The 2021 data was released later than usual as experts continue to grapple with the pandemic’s impact on global health data collection and analysis.

GENEVA — Six of the ten leading risk factors for premature deaths and years of healthy life lost due to disability are within an individual’s control, according to new data from the Global Burden of Disease Study 2021.

The study, the most comprehensive effort to quantify health loss worldwide to date, aims to identify and eliminate disparities in health systems. Its findings were discussed on Monday at the Geneva Graduate Institute’s Global Health Centre during a side event of the 77th World Health Assembly.

“In the absence of a major health innovation, these factors are predicted to remain relevant over the next several decades,” said Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, which conducted the study. “If we intervene, we can change the global burden of disease.”

Of the top 10 risk factors identified in 2021, high blood pressure, tobacco use, dietary risks, high blood sugar, obesity and high cholesterol, are often, although not always, related to behavioural choices such as food choices and physical inactivity, Gakidou and other experts on the panel pointed out.

Similarly, behaviour also drives other leading risks considered in the analysis, including those related to high alcohol use, unsafe sex, poor hygiene [in cases were safe water is available]; drug use, and physical inactivity. 

Malnutrition ranks first, with air pollution second, in a Global Burden of Disease analysis of aggregated risk factors (level 2), in the IHME analysis.

Precise risk factor ranking depends on how you group the data

While it’s clear that a huge burden of deaths and disease could be controlled through individual lifestyle and behaviour changes, economic and social conditions, as well as policy choices are also major drivers.

And the precise ranking of risk factors also depends on how you group the data. For instance, a Lancet report on the same IHME Global Burden of Disease Study, published by Health Policy Watch on 25 May, cited air pollution as the leading risk factor for global disease burden, followed by hypertension.

Study co-author Michael Brauer told Health Policy Watch that the difference in the list is based on how risks are aggregated.

If maternal, neonatal and early childhood nutrition risks, related to a diverse range of intestinal and respiratory diseases, as well as poor maternal nutrition and poor breastfeeding practices, are considered separately, as was the case in The Lancet publication, then air pollution is No. 1. If, however, these various maternal and child “malnutrition” risks are aggregated, they become number 1, with air pollution as number 2.

Significantly, unhealthy diets becomes number 5 in the aggregated analysis. These risks include high consumption of red and processed meats, salt and sugar and low consumption of fruit, vegetable, seeds, polyunsaturated fats – which are largely, although not always, within an individual’s control.

“In the GBD there is a hierarchy for the risk factors,” Brauer explained. “We have four levels of risk factors. The first is just environmental/occupational, behavioural, metabolic. The level two aggregation is what Emmanuela presented, the level three and four are much of the focus of the [Lancet] publication.”

Air pollution ranks as the first health risk factor among 88 considered in the new IHME Global Burden of Disease study, published by IHME in The Lancet.

Study examined data from over 12,000 researchers in 163 countries

The GBD 2021 study examined 459 health outcomes from 88 risk factors, drawing on data from over 12,000 collaborators in 163 countries and territories. It utilised a total of 316,737 data sources, including government reports, surveys, and health sector data.

The 2021 data was released later than usual due to the pandemic’s impact on the organisation’s work. Dr. Gakidou stressed that the report not only tackles the pandemic-induced backlog but also highlights the growing challenges in collecting data from conflict zones, an increasingly significant issue as global conflicts persist.

Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation
Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation

“We struggle to get data from countries in conflict and on populations that are displaced by conflict or have natural displacement, and we know there are conditions that get exacerbated by conflict,” she said. “This is an area of huge interest and a massive data gap.” 

IHME aims to release 2023 data by December 2024 and 2024 data by November 2025, she noted.

The latest report’s results have “profound implications for future thinking of how [countries] should be organizing their health systems [and] social sectors.”

“This is a graph of hope,” Gakidou remarked as she displayed a graph of the leading risk factors. “Things can be done [to reduce] many of them.”

Life Expectancy Disparities Persist Despite Global Gains

“We forecast that life expectancy improvements will be larges in sub-Saharan Africa than in any other super-region between 2022 and 2050,” the study said.

The GBD study revealed that COVID-19’s impact on life expectancy varied across the globe. Yet, even when adjusting for the pandemic’s effects, disparities in life expectancy improvements remain evident among different regions.

From 1990 to 2021, life expectancy rose by 8.3 years in Southeast Asia, East Asia, and Oceania, while Central and Eastern Europe and Central Asia saw a mere 2.1-year increase. 

Sub-Saharan Africa, despite a 7.8-year improvement driven by advancements in treating diarrhoea, pneumonia, and communicable diseases, as well as reducing neonatal mortality, still lags behind with the world’s lowest life expectancy. The gap between this region and others has not significantly narrowed in the past three decades.

Kalipso Chalkidou, head of finance at the Global Fund to Fight AIDS, Tuberculosis and Malaria, pointed out that just 15 countries, accounting for about 5% of the global population, are responsible for 40% of the worldwide decline in mortality. Diseases such as tuberculosis, AIDS, and malaria contribute to nearly half of this figure.

Dr. Gakidou also emphasized that the lack of progress in addressing non-communicable diseases is a significant factor in the regions struggling to keep pace with life expectancy improvements.

More Deaths Than Births in Many Countries

“By 2100, fertility rates will not be high enough to sustain population growth in 97% of countries,” the study found.

Over half of the countries in the study are now “below replacement level,” with more deaths than births. Nearly all countries are projected to face this reality by 2100.

By 2100, over 30% of births will occur in regions classified as low-income by the World Bank, while births in middle- and upper-income countries will decrease by 20%.

“This has significant implications for where these babies are born, what they will need to do well and thrive, and could have implications on migration and other trends around the world,” Gakidou said.

A new global health landscape?

From left: Richard Horton, editor-in-chief of The Lancet; Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington; Kalipso Chalkidou, head of the Department of Finance for the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Haidong Wang, unit head of the Division of Data, Analytics and Delivery for Impact at the World Health Organization
From left: Richard Horton, editor-in-chief of The Lancet; Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington; Kalipso Chalkidou, head of the Department of Finance for the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Haidong Wang, unit head of the Division of Data, Analytics and Delivery for Impact at the World Health Organization

The discussion on the data concluded with a vision of an emerging global health landscape. What does this new landscape look like?

Chalkidou, speaking on a panel alongside Gakidou, Richard Horton, editor-in-chief of The Lancet, and Haidong Wang, unit head of the Division of Data, Analytics and Delivery for Impact at the World Health Organization, pointed to the need to change the global health “architecture.” 

“I think we need to change the way things are hardwired to get different results,” she concluded. 

Wang, meanwhile, said that to envision a new landscape, “we need to remind ourselves how fragile the gains in population health are.”

“Just in two years of the pandemic, we lost a decade,” he said, alluding to the importance of sustaining investment in public health.

As the session drew to a close, Gakidou struck a more optimistic tone. 

“People value health over everything else. I think that the global community has demonstrated that very visibly,” she said. “I think the new global health landscape … is one where health continues to be valued as the most important component of well-being and we take care of our populations globally – regardless of their age, where they live and what they do.”

Image Credits: Maayan Hoffman, IHME , IHME.

Dr Tedros and Barbados Prime Minister Mia Mottley

GENEVA – The World Health Organization (WHO) is seeking $7-billion in flexible funding for its four-year programme of action (2025-2028), and will hold an investment conference towards the end of the year – but the launch of this quest was celebrated at an event at its Geneva headquarters on Sunday evening.

The four-year programme will cost $11.1-billion to implement and little over a third – $4-billion – will come from WHO member states’ membership fees, referred to as “assessed contributions”, said WHO Director General Dr Tedros Adhanom Ghebreyesus.

“Let me put that into context for you,” added Tedros. “Last year, the world spent $717-billion on cigarettes.

“It’s about ensuring WHO is fully funded and improving the quality of the funding we receive. Much of the funding we receive is unpredictable, reactive, and tightly defined,” he added.

