COP 29 in Baku, Azerbaijan.

Baku’s Olympic stadium was always an unlikely arena for the world to strike a landmark climate agreement.

As the world’s first oil town, the Azerbaijani capital’s history is steeped in the fossil fuels driving the climate crisis. Its port launched the maiden voyage of the world’s first oil tanker, and Azerbaijan’s name, derived from ‘Azar,’ the Persian word for fire, is a reference to the natural oil and gas flares that have dotted its mountainous landscape for centuries.

Three flame-shaped skyscrapers tower over modern-day Baku as monuments to fossil fuels’ centrality in Azerbaijan’s story – symbolism reflected in President Ilham Aliyev’s opening declaration of fossil fuels as “a gift from God” and the country’s nickname: “The Land of Fire.”

With Azerbaijan being the third consecutive petrostate to host UN climate negotiations – following Egypt and the UAE – the odds were stacked against COP29 from the start.

The central challenge was finance – how much wealthy nations would pay, and which countries would contribute, to fund developing nations’ clean energy transition and climate disaster response. While previous UN climate summits focused on emissions targets and scientific goals, COP29 marked the first head-on negotiations over funding commitments, making it one of the hardest talks since the Paris Agreement was signed in 2015 in the eyes of veteran negotiators.

With climate change accelerating beyond scientists’ projections – driving global temperatures past 1.5°C for the first time, creating unending droughts in the Horn of Africa, devastating storms in the Caribbean, and floods displacing hundreds of thousands across South Asia – the talks forged ahead.

Debating the ‘quantum’

For two weeks, negotiators from over 200 countries debated the “quantum” – UN-speak for the new climate finance goal under the Paris Agreement – a term borrowed from physics where it describes the smallest possible unit of energy.

As negotiations unfolded, developing nations found “quantum” was darkly fitting: while its original Latin meaning asks “how much?”, wealthy nations’ proposed climate finance matched its scientific definition – the smallest amount possible.

Hours before the final gavel landed early Sunday morning, the entire process appeared on the brink of collapse. It had taken developed countries until the final day of the two-week summit to put their first number on the table – $250 billion per year by 2035.

The outrage from developing countries over the offer was swift. Representatives from small island nations, already watching their homelands disappear beneath rising seas, called it a “death sentence.” Civil society actors described it in terms ranging from “an absolute embarrassment” to “a cruel joke.”

Developing countries, who formed a united front at COP29, demanded a minimum of $1.3 trillion annually to assist countries’ transition away from fossil fuels, adapt to climate impacts, and recover from mounting damages they did little to cause. The figure, based on analysis presented at the summit by independent economists commissioned by previous COP presidencies, was far below what civil society groups demanded, arguing true climate reparations would cost between $5-7 trillion annually.

The final agreement, struck 24 hours after developing nations fiercely rejected the initial offer, barely moved: $300 billion per year by 2035, with the $1.3 trillion acknowledged only as an aspirational target.

COP29 President Mukhtar Babayev hailed it as a breakthrough that would “turn billions into trillions,” while UN climate chief Simon Stiell called it “an insurance policy for humanity” – but only if “premiums are paid in full, and on time.”

“No country got everything they wanted, and we leave Baku with a mountain of work to do,” said Stiell. “The UN Paris Agreement is humanity’s life-raft; there is nothing else.”

‘Betrayal’

June floods in Pakistan killed 1,717. The health impacts of the devastation are still unfolding.

The $300 billion offered to developing nations represents just 4% of global fossil fuel subsidies, which the International Monetary Fund estimates at $7 trillion. It is less than Apple’s 2023 revenue of $383 billion and roughly a third of the US military’s yearly budget. Fossil fuel companies have reaped $1 trillion in annual profits for half a century for extracting the oil, coal and gas fuelling the climate crisis.

“The gavel was hit way too fast and our heart goes out to all those nations that feel like they were walked over,” said Juan Carlos Monterrey Gómez, Panama’s special representative for climate change. “Developed nations always throw text at us at the last minute, shove it down our throat, and then, for the sake of multilateralism, we always have to accept it, otherwise the climate mechanisms will go into a horrible downward spiral, and no one needs that.”

The decade-long timeline for reaching even this modest goal raised concerns, given that the previous $100 billion annual target, set in 2009, was only met last year.

“This outcome is a travesty,” declared the least developed countries (LDC) negotiating bloc, which represents 45 nations and 1.1 billion people. “It sacrifices the needs of the world’s poorest and most vulnerable to protect the narrow interests of those who created this crisis.”

The world’s 46 least-developed countries, home to about 14% of the global population, contribute less than 1% of global emissions. The African continent, with 17% of the world’s population, accounts for just 4%.

“That the developed countries are saying that they are taking the lead with $300 billion by 2035 is a joke,” Mkiruka Maduekwe, Nigeria’s special envoy on climate change, said following the deal. “Let us tell ourselves the truth. It is 3am, and we’re going to clap our hands and say this is what we’re going to do? I don’t think so. We do not accept this.”

India’s lead negotiator, Chandni Raina, criticized the outcome as “abysmally poor,” calling the Baku deal “nothing more than an optical illusion.”

“This, in our opinion, will not address the enormity of the challenge we all face,” Raina said, with rousing applause from delegates in the room. “This has been stage-managed. We are extremely disappointed … [and] oppose the adoption of this document.”

The final text offered only to “note with concern the gap between climate finance flows and needs.” For vulnerable nations, this diplomatic language has run its course.

“We leave Baku without an ambitious climate finance goal, without concrete plans to limit global temperature rise to 1.5°C, and without the comprehensive support desperately needed for adaptation and loss and damage,” the LDC bloc said. “This is not just a failure; it is a betrayal.”

Objects in the future may be smaller than they appear

The Azerbaijani Presidency of COP29 centred the aspiration $1.3 trillion in their communications after the summit.

While the headline figure amounts to a tripling of climate finance – far short of developing nations’ request for 13 times the current amount – the true value of this pledge will be substantially lower when the full bill comes due in 2035.

Climate finance, it turns out, faces the same economic headwinds affecting households worldwide: debt, loans, interest rates and inflation. Combined, these factors have led some observers to view the deal as effectively a step backwards.

Inflation presents the first challenge. When accounting for expected price increases by 2035, the $300 billion target’s real value shrinks considerably. At typical inflation rates, it would be equivalent to roughly $230 billion today – closer to doubling rather than tripling the previous $100 billion goal set in 2009.

The $100 billion finance goal set in 2009 was not indexed to inflation, and developed countries at the negotiations made clear the new target would follow the same approach. 

Debt servicing costs were 20% higher than total energy investment in Africa between 2014 and 2022, according to the IAEA.

The agreement also sidesteps the critical issue of debt as climate change’s financial impacts continue to compound. As storms intensify, droughts lengthen, and countries struggle to repay loans from consecutive recovery efforts from increasingly extreme disasters, developing nations face an ever-deepening climate-driven financial trap.

Vulnerable countries borrow for disaster recovery, face higher interest rates, and lose the capacity to invest in climate resilience, making them more vulnerable to future disasters – a “vicious circle of climate and debt,” according to an expert review released last month.

“Those who are experiencing the worst climate impacts, and contributed the least to the crisis, are paying a double price,” said Sonia Kwami, a lead campaigner at African environmental group 350.org. “Not only is climate change on their doorsteps, but they are also faced with burdensome debts, interest rates, and transition costs that rich countries have evaded for far too long, through an unjust financial system.”

The final text eliminated a clause from earlier drafts requiring at least 50% of finance to be debt-free – a proportion already considered insufficient by developing nations, many facing their worst debt crises in decades. Over three billion people today live in nations spending more on debt financing than education and health budgets combined, according to UN figures.

Do loans count?

The Baku agreement left another critical question unresolved in the debt debate: whether loans should count equally with grants toward meeting the climate finance target. This ambiguity leaves the door open for loans to continue dominating climate finance, despite developing nations’ calls for debt-free support. Some countries heavily favor this approach – France, for instance, provides 86% of its climate finance through loans.

This creates significant discrepancies in accounting. Current climate finance flows measure between $28 billion according to Oxfam, which excludes loans from its calculations, and $116 billion by OECD figures, which count loans equally with grants.

Loans currently make up two-thirds of climate finance for the Global South. If this pattern continues, approximately $200 billion of the new annual target would come in the form of loans – which developing countries argue perpetuates rather than solves their financial challenges.

“COP29 has been a disaster for the developing world,” said Mohammed Adow, director of the climate think tank Power Shift Africa. “It’s a betrayal of both people and planet, by wealthy countries who claim to take climate change seriously.”

‘Some Rich Nations’

The Baku climate deal also leaves unresolved a question that has gained increasing urgency as UN climate talks shift from emissions pledges to financial commitments: who pays?

Countries classified as donors under the UN climate convention, known as “Annex I” countries, comprise about two dozen industrialized nations, including the US, European nations, and Canada. This roster stems from the economic landscape of 1992, when UN climate talks began.

The world’s economic and emissions realities have changed dramatically since. When these categories were drawn, China’s cumulative CO2 emissions were less than half of the European Union’s. Today, China has surpassed the EU in historical emissions while becoming the world’s second-largest economy. Oil-rich nations like Russia and Gulf states have also grown both their wealth and carbon footprints significantly.

This shift has created a paradox at the negotiating table. The EU now finds itself responsible for a smaller share of historical emissions than China while facing pressure to provide more finance. Early drafts of the Baku text proposed expanding the donor list to include wealthy nations like Singapore, China, Saudi Arabia, South Korea, and the UAE. That language was quietly dropped.

The final agreement keeps these nations out of the line of fire. It does not require contributions from China, Russia or Gulf nations – they instead fall in the voluntary category.

Political earthquake

The money problem was further complicated by the political earthquake in the US this month, which loomed over the talks from the get-go. Donald Trump’s return to the presidency in January, along with promises to again withdraw from the Paris Agreement, made current US commitments effectively moot.

The absence of both the world’s largest historical polluter and its biggest economy, the US, alongside its largest current emitter and second-biggest economy, China, creates a massive hole in the global climate finance deal struck in Baku, leaving a small pool of donor countries attempting to shoulder a burden that economists say requires far broader participation.

