After collecting a windfall of nearly US$14 billion in donor commitments in October, the Global Fund to Fight AIDS, TB and Malaria, on Wednesday published its blueprint to distribute most of the money to over 100 low- and middle-income countries worldwide, saying that allocations will increase by 23% over the next three years.

Nigeria, Mozambique and the Democratic Republic of Congo are set to receive the largest awards with over $US 890 million, $US 751 million and $US 644 mllion respectively. according to the  allocation plan published on the Global Fund website. Tanzania, Uganda, South Africa, Malawi, India and Zimbabwe would receive allocations of $US 500-US $600 million each,  followed by grants ranging from tens of million to several hundred million dollars each to other qualifying African, Asian and Latin American countries, as well as Russia and former Soviet Union states. The allocation amounts represent threshholds against which countries then apply for final funding in one or all of the disease categories.

The country allocations total some US$12.71 billion, the agency said in a press release, adding, “The funds will help save 16 million lives, cut the mortality rate for the three diseases in half and get the world back on track to end the epidemics of AIDS, tuberculosis and malaria by 2030.”  In addition, countries can also apply to a separate fund of US$890 million for so-called “catalytic investments” that aim to scale up specific aspects of HIV and TB prevention or treatment, as well as strengthening health services overall.

French President Emmanuel Macron (center), and Microsoft’s Bill Gates, (far right), stand triumphantly with other Global Fund partners and supporters at the end of the successful Replenishment Drive in October that collected nearly US$14 billion in commitments.

Most eligible countries will receive funding increases, the Global Fund said. Countries in Africa are receiving around US$2 billion more than in the previous period, and countries in West & Central Africa have the biggest increase – US$780 million. Worldwide, there are 32 countries with an increase of 40% or higher.

Allocations to individual countries are calculated using a formula that is predominantly based on each country’s disease burden and economy, and then further adjusted to account for “important contextual factors”, the press release stated.

The aim is to drive funding to: “higher burden, lower income countries, specifically accounting for HIV epidemics among key and vulnerable populations, the threat of multidrug-resistant TB, and for the risk of malaria resurgence.” On the other end of the spectrum, the Global Fund aims to provide “sustainable and paced reductions where funding is decreasing” in middle and upper middle income countries that have made significant inroads in reducing disease but still require support.

“World leaders came together at our Replenishment and made commitments to step up the fight to end these epidemics by 2030,” said Peter Sands, Executive Director of the Global Fund, in the press release. “Now the real work begins. Our allocations will allow partners to expand programs that work, and to find innovative solutions for new challenges. In addition to more money, we need better collaboration and more effective programs.”

The Global Fund’s 2020-2022 allocation methodology is geared toward increasing the overall impact of programs to prevent, treat and care for people affected by HIV, TB and malaria, and to build stronger health systems, the press release stated. “The allocations provide significantly more resources for the highest burden and lowest income countries, while maintaining current funding levels or moderating the pace of reductions in other contexts.”

The allocations include increased investments in Eastern and Southern Africa for HIV prevention among adolescent girls and young women; more funding for the countries with the highest burden of TB in Africa and Asia; continued investments in Eastern Europe to cover the costs of treatment for multidrug-resistant TB; more funding for African countries with a high burden of malaria, and increased focus in the Sahel region to boost vector control and seasonal prevention campaigns.

The full list of allocations is available on the Global Fund website, along with a detailed explanation of the allocation process. In the next step of the funding process, countries convene coordinating committees to prepare and submit funding requests to the Global Fund for review and approval of the grant allocations, which may be disbursed to government as well as non-governmental funding recipients and partners.

 

Image Credits: The Global Fund.

Novartis has relinquished a patent granted by the European Patent Office for Kymriah, a promising new gene therapy for certain forms of leukemia, claiming the patent was no longer essential to the development and marketing of the treatment. The decision followed the moves by the Swiss-based NGO, Public Eye and the French-based Doctors of the World/Médecins du Monde to contest the patent in the European Patent Office. Their opposition, filed in in July, claimed that the price of the innovative therapy was “exorbitant” – with one infusion of the therapy costing CHF 370,000 in Switzerland.

Frozen T-cells of cancer patients are genetically modified to attack cancer cells in novel CAR-T therapies.

Kymriah, one of the first CAR-T [Chimeric antigen receptors T cell] therapies to receive marketing approval in Europe, is specifically designed for treating relapsing or treatment-resistant forms of acute lymphoblastic leukemia (ALL). It was developed by the University of Pennsylvania and later licensed exclusively by Novartis. CAR-T cell therapies rely on an innovative process in which a patient’s own T cells, which are critical to the body’s immune system, are collected and genetically modified to target cancer cells more effectively, and then reinfused back into the patient to attack the cancer.

The Kymriah treatment is so far being used in a limited number of patients, for instance about 100 people a year in Switzerland.  However, the underlying technology of CAR-T therapy holds much promise for treating other kinds of cancer as well. This could mean a rapid increase in the demand for similar therapies in the near future. Thus, the decision on the “patentability of such procedures” is “crucial” for setting a precedent, Public Eye said in a July statement about the patent opposition.

In a letter to the European Patent Office dated 29 November, representatives for Novartis and the University of Pennsylvania, requested the revocation of the patent on the grounds that “the proprietor no longer approves the text on the basis of which the patent was granted, and will not be submitting an amended text.”

The unexpected move was welcomed by Public Eye and Médicines du Monde, who had prepared for a long fight after they officially filed an opposition with the European Patent Office in July on the grounds that the “subject-matter lacks novelty.” The NGOs said the patent would pave the way for the Swiss pharma company to claim broad, exclusive rights not only over Kymriah, as such, but over other CAR-T cell technologies on the European market. Surprisingly, the patent holders submitted a request to withdraw the patent before the opposition procedure had in fact begun.

In response to the recent patent revocation request, Public Eye said in a statement, “This volte-face confirms that the patent should never have been granted in the first place, given that the underlying technology is not novel. It also questions the validity of other patents on Kymriah and weakens the monopoly position of the Swiss giant in future price reviews.”

The NGO added that the revocation should benefit an initiative by a number of leading Swiss university hospitals, among others, “to develop similar but considerably cheaper cancer therapies.”

In the patent revocation letter, Novartis and the University of Pennsylvania’s representatives claimed that the opposition’s arguments were “without merit.”

“[We] strongly believe in the importance of intellectual property rights as an incentive for ground-breaking innovation such as Kymriah. However, the opposed patent is not critical to the continued developement and marketing of Kymriah and the decision has therefore been taken to withdraw the opposed patent,” a Novartis spokesperson was quoted as saying to the Swiss online journal, swissinfo.ch.

Last September, Novartis also dropped a second patent application for another aspect of the treatment. However, Novartis does hold a patent on Kymriah, as such, in Europe and elsewhere. Experts in intellectual property law say that this patent still protects Novartis against the production of identical versions of Kymriah by competitors.  However, withdrawal of the other two patents leaves open a wider door for competitors to lower costs with the advance of further CAR-T innovations.

Image Credits: Novartis, Novartis.