The WHO currently manages over 3,000 granted for earmarked projects, which did not allow for quick responses in times of crisis, he explained. In addition, because so much of its income was tied to specific projects, many WHO staff were on 60-day contracts.

“When the funding we get is flexible, then we will have the opportunity to prioritise based on the countries’ situation,” he said, adding that it would also boost morale.

“A lot of people invest their time – including directors – managing grants, mobilising resources  instead of focusing on the programmes.”

The launch, on the eve of the 77th World Health Assembly, “marks the start of a year-long series of engagements and events, co-hosted by countries, where member states and other donors will be invited to contribute funds to WHO’s strategy for 2025 through 2028 and show high-level political commitment to WHO and global health,” the WHO noted.

The investment round will culminate in November with a major pledging event to be hosted by Brazil around the G20 Leaders’ Summit.

“It’s about ensuring WHO is fully funded and improving the quality of the funding we receive. Much of the funding we receive is unpredictable, reactive, and tightly defined,” said Tedros Adhanom Ghebreyesus. “The Investment Round aims to change that, by generating funding that is more flexible, predictable, and resilient.”

Sea change

Barbados Prime Minister Mia Mottley told the event that there needs to be “a sea change in the global governance architecture of our international financial institutions”.

“There can be no first class and second class citizens of the world, particularly as it relates to access to pharmaceuticals, and access to medical care,” she added.

“Unless we begin to internalise that the balance sheets of most multinational corporations, in fact, dwarf more than half of the world’s states, we will not be able to get to the point where we need to get,” said Mottley, who received a Global Health Leaders Award for lifetime achievement from Tedros.

“And if we accept that public funds are getting more and more difficult to find, then it means that we can only rely on states to be at the core of funding the global public goods.”

“There can be no first class and second class citizens of the world, particularly as it relates to access to pharmaceuticals, and access to medical care. If we get that right, then the missing part of the equation can be found and what is the missing part of the equation? It is political will,” concluded Mottley.

Norwegian Health Minister Jan Christian Vestre

“Global problems need global solutions, and no other organisation has turned out to be in a better position to provide us a chance to come to global solutions,” Brazil’s Minister of Health Nísia Trindade said in a video address. “We will use the convening power of G20 to help mobilise efforts to make the Investment Round a success.”

Qatar Minister of Health Dr Hanan Mohamed Al Kuwari announced a contribution of $4 million in fully flexible funds to the Investment Round, and an intention to contribute further.

“Health care is a fundamental human right and we must continue to invest in the World Health Organization to safeguard our health. Unity is the key to our success,” Al Kuwari said.

France, Germany, and Norway announced that they would serve as co-hosts for the Investment Round.

Norwegian Health Minister Jan Christian Vestre said that his country was proud to co-host the investment round “which will be an important step in securing the organisation a more sustainable financing”. 

However, he said that “more steps are needed, including an increase in assessed contributions”. Two years’ ago, the WHA resolved that 50% of the WHO’s funds should come from by 2030.

“The increase in assessed contributions will not only make WHO more efficient, but also more democratic, as the organisation will be in a better position to follow the priorities that are decided in the assembly instead of following donor earmarked financing,” said Vestre.

Ashley Bloomfield, co-chair of the Working Group on amendments to the International Health Regulations and Precious Matsoso, co-chair of the Intergovernmental Negotiating Body (INB) for a pandemic accord, speaking on the eve of the World Health Assembly.

Although a draft pandemic agreement may take weeks or months longer to conclude, there are moves underfoot to try to quickly wrap up negotiations and get final member state sign-off on amendments to the 2005-era WHO International Health Regulations  (IHR) at the this week’s World Health Assembly (WHA), said the co-chair of the working group on amendments to the IHR, Ashley Bloomfield, of New Zealand.

He was speaking at the Geneva Graduate Institute‘s Global Health Center, on the eve of the opening of the WHA, which will grapple with an agenda that is perhaps one of the most complex, divisive and also potentially impactful, in the Organization’s 75 year history.

The week-long Assembly will be taking up resolutions and decisions dealing with a new four-year strategy to WHO; it’s new funding appeal to raise some $7 billion more over that period in voluntary funds from donors; the humanitarian crises related to wars in Ukraine and Gaza; as well as a host of other vital health themes – from a new resolution on climate and health to the status of efforts to eliminate malaria, tackle chronic disease as well as head off a wave of drug resistant pathogens and disease, to name just a few.

Amidst all of that, while two-years of negotiations on a proposed new pandemic agreement ended Friday without final agreement on a draft, the committee negotiating parallel amendments to the IHR, the pre-existing set of WHO emergency rules approved in 2005, have moved closer to the end goal with an agreement in principle over its contents.

And out of 34 articles in the IHR amendments, 17 are fully approved, while another 17 remain to be finalised, Bloomfield said.  As a result, he said the group would be sharing the document-in-progress with the assembly, but asking for the go-ahead to continue negotiations during the WHA.

“We will put forward a draft resolution asking the Assembly to continue the work this week, and hoping that it will be adopted by the Assembly before the week is over,” he said.

“I think there is a really strong intent by us to seize the moment,” he added, noting that language advancing more “equity” between countries during health emergencies are among the “significant inclusions” to the draft  IHR amendments – although he did not elaborate.

More predictable financing for disease threats

Many nations imposed strict border controls during the pandemic, contrary to the International Health Regulations call to ensure free movement of people and goods.

The IHR equity achievements include stronger commitments by high-income states, such as the European Union, to support more predictable and sustainable financing for all countries in outbreak prevention, preparedness, other sources told Health Policy Watch.

That, in turn, should help support more robust surveillance of pathogens which pose outbreak, emergency and ultimately pandemic risks, particularly in low- and middle-income countries that lack the tools and resources to track and identify them quickly.

Other elements of the amendments on which the working group is close to an agreement, include an official definition for a “pandemic.” This would be a trigger for WHO to declare a higher level of emergency beyond the current designation of a “Public Health Emergency of International Concern” (PHEIC).

That would activate the more far-reaching provisions of a future- pandemic accord, should that new legal instrument be finally approved and ratified by countries. During the COVID pandemic, no actual “pandemic” designation existed and so when WHO declared that the world was facing a pandemic, on 11 March 2020, moving beyond language for the PHEIC that had been declared in late January, it was more of a symbolic step, rather than one with any legal implications.

Another element of the IHR amendments, also close to conclusion, would involve creation of a mechanism for indpendent monitoring of how countries implement the IHR’s key provisions – to strengthen what one negotiator called “the collective oversight” of the readiness process.

WHO’s new global health strategy and the $14 Billion ‘Ask’

On left: Bjorn Kummel, German Ministry of Health, makes the case for a new approach to WHO funding.

Another key feature of this year’s WHA will be the launch of a first-ever WHO “Investment Round,” which seeks to raise an additional $7.1 billion in voluntary contributions from member states for the four-year, 2025-2028 period, on top of regular asssessed contributions, which are expected to amount to $4 billion.

“The 7.1 billion seeks to expand the envelope to cover what is not covered by the assesssed contributions of WHO,” said senior WHO advisory Bruce Aylward.

While WHO has always sought and received voluntary contributions from member states and philanthropies, the idea is to systemize the giving, allowing the organization to more flexibly allocate funds to agreed-upon priorities and enjoy more “predictability” in its funding cycles.

“The idea is to really lobby at the highest levels, presidents and prime ministers for funding for WHO,” said Bjorn Kummel, a senior official in Germany’s Ministry of Health, who led moves last year to increase assessed member state funding to WHO.  “Most of the funding [now] comes in highly earmarked,” he noted.  Additionally, significant organizational resources from various departments, are expended courting to donors individually and reporting to them. 

“The other challenge is predicability,” Kummel added.  “You may notice that there are many in WHO on short-term contracts, and this is due to the way that we are funding WHO through unpredicatable finances.”

Additionally, he noted, the aim is to broaden the base of voluntary giving to include more countries that have moved up the ladder of economic development and could now shoulder a share of the burden.