German Foreign Minister Annalena Baerbock captured the EU’s frustration: “We are in the midst of a geopolitical power play by a few fossil fuel states. Their playing board is the backs of the poorest and most vulnerable countries.”

“What we are seeing here is the last stand by the old fossil fuel world,” Baerbock said, stating that the EU was increasing its financing commitments through 2035. “We are living up to our responsibilities, including as historical CO2 emitters.”

While developed nations point to budgets stretched by war, COVID-19, and inflation, critics question why governments can find money for military spending but not climate action, and why fossil fuel subsidies persist while green energy funding lags.

As promised climate finance from wealthy nations fails to materialise, developing nations are already committing significant portions of their limited budgets to this fight, spending $1 trillion annually from their own resources on adaptation and disaster recovery, according to the United Nations Development Programme (UNDP).

“Developing countries are actually investing hundreds of billions of dollars a year already from their own taxpayers’ revenue,” UNDP chief Achim Steiner told the Guardian this week. “It wouldn’t hurt or harm anyone on the other side of the table to acknowledge that.”

‘Collective amnesia’ on fossil fuels

Following a historic agreement to transition away from fossil fuels a year ago, Baku’s outcome fell silent on the hydrocarbons at the root of the climate crisis.

Just one year after a historic agreement to “transition away from fossil fuels” at Dubai’s COP28, the Baku summit failed to reaffirm that commitment.

The setback comes as 2024 is on track to be the warmest year on record with temperatures temporarily breaching 1.5°C of warming for the first time, and the world tracks toward 3.1°C of heating by century’s end, far exceeding the Paris Agreement’s targets. Scientists warn such warming would trigger catastrophic climate impacts.

“The world made a deal at COP28 to end the fossil fuel era. Now, at COP29, countries seem to have been struck with collective amnesia,” said Shady Khalil, Oil Change International Global Policy Senior Strategist. “With each new iteration of the texts, oil and gas producers managed to dilute the urgent commitment.”

Swiss representatives complained that the draft text had been so “watered down” as to effectively “backtrack from the commitments taken last year.” 

Saudi Arabia, long known as a “wrecking ball” at UN climate negotiations, vocally opposed any document that mentioned fossil fuels in Baku: “The Arab group will not accept any text that targets any specific sectors, including fossil fuels.” 

The fossil fuel industry’s influence was evident throughout the talks. At least 1,773 fossil fuel lobbyists received access to the COP29 summit, according to analysis from the Kick Big Polluters Out coalition. This contingent outnumbered the combined delegations from the ten most climate-vulnerable nations, which totaled 1,033 representatives.

Only three delegations were larger: host country Azerbaijan with 2,229 representatives, next year’s host Brazil with 1,914, and Turkey with 1,862.

Small islands’ voices drown

For small island nations watching their territories disappear beneath rising seas, the stakes of climate negotiations are existential. Many are already losing land to flooding, with some Pacific islands projected to become uninhabitable within decades.

Ahead of the summit, Papua New Guinea’s foreign minister, Justin Tkatchenko, explained his country’s decision to stay away, calling COP29 a “total waste of time” that would produce “no tangible results for small island states.” By the summit’s end, the voices of island nations that made the journey to Baku were drowned out in the rush to reach a deal.

Island countries on the frontlines of the climate crisis, which receive just 1% of current climate finance, had requested dedicated funding to help them access climate finance – a critical need for small states that lack the capacity to navigate complex application processes that often see climate aid flow to better-resourced middle-income nations. Instead, even these minimum allocations were stripped from the final text.

“We had more hope that the process would protect the interests of the most vulnerable and those with the least capacity,” the Alliance of Small Island States, representing 44 low-lying and coastal nations, said in their closing statement. said in their closing statement. “The level of ambition for taking climate action needs to be much, much higher.”

For these disappearing nations, the UN climate talks, however flawed, remain the only path to advocate for their survival. With no other global forum to turn to, they must continue fighting through a process that keeps forgetting them — even as waters continue to rise.”

Image Credits: OXFAM.

Checking wastewater for poliovirus in Malawi. Sewage-based surveillance, long key to polio elimination, is now being explored for a widening array of diseases.

A method that first developed around polio elimination and matured during the COVID pandemic, is now being tested and used to track a much wider array of emerging disease threats. A unique symposium of scientists and public health experts at the Paris Sorbonne University last week looked at its promise and potential. 

In April 2020, French researchers at the Sorbonne and the Obepine research network,  [Observatoire Epidémiologique dans les Eaux Usées] realized that they could get an “early signal” of the trajectory of COVID-19 case incidence through wastewater surveillance. They began routine monitoring of some 200 large wastewater plants – an initiative that became a trend-setter in Europe and worldwide. 

Wastewater-based surveillance has long been used to track polio as well as a handful of other deadly, waterborne diseases, such as cholera and typhoid. However, the COVID-19 pandemic proved to be a turning point in wastewater-based epidemiology (WBE) – popularizing the method and introducing it to the mainstream of national surveillance programmes. 

Last week, a unique symposium at the Sorbonne University brought together about four dozen scientists from around the world to explore the approach, its challenges and potential to track other diseases beyond COVID, which can also circulate silently under the radar for weeks or months, before symptomatic cases begin to appear in human populations. 

The conference was led by the Sorbonne and Obepine with the 4EU+ university alliance, and the University of Paris-Pantheon, as well as the World Health Organization and the Geneva Health Forum (GHF). 

The conference is part of a series of symposiums developed in collaboration with the WHO on “lessons learnt from the COVID-19 Pandemic,” said Dr Antoine Flahault, director of the University of Geneva’s Global Health Institute and GHF chair. The first such conference Bern in 2023, addressed indoor air pollution; a third session is planned on drug and vaccine development.    

Dutch and French researchers developed first data on wastewater SARS-CoV2 concentrations and COVID disease

Dr Vincent Marechal, professor of virology at the Sorbonne.

“The first data showing that SARS CoV2 levels in wastewater was related to COVID incidence rates in the population came from France and the Netherlands,” said Sorbonne virologist, Dr Vincent Marechal, who led the pioneering French research with the Obepine surveillance network. 

“We need to learn the lessons about what was done during the COVID 19 pandemic… to inform policies,” he said, discussing the goals of the event with Health Policy Watch.  

“We need to normalize the way to do analyses, to treat data. And we need ways to transfer these technologies to low and middle-income countries (LMICs),” he said.

“Although we are aware that this strategy cannot be used for all infections, the benefit/cost ratio is remarkable, particularly for detecting and monitoring epidemics in countries that do not have the logistical or economic means to carry out individual epidemiological monitoring of their populations.”

Roots in polio elimination – SARS-CoV2 pandemic triggered an explosion of interest

“Swabbing” a sewage bore at an Israeli beach to check for SARS-CoV2 variants in 2022 at the height of the wave of the Omicron variant of COVID-19.

It’s a method that has been around for nearly a century – ever since the Yale University researcher Dr John Paul first documented the presence of poliovirus in sewage in Charleston, South Carolina in 1939. 

At the start of the global polio elimination campaign, monitoring wastewater for poliovirus gained traction as a way to identify the presence of virus early on. It was particularly effective since even among the vaccinated, symptomatic cases only occur in 1 out of every 200 people.  Use gradually expanded to include other deadly diseases, such as cholera and typhoid.

Following their 2020 identification of the link between COVID-19 incidence and wastewater concentrations of SARS-CoV2, the Obepine network spent two years monitoring the 200 French wastewater plants providing a regular data flow on the ebb and flow of the disease and its variants to the national and local governments, as well as to the public. 

The initiative, under the auspices of the French Ministry of Research and Innovation and the Ministry of Health, eventually became flagships in a broader EU-wide effort to monitor wastewater during the pandemic period. 

“Just one month of wastewater monitoring, covering about 40% of the population, and producing an incidence curve for the whole population, cost about €300,000,” Marechal remarked in a post-conference interview with Health Policy Watch. “In comparison population-based monitoring would have cost about €1.6 billion over the same period.” 

Post-pandemic, France’s own wastewater surveillance of COVID continues, but it has been taken over by the French Ministry of Health’s Sum’eau network, which is only monitoring about 54 wastewater plants. That, in Marechal’s view, is too small a sample from which to draw robust conclusions about COVID or to track prevalence of other new infections of concern like the mpox virus.

“In our case, the Health Ministry said that we should be doing research, while they took over the more routine monitoring function,” he said. “Although in my opinion, it is a mistake to split these two functions.”

Method still being used widely for COVID tracking 

Countries with wastewater monitoring of SARS-CoV2 at institutional or national level.

Elsewhere in  Europe and beyond, institutions in dozens of countries continue to track SARS-CoV2 in wastewater samples  – albeit with varying degrees of intensity and a diversity of scientific and institutional approaches. 

There are at least a few testing sites in most major countries of Europe, Asia and the Americas, a handful of African nations and Saudi Arabia. About 31 countries, mostly in Europe and North America, but also including Turkey and India, publicly report data, according to a WHO dashboard that follows trends in wastewater surveillance. 

And a detailed WHO technical guidance explains how to conduct wastewater surveys – although ‘guidance’ in WHO parlance is not a formal “guideline” that sets an international standard.  

It’s not surprising that such monitoring, to date, is the most common in middle- and high-income settings, where formal wastewater treatment systems made sampling easy, said Marechal. 

But in the same way that the method has been used to track polio, typhoid and cholera, it’s important to develop cost-effective methods whereby the science of wastewater-based epidemiology (WBE)  can be effectively deployed for more endemic and emerging diseases in developing countries.

What pathogens can be monitored most easily? 

Mpox wastewater surveillance in the USA in October-November 2024.

Post-Covid, mpox is another virus that became the focus of significant WBE tracking in developed countries such as Canada.  Gastro-intestinal viruses, such as noroviruses or rotaviruses are among those other pathogens that can be easily monitored in wastewater, Marechal said. 

“It also works for most major flu viruses, flu A, B, RSV (respiratory syncytial virus), and it can be used for AMR (anti microbial resistance),” Marechal added. 

While flu is not necessarily as deadly, an “early signal” about prevalence from wastewater can alert doctors about the onset of flu season, who then may be quicker to examine and diagnose the virus in their patients, he pointed out. Even more significantly, such a system can also provide critical signals early on of a flu epidemic or pandemic. 