More than one-third of low- and middle-income countries worldwide are facing significant rates of obesity alongside continued pockets of undernutrition, according to a major new study published on Monday in The Lancet.

The four-part series The Double Burden of Malnutrition, led by the World Health Organization in collaboration with a number of universities and researchers worldwide, examined historical nutrition survey data to estimate the prevalence of obesity alongside undernutrition across some 126 countries.

Some 48 of the 126 low- and middle- income countries surveyed had a “double burden” of obesity and undernutrition, the study found. According to the study criteria, this meant that at least 20% of the overall population was overweight or obese, while at the same time a high proportion of children were either stunted (30% having low height for their age) or wasted (15% having low weight for their height) or more than 20% of adult women were particularly thin.

Chubby infants are often seen as a sign of good health in many cultures, although new research indicates that significantly overweight babies may be at greater risks of obesity later in life.

The series heralds “a new nutrition reality in the world,” said Francesco Branca, lead author of a Lancet Comment that is part of the series, and director of the Department of Nutrition for Health and Development at the World Health Organization in a press conference.

“We are living at a time when multiple forms of malnutrition co-exist… They exist simultaneously in the same country, the same community, and often in the same individual – either simultaneously or at different stages of the life-course. And this type of burden of malnutrition is growing.”

Obesity, once a trend mostly seen in higher-income countries has now expanded to middle- and low-income countries – often existing right alongside undernutrition as well, the series emphasizes.

Globally, estimates from the WHO suggest that almost 2.3 billion children and adults are overweight, while more than 150 million children are stunted.  The double burden among children and adults is growing most rapidly in South-east Asia and sub-Saharan Africa.

Children are both experiencing undernutrition in early life and then becoming overweight later – due to the increasing preponderance of processed foods, fast foods and carbohydrate dense and/or fat-heavy foods in local diets, and decreased access to fresh, healthy food options, the authors conclude.  This, in turn, increases the risk of non-communicable diseases such as type 2 diabetes, stroke, and heart disease.

“The poorest countries in the world are carrying an enormous burden of undernutrition and now a growing burden of overweight and obesity,” said Abigail Perry, senior nutrition advisor at the UK Department for International Development (DFID) and the chair of the stakeholder group of the Global Nutrition Report at the launch of the series at a webcast event in London on Monday.

Changing food systems are largely to blame for the dual trends, the report finds.

Since 2004, worldwide availability of unhealthy processed foods, snacks and beverages high in energy, sugar, fat, and salt has soared. These foods are often marketed aggressively and more easily accessible and cheaper than healthy alternatives. Sales of breastmilk substitutes are also growing, despite strong evidence that breastfeeding is a healthier alternative which reduces risks of both undernutrition as well as providing a healthier nutritional balance to infants.

In addition, urban environments and lifestyles are raising barriers to safe, healthy physical activity, that could help reduce some of the obesity risks.

The prevalence of the double burden of malnutrition in the 1990s (top) and the 2010s (bottom). Darker red indicates a higher prevalence of obesity and undernutrition.

“The poorest low- and middle-income countries are seeing a rapid transformation in the way people eat, drink, and move at work, home, in transport and in leisure,” explained author of the first paper in the series, Barry Popkin, professor at University of North Carolina, USA, in a press release.

Ultra-processed foods, he said, are linked to increased weight gain and negatively affect infant and pre-schooler diets. Access to fresh, healthy foods is becoming more constrained in low-and middle-income countries due to disappearing fresh food markets as well as growing “control of the food chain by supermarkets, and global food, catering and agriculture companies in many countries,” he added.

So far, the research informing health sector policies that address malnutrition have focused largely on nutrients and nutrient supplementation, noted Branca, in a press briefing prior to the report’s release.

The report reflects the need to take more of a systems approach, he said, looking at dietary balance, and how health systems and food systems should support dietary choices for a healthy, balanced diet, including including fresh fruits, legumes, seeds, fruits and whole grains, along with modest amounts of meat or fish, as appropriate.

“Without a profound food system transformation, the economic, social, and environmental costs of inaction will hinder the growth and development of individuals and societies for decades to come,” said Branca.

Countries need to adopt a set of “double-duty” nutrition measures to address the double burden – including measures that health systems can take to promote healthy eating during pregnancy and early childhood, adjustment to food supplementation programmes; and also stronger agricultural and food policies to prioritize healthy diets, the report’s authors conclude.

“Double Burden” Evident Within Households & Among Adults and Children

The Lancet report found that the “double burden” manifests at the national level, household level, and even in individuals at different stages of life.

The combination of overweight mothers with children with stunted growth is the most common form of the double burden seen at the household level, although there is also a trend of children being stunted in their early years, followed by being overweight or obese later in childhood or adulthood.

Diets of children, women and girls is particularly important, notes Popkin, as women’s nutrition in pregnancy has a profound effect on the likelihood of an infant and young childre to suffer from the effects of undernutrition, as well as obesity, later in life.

A child is more likely to face stunting if their mother was undernourished during pregnancy, and likewise, a child is more likely to be overweight or obese if their mother was obese during pregnancy, for example. Meanwhile, overweight or obese adults who were undernourished in childhood may be at even higher risk of non-communicable diseases than those who were consistently overweight from childhood, the study notes.

Children who experience stunting in their first few years of life are also more at risk of becoming overweight or obese – rather than growing taller and lean – if they are subsequently provided with high-energy diets. As a result, classic health sector nutrition programmes that made inroads on stunting and wasting by through supplementation with foods high in fats and carbohydrates – may have inadvertently increased children’s health risks, because the diets were too low in protein, fibres, and micronutrients.

“There are strong biological and environmental linkages, and indeed intergenerational linkages that mean we must take a more coordinated and connected approach towards addressing malnutrition in all its forms,” said Alessandro Demaio at the press briefing, professor in the School of Global Health, University of Copenhagen and senior author on the second paper on the report, which explores the causative factors of individual-level DBM.

“By focusing on undernutrition and food insecurity for so long, nutrition programmes have absolutely allowed, or they have prevented, [the dialogue about] foods high in fats, sugars, and salts from moving center stage. So this means that obesity has grown under the watch of programs designed to target undernutrition,” added Corinna Hawkes in the briefing. Hawkes, a professor at City University in London, is lead author of the third paper in the report, which addresses the actions needed to mitigate both undernutrition and obesity.

However, Hawkes says that the answer is not to disregard undernutrition, which still represents a huge burden of malnutrition around the world, but to “redesign” programmes to reduce undernutrition while also reducing the risk of obesity and diet-related non-communicable diseases.

“The good news is, despite the heavy burden of malnutrition, there are some efficient and effective solutions that actually require some fairly modest redesigning of existing actions which can really be used to tackle this problem effectively,” said Hawkes.

But this will also require stronger policies against market actors who press junk food products on children and vulnerable groups by saying that they are “fortified” with some kind of nutrition, noted Perry at Monday’s launch event, saying, “People are still coming in with solutions that involve fortifying donuts.. that hasn’t gone away.”

