Smoke rises over Northern California amid the ongoing Park Fire, set to become the fourth-largest in state history as firefighters brace for a weekend heat wave expected to bring hotter, drier conditions.

New research suggests long-term exposure to wildfire smoke may significantly increase dementia risk, posing a greater threat to brain health than other forms of air pollution.

The study, presented this week at the Alzheimer’s Association International Conference, examined a decade of electronic medical records for 1.2 million older adults in Southern California from 2009 to 2019. Researchers found a 21% higher risk of dementia diagnosis for every microgram per cubic meter increase in fine particulate matter (PM2.5) from wildfire smoke in the air, measured over three years.

By contrast, a three-microgram increase in PM2.5 from other sources like vehicle emissions or industrial pollution raised dementia risk by only 3%. The results, currently under peer review, account for variables including age, sex, race, ethnicity, smoking status, and income.

“There is quite a bit of prior literature that demonstrates an association between exposure to ambient air pollution and dementia, but there’s very limited research on how wildfire PM2.5, specifically, might be associated with dementia,” said Dr Holly Elser, lead author of the study and neurology resident at the University of Pennsylvania.

California’s ongoing Park mega-fire, which has burned 392,480 acres and become the state’s fifth-largest wildfire on record, underscores the study’s urgency. Smoke from this blaze now blankets regions where the study’s subjects live.

A separate study published in the Proceedings of the National Academy of Sciences (PNAS) in February highlighted the growing threat, revealing some parts of California endured nearly 18 months of high wildfire smoke levels over 15 years. Rural and tribal areas suffered the worst exposure, with some regions facing 10 times the average smoke particle levels.

These findings indicate that many Californians may face a 5% to 50% higher dementia risk, with economically disadvantaged communities experiencing the greatest danger.

“As wildfire events become more intense, more frequent, and occur in places outside of the Western US, we felt this was an important, specific source of air pollution to consider as a potential risk factor for dementia,” Elser said. “This is a real problem.”

Why wildfire smoke may be more dangerous

Firefighters respond to the Park mega-fire in Northern California.

PM2.5, the main pollutant in wildfire smoke, consists of airborne liquid and solid droplets smaller than 2.5 micrometres – about 30 times finer than a human hair. These tiny particles can penetrate deep into the lungs, enter the bloodstream, and potentially reach the brain.

Sources of PM2.5 range from coal- and natural gas-fired plants to cars, agriculture, unpaved roads, construction sites, and wildfires. It can take the form of dirt, dust, soot, or smoke.

While researchers are still investigating why wildfire smoke appears more harmful to brain health than other forms of air pollution, several theories have emerged.

Despite sharing the PM2.5 label, particles from wildfires may be more toxic than urban pollution. Their chemical makeup varies widely based on burned materials, unlike the more predictable composition of vehicle or factory emissions.

“There’s a greater concentration of toxic chemicals in wildfire smoke,” said Niki Rubarth, regional director of the Alzheimer’s Association of Northern California. “Wildfires burn everything in their path so that can be anything.”

A 2022 US study of more than 18 million people linked black carbon, a major component of wildfire smoke, to higher dementia risk. Researchers found that each microgram per cubic meter increase in black carbon raised dementia risk by 12%. That same year, a separate study published in Environmental Health Perspectives revealed that even brief exposure to wildfire smoke could impair cognitive functions, including attention.

Another factor is particle size. PM2.5 particles from wildfires are typically smaller than those from urban pollution, potentially allowing for easier penetration into organs and the bloodstream.

The study’s authors emphasize the need for further research to pinpoint which specific components of wildfire smoke might be driving the increased dementia risk.

“I’m really curious to see whether or not we see a similar association with other neurodegenerative processes like Parkinson’s disease or ALS,” Elser added. The link between air pollution and Parkinson’s – a known cause of dementia – is well-established.  

Experts suggest wildfire smoke’s toxicity isn’t the only factor boosting dementia risk; stress and trauma from these events may also significantly impact cognitive decline.

“Exposure to environmental shocks like wildfires can also uncover cognitive changes already underway,” Elser explained. “The stress and depression associated with these events could potentially unmask neurodegenerative processes that were already present.”

Repeated trauma from losing homes and fleeing wildfires has well-documented links to post-traumatic stress disorder, depression and anxiety across California – all conditions that increase a patient’s risk of dementia.

Similar mental health impacts have been observed globally in relation to extreme weather events. Following devastating floods in the Philippine capital of Manila last year, researchers found evidence of worsened anxiety and distress.

“Repeated chronic stress can cause all sorts of physiological changes,” said Vaibhav Narayan, executive vice president at the Davos Alzheimer’s Collaborative. “Stress is a well-known activator of brain health decline and cognitive issues.” 

“It’s not just the physical impact of these stressors,” Narayan added. “It’s also the psychological impact that is detrimental to brain health.”

Growing evidence links air pollution to dementia risk

Map of active global wildfires. / Source: IQAir

The new findings bolster a mounting body of evidence connecting air pollution, particularly high PM2.5 concentrations, to brain health issues.

In its 2024 update released Wednesday, the Lancet Commission on dementia prevention reported that at least nine systematic reviews and meta-analyses since 2019 have established a strong link between air pollution and increased dementia risk.

Studies worldwide demonstrate air quality’s impact on cognitive health. In China, stricter clean air policies slowed cognitive decline in older adults, while another study found 42.4% higher dementia risk in the country’s more polluted northern regions compared to the south.

In 2022, French researchers linked a 12 microgram per cubic meter reduction in PM2.5 levels over 10 years to a 15% lower dementia risk. In the US, meanwhile, older women experiencing larger improvements in air quality over a decade showed lower dementia risk.

High levels of fine particulate matter correlate with increased rates of dementia, mild cognitive impairment, and Alzheimer’s disease in both wealthy and developing nations, the Lancet Commission found. 

Indoor pollution poses additional threats, particularly in developing countries where solid fuels for cooking and heating are associated with higher dementia risk and faster cognitive decline in adults over 45.

While most studies focus on older adults, experts warn that air pollution could affect brain health earlier in life.

“People entering older age now have been exposed to wildfires quite extensively – potentially through their 40s, 50s and 60s,” said Dr Joan Casey, co-author of the wildfire study and a neurologist at the University of Washington. “That might be really important.” 

The Lancet Commission reported growing support for World Health Organization global air quality guidelines, noting, “It is unclear whether any safe concentration of air pollution exists.”

The commission now estimates that addressing “modifiable” risk factors could prevent up to 45% of dementia cases, up from 40% in its 2020 report. These factors include air pollution, less education, hearing loss, hypertension, physical inactivity, diabetes, social isolation, excessive alcohol consumption, smoking, obesity, traumatic brain injury and depression.

“The world can’t afford to ignore the 45%,” said Narayan. “That’s the most scalable way to address this issue.”

Wildfires spread globally 

Smoke from wildfires in North Africa in 2023 crossed the Atlantic, affecting air quality in Latin America.

The study’s findings come amid increasing global wildfire activity. Human-caused climate change has increased atmospheric aridity and fuel dryness, leading to longer, more active fire seasons.

The European Union’s Copernicus Climate Change Service identified significant fire seasons across the world in 2023, from Australia to Bolivia, Algeria, Thailand, North America, Russia, and Chile. 

Canada experienced record-breaking wildfire carbon emissions as climate change more than doubled the likelihood of extreme fire weather in Eastern Canada, while Greece battled the largest wildfire in European Union history. Between 1984 and 2020, the annual area burned by wildfires in the western United States surged by over 300%, with some regions seeing a staggering 1,000% increase. 

Globally, the length of the fire season has lengthened by nearly 20% between 1979 and 2013. 