There is also promise that measles outbreaks might be identifiable early through wastewater samples, he said. Although the science around that is not yet well developed, his team of  researchers have obtained promising results in the context of an ongoing study with the Institut Pasteur in Guinea. 

“A field that is much more difficult, arboviruses, dengue, zika, and chikungunya,” Marechal observed. While the surge in dengue virus makes this a worldwide concern, there are challenges in monitoring through wastewater because “the amount of viruses excreted is much lower than flu or COVID.” 

Deadly endemic diseases such as marburg virus and Ebola also pose special challenges. These viruses may first spread in more isolated rural areas of low-income countries where wastewater is not collected in large concentrations. Also, both marburg and Ebola are highly symptomatic in those infected, so the contribution that wastewater detection may make to early detection and tracking is comparatively lower, than, say polio.  

Applications in low- and middle-income countries  

Nicholas Grassly: strong correlations found between clinical typhoid case incidence and concentrations of s. typhi bacteria in wastewaters in Malawi and India (slide).

While not used routinely in low- and middle-income countries, wastewater monitoring of diseases has paid big dividends in the global polio elimination campaign, where only one in every 200 cases is symptomatic and the costs of human, blood-based screening would be exorbitant.  

Wastewater monitoring was dubbed the “silent hero” that helped public health officials track and ultimately halt a 2021-22 outbreak of wild poliovirus type1 in Malawi and Mozambique, triggered by a strain imported from Pakistan. 

More recently, a polio outbreak in war-torn Gaza was first identified through wastewater samples in mid-July, leading to the launch of a massive vaccine booster campaign. 

“The value of wastewater surveillance….is highlighted by the investments made by the Global Polio Eradication Campaign program and WHO, and there are now thousands of sites where wastewater science is conducted for poliovirus, often from informal surge networks,” said Nicholas Grassly of Imperial College, London. 

For typhoid, as well, the use of such informal networks has been “really key,” Grassly said, because of the close correlation between wastewater levels of the virus and human cases.

A. shows typhoid incidence using hospital reported cases. B. shows case incidence including wastewater surveillance around 3 primary health centres.

In addition, blood-based surveillance of typhoid in the kinds of low-income settings where it typically occurs is very limited. Linked to that, the uptake of typhoid vaccines has been slow, he said.  

“So the question here is, can we use wastewater detection of Salmonella typhi (typhoid bacteria) to motivate and monitor the introduction of typhoid conjugate vaccines, having to sample from informal sewage networks, drainage channels, rivers? 

“It’s a very different system to what we would have in a high income country, but it is possible, and what we’re seeing is that the emergence of data to show that the prevalence of detection of salmonella type in the environment does correlate with clinical incidence of disease.”

Moving ahead, WBE-based sampling to identify the spillover of zoonotic diseases into human populations, early on, as well as pockets of drug resistant pathogens also hold great potential for low- and middle income settings  – where both risks are growing, often without adequate surveillance, conference panelists also noted.

“Antimicrobial resistance is one of the major, if not the major, pandemic disease that we have now affecting global health, while wastewater monitoring is probably one of the most appropriate and efficient ways to cope with this problem,” remarked Alfonos Zecconi, of the University of Milan. 

Alfonos Zecconi, of the University of Milan discusses the role of wastewater in the spread of drug resistant pathogens.

Surveillance for zoonotic spillover, meanwhile, is the focus of a new grant by the Bill and Melinda Gates Foundation in Africa and Asia, Grassly said. Their grant will support the piloting of methods for early detection of zoonotic infections in human wastewater.  

“Can we use waste water surveillance to estimate the extent of zoonotic infection and associated risk factors and look for evidence of human transmission and genetic adaptation – potentially providing an early warning of threats?” Grassly asked. 

“If we can do that, then we can implement risk mitigation activities, not only in public health, but across sectors, and also start to develop those medical countermeasures that we might need, including vaccines and diagnostics.” 

Brazil: standardizing a diagnostic ‘kit’ for wastewater surveillance 

Brazi’s Maria Aguiar Oliveira (center microphone): rolling out standardized WBE testing methods.

Beyond the research questions, rolling out surveillance methods more widely  involves numerous challenges for LMICs, even in countries such as Brazil with a strong research tradition and considerable experience in waste water testing,  said Maria Aguiar Oliveira, of the Fiocruz Institute. 

Fiocruz is working with the Ministry of Health to establish formal guidelines for wastewater surveillance, which would be integrated into the existing National Public Health Laboratory Network. 

Fiocruz also is developing a standardized diagnostic kid for wastewater sampling of viral  pathogen samples so that results from different testing sites are comparable.

“One of the biggest challenges is how to compare the results because everywhere, each group is using a different target, different sampling and so on,” Aguiar Oliveira observed, noting that wastewater sampling also requires entirely different tools and targets, as compared to diagnostics for human populations. 

“We have been designing and validating a kit, a molecular panel, and the idea is from viral concentration to viral detection to have the single product that we can scale up in a very reasonable price to all of our networks – because we are a nonprofit public institution.”

Such harmonization of best practices in sampling and analysis can both improve the reliability of results – as well as bringing costs down making the technique even more accessible, pointed out Marechal. 

“We need to normalize the way to make analyses, to treat data,” he said. “We can find money to set up research projects. What we need is money for sustainable monitoring, for years on end,” he says.

“Efforts must be made to produce high-quality, standardized data that can be integrated into robust epidemiological models with dynamic mapping of outbreaks. This is essential if we are to have early warning systems, and if we are to detect changes in the trajectory of an epidemic, upwards or downwards, as quickly as possible.”

Who owns sewage? 

Who owns sewage – much of it flowing untreated into the wild?

Along with the technical and cost issues, key questions of public trust, individuals’ right to privacy and data ownership also shadow WBE research. 

The thorny dilemmas are illustrated by one study in Missouri, which tracked a novel SARS spike sequence variant to a commercial building of just 30 people in the period of January 2022-23, notes Marechal. 

“The mutations in the spike gene and elsewhere resembled those subsequently found in omicron variants,” reports the paper by researchers at the Universities of Missouri and Wisconsin, published in Lancet Microbe in April 2024. 

In that case, the pinpointing of the variant to just one building did not lead to any particular policy action – but what if an even more dangerous virus had been found in wastewater in the same location?  

“The question is twofold,” said Marechal.  “Would you even be allowed to do that in France – I’m not sure.  And if you did, while it was not the case in Missouri, are you allowed to impose lockdowns or individual confinements as a result? This example prompts a lot of reflection on the legal and ethical framework for WBE work.” 

While emerging diseases may also flourish in marginalized communities with less access to hygiene, sanitation and healthcare, the rights of religious and ethnic minorities, migrants and people with diverse sexual orientations also must be respected, underlined Jean Baptiste Guyonnet, of Panthéon Assas University.

So action on a disease risk discovered through wastewater data would be carefully evaluated through the lens of the “proportionality” of the risk versus any measures that might be considered, and the harm they could do to those communities.  

Building trust 

But the best way to minimize ethical risk is by partnering directly with the affected community, stressed Talia Glickman, of the Canadian Water Network, “for a community informed, if not a community led response.”  

She cited one example from Canada’s Ontario Province response to the global mpox outbreak of 2022-2023 – which WHO had declared a global health emergency and hit hardest a men having sex with men. 

When provincial authorities decided to start monitoring wastewater for mpox infections in mid-2022, they reached out to the Gay Men’s Sexual Health Alliance (GMSH). 

“In particular with mpox being monitored in the wastewater, there was a need to discuss the communication of potentially sensitive data and what those impacts would be on this particular equity deserving population,” said Glickman. “As we all know, there were a lot of uncomfortable parallels to early days of the HIV pandemic…. And so the GMSH were able to coordinate regular meetings between community-based organizations, public health authorities, researchers and policymakers, which helped ensure timely feedback and collaboration.

“The bottom line is that moral obligation, I think when you’re collecting that data, you have an obligation to communicate it back to the affected communities,” Glickman said. 

“This sort of cross sector coordination… improved the speed, the quality of the response, and it made Ontario’s response to mpox one of the most effective mpox responses in the world…. And it provides a great example of integrating all those activities into wastewater monitoring.”

Ethical research principles offer good guidance 

United States law doesn’t require, or prohibit, very much in terms of research on wastewater, added Natalie Ram, of the University of Maryland. 

However, researchers funded by the federal government are entitled to special legal protections that allow them to protect the confidentiality of their research subjects or related data – e.g. say from law enforcement.  

“But ethical practice can impose a much better guiding framework,” added Ram. “Public health only works when we have public trust. And so public trust is a necessary predicate for successful monitoring and implementation, uptake of community responses. 

“Wastewater surveillance gives us a lot of raw data, and we might not need people’s consent to get it right, but if you want to use it ethically, as we heard earlier this morning, you’ve got to have a plan for what to do with that data. And if you go to the community and say, oh, we’ve been spying on your wastewater all of this time, surprise, now go get a vaccine, that’s not going to go very well. You have to have buy-in from the community, and support. 

“And that gets all the more important as the watersheds get smaller because then they can become very population specific. 

Integrating into policy decision-making 

Chikwe Ihekweazu, WHO’s ADG for Health Emergency Intelligence and Surveillance lays out WHO’s pandemic preparedness and response policies, related to WBE.

Amidst this plethora of legal and ethical questions, WHO has not been in a rush to set down strict, prescriptive guidelines on exactly how countries should manage wastewater surveillance. 

Part of that is likely related to the unsettled legal issues around privacy and the ownership of data on wastewater pathogens – which so far lacks a global standard of consensus upon which WHO could build a guideline standard. 

But that also reflects the changing role of WHO in the global health scene, said Dr Chikwe Ihekweazu, WHO’s assistant director general for Health Emergency Intelligence and Surveillance Systems, at a closing session of the Paris event. 

“Thirty years ago, …the world would wait for WHO to come up with guidance, and everyone would be paralyzed until it does,” Ihekweazu observed.

So now we’re in a different world; when there’s an opportunity, there are lots of initiatives driving it forward, and our role is changing. We have to think together, and respect the opportunity that academia provides, digital surveillance systems offer, countries offer, regional bodies offer, financing bodies offer, philanthropic organizations offer, and see how we can make the best use of the various skills, resources and expertise that we all bring to the table. 