Restructuring Food and Health Systems for “Double-Duty” Actions Against the Double Burden – Promoting Healthy Diets and Reducing Consumption of Processed Foods

The authors propose a series of “double-duty” approaches by the health sector, the agricultural sector as well as school systems and the social welfare sector to simultaneously decrease undernutrition and obesity.

Some of the proposals are actions that the health sector can lead, while others would involve a broader restructuring of agricultural development and food system priorities – to increase incentives for production and promotion of healthier foods, more fresh foods, and more diverse diets.

Currently, economic incentives in low and middle income countries are pushing systems in almost the opposite direction – towards cheaper foods, less diverse foods, and more packaged and processed foods, the studies authors acknowledged.

“It’s an epidemic of systems,” said Perry.  “The reality is that health is not really in the core objectives of the food system.”

“Without a profound food system transformation, the economic, social, and environmental costs of inaction will hinder the growth and development of individuals and societies for decades to come,” said Branca.

Still, the report notes that there are some immediate policy measures that health, education and social welfare sectors could advocate around to initiate changes, including: better labeling of healthy and unhealthy foods, using domestic fiscal policies to support healthy foods production; healthier food procurement for schools; and more systematic restrictions of marketing around junk food.

For its part, Branca said that WHO was working on new guidelines to indicate the optimal proportion of plant-based foods in a healthy diet, and another set of guidelines related to processing of food products – which should help to contribute to more of a whole diet and whole systems approach to nutrition.

For civil society actors, the report’s strong call for fixing food systems is a welcome one.

Katie Dain, chief executive officer of the NCD Alliance, said, “We’ve long known that NCDs are a global health emergency and this report’s stark warning of the consequences of inaction on the double burden of malnutrition may well be the jolting wake-up call that political leaders need.”

“The globalisation of processed junk food has brought us all to this precipice, and getting off it will require swift, coordinated and creative action from a range of decision makers across society who recognise the value in ensuring healthy diets for all in all countries. The costs of ignoring NCD prevention as we tackle all forms of malnutrition will be borne by us all.”

Richard Horton, editor-in-chief of the Lancet and moderator of the launch event, said the study would propel the nutrition research community to embrace a more holistic approach, breaking down the silos between obesity and undernutrition research

“We’ve rather badly separated off obesity from undernutrition, and we will never do that again,” said Horton.

Image Credits: Flickr/Jen Wen Luoh, Lancet Series on the Double Burden of Malnutrition, Twitter: @TheLancet, Lancet Series on the Double Burden of Malnutrition.

The number of new Ebola virus cases in the ongoing outbreak in the Democratic Republic of the Congo shot up to 27 confirmed cases in the last week, triple the number of 9 confirmed cases reported between 27 November to 3 December. The recent surge in cases comes in the wake of insecurity and a series of violent attacks on Ebola workers that froze the response.

“Since the beginning of the response, there is a factor that we cannot control – the context of the intervention, including insecurity,” Michel Yao, incident manager for the World Health Oganization’s Ebola Response in the DRC said at a press conference (translated from French). “In the zones [where cases are arising], there is one particular zone, Lwemba [in Beni Health Zone], that we have not been able to access for three weeks.”

Ebola vaccinators return to Biakato Mines following a deadly attack on healthcare workers in the area on 27 November.

According to the latest WHO Disease Outbreak Notice, most cases in the past week have arisen from Mabalako and Beni Health Zones, where the Ebola response seems to be mobilizing again after temporarily scaling back activities in the last two weeks of November due to violence and riots in those affected areas. Some 18 cases were reported from Mabalako, and 6 cases from Beni, and the remaining 3 cases originated from Mandima and Oicha. Six of the confirmed cases were health care workers – including 5 traditional practitioners – representing a spike in the number of health care workers infected in the outbreak.

Despite the surge, WHO says that the average proportion of contacts under surveillance in the last seven days has returned to normal levels, and the investigation of alerts has also been improving. To ensure continued care, WHO has mounted a limited daily helicopter “air bridge” operation to transport epidemiologists to investigate cases, but to also primarily send vaccinators to hard-to-reach communities. Dr Yao noted that the communities had come to the Ebola responders seeking help.

They “want the intervention”, he insisted, “but around we have armed groups that prevent us from reaching these communities…We’re mobilising communities all around to come and get vaccinated in a situation where there are (health) alerts but we can’t go to investigate because access is restricted.”

On Thursday, the first Ebola vaccinators returned to the Biakato Mines Area, where three Ebola responders were killed in late November, to continue fighting the outbreak.

So far, 17 of the new cases have been linked to one individual – who reportedly presented with EVD illness for the second time within a 6-month period. According to WHO, rare cases of relapses of Ebola, in which a person who has previously recovered from EVD gets symptoms again, have been recorded. However, DRC officials are also investigating the possibility of reinfection – a scenario in which an individual who has recovered from Ebola gets infected with EVD from another person – which has never been documented before.

Previous studies have shown that Ebola survivors can develop immunity to the disease which can last for over a decade, but experts have long been concerned about the possibility of relapse or reinfection. The possibility of relapse or reinfection could indicate a need to revisit the kind of care provided to survivors, and how Ebola survivors are involved in future response activities.

Image Credits: Twitter: @DamelSoceFall.

The World Health Organization issued new guidelines for the treatment of multi drug-resistant (MDR) tuberculosis on Wednesday, prioritizing for the first time an all-oral treatment regimen. The new treatment recommends replacing the painful injectable drugs that patients had to endure under previous treatment guidelines with a shorter course of oral bedaquiline – one of only three new drugs approved for treatment of TB within the last half century.

A healthcare worker counsels a patient with MDR-TB

The update was announced in a rapid communication released by WHO after an independent panel reviewed new evidence on treating multi-drug resistant (MDR) and rifampicin-resistant (RR) TB in November. Compelling data from the South African TB programme, collected in collaboration with research and technical partners such as The Union, showed that replacing injectable drugs with oral bedaquiline resulted in significantly better treatment outcomes for patients with MDR/RR-TB. Not only that, but more patients also completed the full 9-month treatment when provided all-oral regimen.

“The Union supports the move towards shorter all oral treatment regimens with better outcomes, lower toxicity and reduced side effects for people with drug-resistant TB,” said Grania Bridge, director of the Department of TB at The Union said in a press release. “As new all-oral regimens are developed, there is a clear need for more and better evidence to support their implementation around the world.”

Much of the new recommendations were based on evidence coming out of traditional clinical trials and operational research – which tests the regimens that pass through clinical trials under real-life conditions, where barriers to health care, stigma, and other factors can contribute to the likelihood of patients successfully completing a full course of treatment. This is especially important to observe for the long 9 to 11-month treatment regimens recommended for MDR/RR-TB.

“The WHO rapid communication emphasizes the importance of operational research in generating high quality programmatic data,” said Bridge, highlighting the need for countries and funders to “prioritise operational research to guide future treatment guidelines, as well as complement the data expected from clinical trials currently underway.”