“It’s been the same 18 key donors  [for voluntary contributions] over the past 50 years,” Kummer said.  “That can’t continue.”

Geopolitical and cultural divides deeper than ever

Against all of the complexity, the WHA convenes in a period where geopolitical and cultural divides are deeper than ever.

Two residents stand in the ruins of homes in Borodianka in the Kyiv region.

Two more resolutions on the humanitarian situation in Ukraine following Russia’s 2022 invasion may come before the assembly, said Gian Luca Burci, WHO’s former chief legal counsel and now a senior faculty member at the Geneva Graduate Institute.  That follows divisive debates in 2022 and 2023 over previous WHA resolutions, initiated by the European Union and its allies, on the Ukraine situation.

And the health and humanitarian emergency in Gaza, triggered by Israel’s war against Hamas, following the bloody 7 October 2023 Hamas incursion into Israel, will be the focus of a dedicated resolution that member states will debate alongside a perennial resolution and debate on the health conditions in the Occupied Palestinian Territories, including the West Bank.

That latter resolution, however, has taken on added significance since the war began, insofar as West Bank Palestinians also have faced tough Israeli military lockdowns and curtailment on routine movements, including to obtain health care.

In addition, there may be moves afoot to enhance Palestine’s status at the WHA, where it is now merely an observer, like the Vatican:  “There may be an initiative to adopt a resolution giving Palestine … rights of member states,” Burci said, referring to a similar move recently taken by the UN General Assembly.

The UN GA resolution greatly expanded Palestine’s rights before the body, although it stopped short of giving it the right to vote, or allowing it to posit its candidacy for the UN Security Council, rights that only the UN Security Council may bestow.   Finally, he said that there could be moves afoot to curtail Israel’s eligibility to serve on WHO’s governing body, the 34-member Executive Board, although that would have little immediate meaning as Israel recently completed a three-year EB term.

Gender inclusion and sexual and reproductive health rights

Another flashpoint that has been the focus of gathering stormclouds is the issue of gender inclusion and sexual and reproductive health rights.

Standard language about those issues was traditionally a part of most resolutions and decisions on topics ranging from HIV/AIDs to maternal and child health, as well as environmental health. But increasingly an alliance of conservative countries have sought to have such references watered down or removed, not only from WHA-approved resolutions but even from WHO Secretariat reports.

Pascale Allotey
Pascale Allotey

“There’s really a much more fundamental question that is happening within the lines of gender equality as a shared value,” said Pascale Allotey, a Ghanaian public health researcher who is now director of WHO’s progamme on Sexual and Reproductive Health (SRH) and its joint programme on Human Reproductive Health (HRP).

“We hear a lot now of the use of the term ‘gender ideology’  – this idea that it’s just about imposed concepts,” she said. “But this agenda isn’t about imposed concepts or about concepts at all. It’s really just a …framework for understanding the realities of people’s lives – the ways in which your lack of power and agency restricts people’s capacities and opportunities in unjust ways.” 

Image Credits: The National Guard/Flickr, Matteo Minasi/ UNOCHA.

Most air pollution-related deaths are due to cardiovascular diseases, according to the latest report by the World Heart Federation.

Almost 70% of the 4.2 million deaths attributed to ambient (outdoor) air pollution in 2019 were caused by cardiovascular diseases, notably ischaemic heart disease (1.9 million deaths) and stroke (900,000 deaths), according to a new report by the World Heart Federation (WHF).

The report highlights the outsized impacts air pollution is having on the worldwide epidemic of cardiovascular diseases (CVDs).

Meanwhile, air pollution has become the leading risk factor for global disease burden, overcoming even hypertension, according to a recently published Lancet study, in a ranking of 88 environmental and health risk factors across 204 countries and territories. The analysis was a part of the Global Burden of Disease (GBD) study 2021, conducted by the Seattle-based Institute of Health Metrics and Evaluation (IHME).

The GBD study is published once every two years but publication of the 2021 data was delayed until now, due to the pandemic. It considered risk factors ranging from environmental and occupational hazards, such as air pollution, to behavioural factors such as tobacco use, physical inactivity, unsafe sex and poor nutrition.

Air pollution was also one of the leading risk factors in the last GBD study published in 2020, but as the disease burden was calculated separately for ambient and household pollution, which have overlapping mortality, it did not rank as the highest.

But in the 2021 Lancet report, malnutrition risk factors, largely related to low birth weight, child growth failure and suboptimal breastfeeding were ranked separately. If those were ranked together, then malnutrition [primarily neonatal, newborn and early childhood] becomes the Number 1 risk, with air pollution, second and hypertension third, said Michael Brauer, lead author of the study for the Institute for Health Metrics and Evaluation (IHME), in a comment to Health Policy Watch.

Air pollution ranks as the first health risk factor among 88 considered in the new IHME Global Burden of Disease study, published by IHME in The Lancet.

Cardiovascular – not lung disease – associated with the lion’s share of air pollution-related deaths

However, among the diseases most closely associated with ambient (outdoor) air pollution-related exposures, cardiovascular disease is responsible for the lion’s share according to the new WHF report. And that is a striking new finding.

“Most people, when they think of air pollution they think of someone coughing, they think of lung conditions like asthma and pulmonary disease. But actually, it is the cardiovascular conditions which are probably the most concerning,” Dr Mark Miller of the University of Edinburgh, and the WHF’s Chair of the Air Pollution and Climate Change Expert Group told Health Policy Watch.

“This report essentially is like a reappraisal of the most recent World Health Organization (WHO) data to emphasize how bad the cardiovascular effects of air pollution are,” he said.

The report titled ‘Clearing the Air to Address Pollution’s Cardiovascular Health Crisis’ was launched during the World Heart Summit underway this weekend in Geneva, Switzerland. It represents one of the most sweeping reports, to date, by the global federation on a risk factor that many cardiologists have failed to fully acknowledge.

In terms of household air pollution – the link to CVD is also clear – if not quite as pronounced.

Amongst the 3.2 million deaths attributed to household air pollution in 2019, 53% was attributable to CVDs – including one million deaths from ischaemic heart disease and 700,000 from stroke.

Seen from the disease perspective, some 37% of all CVD deaths globally were attributable to air pollution in 2019, including 22% of deaths from ischaemic heart disease and 15% from stroke, according to the report.

Air pollution – the greatest single environmental health risk

The report calls air pollution “the greatest single environmental health risk.” In some regions air pollution is over ten times the recommended limit by the WHO, the report noted.

Air pollution levels have remained stagnant in many parts of the world, or even increased slightly, despite increased awareness of its harms.

Cardiovascular disease kills more than 20 million people every year globally. Air pollution has the most impact on people with pre-existing cardiovascular conditions, the report said.

The report warned that without adequate policies in place, deaths and disability from cardiovascular conditions caused or worsened by air pollution is set to increase further.

“These two reports highlight how critical it is for governments to prioritise measures to rapidly improve air quality, to save lives and reduce the toll and cost of cardiovascular disease – the world’s biggest killer,” said Nina Renshaw, Head of Health at the Clean Air Fund. “The fact that air pollution is the number one risk factor driving the global burden of disease requires attention from health donors too. Efforts to tackle air pollution remain chronically underfunded, receiving only 1% of global development funding in recent years. Air pollution must quickly become a higher priority in global health.”

Why air pollution is such a CVD killer

In fact, while not intuitive, there are clear physiological reasons why air pollution, and particular fine particulates are so closely associated with heart disease and stroke.

Air pollution particles are absorbed in tissue deep in the lungs where they can cause inflammation setting the stage for chronic lung disease and cancers. But the finest particles, of PM2.5 or smaller in diameter, penetrate the lung walls and enter the bloodstream. Circulating in arteries and veins of the body and the brain, these fine particles exacerbate the build-up of plaque over time, as well as contributing to the constriction of the arteries, setting up a perfect storm of conditions for heart disease and stroke.

Air pollution-related CVD deaths increasing sharply in Southeast Asia and the Eastern Mediterranean 

The report also finds that the number of deaths from heart disease attributable to air pollution has increased in some regions by as much as 27% over the past decade.