“The biggest thing will be to slow climate change, stop burning fossil fuels and figure out how we’re going to better manage wetlands so we have reduced wildfire exposures,” said Casey. “Of course, that’s quite complicated.”

Wildfire smoke can impact air quality thousands of miles away. In 2023, Canadian wildfire smoke reached Europe and turned New York City skies orange. Smoke from Algerian wildfires made the reverse journey across the Atlantic, reaching Latin America. 

Experts recommend several strategies to reduce exposure to wildfire smoke, including staying indoors on poor air quality days, using high-efficiency air filters, and wearing N95 or KN95 masks when outdoors during smoke events. However, these measures may not be equally accessible to all populations.

“This is a global problem. Wildfire smoke can travel across oceans and impact everybody,” said Narayan. “But like in everything in life, poor people are always disproportionately impacted.”

Women and children wait outside the MSF clinic in Zamzam camp in January 2024, where a malnutrition crisis was causing one child to die every two hours, according to Médicins sans Frontières.

More than half a million people in Sudan’s North Darfur region are now suffering from famine conditions, the Famine Review Committee (FRC) of the UN’s Integrated Food Security Phase Classification (IPC) announced Thursday. 

The escalating violence in Sudan between government troops and the paramilitary Rapid Support Forces, which broke away from the Sudanese Armed Forces in 2023, is at the root of the food crisis. 

Meanwhile, armed conflicts in the Democratic Republic of the Congo (DRC) and in Gaza continue to perpetuate two more of the world’s other most acute hunger and food crises.

In Sudan, the FRC assessed the conditions in the Zamzam refugee camp near El Fasher town, where some 600,000 people have taken refuge, as experiencing famine risks, the worst of the IPC classification levels. 

Famine is declared when at least 20% of an area’s population suffers from extreme lack of food and hunger (IPC level 5), facing actual starvation. Though the IPC analyzed only the Zanzam camp, the food crisis is likely of a similar scope in other regions of North Darfur, said the IPC.

The camp, set in the southwest of the country, has been besieged by the RSF for months, and famine risks will likely remain severe through the end of October 2024, the IPC assessment concluded. 

In Sudan, 26.6 million people, more than half of the population, are food insecure, according to the World Food Programme (WFP) data. Fighting between the country’s army and RSF, said to be backed by Russia’s Wagner Group, continues to impede the operations of aid organisations. Over 10 million Sudanese are internally displaced and 2 million abroad – the largest number in the world, according to a WHO update July 17.

In Khartoum, free kitchens operating there were forced to shut down in mid-July, due to a lack of funding and food supplies.

The RSF, a rebranded name for the Sudanese Janjaweed militia, has been accused of war crimes over the past decade in Darfur, as well as South Kordofan, and Khartoum, according to groups like Human Rights Watch. The violations include burning villages, raping women, unlawful detentions, and repurposing hospitals and churches as military shields. 

In the Darfur region, many people face hunger (IPC 5), the Famine Review Committee assessed after analysing the situation in the refugee camp next to El Fasher (al-Faschir).

DRC has the largest number of people in need of humanitarian aid in the world 

In the neighbouring Democratic Republic of Congo, meanwhile, more than one million children are at risk from acute malnutrition as rising violence perpetrated by armed militias drives up needs among millions of displaced people, the World Health Organization said on July 12.

The DRC currently has the highest number of people in need of humanitarian aid in the entire world, with 25.4 million people affected, Dr Adelheid Marschang, WHO Senior Emergency Officer, said at a UN press briefing in mid-July. 

Despite this, in the DRC “underfunding is indeed severe,” said Dr Adelheid Marschang, WHO Senior Emergency Officer, in a press briefing July 12.

The WHO is aiming for a $30 mln budget “to address the situation till the end of the year,” she said, but could only access about $6 mln on the day of the briefing.

In the eastern DRC provinces of Ituri, North Kivu and South Kivu, where the rebel M-23 militia, reportedly backed by Rwanda, has made significant inroads, 5.4 million people are food insecure, while almost three million children across the country are severely malnourished, according to the World Food Programme. 

With floods having destroyed this season’s crops, the prospects for next year are even more grim. Unless immediate action is taken, over one million children will suffer from acute malnutrition, the WHO warned.

In Gaza, 96% of the population still faces crisis levels of hunger

Gazans struggle to obtain basic supplies of food and water amidst mounting piles of garbage and debris.

In Gaza, where Israel continues its nine-month military campaign to crush the Islamic Hamas organization following Hamas’ deadly 7 October 2023 raids on Israel, WHO officials have warned that one in four people remain at risk of starvation – even if previous forecasts of widespread famine by July did not yet materialize.  

Some 96% of the enclave’s 2 million residents are facing crisis levels of hunger (IPC 5) – according to the World Food Programme. 

Israel’s closure of the Rafah crossing into Gaza in mid-May has paralyzed the flow of health supplies and humanitarian aid from Egypt – forcing exclusive reliance on Israeli aid crossing points.  

Meanwhile, the World Food Programme (WFP) was forced to reduce food rations in Gaza City in May to ensure broader coverage for people who have been newly displaced after new Israeli incursions in the north and south.  

In June, WFP provided more than a million people in Gaza with food assistance, and more than 153,845 individuals in the West Bank received cash-based transfers.

Image Credits: MSF.org, Domenico-de-ga, UNRWA .

Exposure to infected poultry is among the main sources of avian flu infections

As more avian flu cases are detected across the Asia-Pacific region, the Food and Agriculture Organization (FAO) is calling for “regional efforts to combat a rise” of the disease. Over the past year, highly pathogenic avian influenza clades, especially H5N1, have gained ground globally, infecting an increasing number of species, including poultry, dairy cows, and domestic animals.

As of July 31, one single avian flu variant of H5N1 had infected 172 dairy herds and 13 farm workers in the United States  and continues to spread further, raising questions about the country’s ability to curb the transmissions. 

In the Asia-Pacific region, there have been 13 human H5N1 avian flu cases since late 2023, six of which were reported in Cambodia this year. The newly-reported cases point to a trend of more human infections from the virus.  And in the Asian-Pacific, at least one other avian flu variant is circulating along with the H5N1 type, clade 2.3.4.4b, prevalent in the US.  

“All these cases involved direct contact with poultry or wild birds, and so far, no human-to-human transmission has been observed,” confirmed Filip Claes, FAO’s Asia-Pacific Regional Laboratory Coordinator in an email response to Health Policy Watch.

“The primary threat is that HPAI continues to circulate in poultry causing economic losses. Additionally, it provides an opportunity [for the virus] to continuously adapt, and spill over to additional species, including humans,” he added.

He called for building diagnostics capacity and more data sharing, along with strengthening farming biosecurity and biosafety measures.

Avian influenza has even reached the arctic and Antarctic regions, infecting scavenger species, marine mammals, carnivorous domestic pets, and mammals farmed for fur, and dairy cattle. Since last year, there have been human cases in Australia, India, the US, Mexico, Vietnam, China, and Cambodia. 

Of the 886 human infections reported from 2003 to May 2024, more than half were fatal.

Alhough the World Health Organization continues to assess H5N1-related risks to the public as low (and low-to-moderate for farm workers), the emergence of new, more easily transmissible strains “increases the pandemic threat,” warned Kachen Wongsathapornchai, Regional Manager of FAO Emergency Centre for Transboundary Animal Diseases earlier this week. Calling the recent bird flu surge “deeply concerning” the FAO official appealed for “immediate action.”

Insufficient outbreak response

Avian flu H5N1 situation update as of 31 July 2024 – all reports since outbreak began in March.