In the update, WHO also issued guidance for the BPAL regimen – a breakthrough regimen for treating XDR TB that just received regulatory approval from the US Food and Drug Administration this August. In the rapid communication, WHO recognized that the BPAL regimen showed high treatment success when used in 108 XDR-TB patients in South Africa, but has refrained from recommending programmatic implementation of the regimen worldwide until more evidence has been generated. For the time being, WHO recommends collecting more evidence for the BPAL regimen under operational research conditions conforming to WHO standards.

WHO is set to release the next full update of consolidated guidelines on the treatment of all forms of drug-resistant TB in March 2020. The rapid communication was preemptively issued in order to prepare national TB programmes and other key stakeholders for what changes they can expect, in order to roll out the new guidelines as quickly as possible.

Image Credits: WHO PAHO.

From clearing the air of hookah smoke in Amman, Jordan to bike lanes in Fortaleza, Brazil and salt-free menu options in the restaurants of Montevideo, Uruguay,  the Partnership for Healthy Cities has been seeding small grants to cities across the globe – backed by a big ambition. The aim is to build a network of cities equipped with smart strategies to combat the epidemic of noncommunicable diseases (NCDs) and injuries that are the cause of 8 out of every 10 deaths annually.

And that now that network just became a lot bigger and stronger – with the addition of the megacity of Tokyo along with 15 other cities to the Partnership – and a new $12 million reinvestment by Bloomberg Philanthropies into the initiative.

“Today, cities are where the action is on issues from climate change to health, and the people who lead them are more important than ever,” said Kelly Henning, head of Bloomberg Philanthropies’ public health programmes, in a press release announcing the expansion of the network to 70 cities, and the new funding commitment.

Cycling in Fortaleza, Brazil – the city strengthened its active transport plans as part of the Healthy Cities Partnership.

Cities have the Power and the Opportunity

“Cities have the power and opportunity to take action to protect people’s health,” said Tedros Adhanom Ghebreyesus, Director-General of WHO, which is providing technical support to the initiative.

Launched in 2017 with some US$ 8.5 million in funds, the Partnership— including WHO, the global health NGO Vital Strategies, and Bloomberg Philanthropies, founded by former New York City Mayor Michael Bloomberg — provides cities with financial assistance and technical advice from publiof health experts to implement their chosen intervention to reduce noncommunicable diseases (NCDs) or injuries.

The Partnership supports, urban action in six key areas , including tobacco control; food policy; road safety; walkable streets and cycle networks for active mobility; drug overdose prevention; and monitoring of NCDs and NCD risk factors.

Grants are modest – each city gets a total of around $US 100,000 – $US 150,000 to plan or implement an intervention, says Ariella Rojhani, director of the partnership at Vital Strategies, which is the lead implementer.  But even so, the initiative aims to support practical measures that “help close the gap between rhetoric and action around NCDs and injury prevention.”

New Tools & Tactics for Preventing NCDs

The tools and tactics cities may choose to use are not always the traditional ones associated with hospitals and health care settings.  They may range from improved physical planning of streets and sidewalks that encourage more physical activity to edgy social media campaigns that build awareness about bad smoking and drinking habits among youth. Often, they may involve the creative use of health and safety regulations to promote, for instance, healthier foods in schools, restaurants and markets.

For instance, in Accra, Ghana, redesigning the pedestrian crossing at a major highway intersection with the highest rate of road crashes and fatalities in the city led to a nearly 35% reduction in serious injuries at the site.

Accra, Ghana redesigned a high-risk pedestrian crossing, resulting in a nearly 35% reduction in serious injuries at the site.

In Quito, Ecuador, school menus were purged of unhealthy foods, and healthier fresh food options were added. The City of Montevideo, which had already adopted a number of forward-looking policies on sugary drinks, targeted salt reduction to reduce high blood pressure risks as their next goal.

“The city they really wanted to address hypertension by reducing salt consumption,” Rojhani noted. “So they passed an innovative regulation that food establishments have to have ten percent of their menu items be salt free.”

Quito, Ecuador launches a healthy foods in schools project as part of the Partnership for Healthy Cities.

The Partnership supported the planning and launch of the Montevideo strategy, including critical consultations with the food industry and private sector, in order to get them on board.  Now, the Health Department is rolling out enforcement policies.

In Ouagadougou, Burkina Faso, where traditional problems of food storage and safety remain a critical issues, even as unhealthy diets lead to growing obesity and hypertension, the challenge was how to adapt the WHO “best buy” recommendations for low-fat, low-salt and low-sugar foods – when ingredients like salt, for instance, might also be an important traditional preservative.

The response was to adopt a ¨ food hygiene¨ approach, said Rojhani, including development of guidelines for local food establishments that stressed safe food preparation and storage, but also built in recommendations for reduced salt and sugar into food and drink preparations.

“Obviously every city has a context that is quite different, so success always looks a little bit different as well,” Rojhani said.

In Amman, Jordan, a country with one of the highest rates of smoking in the world, the Municipality set out to strengthen and enforce a long-ignored law prohibiting smoking in public places, also confining smoking in restaurants and cafes to separated smoking areas. The city also also created a municipal ban on the advertising of tobacco in cafes and restaurants, including hookahs, the traditional water pipes known locally as shisha, which have experienced a resurgence among youths.

Growing the Network & The Commitment

The initiatives may start modestly, but they are structured so as to have long-term impacts on urban policies, after the Partnership support has ended, and strategies used in one city can also provide an example of a successful approach that other cities may want to follow, Rojhani noted.

“By adding 16 new cities, we now have the ability to reach an additional 62 million more people, a total of 300 million people worldwide”, she added.

“Each city is demonstrating that rapid progress against the world’s leading killers is possible, and each serve as a model for change at the country and regional levels,” said José Luis Castro, President and CEO of Vital Strategies, in the news release.

“We recognize the commitment and early successes of our partner cities as they work to ensure healthier and safer environments for their residents, an outcome that will only grow as we expand the global network.”

NCDs—which include heart disease, cancer, diabetes, and respiratory diseases—as well as injuries such as road traffic crashes, together cause an estimated 80% of the world´s deaths every year.

While NCDs are responsible for more than two-thirds of deaths annually in low- and middle-income countries, and account for trillions of dollars in economic losses, they receive only 1-2% of total donor development assistance for health.

With some 68% of the global population projected to be living in cities by 2050, cities are a natural focus for many innovative NCD strategies, officials connected with the Partnership initiative point out.

The 70 cities in the Partnership for Healthy Cities

Municipal and Metropolitan authorities often have significant budgets and authority over a wide array of local planning policies, health and safety codes as well as regulations. And they can use these tools  to shape healthier environments and encourage healthy behaviours that reduce risks of NCDs.

Although the preponderance of cities in the Partnership are low and middle income, high-income cities are very visible and welcome too.

Along with Tokyo, the other new cities joining the Partnership now reflect that diversity and range. They include not only the megacities of Athens and Hong Kong, in upper income countries, as well as Muscat, Oman; Helsinki, Finland; Vancouver, Canada; and Birmingham, United Kingdom, but also low and middle income cities, such as Abidjan, Cote d’Ivoire; Colombo, Sri Lanka; Dakar, Senegal; Freetown, Sierra Leone; Hanoi, Vietnam; Harare, Zimbabwe; Istanbul, Turkey; Kumasi, Ghana; and Tunis,Tunisia.