A key reason for this is the rising air pollution levels in some countries of Southeast Asia and the Eastern Mediterranean, where average air pollution concentrations are nearly ten times the WHO – recommended levels, experts say.

The Western Pacific region saw the highest number of deaths from heart disease and stroke due to outdoor air pollution with nearly one million deaths in 2019, and the Southeast Asian Region was a close second, with 762,000 deaths.

Countries facing the some of greatest challenges with air pollution include those in the Eastern Mediterranean, with Kuwait, Egypt, and Afghanistan.

Real number of CVD deaths related to air pollution is likely higher

Moreover, the real number of CVD deaths from air pollution is in fact likely to be much higher, as currently, mortality is only assessed for a single air pollutant i.e PM2.5, and only for ischaemic heart disease and stroke, while there are a range of other cardiovascular diseases that may be exacerbated by air pollution.

“The reality is that there is a real lack of reliable and granular data, mostly due to the absence of ground monitoring systems. This is especially true in low-income settings where millions of people live in unmonitored areas,” said Mariachiara Di Cesare from the University of Essex who was involved with the WHF’s report.

“To give an example, IQAir’s 2023 World Air Quality Report provides a comprehensive overview of PM2.5 data across almost 8,000 cities in 134 countries, regions, and territories. When you look at Africa out of 54 African countries, only 24 have the capacity to monitor air quality in some capacity, with most of the existing stations concentrated in the western and southern regions of the continent,” Di Cesare said.

This makes the results of the report an underestimate, Cesare told Health Policy Watch. She said that improved air pollution monitoring in both rural and urban areas will help provide more accurate estimates of air pollution levels and trends.  

Global distribution of PM2.5 monitoring stations

WHF study relies upon 2019 data – Lancet updates that air pollution is now the top killer

Significantly, the new WHF report relies upon 2019 data regarding air pollution impacts on cardiovascular health. The latest IHME Global Burden of Disease study, published in The Lancet, provides slightly updated data – linked to 2021. Also, the WHF report focuses its analysis primarily on air pollution related CVD deaths, while the Lancet study looks at both mortality and morbidity. But the overall message regarding the killer impacts of air pollution is the same.

Over 11,000 researchers were part of the IHME GBD study. Following air pollution, high blood pressure and smoking were the second and third-ranking risk factors contributing to excess disease and disability – or Disability Adjusted Life Years (DALYS). However, if all of the dozen or so

“These are groups of risk factors where the exposure to the risk factors is increasing. And then, that is exacerbated by these demographic factors, the growing populations, the aging populations,” said Brauer in a podcast unpacking the findings.

At the same time, if malnutrition risks are aggregated together, then they become the top risk, with air pollution ranking number 2, Brauer said, noting that the original IHME GBD analysis, upon which The Lancet publication was based, considered several “levels” of aggregation of the risks that were analysed. These malnutrition risks are mainly related to poor maternal, neonatal and early childhood nutrition, including infections from parasitic and water-borne diseases, tuberculosis and other respiratory conditions. Risk factors linked to unhealthy diets, including factors like high red meat consumption, low fruit, vegetables, nuts and seeds; and high salt and sugar intake, ranked fifth in the aggregated analysis.

Malnutrition ranks first, with air pollution second, in a Global Burden of Disease analysis of aggregated risk factors (level 2), in the IHME analysis.

The 2021 Lancet study also looks at how health risks have evolved over the past two decades – comparing the most recent findings with those in 2000. That was the year that GBD study quantifying deaths and disease linked to a set of 25 environmental, occupational and behavioural health risks was published by the WHO. A comparison between the two shows risk factors that stagnated or become more significant, along with those that have moved down the list as conditions improved, notably for safe water, hygiene and sanitation.

While its ranking has varied somewhat over years, air Pollution was the leading risk factor for disease burden in the year 2000 and 2021, this graphic from the most recent IHME GBD study demonstrates.

Climate change is compounding impacts

Climate change is also turning out to be an additional stressor, compounding air pollution risks, as global temperature rise continues unabated, the WHF experts note.

This year has already seen heatwaves from Mali to India and temperatures have soared. Climate change has increased the frequency and the intensity of heatwaves, according to climate scientists. Heatwaves are also known to exacerbate underlying non-communicable diseases like diabetes and heart ailments as Health Policy Watch has reported earlier.

“That’s the sort of, that’s the sort of main message that the science is telling us now, as we’re starting to see all these environmental stressors compounding each other,” said Miller. “And you would expect that, for example, if you have heat waves that were accompanied by higher air pollution, that would make cardiovascular disease worse.”

Global air pollution-related healthcare costs are already projected to surge from $21 billion in 2015 to USD 176 billion in 2060, with annual lost working days potentially increasing to 3.7 billion by 2060. Any additional stressor will make the costs worse, the WHF report notes.

The key message, however, is that action will make a difference, Miller said. “While highlighting some really terrifying figures here, these huge numbers of deaths worldwide as well…we’re referring to them as preventable deaths, because air pollution is preventable. So, there’s an opportunity here, as well that, you know, if we can tackle these issues, and we know some of the measures to do so then hopefully, we will see improvements in cardiovascular health.”

–Updated to include reference to “malnutrition” risks and their ranking, as relates to air pollution, in the IHME analysis.

Image Credits: Unsplash, IHME, Clearing the Air to Address Pollution’s Cardiovascular Health Crisis report., Clearing the Air to Address Pollution’s Cardiovascular Health Crisis Report, IHME , Global Burden of Disease Study 2021.

Precious Matsoso, INB co-chair, South Africa, closing out the last session of the Intergovernmental Negotiating Body, which ended Friday with no final result.

A last ditch effort of WHO member states to finish negotiations on a pandemic accord has failed to yield agreement ahead of next week’s World Health Assembly (WHA) – with key articles in the draft text still unresolved including the thorny formula for global sharing of vaccines and medicines during international health emergencies.

As of Friday evening, member states of the Intergovernmental Negotiating Board, assembled in Geneva, had stopped negotiating over the draft text, and were instead talking about the way forward.  And on that, as well, there was no accord, leaving a future pathway in the hands of the WHA.

According to sources who spoke to Health Policy Watch, member states were debating over recommendations to try to conclude the accord in parallel talks during next week’s WHA; to extend the negotiations by another six months; or even by a year.

The most radical proposal was for a ‘suspension’ of the global health assembly in mid-week, so that delegates could focus solely on the treaty negotiations.  But that seemed highly unlikely in light of the packed WHA agenda, which also includes highly political items related to the war in Ukraine and in Gaza.

“This is setting a new precedent on negotiations,” one NGO observer said. “Usually all of the negotiations are before the assembly, or at worst, there may be negotiations on one or two outstanding issues during WHA.”

‘We will see what we can do to finish the process’

US lead negotiator Pamela Hamomoto in Friday’s closing session.

Speaking to stakeholders in the room at the close of Friday’s session, INB co-chair Roland Driece, of the Netherlands, declared that “we said that we will see what we can do to finish this process. But for now the mandate of this team of the INB is going to finish.”

“Everyone tried to make this work,” said Precious Matsuso, the other co-chair, of South Africa.  “Yes we may not have finished, but there is still an opportunity and we will make sure it happens.”

Despite the impasse, delegates from diverse countries and geopolitical alliances that had clashed repeatedly on the actual text, also sought to strike an optimistic note, that eventually agreement could be reached.

“We have made real progress toward an agreeement that will in the future ensure the world is better able to prevent prepare for, and respond to pandemics,” said the delegate from the United Kingdom.  “We look forward to discussions at the World Health Assembly and building on the progress that we have made.”

Said the lead US negotiator on the treaty, Pamela Hamamoto, “I know we are all disappointed that we don’t have a dance and champagne in the room today…This is hard, but I will certainly continue to believe in multilateral solutions and I know that everyone in this room is committed as well.”

Kenya’s delegate to the INB on Friday evening.