So …it’s a good problem to have. We’re not in a position of absolute scarcity; we have a problem of making the most efficient use of the expertise and resources that we all bring to the table. And it’s a humbling position to be in, and maybe that’s why this meeting is so important with the players in the room.

Image Credits: WHO , Kando , Naughton et al, January 2023, US CDC Mpox wastewater data, Uzzell et al, 2024/PLOS Neglected Tropical Diseases, Eric Comte, The Rivers Trust , Eric Comte .

WHO Director-General Dr Tedros Adhanom Ghebreyesus (left), President of Brazil Luiz Inácio Lula da Silva (centre) and Brazil’s Minister of Health Nísia Trindade (right).

The World Health Organization (WHO) received $1.7 billion in new pledges of financial support at the G20 meeting this week, taking the total of voluntary pledges so far to $3.8 billion for the coming four years. With this, the WHO has met 53% of its investment requirement for its 2025–2028 strategy, in WHO parlance, the 14th General Programme of Work (GPW 14).

Australia, Indonesia, Spain and the United Kingdom were among the G20 countries to make the largest pledges at the leaders’ summit in Rio de Janeiro, chaired by Brazil’s President H.E. Luiz Inácio Lula da Silva.

They committed $410 million, $300 million, $620 million and $392 million respectively.

The G20 group includes all of the world’s biggest economies, including the United States and Canada, the European Union, the African Union, Japan and Australia, as well as Brazil, China, South Africa and India. Together the group accounts for 85% of the world’s GDP, making it a strong economic and trade group.

Notably, several other large G20 members such as France and Canada have not yet made commitments to the WHO “Investment Round” – nor has the United States, where support for the global health agency by the incoming administration of President-elect Donald Trump remains uncertain, following his withdrawal from the organization altogether in 2020, during his last term as president.

WHO aims to recruit large, multi-year commitments

 The new WHO donor strategy aims to stabilize the organization’s funding but collecting large, multi-year donations from member states in the form of “undesignated” funds, rather than as piecemeal contributions to various programmes and activities. Voluntary funding made up about 87% of WHO’s budget in 2022-23, and is thus a critical element alongside required member state assessments. Those have comprised only about 20% of the WHO budget in the past decade, although the World Health Assembly in 2022 voted to gradually boost assessments so that 50% of the WHO budget would be derived from member state fees by 2030.

But voluntary donations will continue to be critical, and so WHO officials launched the “investment round” as a new approach to voluntary fundraising – roughly modeled on the more high-profile, high-prestige “replenishment drives” staged by organizations such as The Global Fund.

“The WHO Investment Round is about mobilizing the predictable, flexible funding WHO needs to save lives, prevent disease and make the world a healthier and safer place,” said WHO Director General Dr Tedros Adhanom Ghebreyesus in a statement, welcoming the new contributions.

South Africa, which will host the next G20 summit, will be carrying the baton for sustainable financing for WHO forward, Tedros added.

G20 support for WHO’s Investment Round 

The support of the G20 for WHO was reflected in the final  Leaders’ Declaration issued at the close of this week’s summit. “We reiterate the central coordinating role of the WHO in the global health architecture, supported by adequate, predictable, transparent, flexible and sustainable financing. We support the conducting of the WHO Investment Round as an additional measure for financing the WHO activities,” the declaration stated.

Other funding events in Europe and Asia have yielded another $2.1 billion making up the $3.8 billion total for the next four years. This represents about 53% of the US$ 7.1 billion in funding WHO needs to fill out its $11.15 billion budget plan, after assessed member state contributions are counted.

See related story: WHO Secures $1 Billion at First European Investment Round

WHO said this year’s investment round initiatives, which have focused on large regional events or global gatherings like the G20, have successfully increased predictability as compared to 2020 when WHO had only 17% of funding secured for its previous strategy.

All in all, since the funding drive was launched in May, here have been 70 new pledges from Member States, and philanthropic and private sector donors, 39 of which are contributing voluntary funds for the first time. This is making WHO’s funding more diversified.

Seven of these new donors are low-income countries and 21 are middle-income countries, representing a shift in WHO’s funding base. Forty-six donors have so far pledged more flexible funding, compared to 35 in the last four years, increasing the ability of WHO to use the funds where they are most needed.

The Bill & Melinda Gates Foundation, Wellcome Trust, Islamic Development Bank, and Africa Development Bank are among the leading non-state donors.

Improvement in Financial Stability for WHO

WHO has projected that its new strategy, GPW14 can save an additional 40 million lives over the next four years. The investment round was aiming to shift WHO’s funding model so that it is more predictable, flexible and resilient, and it appears to have succeeded in doing that.

During the COVID pandemic, WHO was criticized for its heavy reliance on funding from the Gates Foundation. Countries like the United States accused WHO of going soft on China.

The Investment Round thus was aimed to broaden WHO donor base to reduce its reliance on a few donors and keep its agenda independent.

WHO estimates that the strategy for the years 2025-28 will save 40 million lives.

“The World Health Organization represents humanity’s greatest ideals. Investment over the next four years will be repaid many times over in well-being gained. It will set the foundation for future generations,” said Brazil’s President Luiz Inácio Lula da Silva.

“We are proud to carry the baton on from Brazil and continue to spotlight the importance of WHO and the need for sustainable financing towards the goal of health for all,” said Cyril Ramaphosa, President of South Africa, which will hold the G20 Presidency in 2025.

Image Credits: PAHO/WHO/Karina Zambrana, WHO.

The WHO chief was in Rio to attend the G20 summit.

The director-general of the World Health Organization, Dr Tedros Adhanom Ghebreyesus, is “back to work” following an overnight stay in a Rio hospital during his trip to the G20 summit, the WHO chief said Thursday.

The reason for the hospital visit, first reported by the Brazilian paper O Globo, was not disclosed in a statement by the hospital, although media reports cited symptoms of hypertension and labyrinthitis (inner ear infection causing vertigo) as causes for the hospitalization.

“The patient spent the night under observation, underwent all the necessary examinations, which found clinical indicators with no signs of infection,” said Samaritano Hospital, located in a western district of Rio.

“I was discharged this morning and am back to work,” Tedros said in a post on X. “My heartfelt gratitude to the healthcare workers for their outstanding service.”

Tedros, 59, was first attended to on-site Monday at the G20 meeting, a forum of the world’s largest economies, following signs of hypertension but was still able to deliver his speech to world leaders.

He was in Rio attending the G20 summit alongside other G20 and world leaders including UN Secretary-General Antonio Guterres, US President Joe Biden, Indian Prime Minister Narendra Modi and European Union representatives.

“Please take care of your health,” Tedros said.

The sun sets over UN climate negotiations in Baku as hopes of a historic deal on climate finance fade in the summit’s final hours.

With only hours remaining on the clock at UN climate negotiations in Baku, talks are at risk of collapse as nations remain divided over where to find the money developing countries need to respond to the crisis.

Well before the summit began two weeks ago, it was clear that success at COP29 hinged on nations reaching an agreement on difficult questions: who will pay for climate finance, how much, and what types of funding count toward global finance targets?

Following last year’s landmark deal in Dubai to “transition away” from fossil fuels, the climate fight has shifted to securing the money to make that global transition possible.

Independent economists told negotiators this week that developing nations need at least $1.3 trillion per year to adapt to climate impacts and fund recovery efforts. Civil society groups pushed for a higher floor, demanding up to $5 trillion annually during the Baku talks.

As hopes rose ahead of the Friday deadline that countries would move towards compromise, negotiations instead began backsliding on Thursday when Azerbaijan, the summit’s host and president, released a decision text that failed to bridge the divide between wealthy and developing nations.

“The new finance text presents two extreme ends of the aisle without much in between,” said Li Shuo, a climate expert at the Asia Society Policy Institute. “We are far from the finish line.”

The Azerbaijani presidency’s core task of finding common ground appeared to falter as the text presented two opposing positions that had been clear since the talks began: developing nations demanding trillions per year in public grants, and wealthy nations offering hundreds of billions, insisting private investment and carbon markets must count toward the total.

Neither choice specifies actual funding figures, using “X” placeholders where funding numbers should be.

“This is the ‘finance COP’. We came here to talk about money. The way you measure money is with numbers,” said Mohammed Adow, director of the think tank Power Shift Africa. “We need a cheque but all we have right now is a blank piece of paper.”

Leadership vacuum

In nearly three decades of UN climate talks, Azerbaijan had never taken a leading role, until hosting this year’s summit. Now tasked with brokering a deal, the presidency’s inexperience threatens to derail the talks, drawing rare direct fire from veteran negotiators.

“We are confronted with a text on finance that is laid out to divide us, exactly at a time when the presidency should be working to unite us,” said German climate envoy Jennifer Morgan.

“The presidency has not delivered as we had expected,” Morgan added. “Instead of bridging divides, we see extreme positions.”

EU climate chief Woepke Hoekstra told reporters the text was “unacceptable.”

“There is not a single ambitious country who thinks this is nearly good enough,” Hoekstra said.

“We have two options,” said Andreas Sieber, Associate Director of Global Policy and Campaigns at African environmental group 350.org.

“One says there will be a core of money in grants in the scale of trillions,” Sieber said. “The other one doesn’t, and therefore doesn’t count as a viable option for real climate action.”

Overtime Ahead

COP 29 in Baku, Azerbaijan

While negotiations are slated to end Friday, veterans of UN climate summits are bracing for talks to extend well into the weekend.

The last time a major climate conference collapsed was COP6 in The Hague in 2000 although COP15 in Copenhagen in 2009 was also a major disappointment at the time, with no clear pathway for binding commitments on reducing emissions. But a more recent parallel emerged just 19 days ago, when UN biodiversity talks in Cali, Colombia, fell apart over similar finance disputes.

While the Conference of the Parties of the Convention on Biodiversity (COP16) struggled in Cali for two weeks over funding disagreements, talks ultimately had to stop when several developing nations’ delegations were forced to return home, unable to afford rebooking flights and extended hotel stays in Colombia. Without enough countries present to make decisions, negotiations over critical outcomes collapsed – laying bare the fundamental inequality at these summits.

If COP29 collapses, it would mark the failure of two consecutive UN environmental summits – which had been widely anticipated as watershed moments.