Explains Rojhani, “High income cities still have a ways to go on NCD and injury policy. Similar to the reasoning behind countries of all income levels adopting the UN Sustainable Development Goals, all areas of the world are facing similar challenges. They likewise all have a role to play in addressing the enormity of the NCD challenge.

“There are regional difference to be sure, but we need action in all parts of the globe. To double down on that point, there are of course large disparities within cities, as well. In high-income cities, we are largely working in lower-income areas,” she added.

And finally, high income cities often have useful approaches that can be replicated even in less affluent cities. Said Rojhani: “There is no need to start from scratch when we have proven policies and programmes already in place.“

Image Credits: City of Fortaleza, Accra Metropolitan Assembly, City of Quito/Juan Carlos Bayas, Vital Strategies.

On 22 November, the Norwegian government broke new ground for the non-communicable disease response. The Norwegian Ministry of Foreign Affairs launched the first international development strategy to focus on combatting NCDs in low- and middle-income countries (LMICs). The NCD Alliance, the Norwegian Cancer Society and other civil society partners around the world have heralded this as a major milestone. I had the pleasure of attending and speaking at the launch event of “Better Health, Better Lives” in Oslo. But why is this such a big deal and what are the broader implications?

A panel at the launch of Norway’s new NCD-focused development strategy. (left-right) Maria Neira, WHO; Omnia El Omrani, (IFMSA); Mamka Anyona, UNICEF; Tiy Chung, CCA Coalition; Andrea Winkler, Centre for Global Health, the University of Oslo; Katie Dain, NCD Alliance.

Let’s start with the numbers, as they speak volumes. NCDs including heart disease, stroke, diabetes, cancer and respiratory disease are now the cause of some 70% of total deaths worldwide. It is widely recognised that NCDs have a detrimental impact on many aspects of sustainable human development. Contrary to the perception of NCDs as a rich world problem, they impact most heavily on LMICs, where NCDs are responsible for over two-thirds of deaths and will cost $7 trillion in economic losses over the next two decades. However, the world’s biggest cause of premature death and disability are collectively the target of an astoundingly pitiful 1.7% of health-related development assistance (or $611 million).

Whilst bilateral donors (e.g. national governments or their development agencies) are the dominant source of funding in global health more broadly, providing 52% of overall development assistance for health, they have until now simply been absent in the field of NCDs. Between 2010-2015, non-governmental organisations (NGOs) collectively provided more than twice as much aid for NCDs than bilateral donors, and considerably more than multilateral organisations such as the World Bank and WHO.

The picture of resources available to tackle NCDs hasn’t changed markedly since 2015, despite the transition from the Millennium Development Goals (MDGs) to the era of the UN Sustainable Development Goals (SDGs), when NCDs were finally included as a priority for global health and sustainable development. After many years of campaigning, NCD advocates around the world could have hoped that this would be the moment that would trigger donor countries to incorporate NCDs into their development policies and strategies. But although many development agencies including from the UK, US, Sweden and Australia are supporting NCDs via different channels (for example, via health system strengthening efforts, integrating NCDs into existing global health programmes, or tobacco control programmes in LMICs), overall they have remained far too silent and passive on NCDs.

Consequently, LMICs have been left to respond to increasing burdens of NCDs within their own scarce resources. Governments are juggling a backlog of common infections, undernutrition and maternal mortality together with growing burdens of NCDs, pandemics and the alarming health effects of the climate emergency. Budgets and health systems are crippled and few poor countries provide care for NCDs in their health benefits packages. The result of this is a hugely unjust and unjustifiable burden: in lower-middle income countries, people are largely asked to pay for the care and treatment they need out of their own pockets. 56% of health spending is taken from the people who need treatment, rather than from government spending or other sources. For the many who cannot afford treatment, this means the agonizing choice between foregoing life-saving or life-improving care or tipping their family into poverty. This is a desperate reality particularly for the poorest, most marginalized populations, who are still all too often left behind.

These statistics and realities are why the Norwegian government’s international development strategy on NCDs is so important and such a welcome step. Norway is the first OECD country to translate the inclusion of NCDs within the SDGs into their development policy, and back it up with a clear and much-needed overseas development resources. Norway has announced a tripling of its assistance for NCDs, allocating over $20 million to support the strategy for 2020 and this commitment is expected to increase towards 2024. This is a relatively modest amount in the context of global health giving, but already catapults Norway to the ranks of the top three supporters for NCD prevention and control, well ahead of the US, UK, France, Germany and Canada.

The Norway example provides an important precedent as well as a model for other OECD countries to follow, not just for it being the first, but also the substance and approach taken. First, while the strategy is led by the Ministry of Foreign Affairs, the launch event in Oslo made clear that this was a product of cross-government collaboration, with both the Minister of International Development, Dag-Inge Ulstein and the Minster of Health, Bent Høie taking the stage together, sending a strong signal of whole-of-government leadership. Secondly, the strategy builds upon WHO’s normative work on NCDs by supporting low-income countries implement the “Best Buys” and embracing the broader “5×5” approach to NCDs with a welcome focus on mental health and air pollution. Thirdly, the pillars of the strategy build off Norway’s track record in NCDs and public health domestically and internationally, evident by the strong focus on proven prevention measures; tobacco control and the FCTC, regulation and taxation of unhealthy products, and attention to the commercial determinants of NCDs which is so urgently needed in many LMICs. Fourthly, it clearly articulates this new focus on NCDs as an opportunity to build on and augment (rather than divert) Norway’s global health and development priorities and investments to date, such as women and children’s health, climate and the environment, and humanitarian crises. And finally, both at the event and in the strategy, there is clear recognition for the integral role civil society and communities play in responding to NCDs.

Five ingredients of a strategy that has positioned Norway as a global leader in responding to NCDs in low-income countries and saving lives, and a model for other OECD countries to follow. Who will be the next to follow?

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Katie Dain is Chief Executive Officer of the NCD Alliance, a global network of civil society organisations dedicated to transforming the fight against non-communicable diseases (NCDs). Katie has worked with the NCD Alliance since its founding in 2009. Katie is widely recognised as a leading advocate and expert on NCDs. She is currently a member of the WHO Independent High-Level Commission on NCDs, co-chair of the WHO Civil Society Working Group on the UN High-Level Meeting on NCDs, and a member of The Lancet Commission on NCDIs of the Poorest Billion. 

 

 

 

 

Image Credits: Stine Loe Jenssen.

Make the ¨healthiest choices the easiest choices¨ to prevent many non-communicable diseases. This was a key message from an Independent High-Level Commission report on Non-communicable diseases (NCDs), released Tuesday at a WHO Global Meeting to Accelerate Progress NCDs and Mental Health in Muscat, Oman.

WHO

The report, ¨It´s Time to Walk the Talk¨, released on the second day of a four-day meeting (9-12 December) is the final report in a series produced by the High-Level Commission, which was convened by WHO Director General Dr Tedros Adhanom Ghebreyesus in 2017.