“Strengthening and integrating surveillance systems is crucial,” Claes said, enumerating measures South-East Asian countries should implement to fight the outbreaks. “Countries should invest in advanced diagnostic infrastructure and training for laboratory personnel,” as well as enhance international and inter-agency collaboration, prepare biosecurity protocols for farms and consider vaccination campaigns.

In the US, where the virus has infected an expanding circle of dairy cattle herds since first reports emerged in March, the country response is insufficient, US experts have long maintained.

There is, for instance, too little data and research that would ensure better understanding of the virus and the ways in which it transmits – not only through the mammary glands during milking, as was previously thought, new research seems to suggest.

Farmers reluctant to have herds and workers tested

Modes of infection with avian flu from poultry – a likely transmission path for some of the human cases

There is not enough testing infrastructure either. And farmers and their employees are reluctant to get themselves or their cattle tested, posing yet another problem in the US where there is no legal framework for mandatory animal tests.  

Similarly, for farm workers, testing and even wearing personal protective equipment is neither compulsory nor popular due to a general mistrust towards the official agencies, fear of lost revenue or, in the case of the workers, lack of a healthcare insurance.

Meanwhile, lax sanitation procedures in large dairy operations are big enablers of virus transmission, allowing cow-to-cow transmission when milking machines are not cleaned between every individual animal.

“Much more extensive follow up, serology studies and close monitoring of ‘mixing vessel animal species’, for instance pigs,” which can more easily incubate and transmit viruses to humans is needed, said Michael Osterholm, director of the University of Minnesota-based Centre for Infectious Disease Research and Policy (CIDRAP), in earlier comments to Health Policy Watch.

Overall, a more coherent plan of response is urgently needed in the Americas as well as Asia, Claes emphasized. In creating a plan, communication about the risk “with all stakeholders, from national governments to grassroots levels, is crucial to develop awareness and community engagement in tackling and controlling avian influenza.” 

Image Credits: Pickpik, USDA, CDC.

Dr Hans Kluge is working on access to cheaper medicines in Europe.

The World Health Organization’s (WHO) vast European region – 53 countries, including the entire European Union, Russia and even Israel – is often excluded from cheaper medicine deals because of member states’ high- and middle-income status.

But one of the flagship programmes of WHO regional director Dr Hans Kluge is the Novel Medicines Platform (NMP), aimed at enabling access to innovative new medicines such as gene therapy for cancer, that are effective but extremely expensive.

Norway was the inspiration for the NMP, Kluge told Health Policy Watch in a recent wide-ranging interview.

Before Kluge was elected regional director in 2021, he visited Norway, one of the richest countries in the region, and discovered that it was anxious about the financial sustainability of its universal health coverage if it were to open the door to these effective but costly medicines.

“Because they have universal health coverage, this means if they allow one medicine on the market, they’re obliged to give it to everyone. And they were concerned about these innovative cancer and diabetes medicines,” said Kluge.

Norway had started an initiative for cheaper novel medicines, and this was transformed into the NSP,  a multi-stakeholder collaboration that has country, pharmaceutical and patient representatives.

“Recently, [3-4 July] for the first time in two years, we had a physical meeting of the NSP where we convened all 53 member states, big pharma, patients and the insurers,” said Kluge.

The upshot of the meeting was the establishment of four time-limited working groups focused on transparency, solidarity, sustainability, and novel antimicrobials, which will conclude their work by December 2025. 

Joint procurement for non-EU countries?

For the first time, countries outside the European Union (EU) may have access to joint procurement for novel medicines, particularly the smaller countries in the region with little buying clout with pharmaceutical companies, said Kluge.

Describing the NSP as a “policy lab”, Kluge hopes it will open the door to access to cheaper medicines in the region – not just novel medicines.

The WHO has also resolved to second a representative to the EU’s Health Emergencies Preparedness and Response Agency (HERA) to assist non-EU members to get better access to medicines.

“We have been telling the EU that they will never be safe without the Western Balkans, countries such as Georgia, Ukraine and Moldova. We have said, ‘Guys, if you are procuring mpox vaccines, H5N1, don’t forget your neighbours’,” said Kluge, who hails from Belgium. 

He points to a recent EU meeting chaired by Germany on the price of multi-drug-resistant tuberculosis drugs, currently costing $15,000 a year.

“I would like to give some a positive example because I’m a born optimist,” added Kluge. “In Poland, through their parliament, they got concessional prices and also registered them for the Ukrainian refugees. So if there’s political will and determination, it is possible.”

Hepatitis medicines are also cheaper because of advocacy, while Sweden is spearheading an initiative on antimicrobial resistance (AMR),  he added.

The ‘magic bullet’ of primary healthcare

Kluge is also urging all member states to move from expensive hospital-based care to integrated primary health care (PHC), including health education.

“I used to say there is no magic bullet, but I have changed my mind. The magic bullet is called primary health care. We need to strengthen primary health care and make it multidisciplinary.”

PHC, involving “task shifting” to nurses and more digital solutions, can help to address “medical deserts” – found everywhere from Ukraine to rural France.

“Cardiovascular disease is the biggest killer in our region, but two-thirds of people with hypertension don’t know they have it. And only a minority of those who know are adherent to treatment,” says Kluge. “This is basic case management that should be decentralised to primary level.”

He adds that Europe controlled mpox by “empowering trusted messengers in the community”. 

However, the lack of agency of such civil society messengers in certain member states concerns Kluge – such as the criminalisation of LGBTQ groups and civil society organisations that can reach “key populations” most vulnerable to HIV.

“In the EU, and in whole or region, we have to hold the fort, even on basic issues like sexuality education in school. There is a call for family values, but the data shows an increase in infertility because of unsafe abortion; because of the rise in sexual infection related to no condom use. All of a sudden, the European region is not doing well on condom use.”

Ukraine and Russia

Both Ukraine and Russia are in Kluge’s region.

“We have about 300 people in Ukraine double the number of people we had before the war,” says Kluge. “They work on what we call three Rs: response, recovery and healthcare reform.”

This ranges from providing trauma kits at the frontline to assisting with mobile services and modernising Ukraine’s healthcare with the focus on PHC.

“Thanks to the cooperation of civil society, Ukraine has one of the best HIV responses in the region,” Kluge notes.

While the WHO still has a country office in Moscow and continues to provide Russia with technical support, the regional committee decided to move the regional office on NCDs from Russia to Copenhagen. 

Concern for LGBTQ communities, attacks on healthcare

“I am concerned about what are called the key populations, LGBT communities,” Kluge says. “We need to stand strong for those people.  I worked for two years in the former [Russian] gulags with  Medecins sans Frontieres in TB control so I know the situation quite well. 

“What happens with HIV patients in Donbas [the Ukraine territory under Russian control] is a bit of a black hole. The international community needs to ensure these people get access to treatment. I strongly believe dialogue is very important.”

Kluge also condemns the attacks on healthcare – “be it in Ukraine or in Gaza, the second war in my region”. 

“This is a major concern. People get used to this. But each time, we should scream heaven and earth. You cannot attack a doctor. We already have a lack of doctor and nurses.  It is completely unacceptable to kill them.”

Kluge, who is the only candidate staning for regional director in the WHO Europe elections, is expected to be re-elected unopposed at the regional conference in October.

The Global Pandemic Preparedness Summit in Brazil was addressed by arounf 80 experts over two days.

As climate change drives disease outbreaks, the world remains ill-prepared for another pandemic – lacking in collaborative surveillance, diagnostic tools and finance, speakers told the Global Pandemic Preparedness Summit (GPPS) in Brazil.

The two-day summit, attended by a global who’s who of pandemic experts, aimed to “reinvigorate the momentum for pandemic preparedness and response” – but it also offered a sober assessment of global shortcomings.