In comparison, both the accord on a Global Biodiversity Framework reached in Montreal in 2022, and the 2023 UN Climate Summit agreement in Dubai to “transition away” from fossil fuels dominated international headlines for weeks, with world leaders hailing them as turning points in humanity’s response to planetary environmental crises.

Current climate policies put the world on track for a 3.1°C temperature rise. The issues of ecosystem preservation that negotiated in Cali and other CBD summits also are crucial to slowing this warming, making both sets of talks interdependent.

“All of this is turning into a tragic spectacle,” Panama’s lead negotiator Juan Carlos Monterrey Gómez told Reuters. “When we get to the last minute, we always get a text that is just so weak.”

The Debt Burden

Mukhtar Babayev, who spent 26 years at Azerbaijan’s state-owned oil and gas company Socar, takes over the presidency of UN climate negotiations from Sultan Al-Jaber, CEO of the UAE’s national oil giant ADNOC.

For many developing nations, a weak deal could be worse than no deal at all.

The current text proposes that “more than 50% of climate finance” come through “non-debt instruments” – implying that up to half could still be loans.

To date, two-thirds of climate finance for the Global South has been loans, even as 60 countries face crippling debt while bearing the brunt of climate impacts.

According to the World Bank, the world’s poorest countries face the worst debt crises in decades, with over 3 billion people living in nations spending more on debt financing than education and health budgets combined, according to UN figures.

For these countries, already bearing the brunt of climate impacts, the prospect of financing an energy transition through more loans appears impossible when basic necessities like electricity, healthcare, and education remain out of reach.

“Leaving with no decision is better than a bad decision that stays with us forever,” said Uganda’s lead negotiator Bob Natifu.

Who pays?

The new text also sidesteps another contentious issue: which countries have a responsibility to pay for climate finance.

A section in the Baku text proposing to expand the list of donor countries – targeting wealthy nations like Singapore, China, Saudi Arabia, South Korea, and the UAE – has been quietly dropped.

This debate strikes at the heart of a 30-year-old framework that no longer reflects economic reality. When the UN climate convention established its categories in 1992, it split countries into donor “Annex I” nations — primarily wealthy industrialized countries — and recipient “developing” countries.

Singapore, now with one of the world’s highest per capita incomes, remains classified as “developing” alongside nations like Somalia and Haiti.

When negotiations drew these lines, China’s cumulative CO2 emissions were less than half of the European Union’s. When the Paris Agreement was signed in 2015, China still trailed the EU by 20%.

Today, China has overtaken the EU in historical emissions, according to both the UN Environment Programme and Carbon Brief analysis. This shift has become a major sticking point for EU negotiators, who now find themselves responsible for a smaller share of historical emissions than China while facing pressure to provide more finance.

While developing nations are projected to surpass wealthy countries in cumulative emissions within six years, this shift masks stark inequalities. Africa, home to 17% of the world’s population, contributes just 4% of global emissions, with the world’s 46 least developed countries collectively responsible for less than 1%.

Many nations classified as “developing” are now drawing clear distinctions between themselves and major emitters like China, currently the world’s largest polluter.

“China and India cannot be classified in the same category as Nigeria and other African countries,” Nigeria’s environment minister Balarabe Abbas Lawal told the Guardian this week.

“Those that actually deserve this support are African countries, poor Asian countries and small island states that are facing devastating climate impacts.”

G20 declaration a warning signal – no reference to transition away from fossil fuels 

The venue of COP29 in Baku, Azerbijan.

Early warning signs emerged this week when the G20’s Rio declaration omitted any reference to transitioning away from fossil fuels – language that had been supported by the group’s ministers just months earlier and formed a cornerstone of last year’s COP28 agreement in Dubai.

And while dozens of heads of state attended the G20 summit, many skipped the Baku climate talks entirely.

The G20 nations, comprising most of the world’s largest economies, responsible for around 80% of global emissions, struggled to find common ground amid escalating global tensions.

Russia, a G20 member, struck Ukraine with an intercontinental ballistic missile during the meetings. Europe verified the presence of Chinese-provided weapons among Russian troops. North Korea – a Chinese satellite state – sent troops into Ukraine as European Union nations and the United States gave the green light for long-range missiles to strike within Russian territory.

“[COP29] is a fragile enough process as it is,” one G7 negotiator in Baku told the FT. “The gradient of the climb we have this week just got steeper.”

Meanwhile, at the COP29 summit, Azerbaijan’s President Ilham Aliyev has twice referred to fossil fuels as “a gift from God”. Oil comprises 90% of the country’s exports and 60% of state revenues.

The selection of Azerbaijan as host itself reflects broader regional complexities. Although this year’s climate conference was due to rotate to a European nation, Russia vetoed EU member states from hosting climate conference, leaving only Armenia or Azerbaijan as options. Armenia withdrew its bid following a prisoner exchange with Azerbaijan in December 2023, just as COP28 was concluding in Dubai.

INB co-chair Precious Matsoso, Co-Chair of INB.

CAPE TOWN – Warning that the process of negotiating a pandemic agreement has days not months left, talks co-chair Precious Matsoso hopes that a deal will finally be clinched at the next meeting of the Intergovernmental Negotiating Body (INB) in early December.

“We don’t have six months left to finish negotiations. We only have a couple of days left, precisely because the geopolitical environment is so challenging. There is huge, huge pressure on the talks and we don’t know what the outcome will be,” said Matsoso of the negotiations by World Health Organization (WHO) member states on an internationally binding accord that aims to better prepare for, and respond, to the next pandemic.

The cloud hanging over the talks is the distinct possibility that President-elect Donald Trump would pull the United States out of the negotiations, or even out of the WHO, after he takes office on 20 January.

The signals are hard to ignore in light of his decision to withdraw from the global health agency during his last term as president, as well as his recent nomination of vaccine skeptic Robert F Kennedy Jr, as secretary of Health and Human Services. The US withdrawal from the talks could set off a chain reaction from other conservative states that torpedoes the remaining goodwill among WHO member states, which must find a consensus on the text.

The talks resume on 2 December and run until 6 December with a crammed agenda dedicated to the most contentious issues: ‘One Health’ in the context of pandemic prevention, a mechanism for Pathogen Access and Benefit Sharing (PABS), and whether sharing of vaccines, medicines and therapeutics for use as comparative products in clinical trials should be voluntary or not. 

Tit-for-tat annexes

Recalling that the negotiations started in February 2022, just a day after Russia invaded Ukraine, Matsoso said she was reflecting on 1,000 days of work, which started with a blank page.

The draft agreement has been built around five areas: prevention, equity measures, health systems, financing and governance.

The Latest Draft Pandemic Agreement (15 November at 17.14 CET) shows that much of the text has already been agreed (highlighted in green) or mostly agreed (yellow).

While settling some of the contested clauses is challenging, other disagreements – like whether to use the term ”people” or “persons” – appear silly.

“Some negotiators lose touch with reality,” Matsoso admitted. “Our job is to bring them back to reality.”

The two dominant negotiating blocks – represented by the Africa Group, on the one hand, and the European Union and USA on the other – are deadlocked over Articles 4 and 5 (Prevention and One Health) and Article 12 (Pathogen Access and Benefit Sharing, or PABS).

Key outstanding substantive issues in the pandemic talks.

The Africa Group is reluctant to agree to an annex linked to Article 4 that lists countries’ responsibilities to prevent pandemics (including better surveillance of humans, animals and the environment for threatening pathogens) unless there is also an annex related to the operationalising of a system for PABS.

What the Africa Group wants from PABS is preferential access to any pandemic-related products that are developed from them sharing information about pathogens of concern.

The group is also concerned that a prevention annex could impose costly requirements that they are unable to finance. However, the first beneficiaries of prevention measures are individual countries’ citizens who would be protected by, for example, heightened surveillance of bats that harbour Ebola and Marburg.

“These two areas are the make-or-break articles of the negotiations. If we can reach agreement on these, we will make the deal,” Matsoso noted.

Disagreement centres on a handful of words

In some cases, a handful of words and phrases obstruct agreement. 

“Voluntary” is one of the sticky words. In the case of research and development (Article 9), the final outstanding issue relates to whether it is possible to compel industry to provide people who take part in clinical trials access to whatever products arise – or whether this should be voluntary. Related to this article, there is a push for trialists’ communities to also get access to these products.

Outstanding disputes over terminology in the pandemic talks.

This word crops up again in connection with technology transfer (Article 11) – and whether this should be mandatory or voluntary or on “mutually agreed terms”. 

The other sticking point in Article 11 is whether the terms of the licences of “government-owned health technologies” related to pandemic products should be made public.

Although it may seem like a no-brainer that taxpayers should have the right to know where their money goes, pharmaceutical companies often like to keep the terms of these agreements secret. 

Ten countries are pushing for the term “unhindered access” to be included in Article 13 and 13 (bis) dealing with the logistics and procurement of pandemic products. The 10 – including Russia, Iran, Syria, North Korea and Cuba – face “unilateral coercive measures” (sanctions) and want these lifted during pandemics.

“This is one of the difficult issues that the Bureau has to deal with, and we have to ensure that the pandemic agreement doesn’t become a platform for other issues,” Matsoso noted.

What’s in a word?

Some outstanding clauses can simply be resolved if negotiators agree on definitions, said Matsoso.

Agreement on “relevant stakeholders” would resolve 18 paragraphs; “know-how” would resolve eight paragraphs; “voluntary” would resolve six; “mutually agreed”, five. Deciding on “persons or people” would also resolve five.

Articles agreed on at the Intergovernmental Negotiating Body.

Despite the two substantial issues and the many ratty little details, Matsoso is hopeful that negotiating parties will reach agreement at the next short meeting between 2-6 December.

But, she notes, there is agreement on five major areas (give or take the odd phrase) – health system resilience (Article 5), health and care workforce (Article 6), R&D (Article 9), geographically diverse local production (Article 10) and regulatory systems strengthening (14).

“If we adopted this draft tomorrow, it would ensure health workers are protected, there are measures to build resilient health systems and regulatory systems are strengthened. But these provisions alone aren’t sufficient,” said Matsoso.

Image Credits: Rodger Bosch / Medicines Patent Pool.

Lab technicians work in laboratories in Afrigen, a company in Cape Town selected as the WHO Vaccine Hub, in South Africa.