It calls for WHO to lead the way in advocating for national government policies that create healthier environments and encourage healthier behaviours, which can prevent many chronic diseases – through measures such as stronger government taxes and regulatory measures. Promoting greater ¨health literacy¨about healthy choices individuals can make as well as incorportating NCD prevention and treatment fully into health systems are other cornerstone recommendations of the new report.

The Commission, co-chaired by Finland, Sri Lanka and the Russian Federation, was created by the WHO Director General shortly after he took office; it was charged with identifying innovative ways to curb NCDs that are responsible for seven out of ten deaths worldwide, including from cardiovascular disease, cancers, diabetes, respiratory diseases and mental health conditions.

The first Commission´s first report, focusing on actions countries can take to beat NCDs, was released in June 2018. This second report, focuses on the role that WHO can play, WHO said in a press release.

Sir George Alleyne, Speaking in Muscat, Oman.

However, WHO should play a strong leadership role in recomending effective policies to UN member states, said Commission member Sir George Alleyne who led Tuesday´s presentation on the report´s recommendations.

“The first recommendation [of the report] is how to encourage heads of state and governments to fulfill their commitments, emphasizing the role of WHO to provide strategic leadership,¨ said Alleyne, director emeritus of the Pan American Health Organization and former UN special envoy on HIV/AIDS in the Caribbean. He spoke in Muscaat before the conference attended by some 600 representatives of countries, UN agencies, academic, philanthropy and civil society.

“Key measures recommended in the report involve involve promoting health literacy and accelerating multisectoral collaboration,¨ he added, saying that while “WHO should use its technical cooperation to motivate ….governments to fulfill their obligations. The heads of state and government have an inescapable responsibility to ensure that there is a redution in the burden of NCDs throughout the world, to empower individuals to make healthier choices, and to make the healthiest choice the easiest choice.”

He said that strategies thus need to take a ¨twin approach” targeting, ¨responsibility at the level of individual  behaviour and at the level of the contextual environment.

“WHO should work at both levels, at the level of the individual and the level of the environment. While providing information to the individual, it should not forget the fundamental responsibility of the government, which is the responsibility of regulation, legislation and taxation, the various regulatory measures that should be applied.”

NCD prevention, diagnosis and treatment should also be embedded into Universal Health Coverage, Alleyne emphasised. ¨There should be no debate about the essentiality of NCDs in that package of health service that should be offered.”

Huge Gap Between SDG Ambition & NCD Trends

WHO´s Menno van Hilten told the meeting that the High Level Commission was part of an initiative by WHO to step up its actions with bold recommendations on how to close the gap between the Sustainable Development Goal target (SDG3.4) that aims to slashing premature NCD deaths by one-third by 2030, and the reality of rising NCD deaths and disability in many countries today.

“The problem of NCDs fits onto one slide,¨ he said. ¨The world is off track to meet SDG 3.4 on NCDs, the red line is the current trend, the green line is the path that we shoudl have been on.  There is a huge gap between the red and the green line . This gap is a major problem because the UN General Assembly has said that NCDs constitute one of the major challenges for development in the 21st century,” declared VanHilten.

Norwegian State Secretary Aksel Jakobsen told conference participants that Norway´s new NCD strategy for its international development assistance – launched last month – will support low-income countries in combatting deaths from air pollution, tobacco, unhealthy diets and physical inactivity through strengthened health systems, healthy behaviours and cleaner environments.

For countries that request assistance, the strategy will help governments build stronger systems of taxes and regulations to reduce air pollution and discourage consumption of health-harmful tobacco, sugary foods and drinks  all of which are key NCD risk factors. “Norway will work to support global commitments and effective measures to prevent harmful air quality. We will, for instance, support work on taxation and regulations,” Jakobsen said. 

In terms of how the private sector can contribute to fighting NCDs, including better access to NCD treatments, Thomas Cueni, head of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), told the Oman conference that the Private Sector Constituency Statement on Universal Health Coverage, released by the civil society stakeholder movement UHC 2030 on the sidelines of September’s UN High Level Meeting on Universal Health Coverage, is an important starting point.

“Critical enablers which are all equally applicable to NCDs are: processes that allow for structured and meaningful engagement of all partners; national health strategies and plans; a robust regulatory and legal system; more and better investment in health; and the appropriate capacity to work with non-state actors,” Cueni said.

He cited as an example, one IFPMA-member supported project City Cancer Challenge, an initiative launched by the Union for International Cancer Control (UICC) that is supporting nine major cities and nearly 200 health care institutions in low and middle income countries with a combined population of over 45 million people develop more sustainable financial models for cancer treatment and control.

“This is ambitious, joined-up thinking that is trying to move beyond the piecemeal nature of individual programs into something more coordinated and hence, potentially more impactful,” Cueni said.

Altogether, the new report lays out 8 sets of recommendations for WHO including:

  • Encourage Heads of State and Government to fulfil their commitment to provide strategic leadership by involving all relevant government departments, businesses, civil society groups as well as health professionals and people at risk from or suffering from NCDs and mental health conditions;
  • Support countries in efforts to empower individuals to make healthy choices, and “make the healthiest choice the easiest choice, including through the creation of enabling environments”, health literacy, and policy, legislative, and regulatory measures that reduce exposure to risk factors for NCDs and mental health conditions;
  • Encourage countries to invest in the prevention and control of NCDs and mental health conditions as a key opportunity to enhance human capital and accelerate economic growth;
  • Advise countries to include services to prevent and treat NCDs and mental health as essential components of Universal Health Coverage;
  • Ensure that no one falls into poverty because they have to pay for health care out of their own pockets through the provision of adequate social protection for everyone;
  • Increase engagement with businesses and provide technical support to Member States so they can mount effective national responses to NCDs and mental health conditions;
  • Encourage governments to promote meaningful engagement with civil society;
  • Advocate for the establishment of a multi-donor trust fund to support countries in activities to reduce NCDs and promote mental health.

WHO estimates that every year, some 41 million people die from NCDs, 15 million of them between the ages of 30 and 69. Although only about 35% of total deaths in low-income regions such as Sub-Saharan Africa are due to NCDs today, NCD deaths are projected to increase to more than 50% of the toll by 2030. And already, people stricken with NCDs in low- and middle-income countries tend to die at a younger age because they cannot access prevention and treatment as easily.

See the livestream from the conference here:

Image Credits: WHO.

A new plan to dramatically accelerate global efforts to end tuberculosis, one of the world’s deadliest and oldest known infectious diseases, was launched Tuesday by the Stop TB Partnership in Jakarta.

The fully-costed plan is based on commitments made at a 2018 United Nations High-Level Meeting on Ending TB (UNHLM) to reduce TB deaths by 1.5 million people by 2022.  Two other initiatives – one to mobilize civil society support and another to launch a new regimen for treating drug-resistant TB in Indonesian children – were launched in tandem to increase efforts towards.