“Over half of pathogens are being amplified by climate change. With the global circulation of pathogens, there is a larger risk for transmission across different continents,” warned Professor Tulio de Oliveira, the South Africa-based scientist who is a key driver of Africa’s pathogen genome surveillance.

One of Prof Tulio de Oliveira’s slides.

Ethiopia is experiencing its biggest dengue outbreak, while Burkina Faso is also dealing with dengue after a four-year break. There’s a new strain of Chikungunya and a new lineage of cholera in Cameroon, he noted.

The increased interaction between animals, humans and the environment – in part caused by the destruction of environments and migration – has increased the mobility of pathogens, De Oliveira told the summit, hosted by Brazil’s Ministry of Health of Brazil, the Coalition for Epidemic Preparedness Innovations (CEPI), and the Oswaldo Cruz Foundation (Fiocruz).

The WHO is responding to 42 graded emergencies, 15 of which are Grade Three emergencies requiring international assistance, said Dr Mike Ryan, the WHO’s Executive Director of Health Emergencies.

“We’re tracking today a further 168 ongoing health emergencies around the world being managed at a national level, and … responding to cholera in 30 countries, mpox, avian influenza, H5N1, dengue and yellow fever, as well as multiple health emergencies related to war and natural disasters.”

“It’s our very connectedness that exposes us. We are the most connected human population in history. We live in mainly densely populated urban areas where we work, move, gather and socialise intensely.”

Prof Tulio de Oliveira, Director of the Centre for Epidemic Response and Innovation in South Africa.

Diagnostic gaps

According to the non-profit organisation FIND, of 21 pathogens with outbreak potential, SARS-CoV-2 is the only pathogen for which there is adequate diagnostic readiness.

FIND launched its Pathogen Diagnostic Readiness Index (PDxRI), a comprehensive tool for evaluating diagnostic preparedness at the summit. 

“Fast, equitably distributed diagnostics are essential to spot & stem an emerging pandemic. FIND have a partnership-driven, five-year roadmap for diagnostic readiness to achieve the 100 Days Mission. But this requires $100 million in seed funding,” said FIND’s Dr Marta Fernandez Suarez.

The 100 Days mission refers to the need to develop vaccines, tests and treatments within 100 days of an outbreak, and enable access to those who need them most to prevent pandemics.

“Infectious diseases can pop up quickly and we need to make sure we are ready to respond quickly and equitably,” said CEPI CEO Dr Richard Hatchett.

“If a new coronavirus were to emerge, there is the potential we could respond in 100 days. But if a new disease were from the Paramyxovirus or Orthopoxvirus family, we’d likely not be ready yet. Importantly, we are moving in the right direction – but to reach the 100 Days Mission we need to advance capabilities with medical countermeasures and globalise access to these technologies. ”

Access gaps

Anban Pillay, South Africa’s Deputy Director-General of Health, noted that his country had been charged a higher price for COVID-19 vaccines than Europe.

“There are huge problems with the conduct of the pharmaceutical industry when it came to access to vaccines,” said Pillay. “They didn’t provide access. They raised the prices. They decided not to give certain countries stock, even though we were paying higher prices than Europe.

“So we need a different global system about where we access vaccines and other countermeasures, a system that’s equitable, that is linked to need.”

“But access supposes that you have something to access,” noted Dr Mona Nemer, the Canadian government’s Chief Scientific Advisor and Chair of the 100 Days Mission Steering Group.

“And clearly, when it comes to diagnostics and therapeutics, and I dare say to vaccines, for the for the all the different viral families that we now have in front of us, we have a long way to go.”

Financial gaps

The Pandemic Fund’s Priya Basu said that the World Bank had been able to mobilize $2 billion in seed capital from 28 contributors to start the fund and seen “tremendous demand, and good quality projects”. 

During the first round of funding last year, projects “really focused on coordination and collaboration across different arms of government – health, finance, agriculture, animal husbandry, livestock, environment, all coming together”

But demand has far outstripped available finances, with the Fund having raised $850 million but received high quality proposals worth $7 billion.

“One of our biggest challenges is really to raise more money to maintain that momentum, because soon we’ll see a lot of disappointed countries if they don’t receive the money. And so that’s why we’ve just launched our investment case, our short term resource mobilization effort, last week,” said Basu.

Political progress at INB

Ambassador Tovar da Silva Nunes

Post-COVID, much of the world’s focus has been on politicians at the World Health Organization (WHO) negotiating a pandemic agreement. 

Brazil’s Ambassador Tovar da Silva Nunes, who is a vice-chairperson of the WHO’s International Negotiating Board (INB), told the summit he was confident that an agreement would be reached before the next World Health Assembly.

Da Silva Nunes and Ambassador Anne-Claire Amprou will be chairing a sub-committee on pathogen access and benefit sharing (PABS), the biggest sticking point in the talks.

“If we are able to solve what we call article 12, the doors are open for us to conclude the agreement in good time,” Nunes told delegates.

He added that there was no longer much disagreement on clauses relating to One Health.

“There was a perception that a One Health approach that is not a complete approach was wrong and it was not leading to equity,” he explained, adding that lack access to clean water, for example, was a factor in the spread of certain diseases.

“Vector-borne diseases are clearly related to [access to water]. So it has to be complete. This is overcome. We have decided to incorporate one health. It’s a major step for global community health, provided that it is done in a very balanced way.”

Ryan noted that the finer details of PABS might take time, but without a broad international “it will be very hard to achieve what this conference is setting out to achieve”.

Global South solidarity

“Global partnerships are key to the 100 Days Mission’s success,” said Brazil’s Minister of Health, Dr Nísia Trindade Lima. 

“Post-COVID, we’ve learned that equitable R&D, investment and access are crucial for public health. We cannot work only within our countries; we must think beyond borders. It’s time for science, technology, and innovation to unite for robust public health policies. We must work together in global health so that it becomes a reality.”

Summitt attendees from the Global South signed the Rio de Janeiro Declaration, which calls for greater collaboration between partners within the Global North and Global South to overcome disparities in access to health tools and countermeasures in low- and middle-income countries. 

The Declaration also urges global health partners to prioritise research and equitable access policies to focus on end-to-end R&D and support the establishment of the Alliance for Regional and Local Production, Innovation and Access, as discussed within Brazil’s G20 Presidency framework.

“It’s time to think and design a different world with a new mindset to build global health systems and strengthen global pandemic preparedness and response, with coordination between the Global South and North,” Professor Mario Moreira, President of Fiocruz, which initiated the declaration.

Around a quarter of young women have experienced abuse in an intimate relationship by the age of 20.

By the time they turn 20 years old, nearly a quarter (24%) of adolescent girls who have been in a relationship will have experienced physical or sexual violence from their intimate partner, according to a report from the World Health Organization (WHO) published Monday found.

Even though the prevalence of violence among teenagers largely parallels that of women overall, minors are more affected because of their economic dependence and the devastating effect it has on their health and life prospects.

“Intimate partner violence is starting alarmingly early for millions of young women around the world,” said Dr Pascale Allotey, Director of WHO’s Sexual and Reproductive Health and Research Department in a press release.

She highlighted the “profound and lasting harms” such experiences have and called for more health focus on prevention and targeted support for girls.

Using  WHO’s Global database on prevalence of violence against women, the report analyzes data over the last two decades from 161 countries on violence against adolescent girls aged 15-19 years old.

The analysis focuses on sexual and physical violence; psychological violence was excluded due to a lack of commonly agreed on comparison measures.

Long-lasting consequences of partner violence 

Health, educational achievement, future relationships, and the lifelong prospects of young people overall are all affected by intimate partner violence. 