Major pharmaceutical companies have made minimal progress in expanding access to essential medicines since the COVID-19 pandemic, according to an industry watchdog report released Tuesday.

The 2024 Access to Medicine Index, which evaluates 20 of the world’s leading drugmakers, found that despite modest improvements from certain companies, the overall pace of change in improving availability of life-saving medicines remains slow across more than 100 low- and middle-income countries.

The biennial rankings show major access initiatives launched by firms like Pfizer, Novo Nordisk and Bristol Myers Squibb to make treatments more affordable and available are operating in less than a quarter of their target countries.

The 20 companies assessed by the index, which control over half of global pharmaceutical revenue, face mounting pressure to improve access amid growing threats from drug-resistant infections and future pandemics. Two billion people, particularly in the world’s poorest countries, still lack access to essential medicines accessible for decades in other parts of the world. 

“Companies could do a lot more to scale up their initiatives to make lifesaving treatments accessible and affordable everywhere they are needed,” said Dr Jayasree Iyer, CEO of the Access to Medicine Foundation. “Until that happens, many essential medicines and healthcare products will remain out of reach for billions of people living in low- and middle-income countries.” 

Nearly half of essential medicines – from treatments for diabetes and cancer to cardiovascular and infectious diseases – remain unregistered in countries where disease burdens are highest, the report found. As clinical trials continue to bypass low-income countries, and with most drugmakers having policies to seek approval only where they run trials, new treatments do too, the analysis showed.

“We’ve seen what’s possible when global health becomes a priority, as it did during the COVID-19 pandemic,” Iyer said. “The tools exist, and so do the partnerships. What we need now is sustained commitment and deliberate action to reach those who have been left behind for far too long.”

“Why create medical innovations if they’re out of reach to those who need them?” Iyer added.

Clinical trial disparities widen access gap

Over half of the 117 low- and middle-income countries covered by the Index have no active clinical trials.

Clinical trials remain heavily skewed toward wealthy nations. While low- and middle-income countries are home to 80% of the world’s population, they host only 43% of trials for new medicines, with just 3.6% taking place in low-income nations, according to the report.  

Even within developing regions, trials cluster in a handful of upper-middle-income countries like China, Brazil and South Africa, leaving over 70 of the 113 nations covered by the Index with no active trials at all. 

This matters, as a majority of pharmaceutical companies covered in the index only file for drug approvals in countries where they run clinical trials, making early access planning critical for ensuring treatments reach patients in low-income regions after regulatory approval.

“Since trials are conducted only in a few low- and middle-income countries, access plans are often confined to these regions, ultimately widening the access gaps instead of closing them,” Iyer explained. “This is a big problem.” 

Registration gaps leave the poorest nations behind

The disparity in clinical trials has led companies to register products five times more frequently in upper-middle-income countries than in low-income ones. Of 179 products analysed in the Index, 87 are not registered in any of the top 10 countries with the highest disease burdens associated with the medications.

While 85% of products have company-led programs to ensure availability and affordability in upper-middle-income countries through measures like equitable pricing and licensing agreements, this drops to just 39% for low-income nations. The proportion of products lacking any affordability or access programs in low-income countries has barely improved, falling to 61% from 65% in 2022.

“This low overall registration coverage of countries with high disease burdens means that products may not be available where people need them the most,” the report found.

Nearly half of innovative medicines approved in the past five years remain unregistered in any African country as a result, contributing to $2.4 trillion in annual costs from preventable disease across the region.

“This imbalance is unacceptable,” Iyer said. “Every delay in expanding access to medicine translates to more lives lost and communities devastated.”

Manufacturing gap widens as technology transfers stall

Sub-Saharan Africa is largely overlooked by companies’ technology transfer efforts. As a result, 43% of innovative products approved within the past five years have not been registered in any African countries.

The barriers to access are further compounded by stagnating efforts to boost local manufacturing capacity in low-income countries. Technology transfers, where companies share manufacturing knowledge with local producers, remain heavily concentrated in a handful of emerging markets.

Like clinical trials, the majority of technology transfers undertaken by major pharmaceutical firms benefit a small share of upper-middle-income nations. Of 47 ongoing technology transfer initiatives identified, India hosts 11, Brazil nine, and China seven. 

Sub-Saharan Africa, which bears 20% of the global disease burden and relies on imports for up to 90% of its pharmaceutical products, sees minimal investment outside South Africa. The manufacturing gap is at its widest when it comes to vaccines, with Africa importing 99% of its doses. 

“Right now, these efforts are heavily skewed toward upper-middle-income countries like China and India, leaving Africa behind,” said Claudia Martinez, Research Director at the Access to Medicine Foundation. 

Progress in voluntary licencing agreements, which allow generic manufacturers to produce and distribute patented medicines at lower costs, has also slowed, with just two new agreements in 2024, down from six in 2022.

“The infrastructure exists in places like South Africa, Nigeria, and Kenya,” Martinez said. “The challenge lies in companies’ willingness to expand their efforts and commit to long-term partnerships.”

New access models show mixed early results

Five companies – Novartis, Novo Nordisk, Sanofi, Pfizer, and Bristol Myers Squibb – have pledged to tackle systemic access barriers by making their products available in 102 countries through “inclusive business models” (IBMs), targeting all 48 low-income and least developed nations.

Early results show varying progress. Bristol Myers Squibb’s ASPIRE program, launched this year, is active in 19 of its 85 target countries – an implementation rate of 22%. Pfizer’s Accord for a Healthier World, announced in 2022, has signed agreements with only eight of the 45 countries covered in the plan.

Longer-running programs fare better. Novo Nordisk’s iCARE, launched in 2021, is active in 17 of 46 countries. Novartis, with the oldest program launched in 2019, states its products are available in “most” of its target countries but does not provide specific numbers.

Sanofi is the only company providing specific patient numbers under its IBM, the report said. The drugmaker reached 261,977 patients with treatments for non-communicable diseases across 31 countries, while serving 23 countries for tuberculosis and 19 for malaria, though it doesn’t provide country-by-country breakdowns.

New leader, slow pack 

Overall rankings of the 2024 Access to Medicines Index.

The Index ranks companies on a five-point scale, measuring their efforts to improve medicine access in poorer nations. While Novartis claimed the top spot for the first time with a score of 3.78, displacing long-time leader GSK to second place, even these best performers remain well below the maximum score.

The Index shows steady progress over its 15-year history, with the average scores across the 20 pharmaceutical companies rising more than a third since 2010 and the gap a steadily narrowing gap between the best and worst performers. 

Companies like GSK and Novartis have consistently maintained the top spots, while Gilead, despite its crucial role in HIV/AIDS and hepatitis treatments, has seen its score decline significantly.

David Reddy, director of IFPMA, the pharmaceutical industry group representing most indexed companies, points to initiatives like tiered pricing models and voluntary licensing agreements as evidence of progress.

“These efforts demonstrate the value of partnerships with governments, healthcare systems, and local organisations,” Reddy said. “Despite these strides, the report underscores the need for accelerated efforts to close persistent gaps in access, particularly in low-income countries.” 

Researchers at the United Nations University International Institute for Global Health have questioned the rankings’ reliability, noting they rely heavily on self-reported corporate data that cannot be independently verified. 

Image Credits: WHO.

Afrigen’s Petro Terblanche at the progress meeting.

CAPE TOWN – Sustainability is the priority for vaccine manufacturers that are part of the mRNA technology transfer programme established by the World Health Organization (WHO) and the Medicines Patent Pool (MPP).

The programme was launched in 2020 to equip low and middle-income countries (LMIC) to make their own COVID-19 vaccines to address the inequity exposed by the pandemic – but few countries want or need these vaccines now. 

“The network was built on the premise of a COVID-19 vaccine market. What do the manufacturers do to stay alive?” asked Martin Friede, head of WHO’s vaccine development unit, at a three-day progress meeting in Cape Town.

The immediate priority is to ensure that the 15 partners in the network can “make commercially viable products that they can sell and that there are people out there who want these products,” he added.

Dengue, H5N1, malaria, cholera and Rift Valley fever (RVF) are some of the vaccines under research and development (R&D). Meanwhile, South Africa is putting much of its focus on trying to develop an mRNA vaccine for tuberculosis, the world’s biggest infectious disease.

Some manufacturers also looking at vaccines for zoonotic diseases like leishmaniosis, which affects people and animals, and animal vaccines to keep their new facilities “warm” and ready for the next pandemic.

MPP executive director Charles Gore said that manufacturers can also go beyond mRNA:  “We need monoclonal antibodies and immune modulators.”

But unless the manufacturers sell vaccines and other products to address the health challenges of their regions, they will either go bankrupt or move on to commercially viable products, and their new capacity will be lost by the next pandemic.

In 2023, the South African government, which hosts the mRNA hub, opted to procure pneumococcal vaccines from an Indian company rather than local company Biovac, which is part of the programme, because they were cheaper. In the meantime, the vaccine platform, Gavi, has set aside money to assist up-and-coming vaccine manufacturers particularly in Africa to compete in a tight market.

Amazing progress – and financial challenges

Charles Gore, executive director of the Medicines Patent Pool.

Despite the challenges, progress has been “really amazing,” said Gore of the programme that started in Cape Town, South Africa.

“We are now poised to establish a sustainable mRNA vaccine production capacity that will benefit millions across the Global South, truly redefining what health equity can look like on a global scale,” added Gore.

From zero mRNA manufacturing capabilities in LMICS at the launch, the initiative expects 11 state-of-the-art good manufacturing practices (GMP) certified mRNA manufacturing facilities to be launched in 10 countries by 2030 – two within the next year. 

Should this happen, the network will be able to make 60 million doses annually by 2030, with the potential to scale up to a maximum of two billion doses in the event of a pandemic. 

The initiative is supported by the governments of South Africa, France, Belgium, Canada, the European Union, Germany, Norway, and the ELMA Foundation.

“Despite remarkable progress, additional funding is required to fully achieve the programme’s ambition. An estimated $200 million is needed to advance all manufacturers to GMP standards and continue to strengthen the R&D pipeline in support of at least 12 mRNA products currently in development,” the MPP noted in a statement on Wednesday.

South Africa leads

South Africa was chosen to lead the initiative because of its strong research community and manufacturing sector, according to Gore.