“I feel we are finally starting to get what we need to end TB. There is a long way to go; but we see light at the end of the tunnel,” said Stop TB Partnership’s Executive Director, Lucica Ditiu, in a press release.

According to the roadmap, funding for TB prevention, care, and R&D must be rapidly scaled up in order to reach global targets for reducing TB in line with 2022. Currently, funding for TB treatment and prevention stands at less than US $7 billion per annu; that must be doubled to at least US $14 billion per annum. R&D funding must be nearly tripled to over US $2.16 billion per annum.

“It is not just about launching the Global Plan, it is also about launching concrete tools and funding to implement it,” said Ditiu. “We have the largest-ever call for proposal from grassroot organizations as we must ensure that civil society and communities remain our full partners in ending TB. And we share with the world the pediatric formulations for children with drug resistant TB.”

Political leaders, Ministers of Health, TB survivors, donors, and TB experts from around the world gathered Tuesday for the official launch of the “Global Plan to End TB 2018 – 2022: The Paradigm Shift” in Indonesia, a country with one of the highest TB burdens in the world.

Globally, it is estimated that 10 million people developed TB disease in 2018, and around 3 million people who developed the disease were unable to get proper treatment for it.

In Pakistan, a healthcare worker listens to a child’s lungs for signs of pulmonary tuberculosis.

The new plan is an update and extension of the “Global Plan to End TB 2016-2020,” and follows on from last year’s first ever UNHLM on tuberculosis. While some heads of state from the G7 countries – the biggest donors to global health aid – and some high-burden TB countries were noticeably absent from the High Level Meeting, the event still  set a new tone for TB advocacy, and led to 129 countries signing onto the first ever Political Declaration on TB during the 73rd UN General Assembly – which outlines goals that are embedded in the Stop TB Partnership’s roadmap and budget.

If the plan is fully implemented by 2022, the Stop TB Partnership estimates that 40 million people will be treated for TB, including 3.5 million children and 1.5 million people with drug-resistant TB, and over 30 million people will receive TB preventive therapy. This will lead to 1.5 million fewer deaths due to TB and there will be a US $44 return on investment for every US $1 spent.

While the plan encourages upper-middle- and high-income countries to scale up domestic funding, it also notes that donors will need to step up external commitments to help support low- and lower-middle income countries. With the Global Fund to Fight AIDS, TB, and Malaria’s recent successful US $14.2 billion replenishment in October, the fight to end TB received a US$840 million annual boost for the next three years.

However, the Stop TB Partnership says that external funding will still need to be scaled up to fill the remaining funding shortfall of US $5.1 billion per year, warning that a five-year delay in increasing funding for TB R&D could lead to 13.8 million more people developing the disease and 2 million more people dying by TB.

Launch of a Multimillion Funding Facility for Civil Society 

Along with the updated global plan, the Stop TB Partnership is launching the “Challenge Facility for Civil Society 2019” – a fund of US $2.5 million in grants for civil society and community-based organizations (CBOs) who provide crucial advocacy and support to some of the hardest to reach populations impacted by TB.

According to the Stop TB Partnership, certain vulnerable populations face both an increased risk of contracting active TB and facing stigma due to where they live or work, leading to limited access to quality TB care. A number of community-based organizations and small non-governmental organizations have sprung up around the issue to help provide support to these affected communities.

The new funding facility will hold the largest-ever call for proposals for TB-affected community and civil society grassroots organizations. It will be supported by funding from USAID and the Global Fund, and the 12-months grants will range from US $25,000 to US $150,000.

Organizations from 14 high-burden countries – Bangladesh, Cambodia, DR Congo, India, Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Pakistan, Philippines, South Africa, Tanzania, and Ukraine – are eligible to apply for funding. Organizations that operate regionally in anglophone Africa, francophone Africa, Asia, Latin America, the Caribbean, or Europe are also invited to apply.

Fighting Drug Resistant TB in Children – A New Initiative 

Tuesday also marked the official launch of the Stop TB Global Drug Facility’s Pediatric Drug-Resistant TB (DR-TB) initiative, launching child-friendly formulation of medicines used to treat drug-resistant TB (DR-TB) in Indonesia.

Of the estimated 1.1 million children under the age of 15 who became sick with TB around the world in 2018, an estimated 32,000 had MDR-TB. Of those, fewer than 5% are diagnosed and receive treatment. It’s estimated only 500 children under the age of five received treatment for DR-TB in 2018.

The Pediatric DR-TB Initiative will make child-friendly formulations of TB drugs like cycloserine (above) available to children who need them.

The dissolvable, flavored formulations of essential DR-TB drugs are already used in 56 other countries, including high-burden countries Nigeria and Haiti, and will replace the crushed-up tablets and intravenous injections currently used to treat drug-resistant TB in Indonesian children. The new treatment regimens for children are also shorter, and cause less dangerous side effects than traditional treatments for drug-resistant TB.

“What you often don’t see when looking at the crushing problems posed by TB—either at home or around the world—is how the disease affects children,” said Nigeria’s Minister of State for Health and Stop TB Partnership Board Member Osagie Emmanuel Ehanire.

“No child should have to suffer from DR-TB and we are committed to reaching these young children and treating them with these new medicines.”

The Stop TB Partnership’s Global Drug Facility (GDF) piloted the pediatric drug procurement initiative last year, with help from the Sentinel Project, in early adopter countries in order to pool demand from eligible countries and facilitate access to the child-friendly medicines. Through the pooled-demand mechanism, the GDF has negotiated price reductions of up to 85% for certain medicines in the child-friendly regimen, and has facilitated the procurement of the treatments in 16 countries in 2018 and an additional 40 countries in 2019.

So far, 1,100 treatments for children with drug-resistant TB have been procured, with the goal to reach the UNHLM target of treating 115,000 children with drug-resistant TB by the year 2022.

Image Credits: Stop TB Partnership, Maggie Steber/Stop TB's Global Drug Facility.

Madrid, Spain – India’s Environment Secretary has said that he does not deny the link between air pollution and its health impacts – and affirmed that India needs to act on the issue because “even a single death” from poor air quality would be too much.

“Nobody denies that poor air quality causes morbidity and may also cause mortality. Certainly …it must be causing mortality,” said CK Mishra, Secretary of the Ministry of Environment, Forestry and Climate Change, in an interview with Health Policy Watch and two Indian media reprsentatives at the COP 25 Climate Conference, where Mishra was leading the Indian delegation in negotiations last week.

 

Indian students at a recent protest over Delhi’s poor air quality.

“I mean it may not be 7.5 [million deaths],” Mishra added, an apparent reference to  WHO estimates that there are 7 million deaths globally every year from air pollution, “It could be 2 it could be 5. …But the fact remains that there are numbers to be attended to.

“As far as the ministry is concerned, we are very conscious of the fact that it is leading to loss of human life and we need to correct this situation.”

Mishra made his remarks prior to Friday´s controversial and widely-quoted comments by Environment Minister Prakash Javadekar who declared before the Indian parliament that “No Indian study has shown pollution shortens life. Let us not create fear psychosis among people.”

