigns.

“All resources and capabilities will be utilized to stop the spread of polio virus and for high-risk areas, the federation and the provinces have jointly formulated an integrated strategy,” said Bharath.

“Complete eradication of polio is our national goal, and the cooperation of parents is very important to achieve this goal.”

The health ministry’s spokesperson Sajid Shah, told Health Policy Watch that that a high-level review meeting,  chaired by the Federal Secretary of Health and the Chief Secretary of Khyber Pakhtunkhwa, was held to discuss the current situation of polio and its related challenges.

The meeting resolved to take strict disciplinary action against those who make fake finger markings in anti-polio drives while special integrated strategy attention is being formulated for the high-risk areas.

“With all efforts from the government parents are requested to cooperate fully with the polio teams for the healthy future of their children,” said Shah.

 

Image Credits: Pakistan Polio Eradication Program .

Sugary drinks now face additional taxes in Brazil.

Brazil’s National Congress approved a selective tax on tobacco, soft drinks, and alcohol this week as part of wide-ranging fiscal reform that also saw a reduction in taxes on healthy foods.

The trio of unhealthy consumables is now located in the same tax category as harmful goods and products including coal, vehicles and betting.

The specific tax rates for tobacco, alcohol, and soft drinks will be determined in 2025, but they will need to be high enough to deter consumers from buying these products to have an impact on health. 

The Congressional vote is a victory for advocacy groups as the Brazilian Senate had removed sugary drinks from the selective tax a week earlier, causing a public outcry.

The tax reform also establishes a National Basic Food Basket (CBNA) that will be tax-exempt. Meat, poultry and fish are included in this basket.

In addition, taxes have been slashed by 60% on horticultural and minimally processed goods including crustaceans, dairy products, honey, flour, cereals, pasta, juices, bread, nuts and fruit.

Lowering the price of healthy food

Brazilian legislators and civil society advocates aim to ensure that the prices of healthy foods are not higher than those of ultra-processed and unhealthy products.

 “This is a landmark moment for Brazil and a historic victory for global public health,” said Pedro de Paula, regional country director for the global public health organisation Vital Strategies in Brazil.

“By implementing a tax on these products, Brazil is not only saving lives by curbing the consumption of harmful products but also championing equitable access to healthier, more sustainable alternatives.  We commend Brazil’s National Congress for their leadership in this critical effort.”

De Paul said fiscal reform was necessary as Brazil had a “very complex, clunky system for production and consumer taxes”.

The new selective tax is an excise tax “for a handful of products which had clear negative externalities in terms of health and environment’, he added.

“This is landmark change, since it establishes a system that has clear taxes on top of the general VAT-like taxing structure with a clear narrative and purpose of reducing consumption and internalising the costs of the mentioned negative externalities,” he added.

While the tax will not be ring-fenced for health, De Paulo said that as the health system in Brazil is based on universal and free access, “any additional revenue implies additional minimum investments on health.”

However, Vital Strategies raised concerns about some of the provisions, such as “the inclusion of infant formula in the basic food basket and reduced tax rates for small alcohol producers.”

It will “collaborate closely with partners to advocate for tax rates that prioritise public health”, as “setting these rates at levels that significantly reduce consumption of harmful products will protect communities from preventable diseases.”

Sweetened beverages including soft drinks, artificial juices, and teas are “among the most consumed food groups in Brazil, with an average consumption of 65 litres per year per individual,” according to a recent article in the journal, Nature.

“Excess sugar is considered one of the main causes of excess weight and, consequently, its associated diseases (type 2 diabetes, hypertension). Therefore, the consumption of sugar-sweetened beverages is associated with an increased risk of developing obesity.”

Image Credits: Heala_SA/Twitter.

Africa CDC Director General Dr Jean Kaseya (centre) visiting DRC to assist with its mpox outbreak

Although malaria, compounded by malnutrition, seems the most likely cause of the mysterious illness in the Democratic Republic of Congo (DRC), haemorrhagic fever syndrome has not been ruled out.

Dr Ngashi Ngongo, mpox lead for Africa Centres for Disease Control and Prevention (Africa CDC), told a media briefing on Thursday that there were two “working hypotheses” currently being verified: either severe malaria against a background of malnutrition and viral infection, or a viral infection against a background of malaria and malnutrition.

The DRC had reported to Africa CDC earlier that day about the death of a man from the Panzi district suffering from the haemorrhagic fever syndrome, a term used for a group of viral diseases that can cause bleeding and damage to the body’s organs.

“His sample has been taken and sent to Kinshasa for laboratory testing,” said Ngongo.

However, with malaria confirmed via PCR in 86% of patients tested, “the diagnosis is leaning more toward malaria”, he said.

But the high case fatality rate of 6.2% (37 deaths out of 592 cases) triggered further investigation as this is way higher than usual for malaria.

The 37 deaths happened in health facilities but a further 44 community-based deaths are still being investigated, he added.