Such violence also has direct effects on physical and mental health, heightening the risk of depression and anxiety disorders, but also injuries, unplanned pregnancies, and sexually transmitted infections.

According to the WHO, 42% of women aged 15-49 who experienced intimate partner violence report an injury as its consequence. 

Intimate partner violence also raises the risk of a miscarriage (16% more likely) or a pre-term birth (41% more likely). Victims were also nearly three times as likely to be infected with a sexually transmitted disease, in comparison to other girls and young women.

Power imbalances drive partner violence

The prevalence of intimate partner violence varies depending on region: from as little as 3% of teenage girls experiencing it in Georgia to as much as 49% in Papua New Guinea.

There are considerable regional differences in the prevalence of intimate partner violence, ranging from 47% in Oceania and 40% in Sub-Saharan Africa to 10% and 11% in Central Europe and Central Asia respectively.

It is generally more common in lower-income countries where women have less power than male partners.

A lower proportion of girls enrolled in secondary school, weaker legal property ownership and inheritance rights, and child marriage all conspire to foster conditions of economic dependency and social isolation that increase the risks of abuse in intimate relationships, the research found.

The keys to improving the situation are “ensuring secondary education for all girls, securing gender-equal property rights and ending harmful practices such as child marriage, which are often underpinned by the same inequitable gender norms that perpetuate violence against women and girls,” said the report’s author, Dr Lynnmarie Sardinha.

Education, legal, and economic empowerment

Currently, no country is on track to achieve the target of eliminating violence against women and girls by 2030, as countries pledged to do under Target 5.2.1 of the 2030 Sustainable Development Goals.

The study highlights the urgent need to strengthen early prevention measures and support services made especially for adolescents. Actions to advance women’s and girls’ agency and rights are another important measure.

Effective interventions can include school programmes that educate all students on healthy relationships and violence prevention, but also more general legal protections and economic empowerment.

Image Credits: USAID, WHO.

A Palestinian girl on bus from Gaza to Israel’s Ramon airfield for airlift to the UAE

Updated: The World Health Organization confirmed Tuesday evening that it had evacuated 85 severely ill and wounded Gazans to the United Arab Emirates for advanced treatment via Israel’s Ramon airfield. 

The complex operation occurred as tensions escalated in the region following the deaths of 12 children in a Golan Heights Druze community –  apparently from a missile fired by the Lebanese Shi’ite Hizbullah. 

The carefully planned evacuation had originally been scheduled to take place on Monday, WHO confirmed. Israel’s Prime Minister Benjamin Netanyahu reportedly had delayed the plan after a missile hit on the soccer field of Majdal Shams, a mountain tourist town near the Lebanese border, early Saturday evening, killing a dozen children aged 10-16. Hizbullah denied responsibility for the attack, but western experts and intelligence sources said that evidence points to a rocket from Lebanon. 

Tuesday’s evacuation of some 35 children and 50 adults, along with 63 family members and care-givers, finally took place under a shroud of secrecy, and on a day when tensions between Israel and Hizbullah soared to new heights as Hizbullah fired over 50 more missiles into northern Israel, killing one more person.

In the early evening, Israel’s response for the Majdal Shams attack finally came in the form of a retaliatory strike on a Beirut apartment building, targeting a senior Hizbullah military commander in an area near the milita’s headquarters, and causing dozens of casualties, according to Lebanese reports. 

Hizbullah has been fighting alongside Gaza’s Hamas ever since the deadly 7 October attacks that triggered the current war.  The Druze, meanwhile, are members of an ancient religious minority whose communities dot the border regions of pre-1967 Israel and the Golan Heights, not to mention Lebanon and Syria – implicating them in the wider Israeli-Arab conflict on multiple fronts.

Majdal Shams, in the Golan Heights, is considered occupied Syrian territory by the United Nations, but it was annexed by Israel in 1981, becoming a popular Israeli tourist destination with rich natural resources and archeological history. Since the eruption of the Syrian civil war over a decade ago, an increasing number of Golan Druze, who already had Israeli residency, have also taken on citizenship. 

‘We hope this paves the way for evacuation corridors via all possible routes’

Sick and injured Palestinians board a bus leaving Gaza for an airlift  to medical treatment in the UAE via Israel’s Ramon airfield.

Reports of a plan to begin airlifting hundreds of seriously ill and wounded children out of Gaza to the UAE via Israel’s Ramon airfield in the Negev desert first surfaced in media reports last week, despite WHO’s efforts to keep the mission under tight wraps. 

The airlift scheme came against a background of mounting international criticism of Israel’s seizure of the Rafah border crossing between Gaza and Egypt in early May. That effectively sealed off the only available route for medical evacuees, as well as for Gazans who could afford the hefty visa fees to escape the war. 

“The patients had cancer, injuries, blood diseases, congenital conditions, neurological conditions, cardiac and liver and renal disease,” said WHO’s Director General Dr Tedros Adhanom Ghebreyesus in an X post, Tuesday evening.

“We hope this paves the way for the establishment of evacuation corridors via all possible routes,” he added.

The WHO team organized and managed the transfer of patients from over half a dozen areas in Gaza to Israel’s Kerem Shalom crossing under “extremely challenging conditions” the organization said, including active conflict in various parts of Gaza. After the original mission was postponed Sunday, some injured and ill patients had to be held at a Médecins Sans Frontières (MSF) field hospital site, pending Tuesday’s final evacuation.

Speaking at a UN press briefing in Geneva on Tuesday, WHO spokesperson Christian Lindmeier said that some 10,000 people, in all, were in need of medical evacuation – as continued waves of conflict-related displacement, malnutrition and interruptions in medical services continue to haunt Gaza’s 2 million Palestinian residents.  

Since October 2023, around 5000 people have been evacuated for treatment outside Gaza during the grinding nine months of war, with over 80% receiving care in Egypt, Qatar and the UAE.

Many Gazans new rounds of displacement as WHO dispatches 1 million polio vaccines

Administering oral polio vaccine – Gaza’s vaccination rates have dropped sharply.

Lindmeier also echoed recent calls by regional health ministers for a cease fire and an ‘enabling environment’ so that a massive polio vaccination campaign could safely take place in the coming days and weeks.

“Otherwise, the vaccines would be sitting as many other trucks are across the border, either on the Rafah side or at the other checkpoints either inside…or outside Gaza,” Lindmeier said.

WHO last Friday said that it was dispatching 1 million polio vaccines to Gaza after evidence of vaccine derived polio virus was found in local sewage sources. 

No actual cases of polio, which can lead to paralysis and even death, have been reported so far in Gaza. But since the beginning of the war on 7 October, 2023, polio immunization rates have dropped by about 10%, WHO and other global health authorities have observed. And that increases the risk that under-vaccinated Gaza children and adults, who are also suffering from a lack of clean water access and widespread malnourishment, could fall ill. 

“Having vaccine-derived polio virus in the sewage very likely means that it’s out there somewhere in people,” Lindmeier said. “So the risk of (it)… spreading further is there and it would be a setback definitely (for global efforts).”

This is not the first time, either, that polio has circulated in sewage in the densely-populated region. In 2022, Israel conducted its own emergency polio vaccination campaign amongst under-vaccinated groups after a 4-year old Jerusalem child fell ill while six others were diagnosed with asymptomatic cases, and the virus was identified in sewage samples, as well. 

Mounting water, sewage and sanitation crisis 

Explosion of a vital water reservoir in Rafah has prompted outrage internationally and within Israel.

Along with that, there is a mounting water, sewage and sanitation crisis in Gaza – exacerbated by the recent Israeli army explosion of a large water reservoir in Rafah. 