Said the delegate from Kenya, “together we can ensure that the world is safer, fairer and better prepared for future outbreaks and pandemics. I look forward to further discussion on how to take this forward.”

WHO Director General looks for World Health Assembly as next step

Dr Tedros Adhanom Ghebreyesus, WHO Direcctor General

WHO Director General Dr Tedros Adhanom Ghebreyesus said he is now looking to the upcoming WHA, when member states will assemble again, to define a way forward.

“Where there is a will there is a way, so I am still positive, despite the outcome.  There may be hiccups, but I don’t call it failure,” Tedros said. “You have really progressed a lot and done a lot.”

He urged people to remember the harsh impacts of the pandemic and the need to prevent the recurrence of the same scenario again – although memories of that period now seem to be fading.

“I don’t know if there was any anyone who has not been affected by COVID,” he said. “Not only losing loved ones, but economic problems, loss of jobs, you name it. This impact was because the world was unprepared, and by the way, it still is.”

‘Wedding at WIPO, funeral at WHA’

The suspension of pandemic accord talks in WHO, came as members of another international agency, the World Intellectual Property Organization (WIPO) came to a milestone agreement on a historic new treaty requiring companies and other entities filing for patents to disclose the sources of indigenous plant as well as traditional knowledge, used in their products.

https://x.com/WIPO/status/1793834029588062464

The new treaty establishes a disclosure requirement for patent applicants whose inventions are based on genetic resources and/or associated traditional knowledge. The treaty aims to protect the indigenous resources of countries, particularly developing countries, and will have wide-ranging relevance for new medicines, as well as cosmetics and other products.

“It’s kind of like a wedding at WIPO and a funeral at WHO this morning,” said Jamie Love of the NGO Knowledge Ecology International (KEI).

Image Credits: Nana Kofi Acquah.

The pandemic has reversed gains in life expectancy according to the WHO.

The COVID pandemic has wiped off a decade of steady gain in life expectancy at birth and healthy life expectancy at birth (HALE), according to the World Health Statistics 2024 report by the World Health Organization (WHO).

In the light of the findings the world health body has urged countries to redouble their efforts towards health-related Sustainable Development Goals (SDGs) by 2030.

“There continues to be major progress in global health, with billions of people who are enjoying better health, better access to services, and better protection from health emergencies,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “But we must remember how fragile progress can be. In just two years, the COVID-19 pandemic erased a decade of gains in life expectancy.”

Between 2019 and 2021 when the pandemic was raging, global life expectancy dropped by 1.8 years to 71.4 years (back to the level of 2012). Similarly, global healthy life expectancy dropped by 1.5 years to 61.9 years in 2021 (back to the level of 2012).

“This is the world’s report card on health. And the bottom line is that we are failing,” said Dr Samira Asma, Assistant Director-General, WHO Data, Analytics and Delivery for Impact Division during a press briefing. “Despite encouraging progress in some countries, and for some conditions, overall, life expectancy has fallen and shockingly. The world is not on track to achieve even single one of the 32 health-related sustainable development goals,” she said, summing up the key takeaways from the report.

Dr Samira Asma, Assistant Director-General, WHO Data, Analytics and Delivery for Impact Division

And the effects have been unequal across the world, according to the report.

Americas and South-East Asia hit the hardest

The WHO regions for the Americas and South-East Asia were hit hardest, with life expectancy dropping by approximately 3 years and healthy life expectancy by 2.5 years between 2019 and 2021.

In contrast, the Western Pacific Region was minimally affected during the first two years of the pandemic, with losses of less than 0.1 years in life expectancy and 0.2 years in healthy life expectancy.

COVID also rapidly emerged as a leading cause of death, ranking as the third highest cause of mortality globally in 2020 and the second in 2021. Nearly 13 million lives were lost to COVID during this period according to confirmed death data – which experts said only partially represented the true levels of mortality from the pandemic.

Except in the African and Western Pacific regions, COVID was among the top five causes of deaths, notably becoming the leading cause of death in the Americas for both years.

Non-communicable diseases back as the top killers

The WHO report also highlights that noncommunicable diseases (NCDs) such as ischaemic heart disease and stroke, cancers, chronic obstructive pulmonary disease, Alzheimer’s disease and other dementias, and diabetes, were the biggest killers before the pandemic, responsible for 74% of all deaths in 2019. Even during the pandemic, NCDs continued to account for 78% of non-COVID deaths.

The world also now faces a massive and complex problem of a double burden of malnutrition, where undernutrition coexists with overweight and obesity. In 2022, over one billion people aged five years and older were living with obesity, while more than half a billion were underweight.

Malnutrition in children was also striking, with 148 million children under five years old affected by stunting (too short for age), 45 million suffering from wasting (too thin for height), and 37 million overweight.

Progress in reducing maternal deaths has slowed or stagnated

Progress in averting maternal deaths has also slowed down or stagnated in many parts of the world.

“The number of women dying from a maternal cause has remained unacceptably high. Every two minutes a women dies from maternal causes equating 800 deaths every single day. Achieving SDG target of a 70 deaths per 100,000 live births by 2030 will avert over a million death among women at the global level,” said Dr Haidong Wang, Unit Head, Monitoring, Forecasting and Inequalities, WHO Data, Analytics and Delivery.

The report further highlights the significant health challenges faced by persons with disabilities, refugees and migrants. In 2021, about 1.3 billion people, or 16% of the global population, had disability. This group is disproportionately affected by health inequities resulting from avoidable, unjust and unfair conditions.

Access to healthcare for refugees and migrants remains limited, with only half of the 84 countries surveyed between 2018 and 2021 providing government-funded health services to these groups at levels comparable to their citizens, according to the report.

Dr Haidong Wang, Unit Head, Monitoring, Forecasting and Inequalities, WHO Data, Analytics and Delivery reading out the key highlights from the report.

Health-related SDGs unlikely to be met by 2030

Despite setbacks caused by the pandemic, the world has made some progress towards achieving the WHO’s Triple Billion targets, which aimed to improve the health of 3 billion people between 2019 and 2023, as well as the health-related indicators of the 2030 Sustainable Development Goals (SDGs).

Since 2018, an additional 1.5 billion people achieved better health and well-being, WHO said in its report. Despite gains, rising obesity, high tobacco use, and persistent air pollution hinder progress.

Universal Health Coverage expanded to 585 million more people, falling short of the goal for one billion more people accessing UHC. Additionally, only 777 million more people are likely to be adequately protected during health emergencies by 2025, falling short of the one billion target set by the WHO for emergencies. This protection is increasingly important as the effects of climate change and other global crises increasingly threaten health security. Only 138 million people were living in healthier environments and lifestyles, far short of the 1 billion envisioned for that part of the Triple Billion Goal.

The progress is far from being enough. “While we have made progress towards the Triple Billion targets since 2018, a lot still needs be done. Data is WHO’s superpower. We need to use it better to deliver more impact in countries,” said Dr Asma.

Image Credits: Unsplash.

reproductive health
Sister Percilda Manhica, a nurse at the Manica Health Center in Mozambique, discusses contraceptive options with Clara Obadias Matavele.

Amid a huge global push against sexual and reproductive health and rights, some of the foremost global experts in the field are calling on the World Health Assembly to protect these hard-won rights. All the authors are listed below.

Progress on comprehensive sexual and reproductive health and rights (SRHR) and its connected goals of gender equality are fundamental for human rights and dignity, national economies, sustainable development, and a healthier planet. 

While SRHR are often thought of in terms of the services needed to prevent unwanted pregnancies, unsafe births and avoidable sexual or reproductive illness, injury or dysfunction, it is much broader. 

Vitally, it includes the positive enjoyment of consensual sexual intimacy and pleasure, the development of mutually respectful and loving relationships, as well as the affirmation of individuals and families in all their diversity. 

It is core to human dignity, autonomy, creativity and security. Sexual and reproductive health and rights flourish only where its emotional, mental, and social dimensions are also enabled, free of coercion, discrimination, and violence.