But in the halls of the Madrid Climate Conference, where the Environment Ministry´s top civil servant was leading the Indian delegation in negotiations, Mishra sought to convey a more nuanced view of the Indian position to reporters.

“It’s common sense,” he said. “If you are breathing  bad air, it cannot cause good to your system….Irrespective of the reliability of the number… a number indicates a job to be done….”

CK Mishra

While Mishra said that he was not trying to refute the link between air pollution and ill health – or even with mortality, he did say that more Indian-based studies would help nail down the exact numbers of people affected more clearly.

“We are not questioning the numbers. We are saying, let us get to know very closely how we get to that number. That also helps us find the causes.”

Javadekar’s statement roundly criticized 

Javadekar´s statement refuting the link between air pollution and health impacts was hotly contested by top WHO officials as well as some leading Indian medical experts. WHO has said that the evidence about reduced life expectancy among populations chronically exposed to air pollution is well-established globally, with evidence that recognizes no borders.

“No study shows Indians immune from air pollution: WHO responds to Prakash Javadekar,” said WHO´s Maria Neira, in a tweeted response on Friday. Neira, who leads the agency´s work on health, climate and environment, has become a vocal public advocate for national government action; but it is extremely rare for a WHO official to call out a single national government, or government official, by name.

“Air pollution is one of the biggest risk factors for health, especially impacting children and older people.  Reducing indoor and outdoor air pollution should be a high priority for governments and citizens,” said WHO’s Chief Scientist Soumya Swaminathan, herself a former head of the Indian Council of Medical Research (ICMR), in another tweet. While Swaminathan´s comments were not aimed directly at the Indian Minister, they highlighted a new study published just last week on the immediate health gains that have been realized from reducing air pollution levels in cities and regions around the world.

Indian researchers have indeed confirmed the fundamental linkage between  air pollution and ill health, Mishra acknowedged, referring to studies by the All India Institute of Medical Sciences [AIIMS] undertaken when he was Secretary of Ministry of Health and Family Welfare.

“AIIMS did some studies for us…and the established fact is vulnerable people are severely impacted by air pollution. Ok? The not so established fact is cause of death which is an academic exercise. ..this is an exercise that the Health Ministry is doing.

“As far as Environment Ministry is concerned, the concern is not numbers. The concern is why should even a single death happen because of air quality. That is the point I am making.”

He said, however, that studies ongoing at national level under the auspices of the Ministry of Health in collaboration with the Environment Ministry, would help to confirm the numbers of people impacted in India more precisely.

“Lots of studies are going on. They will have to be collated. The health mission will also give us some indication – the mission in collaboration with the Health Ministry that we launched six months ago. So, we are waiting.”

Estimating deaths attributable to air pollution risks is inherently more complex than counting the numbers of people who died from a particular disease, Mishra pointed out, although he acknowledged that what matters more, is to get a grip on the problem.

In fact, a broad scientific consensus has emerged around the basic methods for calculating deaths from air pollution. Based upon those methods, Indian mortality estimates were released just last year in The Lancet in a study co-sponsored by the ICMR. That study found some 1.24 million people died prematurely in India in 2017 due to air pollution, including 670,000 deaths from outdoor exposures and 480,000 from household air pollution.

But Mishra still contends that the methods used to make such assessments are not yet formalized. “Is there a coherent system, which is internationally accepted, to put a number on mortality caused by air pollution is the question? If that is there, no issues,” he said.

“Diseases are recognizable, identifiable causes. X died of tuberculosis” Mishra noted. “Now that death of the tuberculosis patient could have been hastened because of bad air.  There is a cause-effect…[but as for the] exact estimates of the number of people who died from air pollution [that is] more difficult to calculate.

“Having said that, there is no harm in accepting them and working on them, instead of disputing them,” said Mishra referring to the prevailing expert estimates. His more nuanced views seemed to reflect growing recognition of the gravity of air pollution’s health impacts in some government circles, even if top politicians still seek to play it down.

India Will Improve Air Quality In Coming Years

In the interview, including journalists from The Telegraph India and India Climate Dialogue, Mishra also expressed confidence that within the coming few years, India will make big advances on air quality.

“I would like to dispel this belief that we have not seized this opportunity [to act]. India is very much there, and air pollution is a major concern. But let me tell you that it is not just Delhi or a couple of cities in India. This is a global issue and this issue arises from several things, including the fact that there are meteorological factors which are impacting it.

“Notwithstanding all that, the commitment is that over the next five years or so we will bring about a reduction of 30%, in terms of the particulate matter and the pollutants. We have already done about 15% reduction and we are steadily moving.

“We have a commitment to clean the air. Even if it causes no mortality no morbidity, we still need to do it….”

Mishra said, however, that WHO and other international agencies concerned with India´s air pollution problem should factor in the complexities that must be faced.

“One thing that I would like to emphasize is, that air quality and issues of air pollution, do not have a switch on-switch off solution or technology. It takes time. Efforts are on, resources are being put in, and I think every year it´s improving and by the end of another 4 years or so, we should have a much cleaner air – in the entire Indo-Gangetic plain which incidentally is the only problem area for India. It is a small portion of a big country like India.

“…And yes of course it is about morbidity. I do not know how much of a direct connect you have to mortality in terms of counting numbers. But anyway, be that as it may, it is a commitment of the Indian government. And the Swachh Bharat (Clean India) mission of the Prime Minister – the entire switching over to cleaner fuels… e-vehicles…they are all part of the strategy.”

As for the contribution of rice stub burning in Punjab and other neighboring states to Delhi´s chronic winter air pollution crises, a major focus of media attention this year, Mishra said the focus on crop burning may be “slightly disproportionate to the kind of problem that it poses.

“But be that as it may, there are two solutions we have come up with. Last year and this year, we have tried on what it is known as the in-situ solution of mulching the straw in the ground.

“At the same time, there are private sector players as well as public sector players, which are strongly looking at ex- situ solutions, which include using that straw and the biomass for power generation, for gasification, for bio-ethanol, and many other purposes. So that experiment is going on, and I think over the next couple of years, we are going to see a huge improvement, including some changes in crop patterns as well.

He also praised Delhi officials for playing a strong role to confront the air pollution emergency that has wracked the city over the past month, where levels of small particles at times rose higher than the measurement limits of monitoring equipment.

“The municipal bodies have to really, really come forward to take it up. The kind of work they [in Delhi] have done this year, if they continue to do it for the next two years, we will have much cleaner air. They have really, really responded well this year.”

In the broader climate arena, Mishra also said India intends to take a stronger leadership role in the stalled negotiations – even if that has not been explicitly stated.

“You don´t take a leadership role, by announcing that your leadership. You take a leadership role by your actions, by what are you doing. And the globe watches you very carefully. So when I say India is going to take a leadership role, it is two-fold. “A – India is slowly becoming the voice of many countries which have this problem and are trying to solve it and B – In our own field, in reduction of emissions, we want to lead the rest of the world.”

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Priti Patniak contributed to the research and reporting of this story.

 

 

 

 

 

 

Image Credits: E Fletcher/HP-Watch, @DYFIDELHI.