Also speaking at the Tuesday UN briefing, James Elder, a spokesperson for the United Nations Children’s Fund (UNICEF), denounced the blowing up of the Rafah water facility last week at Tel  Sultan – calling it an act of  “blatant disregard” for children’s rights. 

The range of water availability in Gaza is currently 2-9 litres per person per day, he pointed out – whereas the humanitarian minimum standard is 15 liters – and that is notwithstanding the sweltering temperatures Gazans are currently facing at the peak of summer – with daytime temperatures averaging highs of 36°.

Israel’s military has not commented publicly on the incident. But military police are  reportedly probing the incident as a suspected violation of international law, which may have also been sanctioned by a local commander, Israeli media reported. 

The incident provoked expressions of outrage within Israel, as well as internationally, after a soldier who participated in the demolition of the reservoir, known as Canada well, posted a video on Instagram, and later on X, celebrating the explosion with a caption stating it was “in honor of the Sabbath” – the Jewish day of rest.   

The reservoir and solar-powered water treatment facility, was developed by Canada’s International Development Agency in the 1990s and supplies a large proportion of the city’s water needs.

Some 20,000 Palestinians remain in the Rafah area, including in the Tel Sultan area, which had not been subject to forced evacuation.  Around 1.4 million displaced Palestinians had been sheltering there before Israelis forces moved into the southern border city in May.

“Somehow people are holding on, but of course we are now in that deathly cycle whereby children are very malnourished, there is immense heat, there is lack of water, there’s a horrendous lack of sanitation and that’s the cycle,” Elder observed. “On top of that, of course, there is a very, very active conflict.”

Image Credits: X/@Dr Tedros, WHO, Global Polio Eradication Initiative, X/Times of Israel.

South Africa’s Dudu Dlamini (left) explains that her HIV, diabetes and hypertension are all treated at different health facilities. The Global Fund’s Vindi Singh looks on.

As the disease burden in developing countries shifts from infectious to non-communicable diseases (NCDs), governments and patient advocates are grappling with how to re-engineer healthcare systems to address both.

The extraordinary global focus on HIV has resulted in a siloed network of HIV clinics to treat the virus – but there is growing acknowledgement that countries’ HIV gains will be lost if they don’t get NCDs under control.

“People living with HIV are disproportionately affected with NCDs. It is estimated that one in three people living with HIV have either hypertension or other NCDs,” says Professor Kaushik Ramaiya, General Secretary of the Tanzania NCD Alliance and a member of the NCD Alliance Board.

“People living with HIV (PLHIV) have an increased incidence for more than 20 non-AIDS defining cancers, while women living with HIV are up to six times more likely to develop cervical cancer,” he told an event organised by the NCD Alliance at the International AIDS Conference in Munich last week.

There are almost 40 million people with HIV, mostly in developing countries, and many are succumbing prematurely to heart disease, diabetes, strokes and other NCDs. This is often because HIV programmes are so focused on their patients’ HIV that they don’t diagnose and treat these other conditions early enough.

‘I could take ARVS well and die of high blood’

South African Dudu Dlamini lives with HIV, hypertension and diabetes. As a sex worker and the advocacy officer for Sex Workers Education and Advocacy Taskforce (SWEAT), Dlamini knows what marginalisation means.

“We are criminalised,” Dlamini told the meeting. “It is not easy for me to identify as a sex worker. Our doctors don’t know about us. For my HIV, I am treated in one place. For my high blood, another place and for my blood sugar, somewhere else.”

Having three different treatment sites costs time and transport money, and sex workers default on medication “because we are not able to keep all the appointments”, says Dlamini.

“My vision is for sex workers to be helped for all the conditions at the same time; a place where we can identify freely as sex workers and get treated –  for STIs, and all other conditions – in one place. I need one folder with all my medical history and background because I might be taking antiretrovirals well but tomorrow I die from high blood.”

Her experience echoes that of several other people living with HIV and NCDs, as captured by the NCD Alliance in a collection of testimonies that makes the case for integrated care.

Global commitment to integration made back in 2021

NCD Alliance CEO Katie Dain.

At the 2021 United Nations High-Level Meeting on HIV and AIDS, global leaders committed to ensuring that “90% of people living with and affected by HIV have access to people-centred and context-specific, integrated services for HIV and other diseases, including NCDs and mental health by 2025”, NCD Alliance CEO Katie Dain told the meeting.

“This, in many ways, is one of the real frontiers of the global HIV response, recognising that people living with HIV are living longer thanks to advancements in antiretroviral antiretroviral therapy,” she added.

Ntombifuthi Ginindza, from Eswatini Ministry of Health in southern Africa, knowledges the urgency of “integrating NCD treatment into HIV setting”.

Eswatini has an estimated HIV prevalence rate of 25% in people aged 15 to 49, one of the highest rates in the world. 

It has made remarkable progress, achieving a 72% decline in HIV infections and a 55% decline in AIDS-related deaths since 2010. But its premature mortality for NCDs in moving in the opposite direction, growing from 27% in 2015 to 35% currently.

“We are integrating NCDs into HIV setting. In the spirit of client-centredness, we’re working on an integrated chronic disease framework, which is mainly focusing on integration at primary level facilities,” said Ginindza.

“We are trying to sustain the gains that we have made on HIV. There is a lot that we have achieved through HIV, so we want to leverage the resources that we have in place for HIV as we are transitioning HIV clinics to chronic disease clinics.”

Four different models of integration

PATH Kenya’s Nicolas Odiyo and WHO’s Dr Prebo Barango

Dr Nicholas Odiyo, Senior Technical Advisor for PATH Kenya, says his non-profit healthcare group has implemented various different models for HIV and NCD integration in Kenya, India, the Democratic Republic of the Congo (DRC) and Vietnam. 

One model involves screening for certain NCDs at HIV clinics, based on the patients’ assessed risk factors, particularly hypertension, diabetes and cervical cancer, said Odiyo.

The second involves community-based screening, mainly run by community health promoters with blood pressure machines and glucometers to test for hypertension and diabetes.

The third model is integrating “continuous screening for hypertension and diabetes” into HIV programmes, while the final model involves comprehensive care for all, with NCD and HIV screening for the entire population in universal healthcare.

Blood sugar levels can easily be checked with a glucometer

Some donors are on board

HIV donors are also increasingly accepting that they need to incorporate NCD care to safeguard people living with HIV.

The US President’s Emergency Plan for AIDS Relief (PEPFAR) supports the integration of hypertension in five countries that are doing well with HIV, Botswana, Eswatini, Lesotho, Namibia and Rwanda, said PEPFAR ensior advisor Ritu Pati.

“PEPFAR’s HIV hypertension integration initiative was launched in response to  Ambassador [John Nkengasong’s] keen interest to address the very high rates of uncontrolled blood pressure amongst people living with HIV (PLHIV,” said Pati.

The five countries have received supplementary funding of $5 million for a year to improve  hypertension control in PLHIV, although this funding cannot be used to buy anti-hypertensive medication. 

“Close to 30% of men and women in sub-Saharan Africa over the age of 30 have hypertension, and at the same time, only a small proportion of them have controlled blood pressure. So the idea is, is that if we can proactively address hypertension in the populations that we serve, we can then reduce the incidence of cardiovascular events and thereby reduce mortality.

‘It’s become increasingly clear that we need to address hypertension amongst PLHIV to improve their health outcomes and preserve the gains of our PEPFAR programs.”

Pati adds that the integrated service delivery model has many benefits:  “It reduces the number of clinic appointments for PLHIV, promotes early diagnosis and treatment of co-morbidities, minimises service duplication, which really may lead to cost savings, and allows [healthcare] providers to have a comprehensive view of their patients history and offer them patient-centred care.”