Upholding this holistic understanding of sexual and reproductive health and rights is essential now more than ever. The costs of failure of inaction or purposefully undermining sexual and reproductive health and rights have devastating consequences for the health, wellbeing and survival for 4.3 billion people (See text box at end).

Ensuring well-being

In contrast, investing in and ensuring access to effective sexual and reproductive health services ensures better health, well-being and life. 

Comprehensive sexual education gives life skills to young people and contraceptives enable girls and women to plan their destinies. 

Maternal mortality is largely avoidable and has declined by 34% from 2000 to 2020. When carried out using a method appropriate to the pregnancy duration, and by someone with the necessary skills, abortion is a safe health care intervention. Legislative action broadening access to abortion has led to declines in maternal mortality.  

Antiretroviral therapy has changed the course of the HIV epidemic. Effective primary (Human papillomavirus  vaccination) and secondary prevention approaches (screening for, and treating precancerous lesions) will prevent most cervical cancer cases.

Beyond health and social benefits, investing in SRHR has economic payoffs. For example, every dollar invested in meeting the need for contraceptives accrues $120 of benefits, in the form of reduced infant and maternal mortality and long-term benefits from greater economic prosperity. 

The financial return generated by income and consumption taxes paid by people born through assisted reproduction far exceeds public funding for assisted reproductive technology, not counting other contributions to society.

Today, there are shining examples of progress towards the full realisation of sexual and reproductive health and rights, with impact on broader peace and well-being. At the same time, sexual and reproductive health and rights are being challenged on multiple fronts in today’s increasingly polarised and unequal world.

Ultra-right groups are undermining gains

Girls and women protest outside Gambia’s parliament earlier this year in protest against attempts to reintroduce female genital mutilation.

Ultra-right-wing gender ideologies and religious fundamentalism continue to consolidate political influence. Further threats arise when governments collude with commercial interests to profit from war economies that undermine the basis for sexual and reproductive health rights. 

Some war-makers go further and weaponise sexual and reproductive rights. Similarly, progress made on democratic rights, accountability and equitable development are undermined with trade agreements cleaving global inequalities that corrode the universality of sexual and reproductive health and rights.

Seeking electoral success, ultra-right-wing leaders and movements propagate hate speech, misinformation, and the promotion of retrograde policies and laws that roll back sexual and reproductive services and our rights to them. 

Specifically, these ultra-right-wing activists seek to reverse legal protections against gender-based violence and harmful practices such as female genital mutilation; ban sexuality education; prohibit sex outside of marriage; criminalise LGBTIQ+ populations; implement bans or broad restrictions on safe abortion, and even deny access to modern contraceptive methods. 

They are also rolling back funding for sexual rights and well-being; and last but not least, they target, denounce and outright threaten sexual and reproductive health and rights care providers and advocates.

Rise of disinformation

The growing systematic distribution of disinformation is of particular concern. Sexual and reproductive health and rights issues are purposefully conflated with false claims that these issues deny nature, erase gender, and impose colonial  ideologies or alien agendas. 

The truth is that upholding sexual and reproductive health and rights enhances life and saves lives: enhances women’s agency over their own bodies and destinies; supports respect for gender identities in all their diversity; and transforms gender power relations for greater equality. 

Lastly, not only are elements of sexual and reproductive health and rights found historically across all cultures, but advancing sexual and reproductive health and rights is a means to counter past legacies of coloniality.

By feeding and instrumentalizing fear, prejudice, and misinformation via national and international platforms, politicians, advocates and community leaders supporting these backward steps are wilfully endangering the lives, health, and well-being of others. 

They behave as if their personal morality claims take precedence over their public duties to reduce preventable mortality and morbidity. The results are disastrous, with longstanding consequences for health and development. Even for maternal health, despite the progress made, more recently maternal mortality ratios have stagnated or even worsened across countries of all income levels.

A mother and her new born baby at the Maternal and Child Health Training Institute in Dhaka, Bangladesh. Maternal mortality remains a very serious concern in Asia.

Our call: Protect SRHR

More than 30 years on from the international commitments made to sexual and reproductive health and rights in Cairo, and to fulfil the commitments made to the Sustainable Development Goals, the pressing work to protect lives, well-being and dignity in sexual and reproductive health is far from finished.

In light of this, and the clear current threats to sexual and reproductive health and rights, we call on all delegates to the 2024 World Health Assembly to protect and promote sexual and reproductive rights, which are human rights, without discrimination. 

Anti-health, anti-rights, anti-evidence dynamics should have no place on the negotiating floors of the UN and WHO. 

Instead, the substantial progress that has and must be made should be recognised and applauded, while those who evidently failed in their responsibility for the safety and wellbeing of others should be held accountable. At a bare minimum, countries must fully respect the principle of non-regression.

With more people and nations going to the polls this year, 2024 is a decisive year for the future of sexual and reproductive health rights. 

We call on citizens and communities to mobilise, stand up for, demand and vote for leaders who will defend fact over fear and evidence and science over ideology; who will honour their human rights obligations for all in their totality, including our rights to sexual and reproductive health. Investments to advance, not regress, sexual and reproductive health and rights are essential for broader health, equitable development, sustained peace and planetary survival.

The authors are independent scientists and members of the following independent advisory groups for sexual and reproductive health:

Scientific and Technical Advisory Group for the UN’s Special Programme on Human Reproduction (alphabetical order): Abdifatah Abdullahi, Ivonne Diaz, Ana Flavia D’Oliviera, Silke Dyer, Alison Edelman, Fatu Forna, Asha S. George (chair), James Hargreaves, Caroline Homer, Elin C. Larsson, Dorothy Shaw, Tari Turner (co-chair)

Gender and Rights Advisory Panel for the UN’s Special Program on Human Reproduction: Alessandra Aresu, Kate Gilmore (chair), Anuj Kapilashrami (co-chair), Renu Khanna, Allan Maleche, Brian Mutebi, Mindy Roseman, Marion Stevens, Imani Tafari-Ama,

Strategic and Technical Advisory Group of Experts on Maternal, Newborn, Child and Adolescent Health and Nutrition: Amanuel Abajobir, Narendra Arora, Richmond Aryeetey, Per Ashorn, Peter Azzopardi, Oliva Bazirete, Jay Berkley, Cristina Bisson, Gary L. Darmstadt, Kathryn Dewey, Faysal El Kak, Caroline Homer (chair), Caroline Kabiru, Nuray Kanbur, Betty Kirkwood, Jonathan D Klein, Daniel Martinez Garcia, Sjoerd Postma, Linda Richter, Jane Sandall, Dilys Walker, Stanley Zlotkin

 

Image Credits: Dominic Chavez/World Bank, UN Photo/Kibae Park/Flickr.

Mexican Ministry of Health video promoting vacccination in April 2021. As in many countries, critics alleged that the government’s moves in the early stages of the pandemic were not aggressive enough.

In December 2021, as the COVID pandemic continued to rage, WHO Member States established an Intergovernmental Negotiating Body (INB) to draft an international agreement on pandemic prevention, preparedness, and response (PPPR).

The outcome of the negotiations is to be presented at the 77th World Health Assembly, which will meet next week in Geneva.

Over the past two years, negotiators have worked tirelessly to meet this challenge, facing numerous obstacles along the way, including a very ambitious timeline for extremely complex negotiations.

As we await the outcome of this last-minute, adrenaline-fueled effort, the progress made so far is significant and represents the foundational steps toward improved global pandemic preparedness.

Even if some elements are left open for more detailed discussion in future negotiations, the advancements already achieved are significant – and should be secured by the WHA.

The proposal: an improved global PPPR set of rules

At the launch of the negotiating process, after extensive consultations with a broad spectrum of stakeholders, Member States spearheading this initiative began outlining the foundation for a new global, equitable system of PPPR.

Since the release of the Conceptual Zero Draft, in November 2022, the ambition for this instrument has remained high. Over the six iterations of the draft treaty text released in the past 18 months by the INB Bureau—two co-chairs and four vice-chairs from each of the WHO regions leading the process—the aim has been to cover the entire framework of pandemic prevention, preparedness, and response. 