Of the 88 patients given rapid malaria tests, 55% were positive, while 25 of the 29 samples subjected to PCR tests were positive for malaria (86%). 

It is hard to confirm when an accurate diagnosis will be possible given the complications, including getting samples to laboratories, he added.

Mpox vaccinations too slow

Africa CDC is “not at all satisfied” with the fact that only 56,000 people have been vaccinated against mpox in DRC, said Ngongo.

The country has received over one million doses (people need two doses), so the DRC is “very far from reaching the target that they had set for themselves”.

Meanwhile, the arrival of 50,000 doses of the long awaited Japanese LC16 vaccines that are suitable for children is imminent. Japanese experts have been in the DRC training health workers on how to administer the vaccines.

Africa CDC convened a three-day mpox meeting in Ethiopia this week to review the continent’s response. This was attended by Burundi, Central Africa Republic, Cote d’Ivoire, DRC, Kenya, Liberia, Uganda, Nigeria and South Africa and seven partners including Africa CDC and Gavi.

One of the reasons the DRC gave for its slow vaccination rate at the review was “the demotivation of the response teams”, said Ngongo. While partners “have made allocations to provide some financial motivation, that will be conditional on performance”, he added.

The meeting identified eight priorities, the first being to “intensify resource mobilisation, including a funders conference”, as only 20% of pledges have materialised.

Other priorities include intensified country support for the hardest-hit countries, better data management systems and the acceleration and expansion of vaccinations. Countries also want to tackle co-infections like measles.

The mpox outbreak is now active in 15 countries, and continues to spread steadily. In the past week, 3,095 new cases were reported in comparison to 3,545 the previous week, said Ngongo.

Children below the age of 15 now represent about 34% of cases, while females now represent 54%. There has been a 789% increase in cases over 2023.

The DRC has the highest burden of cases, with 2,632 new cases and 29 deaths in the past week. Children under the age of 15 make up almost half its cases.

While Burundi, which has the second highest mpox burden, has not yet committed to vaccinating its citizens, its representatives at the review were “very interested to learn from the experience of DRC”, said Ngongo. 

The DRC shared their initial experiences at the review, and Burundi intends to integrate lessons from this into their country interaction review and make a recommendation on vaccinations.

Africa CDC will be part of Burundi’s action review in early 2025 “to be able to guide them in setting up priorities, including the decision on mpox vaccination”, Ngongo added.

Rwanda celebrates end of Marburg outbreak

Meanwhile, Rwanda has planned a celebration in its capital, Kigali, on Friday (20 December) to mark the end of its Marburg outbreak.

“This success is the result of the swift and coordinated effort that was laid by the [Rwandan] Ministry of Health, in collaboration with Africa CDC, WHO and all the key partners,” said Ngongo.

“Some measures that have contributed to this success include the leadership commitment with a prompt and transparent communication from the Minister of Health,” he added.

“We’ve also seen the enhancement of the national surveillance systems that allowed for early case detection, the intensified contact tracing and the early case isolation. 

“We also saw very high level of laboratory testing with a very short result to turnaround. We saw also the expansion and the upgrading of treatment facilities that were really of a global standard. 

“And finally, there was really an intensification of the awareness campaign to ensure that the public I got the necessary information on how to prevent the infection.”

Rwanda had one of the lowest case fatality rates in a Marburg outbreak, estimated at 22.7%, in comparison to previous outbreaks where the case fatality rate was around 50%.”

Image Credits: Africa CDC.

An Afghan woman amongst ruins caused by ongoing conflict in the country.

Medical institutions were the last hope for Afghan girls and women seeking higher education since the Taliban banned schools and universities for women

“Why do you torture us every day? Just give us poison and end it all,” a heartbroken Afghan medical student told Taliban forces, expressing the despair of thousands of girls whose dreams of becoming healthcare professionals were shattered by the Taliban’s latest decree.

The hardline group has banned all female medical students from pursuing education, marking the closure of nursing and midwifery programs across Afghanistan, the last lifeline for girls seeking higher education in a country where women’s rights have been systematically eroded since the Taliban’s return to power in 2021.

The Taliban’s recent decree, issued directly by the group’s supreme leader, Hebatullah Akhundzada, has caused immediate devastation. 

For the past three years, nursing and midwifery were the only remaining fields of study open to women after the Taliban banned girls from attending secondary schools and universities. The abrupt closure of these institutions has ignited widespread despair across Afghan society.

The ban comes a few months after the Taliban banned women’s voices and faces in public under so-called new vice and virtue laws. 

‘Are we not human?’

The abrupt ban came just days before completion of the last 2024 semester for many aspiring students like Zohra*, a nursing and midwifery student at the Abu Ali Sina Institute in the country’s northern Balkh province.

She told the Health Policy Watch: “These institutes were our last chance to continue our education after schools and universities were closed. I had set a new goal and worked hard, receiving good grades. I was on my way to becoming a midwifery graduate, to help my family, my country, and other women. Now, I’ve truly lost all hope for life.”

