Nurses| Cameroon
Student nurses prepare for the morning rounds at the Ndop District Hospital in Bamenda, Cameroon

When nursing graduates in low- and middle-income countries (LMICs) receive their hard-earned diplomas, they’re no longer cheered on only by proud family members and university faculty.

“The recruiters pitch up on the nurses’ graduation day in our country,” one delegate told me at the recent World Health Assembly (WHA).

It’s a striking image: nurses, newly educated by their home countries, swarmed by recruitment agencies hoping to attract them to wealthier nations experiencing staff shortages. Experienced and specialist nurses, including critical care nurses, are also being aggressively recruited, depriving their native countries of vital expertise.

Across a week of conversations with the world’s nurses, nurse leaders, and policymakers at this year’s WHA, a clear picture emerged of a worsening nursing migration crisis driven overwhelmingly by a small number of high-income nations, including the UK, USA, Canada, Australia, and certain Gulf states, poaching nurses from vulnerable countries in what some African healthcare leaders have called a “new form of colonialism”.

This is not only a workforce and staffing issue: it’s a public health and global equity issue that threatens the achievement of our shared UN sustainable development goals, including universal health coverage.

Tackling this requires immediate action on multiple fronts. We propose three key measures: a temporary ban on actively recruiting nurses from fragile health systems; a stronger WHO Global Code of Practice with robust monitoring and accountability mechanisms; and meaningful compensation for underresourced countries losing nurses to wealthier nations.

Our world’s most vulnerable health systems need us to develop, not deplete, their nursing workforce—and with crucial worldwide elections and the next G20 meeting fast approaching, now is the time to prioritise this issue on the global agenda.

To chart a path forward, we must first understand the current situation and how we got here. 

Deepening global inequalities

It’s important to protect individual nurses’ rights to migrate in search of better opportunities but the playing field is grossly unequal.

The distribution of the world’s nurses is strikingly uneven across regions — the State of the World’s Nursing report shows that just 3% (less than 1 million) of the world’s nurses are in Africa with over 80% in Europe, the Americas,  and the Western Pacific region. With up to a tenfold difference in nurses per capita between high- and low-income nations, this means affluent countries are recruiting from the most fragile health systems who can least afford to lose their workers.

At WHA, we heard repeated frustrations around high-income countries draining nurses from this scarce pool, offloading the costs of nursing workforce education and planning onto vulnerable nations. In Africa alone, one in ten nurses (and one in five doctors) now work outside the continent, stripping away desperately needed expertise.

Nursing density map
Nurse density maps show a stark divide between high and low-income countries.

We heard that small island states like Tonga and Fiji have suffered even more acute losses. At the Fiji National Economic Summit 2023, health leaders discussed losing 26.7% of their nurses the year previously — and at WHA, we heard that this trend has continued, with 20%–30% of Fiji’s nurses leaving year on year, mostly headed to countries like New Zealand and Australia. 

Stepping-stone migration 

We are seeing new patterns of “carousel migration”, where countries like New Zealand and the UK act as stepping stones for nurses who then go to other nations like Australia, evident in the number of overseas-trained nurses seeking Certificates of Current Professional Status (CCPS) which indicates they’re gearing up to work abroad. We also heard that Canada and Australia are actively recruiting from the UK, with advertisements plastered across public transport hubs urging UK-based nurses to make the move.

Graph of number of UK nurses trained overseas
More overseas-trained nurses are joining the UK workforce — but more of these nurses are then pursuing Certificates of Current Professional Status to practice elsewhere.

We know from historical data that migration left over 40% of nursing jobs in the English-speaking Caribbean unfilled, and the issue hasn’t improved — we heard from Jamaica that ~20% of Jamaica’s nurses were applying for credentials to leave.

Historically the Philippines has been a supplier of nurses for the world but we heard concerns from their representatives at losing a third of Filipino nurses overseas each year and the impact that has on meeting their own country health needs. This sounds a cautionary note on the  “educate-to-export” model that purposefully trains nurses as labour exports, which has been advocated for as a solution to the current global shortage. This is a risky policy that could widen health inequalities as the gap in numbers of nurses grows between source and destination countries — and it locks the sending countries into dependence on nursing exports rather than setting them on a path to sustainably grow their own healthcare workforce.

Crisis made worse by stopgap measures

Poor working conditions, limited opportunities, and economic strains in developing countries drive nurses to seek better salaries abroad. Even as vulnerable nations face nurse shortages, we are hearing that some lack employment for their nursing graduates due to underdeveloped health systems. They need high-income countries to support them in building robust health systems — rather than raiding their workforce. 

Over a year ago, ICN declared a global health emergency based on the global shortage of 6 million nurses and deep-seated health inequalities, exacerbated by the brain drain of skilled nurses from vulnerable nations. We are already off track on our global ambitions to achieve universal health coverage by 2030 — and rising levels of often aggressive and ethically questionable nurse recruitment is a major contributor, widening healthcare gaps and jeopardising our progress.