The intention of negotiators has also been to ensure synergy and complementarity with the International Health Regulations (IHR), a task made more complex by the parallel process to amend the circa 2005 IHR  launched by the Health Assembly in 2022.

The draft pandemic document addresses diverse and complex areas such as One Health, global supply chain, local production of health products, research and development, transfer of technology and know-how, access to pandemic products, pathogen and benefit sharing, and sustainable and predictable financing for PPPR. Its overarching goal is to achieve health security with equity in all these aspects.

At each step of the negotiations, the scope of the work has largely remained true to the original ambition. The depth of certain provisions has certainly evolved, based on political acceptability. 

Some key provisions of initial drafts have now disappeared

WHO member states going line by line in May 2024, in an effort to agree on the proposed WHO instrument on pandemic prevention, preparedness and response.

Some significant exceptions have emerged on key provisions. For instance, reference to human rights and accountability mechanisms, such as a strict reporting system and an implementation and compliance committee, have largely been eliminated from the current draft. However, the core building blocks of the agreement remain intact.

In this final negotiating stage, Member States are negotiating each article line-by-line. As they progress on their work, they use green highlights for parts with consensus and yellow highlights for parts that have reached consensus in working groups but not yet in plenary sessions.

While it is not possible to predict the outcome of these negotiations, an analysis of the green and yellow text as displayed in the draft document on May 10 indicates there would be significant changes, and to some extent improvement, in global readiness and response if the agreement is to be adopted.

Local production and R&D: a first-time step towards equity

Cape Town’s Afrigen Vaccines & Biologics. The pandemic highlighted the dearth of investment in vaccine R&D and manufacturing in developing countries.

On local production of pandemic products, the draft text attempts to respond to the concentration of manufacturing in a few countries in the world. It requests Member States to take measures to achieve more equitable geographical distribution and rapid scale-up of the global production of pandemic-related health products.

This aims to increase sustainable, timely, and equitable access to such products, and reduce the potential gap between supply and demand during pandemic emergencies. The text goes on to identify other collaborative measures Member States will endeavor to take, such as, for instance, supporting skills development and capacity-building, and promoting and incentivizing public and private sector investments. 

While it is not perfect, this is the first time that, to our knowledge, an international, legally-binding instrument seeks to expand local production of health products.

The provisions on research and development (R&D) yields a similar conclusion. While some delegates remain concerned about the imposition of new transparency obligations on R&D and tying global access conditions to publicly funded R&D, there appears to be consensus on the rest of the article. 

Notably, this would also be the first time an international treaty seeks to make R&D for health products more equitable and collaborative.

Pathogen and benefit sharing: a make-or-break article

Most countries agree that pathogen sharing needs to be timely and reliable – creating sharing mechanisms, while ensuring equitable benefit sharing, is challenging.

The draft agreement ambitiously aims to establish a Pathogen Access and Benefit-Sharing (PABS) system as part of the Agreement, which would represent a new and binding obligation for nations that ratify the treaty.

Ensuring timely and reliable sharing of pathogen samples and genetic sequence information, along with equitable sharing of benefits arising from their utilization, is crucial for PPPR and access to health technologies. However, over time, it has become clear that a detailed articulation of PABS would be impossible to achieve by the May 2024 deadline – partly due to the complex technicalities that are involved.

For instance, while draft versions of the text had aimed to define a fixed proportion of vaccine and medicines set-asides to be offered for free or at concessionary prices in the event of a pandemic, agreement on a percentage has remained elusive and may not be responsive to changing conditions in a crisis. Similarly, how to ensure equity alongside other disease priorities remains an issue. 

Additionally, agreement is still lacking on other key aspects of the future system. Issues such as the use of standardized, legally binding contracts, user registration requirements, intellectual property rights, its relation with other international instruments, and equitable access to scientific and monetary benefits are still under discussion.

The negotiators of the PABS system will also have to take into account the parallel discussions concerning the establishment of a multilateral access and benefit sharing mechanism under the UN Convention on Biological Diversity.

Agreement on ‘principles’ seems to be most likely outcome

Ethiopia representing the Africa group at pandemic agreement negotiations in March 2024.

In light of such complexities, negotiators seem to be close to agreeing on principles to be included in a future PABS instrument, listed under draft Article 12, with a proposal to finalize the details by May 2026 through a process open to all WHO member states – and to be launched by the World Health Assembly.

There is, however, agreement on a reaffirmation of  the principle of national sovereignty over biological resources.

Additionally, the emerging broad international recognition that the rapid sharing of pathogen samples and associated genetic sequence information should be linked to equitable benefit-sharing is significant. It responds to a key ask by developing countries to operationalize equity – even if some argue it doesn’t go far enough. 

Overall, it would be the first time governments agree on principles tailored for addressing ABS for pandemics in a legally-binding instrument.

The outstanding points can be addressed in future negotiations regarding the full operational details of the PABS system. 

One Health 

Live animal markets have been a hotspot for pathogen transmission to humans – one of the many issues that One Health principles aim to address.

Negotiators have worked intensively on how to integrate the One Health approach into the Pandemic Agreement. This approach acknowledges the interconnection between the health of people, animals, and ecosystems, marking its first inclusion in an international legally binding instrument.

Developed countries are the main supporters of this approach, while several developing countries have shown concern about the binding regulatory burden as well as the associated costs that One Health provisions in the agreement might impose on them.  Some developing countries have also expressed a concern that tight prescriptions on One Health may result in unpredictable obstacles to their agricultural trade. 

Despite these concerns, there seems to be a consensus on the importance of the inclusion of One Health as an essential approach to PPPR, especially in light of the fact that it is estimated that 75% of all emerging infectious diseases are zoonotic, along with the adoption of selected measures that consider national circumstances. Further discussions after the World Health Assembly have been proposed, potentially to be included in a future Annex, but the outcome remains uncertain and will likely depend on the negotiations’ final stages. 

A glass half full: the road ahead

The current state of the Pandemic Accord can be seen as a glass half full. The green and yellow text represent a considerable step forward from the state of international law before the launch of the negotiations, promising significant improvements in global pandemic readiness and response.

To ensure the glass continues to fill, countries must establish a robust framework for ongoing work. This framework should list a common agenda of unresolved questions, outline guiding principles, and set a strict timetable for completion.  Delegates, on their side, must demonstrate the same determination and resilience they have shown over the past two years.

As the WHA approaches, the international community awaits the outcome with keen anticipation. If the international community can maintain its focus and commitment, the Pandemic Accord will not only represent an improvement over the status quo but also pave the way for a more resilient and equitable global health system.

Daniela Morich is Manager and Advisor at the Governing Pandemics Initiative hosted by the Global Health Centre at the Geneva Graduate Institute. 

Adam Strobeyko is a postdoctoral researcher for the Governing Pandemics Initiative.

Suerie Moon is co-director of the Global Health Centre.

Gian Luca Burci is Adjunct Professor of international law at the Geneva Graduate Institute.

Ava Greenup is a Project Associate of the Governing Pandemics Initiative. 

Image Credits: @RicardoDGPS, Chris Black/WHO, Rodger Bosch for MPP/WHO, NIAID-RML , lihkg.com.

An information and prevention campaign coupled with HIV testing in Côte d’Ivoire at a public transport hub. Despite outreach efforts, new infections from HIV/AIDs still are not declining fast enough to reach 2030 Sustainable Development Goals.

New WHO data show that new infections from HIV/AIDS are not declining fast enough. Also, syphilis along with other sexually transmitted infections (STIs) are increasing in many regions of the world, contrary to the ambitious targets set by the Sustainable Development Goals and WHO member states for ending the epidemics of AIDS, viral hepatitis B and C and sexually transmitted infections by 2030.

Altogether STIs caused 2.5 million deaths in 2022, according to the new WHO report, Implementing the global health sector strategies on HIV, viral hepatitis and sexually transmitted infections, 2022–2030, published Wednesday.