Kabul-based Maryam* echoed the despair. “We are Muslims, we observe Islamic hijab, and we just want access to education. Why do they not open the doors of the medical institutes for us? Since the closure of the institutes, I’ve lost track of day and night. I can’t sleep. My parents took me to a psychologist a few times, but nothing is helping. Are we not human?”

‘I have turned homeless’

“I have turned homeless, wandering aimlessly,” one student said in a viral video. Her words, along with others like it, have echoed through Kabul and beyond as girls wearing full-body black veils, many in tears, left their classrooms for the final time, uncertain if they would ever return.

Fariba*, a mother from Kabul, received devastating news when her daughter, Parwana, called early one morning, sobbing uncontrollably. 

“She never calls at this time,” Fariba, who once taught elementary education to girls, told Health Policy Watch. “It’s when she’s in class.” 

Her daughter Sara* had been studying nursing after her dream of attending university to study computer science was dashed by the Taliban’s closure of higher education for girls.

“Now, we are left without hope,” Sara, 20, lamented. “Our dreams are shattered. We are being pushed into the darkness.”

Conservative estimates suggest that around 35,000 girls were enrolled in over 150 private and 10 public medical institutions offering diplomas in fields such as nursing, midwifery, dentistry, and laboratory sciences before the Taliban’s ban. 

These programs were the last available option for young Afghan women who sought to contribute to their communities, particularly in healthcare.

The abrupt suspension has left students in shock. The administrator of one of the nursing institutes sent a message to all female students: “With a heavy heart, I must inform you that until further notice from the Islamic Emirate, you must not come to the institute for studies.”

Deepening health crisis

Training to be a nurse or midwife was the sole remaining career option for Afghan women after the Taliban takeover in 2021.

This move not only marks the end of the academic ambitions of girls and women, but also deepens the country’s already precarious healthcare crisis.

Afghanistan’s healthcare system was already under strain before the Taliban’s return to power, with one of the highest maternal mortality rates in the world. 

In 2020, the country saw 620 women die for every 100,000 live births – a stark contrast to just 10 deaths in the UK, according to the World Health Organization (WHO). 

Less than 60% of births were overseen by trained health personnel in 2019, according to the  United Nations Population Fund (UNFPA), which estimates that Afghanistan requires an additional 18,000 skilled midwives to meet the needs of its women.

Despite the overwhelming need for female healthcare workers, the Taliban’s decision to block access to medical education for women will exacerbate the crisis. 

Médecins Sans Frontières (MSF) warned that the country’s lack of female healthcare professionals would directly impact the provision of essential health services, especially maternal care.

“There is no healthcare system without educated female health practitioners,” said Mickael Le Paih, MSF’s Country Representative in Afghanistan. 

“In MSF, more than 41% of our medical staff are women. The decision to bar women from studying at medical institutes will further exclude them from both education and healthcare.”

The healthcare sector’s reliance on female professionals is especially critical in Afghanistan, where cultural norms often prevent women from being treated by male doctors. 

Dr Ahmed Rashed, a Kabul-based health policy expert, warned that the Taliban’s latest decree would create numerous social challenges, especially for Afghan women who prefer to be treated by female healthcare workers.

“If girls cannot attend secondary school, and women cannot study at universities or medical institutes, where will the future generation of female doctors come from?” Rashed asked. “Who will provide healthcare to Afghan women when they need it most? For essential services to be available to all genders, they must be delivered by all genders.”

International outcry

Last week, the United Nations (UN) Security Council criticized the medical education ban and the “vice and virtue” law issued in August in a unanimous resolution voicing concern about “the increasing erosion” of human rights in the country.

“If implemented, the reported new ban will be yet another inexplicable, totally unjustifiable blow to the health, dignity, and futures of Afghan women and girls. It will constitute yet another direct assault on the rights of women and girls in Afghanistan,” according to UN Special Rapporteurs working on women’s rights, human rights and health. 

“It will undoubtedly lead to unnecessary suffering, illness, and possibly deaths of Afghan women and children, now and in future generations, which could amount to femicide.”

The Norwegian Afghanistan Committee (NAC), which trains female healthcare workers in collaboration with the Ministry of Health, reported that it had been verbally informed that classes for women would be “temporarily suspended.” 

As the Taliban’s gender-based restrictions continue to devastate the lives of millions of Afghan women and girls, the question remains: What is the future of Afghanistan’s healthcare system? Without access to education, Afghan women will be barred from becoming the doctors, nurses, and midwives their country so desperately needs.

This decision, experts warn, will not only create immediate social and healthcare challenges but will have long-term consequences for generations to come.

* Names changed to protect their identities. Updated 22.12.2024.

Manija Mirzaie is an Afghan journalist now based abroad.

 

Image Credits: WHO EMRO, Ifrah Akhter/ Unsplash.

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.