Better still, PEPFAR has evidence that the integration of HIV services with primary health care “can actually improve HIV clinical outcomes such as continuity of treatment and viral load suppression”.

The Global Fund includes “integrated people-centred health services” in its strategy for 2023-2028, said Vindi Singh, the fund’s senior disease advisor on HIV treatment

HIV funding in some countries incorporates cervical cancer and hypertension services, Singh noted. Kenya and South Africa have also included HIV and NCD integration in their national strategic plans for HIV.

Stigma and competition

STOPAids CEO Mike Podmore.

But as Ramaiya notes, the stigma associated with HIV means that is far easier for people living with HIV to accept NCD integration than HIV clinics than it is to integrate HIV services into non-HIV clinics.

“You need a policy cohesion that starts from the Ministry of Health and local government, because HIV is a vertical program and TB is a vertical program. So when you are trying to integrate an NCD programme within HIV, you need to have a cross communications with those other programs.”

STOPAids CEO Mike Podmore concluded the event by noting that “with a projected 71% of people living with HIV having at least one NCD by 2035”, the focus on “trailblazing quality integration is necessary and compelling”. 

But Podmore warned that “it is essential that we do not allow HIV and other health issues like NCDs to be in competition to each other in a zero-sum game of flatlined resources”.

“We need to champion quality integration and synergies across health issues that build greater equality across diseases. 

‘It is also essential that the global health community restructures and recalibrates itself to ensure that inequalities of the COVID pandemic response cannot be repeated again, and that there is much stronger coordination of external actors at country level, led by country stakeholders.”

Image Credits: Dischem.

Lab technician at Afrigen, the Cape Town-based firm hosting the WHO co-sponsored Vaccine Technology Transfer Hub.

The Argentina-based biotech firm,  Sinergium Biotech, has agreed to share know-how on the production of an mRNA vaccine for Avian influenza (H5N1) with WHO’s  Tecnology Transfer Hub so that an affordable vaccine could rapidly be produced for developing countries, WHO said Monday.

The agreement marks the first time that a vaccine developer has actually volunteered know-how to the hub, which was founded by WHO in 2021 together with the Medicines Patent Pool, and is hosted by the South African firm Afrigen, based in Cape Town.

Sinergium “has developed candidate H5N1 vaccines and aims to establish proof-of-concept in preclinical models. Once the preclinical data package is concluded, the technology, materials, and expertise will be shared with other manufacturing partners, aiding the acceleration of the development of H5N1 vaccine candidates, and bolstering pandemic preparedness efforts.” said WHO in a statement.

“This initiative exemplifies why WHO established the mRNA Technology Transfer Programme – to foster greater research, development and production in low- and middle-income countries, so that when the next pandemic arrives, the world will be better prepared to mount a more effective and more equitable response,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

H5N1 is first vaccine target for the hub since COVID-19

Colorized transmission electron micrograph of Avian influenza A H5N1 viruses (seen in gold) grown in MDCK cells (seen in green).

Following it’s launch, the Afrigen mRNA Technology Transfer Programme focused mostly on testing and developing an mRNA COVID-19 vaccine candidate.  Progress, however, was slow because the major mRNA vaccine manufacturers, Moderna and Pfizer, refused to share their know-how on the WHO-sponsored platform – opting to sign licencing agreements to manufacture COVID vaccines under their brand identities with other manufacturers elsewhere in Africa.

So the agreement by Sinergium to share its IP and partner directly with the WHO co-hosted hub is a breakthrough for the global health agency – which has long sought a role in the emerging mRNA vaccine market –  to reduce costs and make vaccines more accessible in low- and middle-income countries.

The new agreement signed with a Latin-American based firm also takes a small, but meaningful, step towards the ‘regionalization’ of vaccine markets, WHO officials said on Monday.

“This announcement underscores the importance of not only geographically diversifying the innovation and production of health technologies including and recognizing the capacities in Latin American and the Caribbean, but also the importance of early planning for access and the sharing of knowledge and technologies during the research and development processes,” said Dr Jarbas Barbosa, Director of the Pan American Health Organization (PAHO), WHO’s Regional Office for the Americas.

Dr Alejandro Gil, Chief Executive Officer of Sinergium, credited PAHO’s “strong support it offers to regional manufacturers in the Americas” with playing an instrumental role in the deal.

“Sinergium’s enhanced capacity and readiness to apply our expertise to H5N1 will play a vital role in this effort towards global pandemic preparedness. …We are excited to tackle this public health challenge and our R&D team will continue to work closely with the Programme Partners.”

Along with the base at Afrigen, WHO’s mRNA technology transfer hub programme includes Institut Pasteur in Senegal – and is planned to eventually includes manufacturers in over a dozen other low- and middle-income countries around the world.

Moderna also advancing a candidate vaccine with US government help

172 dairy herds in 13 states have so far been affected by the spread of avian flu in dairy cattle since the outbreak was reported in late March.

 

Moderna is reportedly at a more advanced stage in the process of developing and mRNA vaccine for the virus, which is spreading rapidly amongst dairy cattle herds in the United States.  In early July, the US government awarded the Cambridge-based firm $176 million to advance development of “an mRNA-based pandemic influenza vaccine.”

“We have successfully taken lessons learned during the COVID-19 pandemic and used them to better prepare for future public health crises. As part of that, we continue to develop new vaccines and other tools to help address influenza and bolster our pandemic response capabilities,” said HHS Secretary Xavier Becerra, at the time of the announcement.

While WHO has so far assured that the risks to humans of avian flu remain low, as long as human-to-human transmission is not occurring, the ever-widening transmission of the deadly virus amongst different animal species increases the risks that it may one day soon mutate in a way that it can more easily infect, and be transmitted, amongst humans.

And in the absence of effective vaccines, which are also widely available, that could unleash yet another pandemic on the world.

Image Credits: Afrigen, CDC/ Courtesy of Cynthia Goldsmith, CDC.

Mathias Ofoke during his routine blood sugar test at the Ezza Ofu Health Centre, Ebonyi State, Nigeria.

Fifteen-year-old Mathias Ofoke is one of four children in his family born with type 1 diabetes. Whenever his symptoms worsened, he was taken to the nearest primary healthcare (PHC) center where he was repeatedly treated for malaria. 

It wasn’t until February, when a non-governmental organization (NGO), Abby Cares Foundation, organized a clinical outreach at Ezza Ofu Health Centre that Ofoke’s condition was properly diagnosed. 

His blood sugar result of 543 mg/dL alarmed everyone when it was displayed on the glucometer screen. But the understaffed PHC facility at Ezza Ofu could not admit him as they were not properly equipped to care for him.

The NGO facilitated his admission to a secondary health facility and began sourcing insulin for his treatment.

“We frequently see cases of hypertension, diabetes, and cancer but we are not able to manage them, so we refer,” says Elizabeth Nwovu, the officer-in-charge at Ezza Ofu Health Centre. She is a community health extension worker (CHEW) who trained to be a matron.

IDF Diabetes Atlas

An estimated 27% of deaths in Nigeria are linked to diabetes, cancer, cardiovascular and chronic respiratory diseases. These four major non-communicable diseases (NCDs) are the leading causes of mortality globally, with the majority of deaths occurring in low- and middle-income countries (LMICs). 

Diabetes, characterized by elevated blood glucose levels, affects 537 million adults (20-79 years) worldwide. This number is expected to rise by 46% in 2045. 

As urbanization increases, diets change and populations age, Nigeria has also seen a surge in adults living with diabetes, from 209,400 in 2000 to 3.6 million in 2021—only South Africa had a higher prevalence in 2021. 

Diabetes is responsible for about 4.5% of deaths in people under 60 years old in Nigeria, with common complications including hyperglycemic emergencies, diabetic foot ulcers, chronic kidney disease and stroke.