And the estimated number of deaths from viral hepatitis rose from 1.1 million deaths in 2019 to 1.3 million in 2022 despite the availability of effective prevention, diagnosis, and treatment tools. In 2022, around 1.2 million new hepatitis B cases and nearly 1 million new hepatitis C cases were recorded, the report also finds.

“The rising incidence of syphilis raises major concerns”, said WHO Director-General Dr Tedros Adhanom Ghebreyesus, in a press briefing on Wednesday. “Fortunately, there has been important progress on a number of other fronts including in accelerating access to critical health commodities including diagnostics and treatment.

“We have the tools required to end these epidemics as public health threats by 2030, but we now need to ensure that, in the context of an increasingly complex world, countries do all they can to achieve the ambitious targets they set themselves”.

Increasing incidence of sexually transmitted infections

Four curable STIs – syphilis, gonorrhoea, chlamydia, and trichomoniasis – account for over 1 million infections daily. The report notes a surge in adult and maternal syphilis (1.1 million) and associated congenital syphilis (523 cases per 100,000 live births per year) during the COVID-19 pandemic. In 2022 alone, there were 230,000 syphilis-related deaths.

In 2022, member states set a target to reduce adult syphilis infections tenfold by 2030, reducing cases from 7.1 million to 0.71 million. Yet, new syphilis cases among adults aged 15-49 years actually increased by over a million cases in 2022 reaching as much as eight million, with the biggest increase in the Americas and the African Region, the WHO report found.

HIV infections among risk groups

Meanwhile, new HIV infections only declined from 1.5 million in 2020 to 1.3 million in 2022 – an inadequate trajectory to meet SDG target 3.3 to ‘eliminate the epidemic of AIDS’ by 2030. Five key population groups — men who have sex with men, people who inject drugs, sex workers, transgender individuals, and individuals in prisons and other closed settings — still experience significantly higher HIV prevalence rates than the general population. An estimated 55% of new HIV infections occur among these populations and their partners.

The picture is no better with HIV-related deaths, still reaching high numbers. In 2022, there were 630,000 HIV-related deaths, 13% of these occurring in children under the age of 15 years.

New data also show an increase in multi-resistant gonorrhoea. As of 2023, out of 87 countries where enhanced gonorrhoea antimicrobial resistance surveillance was conducted, 9 countries reported elevated levels (from 5% to 40%) of resistance to ceftriaxone, the last line treatment for gonorrhoea. WHO is monitoring the situation and has updated its recommended treatment to reduce the spread of this multi-resistant gonorrhoea strain.

Gains in expanding service access

Efforts by countries and partners to expand services for STIs, HIV and hepatitis are nonetheless chalking up gains. WHO has validated 19 countries for eliminating mother-to-child transmission of HIV and/or syphilis, reflecting investments in testing and treatment coverage for these diseases among pregnant women. Botswana and Namibia are on the path to eliminating HIV, with Namibia being the first country to submit a dossier to be evaluated for the triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis.

Globally, HIV treatment coverage reached 76%, with 93% of people receiving treatment achieving suppressed viral loads. Efforts to increase HPV vaccination and screening for women with HIV are ongoing. Diagnosis and treatment coverage for hepatitis B and C have seen slight improvements globally.

Image Credits: JB Russel/ The Global Fund/ Panos, WHO.

Prof Sharon Lewin, director of the Cumming Global Centre for Pandemic Therapeutics

During the COVID-19 pandemic, therapeutic development took a backseat to vaccines – a potentially disastrous gamble had vaccines not been found.

In future pandemics, therapeutics and vaccines should be treated equally – particularly as COVID-19 treatment options remain expensive and mostly only available in high-income countries, speakers told at a webinar this week hosted by the Cumming Global Centre for Pandemic Therapeutics in Melbourne.

During the first 12 months of the COVID-19 pandemic, $91 billion was publicly invested globally in vaccines compared to just $4.6 billion in therapeutics. 

“The first COVID-19 vaccine was approved in July 2020 and delivered to people in December 2020. However, the therapeutic drug, Paxlovid, was only first administered in late 2021 and approved by the US Federal Drug Administration in May 2023,” according to Cumming Centre, which is based at the Peter Doherty Institute for Infection and Immunity.

“If Paxlovid and Molnupiravir, or a similar therapeutic drug, had been available at scale in July 2020, in line with COVID-19 vaccine approval, millions of lives globally could have been prevented.”

Problems with ACT Accelerator

One of the problems during COVID-19 was the structure of the Access to COVID Tools Accelerator (ACT-A), the global structure that was set up to ensure low and middle-income countries had access to health products such as tests, vaccines, treatments and PPE, said Eloise Todd, executive director of the Pandemic Action Network.

ACT-A was divided into four separate pillars – vaccines, therapeutics, diagnostics, and a ‘health systems connector’.

Civil society warned from early on that unless ACT-A had “a single fundraising strategy and a single entity that’s going to spend against an epidemiological strategy, you’re essentially setting up a competition between those forces”, added Todd.

Sure enough, “by September 2021, the vaccines pillar had achieved 95% of its fundraising target and the therapeutics pillar, just 19%”, she said, adding that the “vaccine gold rush approach” undermined the holistic management of COVID.

Generics also “came too late in the process to have an impact in lower middle income countries”, said Todd.

Eloise Todd, executive director of the Pandemic Action Network.

“When the next threat comes around, the epidemiological approach we need to take means that we have to have a bird’s eye, focused view on saving lives from Day One. So by all means, let’s have the R&D for vaccines, but we have to have the R&D for therapeutics. We also have to look at how to repurpose existing therapeutics.”

Shingai Machingaidze, co-chair of the Science and Technology Expert Group (STEG) of the International Pandemic Preparedness Secretariat (IPPS), said that the development pipeline for therapeutics faced “multiple hurdles, including long development timelines, regulatory challenges, and the need for robust clinical trial infrastructure growth globally”. 

A key recommendation of an expert review of the COVID-19 response commissioned by the G7 and G20 was the need for a global coalition focused on therapeutics, she said, adding that the IPPS is currently working on establishing such a coalition.

The aim is not to create a new entity but to bring together the existing entities and to ensure sustained R&D funding to develop at least two Phase 2-ready therapeutic candidates against individual viral pathogen families of greatest pandemic potential, added Machingaidze.

Shingai Machingaidze, co-chair of the Science and Technology Expert Group of the International Pandemic Preparedness Secretariat

HIV: No vaccine but effective ARVs

“Imagine a situation where we have a new pandemic, and we can’t make a vaccine or it takes 10 years to make a vaccine, not one year,” said Prof Sharon Lewin, director of both the Doherty and Cumming centres.

“As an example, after 40 years of research for HIV, there is still no HIV vaccine. However, therapeutics, but what I mean here is direct-acting antivirals or drugs that stop HIV from replicating, have turned HIV from a death sentence to a chronic manageable disease,” she added.

“Direct-acting antivirals can fill a gap. They can be a second layer of protection, or they can actually be the only intervention we have. So we need to really think hard about how we can make them better, make them faster and make them equitable.”

The Cumming Centre was launched in September 2022 as a joint venture of the University of Melbourne and Royal Melbourne Hospital following a $250-million donation from Geoffrey Cumming, making it the “biggest philanthropic gift in the history of Australia”, said Lewin.

“We’re not a drug company, nor do we plan to do what companies already do well,” she added. 

“We plan to expand the pipeline for drug companies to ultimately commercialise and implement new therapeutics, so our goal is to focus on new platform technologies to develop therapeutics at speed for pathogens of pandemic potential.”

The centre’s goal is to provide “really long-term funding” to  projects that are “high risk, but also high reward”, added Lewin.

“We need treatment solutions, not only for pathogens that we know about but for pathogens that are totally unexpected. And we need to be able to develop those solutions in a much shorter time frame than what’s currently possible with our current technologies. I personally think this can be done but it will need new science, new ideas and transformational changes in how we approach therapeutics.”

Lewin added that her centre had a smaller focus on anti-microbial resistant (AMR) pathogens “because we think the likelihood it of causing a global pandemic is much smaller than a viral cause”.