Commercial company Afrigen was appointed as the “hub” of the programme. Within six months, its scientists had developed an mRNA vaccine based on the Moderna vaccine – although the drug company declined to offer any help.

Afrigen has since trained 15 partners to develop mRNA vaccines from Argentina, Bangladesh, Brazil, Egypt, India, Indonesia, Kenya, Nigeria, Pakistan, Senegal, Serbia, Tunisia, Ukraine and Vietnam. 

Afrigen expects to be GMP-certified within the next year but it too is challenged by the need for commercially viable products, particularly as money for the mRNA initiative only runs to 2026.

CEO Dr Petro Terblanche says her company and others in the network are exploring a variety of options to keep afloat including “blended finance” from governments, donors and development banks.

South African manufacturer Biovac is the manufacturing arm of the country’s consortium. It is in the process of developing a cholera vaccine which enters clinical trials next year.

Scaling up

Some of the partners, such as BioFarma in Indonesia and Egypt’s BioGeneric are not only honing their ability to make vaccines but scaling up their manufacturing capacity to produce millions of vaccines per year.

Biofarma’s Indra Rudiansyah said that the Indonesian company was expanding its site and had a candidate vaccine for rabies.

BioGeneric has four vaccines in the pipeline including rabies and polio, and now has fill-and-finish capacity to make 30 million vaccine doses a year. It has invested $50 million in expansion.

“But it’s very hard to know when we will reach profitability,” said Heba Wali, the company’s general manager.

Companies that are government-funded have more security. Bio-Manguinhos, which falls under Brazil’s science foundation, makes vaccines for the country’s public health programme.

“There is a very strong possibility that our government will use our mRNA COVID-19 vaccine,” said Patricia Neves of Bio-Manguinhos.

Kenya’s Biovax is 100% state-owned, and its government has procured a $120 million loan from the World Bank for its expansion. However, it’s biggest challenge is that it is unable to compete with the salaries paid by commercial companies. 

Meanwhile, Senegal’s Institut Pasteur Dakar, have gone from three employees to 16 and still are far from ready to manufacture vaccines.

Regional co-operation

But, said Friede, “most of the vaccine manufacturers on earth are not research entities. They are manufacturing entities. They go and buy their research from universities or biotech companies.

“How are we going to ensure that these manufacturers get access to a portfolio product that they can manufacture?”

To assist with this, R&D consortia have been set up to lead product-orientated research. Most consortia are aimed at developing vaccine candidates for diseases that are priorities in their regions. 

The partners have organised themselves into R&D consortiums

The consortia are bringing in experienced translational research groups like the International Vaccine Institute in Korea and Hilleman laboratories in Singapore and universities, said Friede.

At least 13 of the 15 partners and the WHO have also signed a memorandum of understanding with Professor Drew Weissman at the University of Pennsylvania, who is assisting in building their research development capacity and they will get access to the portfolio of products coming out of this. Weissman and Katalin Karikó won the Nobel Prize for Medicine in 2023 for their work on mRNA.

The Southeast Asia consortium is fairly advanced in its work on four mRNA vaccines for dengue, HPV, malaria and Enterovirus. Any vaccines developed through this initiative will be shared across participating LMICs.

South East Asia consortium’s mRNA vaccine plan

Moderna has around 5,000 scientists, which is hard to compete with, added Friede. But the consortia are enabling the network to start building “the critical mass that is necessary to ensure that LMICs can get a portfolio of products that have been taken to a certain point in development and then transferred over”. 

“The point of the network is sharing and collaborating,” said Gore, adding that those in the network will get preferential treatment and access to products.

Image Credits: Kerry Cullinan, Rodger Bosch / Medicines Patent Pool.

Delhi and its neighboring city of Gurgaon (pictured above) are engulfed in a layer of smog due to the high levels of air pollution.

Schools were closed, vehicle entry restricted and India’s top court on Monday advised residents of Delhi’s metropolitan area to wear masks as the capital city was shrouded in “severe plus” levels of air pollution for the second day in a row. For the past week, Delhi’s air pollution has been in the “severe” category – dashing government claims that improved surveillance of rural crop burning and other measures to ease the annual pollution emergency are working.

On Monday the PM2.5 air pollution levels – particles so small that they can be inhaled deep into the lungs and even into the bloodstream – were nearly 17 times the limit set by the World Health Organization (WHO). WHO limits for PM2.5 over a 24-hour time period is 25 micrograms per cubic meter of air (μg/m3), while some monitors in Delhi measured PM2.5 levels at 420 μg/m3.

Air pollution is a year-long problem in Delhi, but the halt of monsoons in the autumn as well as low wind speeds – what the government calls “unfavourable meteorological conditions” – have long sent toxic levels of air pollution soaring in the late autumn.

And the burning of rice stubble in surrounding rural states such as Haryana and Punjab continue to exacerbate conditions, said Delhi’s chief minister Atishi Marlena during a press interaction. The problem became much worse ever since 2008, when the national government ordered farmers to delay the planting of rice crops until later in the spring – thus delaying the harvest date and leaving farmers in a rush to plant a crop of winter wheat.

On Monday, Delhi’s PM2.5 levels were 420 μg/m3 – nearly 17 times above the recommended WHO 24-average of 25 μg/m3.

Farmers avoiding surveillance satellites

While state governments claim to have clamped down on farmers who set their fields on fire to clear the paddy stubble, stepping up surveillance and fines, satellite images reveal something else.

To avoid being detected, farmers are merely setting the stubble on fire later in the afternoon, after the satellite that the government uses for surveillance information passes, experts told Health Policy Watch. To improve enforcement, stationary satellites should be used instead, they said.

See related story: Delhi Air Pollution: Is Government’s Satellite Monitoring Missing Stubble Fires?

Aarti Khosla, Director of Delhi-based research consultancy Climate Trends said that rather than blaming only the rural areas, Delhi officials need to better manage the city’s background air pollution levels year-round.

“Agricultural farm burning, contributes, on the days when it’s a peak, to 40% of Delhi’s air [poor] quality,” she said at a press conference on the sidelines of UN climate conference (COP29) in Baku. “And when, when it’s not a peak, it’s 2-3% of its problem.”

Aarti Khosla, Director of Delhi-based research consultancy Climate Trends during a press conference at COP29.

Short-term measures

Along with the advise about masking, the government has ordered most schools to hold classes online, barring a few exceptions.

Vehicles that do not meet pollution norms will not be allowed into the city. All construction activities have been halted given their contribution to increasing dust.

Options to allow government employees to work from home or call in a reduced number of employees to the workplace are also being considered. The government has already deployed vehicles that are spraying mist on the streets and the trees nearby to reduce the dust.

Experts though have been pointing out that such measures are short-term and will do little to reduce the city’s toxic levels of air pollution, or the autumn emergency that recurs annually.

‘We want pollution levels to be down year-round’ 

“Ultimately, we want the pollution levels to be down year round and not just the extremes or winters,” Sarath Guttikunda, director of the Delhi-based Urban Emissions.Info that monitors and researches air pollution research, told Health Policy Watch, in an emailed comment.

“Five items which need a long-term vision,” he added, “aggressive expansion and promotion of use of mass transport (especially buses), walking, and cycling modes; promotion of clean fuels like electricity or gas for heating during the winter months; strict enforcement of a ban on open waste burning; clear mandates for complying with emission norms for all industries including brick kilns; and management of road dust,” he said.

He also said that the promotion of green spaces adds to a city’s air quality and ‘breathability’.

Delhi is currently among the most polluted cities in the world.

In rural areas, officials have long spoken about promoting alternatives to rice-stubble burning, such as machine crushing of stubble and expedited composting formulas. But these, too, have not been backed with sufficient levels of state or national government incentives – or enforcement for those who continue to burn.

Shifting government subsidies away from rice production to support the cultivation of more nutritionally rich, indigenous grains, such as millet, has also been advocated by environmentalists to reduce stubble. They point out that the rice is now largely produced for export and is a heavy consumer of water, draining underground aquifers. However, the rural farm lobby in Punjab and Haryana is a powerful force and politicians have been generally fearful about changing the status quo.

The high levels of air pollution in Delhi and its surrounding cities are a health hazard, warned health experts.

Impacts on climate and health

South Asia which has among the highest air pollution levels in the world reports an estimated two million deaths annually that are linked to air pollution.

The Southeast Asia region typically suffers from the highest pollution levels in the world, with an estimated 2 million deaths annually, according to WHO.

And the annual pollution emergencies that strike at Delhi, in fact affect the shared  airshed of a much larger area – the sprawling Indo-Gangetic Plains and Himalayan Foothills region extending from eastern Pakistan, where crop-stubble burning also is widespread, across northern India and Nepal to Bangladesh.

Satellite image shows smoke from a large number of small fires across the Indo-Gangetic plain and Himalayan foothills, a shared airshed across four countries.

That has led to groups such as the World Bank to call for a broader, regional approach to air quality management. But so far attempts to trigger political cooperation across fraught borders have engaged scientists, but not always top political leaders.

Reducing air pollution also reduces climate change – a “triple win” for health, climate and economic development, experts have maintained.

Fossil fuel burning is directly responsible for a significant proportion of air pollution related deaths, so shifting to renewables has synergistic effects, noted Marina Romanello in the 30 October launch of the Lancet Countdown on Climate and Health. 

In addition, methane waste emissions and black carbon particles emitted by open crops, waste burning and household fuels are short-lived climate pollutants that exacerbate snow melt and warming temperatures.

Speaking from Baku’s COP29, WHO’s Director for Environment and Climate Change Dr Maria Neira, too, drew attention to Delhi’s staggering levels of air pollution during a press conference.

“The same causes that are responsible for global warming, the combustion of fossil fuels,… are the causes of air pollution as well,” she said. “At the moment we are talking here, people in one place in the world are breathing air with 400 micrograms/ per cubic meter of pm.2.5,” she said, displaying a WHO ‘BreatheLife’ gauge that reflects how Delhi’s annual air pollution levels exceed WHO guideline norms more than 12 fold.

WHO’s Maria Neira displays WHO ‘BreatheLife’ gauge showing how Delhi’s annual air pollution levels exceed WHO guidelines more than 12 fold.