PHCs prioritized in NCD management 

A national survey on NCDs conducted between 1990 and 1992 revealed that less than a quarter of the estimated 1.05 million Nigerians living with diabetes were aware of their condition. Following this survey, the Nigerian government attempted to integrate NCDs into PHC facilities, but these efforts met with minimal success.

Efforts to tackle NCDs in Nigeria were reignited in 2021 following the Brazzaville Declaration on NCDs and the subsequent political declaration at the 66th United Nations General Assembly on the Prevention and Control of NCDs. These declarations set the precedent for the WHO Global NCD Action Plan 2013-2020, which has now been extended to 2030.

Over the years, Nigeria has built on these regional and global strategies to develop several national policies for NCD prevention and control. Notable among these are the National Multi-Sectoral Action Plan for the Prevention and Control of NCDs and the National Guideline for the Prevention, Control, and Management of Diabetes Mellitus in Nigeria.

The scope of the national guideline for diabetes management was developed using the Population, Intervention, Professions, Outcomes, and Healthcare setting (PIPOH) checklist. 

The interventions outlined in the guideline emphasize the importance of integrating community health workers, such as CHEWs, and scaling-up screening, diagnosis and treatment in PHC facilities.

Task-shifting to community health workers

According to the national diabetes guideline, a key indicator of progress is the successful delegation of certain aspects of diabetes care to lower-level health professionals, such as CHEWs and lay health workers.

Similarly, the national multi-sectoral action plan, which informed sections of the diabetes guideline, recommends expansion of the Task-Shifting and Task-Sharing Policy for Essential Health Care Services to include NCD management among its priority areas. Currently, this policy focuses on maternal and child health, and communicable diseases (HIV/AIDS, malaria, and tuberculosis).

In line with this recommendation, during the technical session of the 64th National Council on Health (NCH) in November 2023, the Ministry of Health and Social Welfare announced plans for a National Task-Shifting and Task-Sharing (NTSTS) policy focused on the prevention and control of NCDs.

Elizabeth Nwovu, a community health extension worker (CHEW) and the officer-in-charge at Ezza Ofu Health Centre, Ebonyi State, Nigeria.

“This policy, if adopted, will complement the existing Task-Shifting and Task-Sharing Policy for Essential Health Care Services,” said Dr Anyaike Chukwuma, Director of Public Health, during the event.

The NTSTS policy aims to address the rising burden of NCDs in Nigeria by decentralizing preventive, diagnostic, treatment, and rehabilitative services to PHC facilities.

“By implementing this policy, the country hopes to adopt a patient-centered approach, accelerate progress towards NCD prevention and control, achieve universal health coverage, and work towards the Sustainable Development Goals,” Chukwuma added.

PHCs are ready but support is inadequate

“PHCs are not adequately supplied with medications,” said Nneka Nwankwo, founder of Abby Cares Foundation. She has over 20 years’ experience in public health and social services.

Her NGO sources Ofoke’s daily insulin injection from a tertiary hospital in the city center. Nigeria’s annual diabetes-related health expenditure per person is estimated at $499.7, which falls below the African regional average. If current trends continue, the prevalence of diabetes in the country is predicted to increase by up to 120% by 2045.

In his study on improving primary health care services for NCDs in Nigeria, Whenayon Ajisegiri found that some government stakeholders’ skepticism about the qualifications of community health workers, who constitute the majority of the PHC workforce, has been used to justify the limited supply of NCD drugs at PHCs. Ironically, NCD drugs are contained in the list of essential medicine and should be available at PHC facilities.

“When PHC facilities repeatedly fail to provide patients’ medications, it leads to frustration. And when you lose patients’ trust in the initial stages, it is difficult to regain,” said Nwankwo.

Patient flow for NCD service delivery at the PHC level, with enablers and barriers along the pathway.

A survey of 30 PHCs in Abuja, Nigeria’s capital city, reported a readiness to integrate diabetes care in terms of available paper-based health management information systems, equipment, and personnel. However, the poor availability of diabetes medications makes it impossible to harness this opportunity.

“If we can get access to testing kits and the drugs, it will improve our ability to manage patients with diabetes,” said Nwaovu.

The survey recommended a subsidized drug-revolving fund mechanism to maintain drug inventory, drawing from programs like the Hypertension Treatment in Nigeria (HTN) Program and the Academic Model Providing Access To Healthcare (AMPATH) program in Kenya.

Community health workers play an integral role

The slow progress in integrating diabetes and other NCDs into PHCs is also linked to the omission of community health workers from NCD policies.

The critical shortage and uneven distribution of skilled health workers, particularly physicians and nurses, have necessitated the deployment of community health workers to support essential health services delivery.

Prior to the introduction of the NTSTS, existing policies like the National Standing Orders, which guides the training and practice of community health workers, restricted their role to only screening and referral. Ajisegiri noted that frequent referrals to higher health facilities—secondary and tertiary—could undermine public trust in the services provided at PHCs.

Formalization of task-sharing 

Given the Nigerian government’s prioritization of PHCs to tackle NCDs, experts have advocated for capacity building, while formalizing task-sharing and task-shifting policies for NCDs among community health workers.

In a survey of 30 PHCs in Abuja, Nigeria’s capital city, only 37% reported having at least one staff member trained in diabetes diagnosis and management within the past two years. With the NTSTS for NCDs set to be adopted, Nigeria appears to be on track to address this issue. 

This task-sharing and task-shifting model has already been successfully implemented in maternal and child care, as well as in the management of infectious diseases.

While this approach is expected to help the government maximize the available health workforce for NCD management, it is crucial to allocate sufficient resources to PHC to enhance infrastructure, ensure consistent medicine supplies, and bridge the significant skill gap among community health workers. Additionally, refining the practice scope in the National Standing Orders is essential to prevent interprofessional role conflict.

Funding and political will are paramount

The national multi-sectoral action plan acknowledged the problem of medication access and called for action towards ensuring a reliable supply of essential medicines for treating diabetes and other major NCDs.

It recommended expanding the Basic Minimum Package of Health Services, funded by the Basic Healthcare Provision Fund (BHCPF), to cover comprehensive care and treatment of NCDs. The BHCPF serves as a catalytic funding source to enhance access to primary health care, particularly for poor and vulnerable groups. 

This expansion aims to reduce out-of-pocket expenses for treatment. However, funding for the BHCPF has been inconsistent. 

Nwankwo recalled that Ofoke’s father was reluctant to bring his other children living with diabetes for treatment due to the costs. Despite her offer to subsidize the insulin injections by 50%, her efforts to persuade him were unsuccessful. 

“Even with your help, I can’t afford it,” she remembered him saying. Eventually, he brought one more child for screening.

Nneka Nwankwo, founder of Abby Cares Foundation in her office in Abakiliki, Ebonyi State, Nigeria

Only half of the initial 55.1 billion naira allocated to the BHCPF in 2018 was released and by 2021, the budget had decreased to 35 billion naira. Between 2019 and 2022, it is estimated that 89 billion naira was allocated through the BHCPF, with only 7,250 out of the 35,514 Primary Healthcare Centres in the country receiving these funds.

This scenario is all too familiar for Nwankwo. “At Ezza Ofu Health Centre, the quota for the health insurance scheme is around 300 people, but it’s just a drop in the pond,” she said. During her organization’s first outreach at the PHC, over 1,000 people showed up seeking medical care. “Creating policies is not enough if they are not backed with the right resources,” she added.

Pius Ukpai contributed to this reporting from Ebonyi State, Nigeria.

Image Credits: Chimdiebube Ikechukwu, IDF Diabetes Atlas, Whenayon Ajisegiri.