The acutely high air pollution levels are a long-term term risk for health, with one-quarter to one-third of deaths from hypertension and other cardiovascular diseases, lung disease as well as lung cancer attributable to air pollution.

But they are also a very immediate health emergency, said Dr Courtney Howard, vice-chair of the Global Climate and Health Alliance (GCHA), at the same COP press briefing.

“So when air pollution levels are as high as they are in Delhi today, what we’ll be presenting to emergency departments are people with breathing problems from asthma, from chronic obstructive pulmonary disease. People will be coming in with chest pain due to heart attacks that get worse. Strokes are made worse by high levels of air pollution on a more chronic basis. It does increase risks to newborns,” said Howard.

Image Credits: Chetan Bhattacharji, AQI, IQAir, Our World in Data, NASA, WHO.

After decades of advocacy, health secures a permanent spot on the UN climate summit agenda.

The World Health Organization’s marquee event at COP29 in Baku produced a document that captures the growing frustration felt by delegates, civil society, and people across the globe with UN climate negotiations: a “letter of intent” to form a coalition to continue discussions about taking action.

In stark contrast to the glitzy, Bill Gates-adorned fanfare of the inaugural COP Health Day in Dubai a year ago, the WHO-led high-level ministerial on Monday took place in a cramped, windowless meeting room – though, to be fair, the ground floor of Baku’s football stadium, the venue for COP29, has no windows.

Seasoned UN observers sensed the event, billed as a “round table” emphasising “sharing best practices” and “reinforcing sustained action,” was unlikely to make headlines. While Dubai’s celebration drew VIPs and global attention, this year’s event peaked at just 18 guest attendees on a Microsoft Teams call attended by Health Policy Watch.

The meeting resulted in the “Baku COP Presidencies Continuity Coalition for Climate and Health,” an acronym sure to catch on at the UN climate talks: BCPCCCH.

The new coalition, coordinated by Azerbaijan in partnership with previous COP hosts Egypt, the United Arab Emirates, the United Kingdom, and the next host, Brazil, commits COP presidencies to ensure health is a central agenda item at future UN climate summits.

“By signing the Letter of Intent, we commit to a shared vision of a world where climate and health policies are not isolated but integrated into all aspects of governance and development,” Azerbaijan’s Minister of Health, Teymur Musayev, said in a press conference following the signing.

Musayev said the coalition was “not created for dialogue alone,” though provided few specifics on objectives beyond strengthening health initiatives agreed upon at past COPs.

‘Significant milestone’

WHO hailed the letter of intent as a “significant milestone,” while its director-general, Tedros Adhanom Ghebreyesus, said it “unites the visionary leadership” of COP host countries and shows “a collective will to prioritize climate and health now and for the future.”

Adding to the chorus of UN buzzwords, COP29 President Mukhtar Babayev called the coalition “another step towards synergistic action on climate and health.”

The agreement falls short of making health a formal topic in UN climate negotiations – long considered the holy grail for the health community – despite evidence climate change-related developments, from air pollution to extreme weather, cost nearly ten million lives annually.

While both the Azerbaijani presidency and WHO have issued press releases, the letter of intent itself has not been made public at the time of publication.

“With the Continuity Coalition, there is now a mechanism to foster presidency-led, high-level attention to health as the norm,” Dr Jeni Miller, executive director of the Global Climate and Health Alliance, told Health Policy Watch. “What we will be looking for is how it makes that a reality.”

Missing the mark

Delegates celebrate the creation of the Baku coalition following the WHO-led Baku Coalition signing ceremony.

For communities on the frontlines of the climate crisis, the pledge to have future discussions about potential actions to protect health – and the celebratory tone adopted by ministers like Babayev and Musayev – miss the mark.

The loss of life from climate change and disease that could be prevented by nations living up to Paris Agreement Targets – an ambition so far absent at the midway mark in Baku – would save two million lives annually, WHO said in a report ahead of COP29.

Civil society stakeholders from frontline countries are demanding $5 trillion in annual funding as the bare minimum outcome of the summit to cope with the damage already incurred and to adapt and mitigate future climate change.

Nations are less ambitious than civil society in their demands, with most targets from developing countries, including the Arab and the African Groups, hovering around the $1-2 trillion range.

As the summit enters its second week and UN climate negotiations near the three-decade mark, words on a page, absent any legally binding or financial backing, are ringing increasingly hollow.

“I see a disconnect between the global conversation and discourse with the reality that countries are facing,” Nigeria’s Minister of Health, Mohammed Ali Pate, said following the signing ceremony including the countries that inaugurated the coalition.

“Nigeria and other countries are pulling within their limited resources,” Pate said. “We need to reconcile this divergence between global rhetoric and real action backed by resources for those who are bearing the brunt of climate change.”

What’s the point?

WHO COP29 high-level ministerial in progress in Baku.

For frontline communities, the Baku coalition’s non-binding ‘promises’ are pyrrhic victories. But for the WHO and health advocates, they represent hard-fought institutional progress.

The fight for health to be recognised as a central concern in UN climate summit agendas has been an uphill battle, mirroring the decades-long struggle to force nations to acknowledge the role of fossil fuels in the climate crisis.

Just as it took nearly three decades of UN climate negotiations for the global community to finally commit to “transitioning away” from fossil fuels in Dubai last year – making headlines across the globe – the inclusion of health in the climate agenda is a victory that was won over decades.

The health breakthrough is also reminiscent of another recent milestone in global environmental negotiations. Just a month ago in Cali, Colombia, Indigenous communities were granted an official expert body seat in UN biodiversity negotiations after years of tireless advocacy, prompting emotional scenes from people and communities who fought relentlessly for recognition.

“The place that we have gained over the years for health at the COPs is now secured,” Dr Maria Neira, WHO’s health and climate lead, told Health Policy Watch. “We don’t need to fight every year to obtain this space.”

Indigenous delegates at COP16 in Cali, Colombia, celebrate victory as decades of advocacy and activism lead to official representation in international negotiations.

The coalition’s key achievement, while bureaucratic, is significant: after decades of fighting, health advocates and WHO officials will no longer have to relitigate the importance of health as a central concern in climate talks.

“Each victory has been a step forward in getting health into the climate conversation,” Miller said. “Negotiators and heads of state [now] recognise that when they are making decisions about climate action, they are making decisions about people’s lives.”

WHO can also claim the establishment of the Baku Coalition meets its basic goal for the talks – ensuring delegates recognize they’re negotiating the health of eight billion people – though the 18 attendees on Teams suggest the message may not have reached many member states.

That such a modest procedural win emerges as COP29’s headline health achievement however challenges WHO’s message, pushed through two decades of pre-COP media blitzes, that health – as the lived experience of climate change – would be “the argument” driving meaningful climate action.

So far, the evidence from Baku suggests that national delegations still aren’t listening.

Time saved?

It remains to be seen whether the time saved on bureaucratic wrangling with COP presidencies can translate into more careful tracking of achievements or barriers to fulfilling health-related commitments made at previous COP summits. 

At Glasgow’s COP26, the Alliance for Transformative Action on Climate and Health (ATACH) was launched with a promise to transform health systems to be more climate resilient. The coalition now includes 91 nations – half of UN climate summit participants – after Azerbaijan joined on Monday.

While WHO monitors commitments made by ATACH members to low-carbon and net-zero health systems, there is no oversight of whether these have translated into action.

Limited international funding available for health has gone largely unnoticed, even by the only country receiving support from the world’s leading climate fund, the Green Climate Fund (GCF).

Malawi is the sole recipient of a GCF grant targeting the health sector’s climate needs. Yet Malawi’s own climate minister, interviewed by Health Policy Watch this week, was unaware of the GCF-funded project in their country.

GCF has not responded to a request for comment.

Baby steps, urgent crisis

Delegates convened for the first-ever Health Day at a UN climate summit in Dubai.

Last year seemed to mark another step forward in health action, with 150 nations signing a Health and Climate declaration during the first dedicated Health Day in three decades of climate talks.

The Dubai COP also featured a two-week series of climate side events at an expanded WHO Health Pavilion, highlighting the impacts of climate change on food systems, air pollution, household air pollution, energy, and biodiversity.   

But beyond the political rhetoric, it remains unclear the level of progress being made in getting health into formal adaptation and mitigation processes. 

Health-specific climate action remains severely underfunded, still capturing only 2% of adaptation funding and 0.5% of multilateral climate funding – unchanged since Glasgow five years ago. 

At COP29, health financing announcements have amounted to a single $10 million grant from the Islamic Development Bank to the WHO. 

WHO influence in jeopardy

WHO kicked off a funding drive to fill its multi-billion budget shortfall in Berlin last month.

The WHO’s influence in the funding arena is further complicated by its own financial instability.

Already grappling with a multi-billion dollar budget shortfall, the organization faces additional uncertainty with the possibility of the US, its biggest single donor, cutting funds when President-Elect Donald Trump returns to office in 2025. 

Trump withdrew from WHO in his previous term, and many in his orbit expect the incoming president to do the same this time around. 

Top WHO officials told Health Policy Watch last month another Trump withdrawal of funding reinstated by Biden would result in a “dramatically bad crisis” for the UN health agency. 

Brazil offers a glimmer of hope 

The Amazon Rainforest, Brazil.

The buzz in the health world ahead of talks in Baku was to not  expect significant health outcomes from COP29. 

Finance was always going to dominate the agenda, and Azerbaijan – whose delegation has by some accounts never spoken at COPs before hosting this one – was unlikely to lead on the issue.

Looking ahead, Brazil’s hosting of COP30 offers a glimmer of hope to many in the health world.

Brazil’s president, Luiz Inácio Lula da Silva, has pledged to act on climate and protect the Amazon, reversing four years of the legacy left by his predecessor, Jair Bolsonaro, who denies climate change and allowed deforestation and exploitation of the tropical rainforest to expand at an unprecedented rate.

Brazilian officials have also committed to prioritizing health initiatives on next year’s agenda, already participating in high-profile WHO events in Geneva and Berlin ahead of the summit.

In Baku, Brazil’s health minister announced that equality will be a key focus of its upcoming COP presidency. And with universal health coverage deeply embedded in Brazil’s national identity, there’s cautious optimism that meaningful health and climate action might finally move from rhetoric to reality in Rio.

Image Credits: COP16, WHO , CIFOR-ICRAF.