Nurses in high-income countries are ageing and burning out — and we are consistently seeing governments make the unethical and unsustainable choice to plug their staffing gaps by looking abroad, rather than addressing the root causes and investing in both educating and retaining their nurses. 

This is a short-sighted, leaky-bucket approach. It’s also self-defeating to simply try to turn the tap of nursing education to fully open, without fixing the holes of poor employment and working conditions that cause so may to leave. The failure to create decent working conditions and retain the valuable nurses we already have has led to an alarming rise in strike action by healthcare workers worldwide. Increased pressures on the nurses left behind in countries like Fiji and Tonga has sparked labour unrest.

In high-income destination countries like Sweden, where nurses are currently on strike, health leaders at WHA side events said “migration is being used to short-cut the issues of decent work and investment in the education, recruitment and retention of our health and care workers.” An unsustainable dependence on nurse immigration also undermines healthcare resilience and pandemic preparedness in wealthier nations — we saw how temporary blocks on health worker mobility during Covid left wealthier countries massively short staffed.

Reshaping global policy and practice 

The WHO’s Global Code of Practice on the International Recruitment of Health Personnel calls for countries to prioritise self-sufficiency by training and retaining domestic health staff and identifies vulnerable states off-limits for hiring unless bilateral agreements are in place where hiring countries invest in the source nation’s health workforce or education.

So far, though, we have seen little evidence for meaningful, well-defined bilateral agreements with clear financial commitments. Often, these agreements give more of a whiff of creating an ethical veneer than ensuring truly proportional and mutual benefits.

To actually stem the tide of nurse migration from developing countries, the Code must be drastically strengthened and universally and consistently enforced.

We need at least a temporary freeze on active recruitment of nurses from the world’s most fragile health systems.

We need a better system for monitoring and reporting on international nurse mobility, national self-sufficiency, and compliance with the Code, and we need measures to ensure accountability. Only seventy-seven countries, representing 55% of the world’s population, are currently reporting their health worker migration information to WHO. At a time when we need nations to take this worsening issue more seriously than ever, European countries are actually reporting less than in previous years — fewer than half submitted data to WHO in the latest reporting round.

WHO code reporting graph
The last round of global WHO code reporting shows major gaps in the participating countries.

We need wealthier countries to compensate vulnerable countries when recruiting from them, by directly investing longer-term in their health infrastructure and education, perhaps through an “offsetting” program akin to carbon credits.

Above all, we need to act now — we cannot afford to wait until next year’s WHA to address this burning problem.

That is why the International Council of Nurses is calling on the G20 heads of state to make effective implementation of ethical health worker migration policies a central agenda item when they convene in November.

Building self-sufficient nursing workforces is the only way to achieve our global goals of health for all.

Howard Catton, a registered nurse, is the Chief Executive Officer of the International Council of Nurses, a federation of more than 130 National Nursing Associations representing the 29 million nurses worldwide. He has worked extensively on nursing and healthcare workforce issues, co-chaired the first State of the World’s Nursing Report, led ICN’s efforts to support nurses during the pandemic, and continually advocates for health in all policies and the essential contribution of the nursing profession to addressing the global health agenda.

Image Credits: © Dominic Chavez/The Global Financing Facility, State of the World’s Nursing Report, UK Health Foundation, WHO, Studioregard.ch.

Alzheimer's Disease and dementia can lead to loneliness in old age.
Alzheimer’s disease is the most common type of dementia found in elderly people.

Around 55 million people worldwide live with dementia, and an estimated 60% to 80% of those individuals suffer from Alzheimer’s Disease (AD), according to the World Health Organization (WHO). That number is expected to increase to around 139 million within 25 years.

Projections from the National Center for Health Workforce Analysis indicate that by 2025, the demand for neurologists will surpass the available supply across all regions of the United States. Access to specialist services is already restricted or nonexistent in some low- and middle-income countries. Consequently, many individuals with cognitive impairments do not and will not receive proper evaluations, and it is anticipated that access to dementia specialists will become increasingly constrained in the future.

Already, data suggests that 31- 74% of patients with symptomatic AD are not identified, which can lead to delays in care, administration of inappropriate therapies and incorrect prognostic guidance.

Last week, a peer-reviewed article was published in Nature Reviews Neurology by the Global CEO Initiative on Alzheimer’s Disease BBM (blood biomarker) Workgroup, highlighting why “blood tests for Alzheimer’s disease promise to provide an earlier and more accurate diagnosis for many patients with cognitive impairment.”

“Some currently available blood tests are extremely accurate while others are little better than flipping a coin,” explained Workgroup lead Suzanne Schindler. “We worked with many stakeholders to develop minimum standards for the accuracy of these blood tests because we know that a timely and accurate diagnosis of Alzheimer’s disease has a major impact on a patient’s life.”

Since 2021, new treatments for AD that modify the disease’s progression have started to be used in clinical practice. The FDA has approved two amyloid-β antibody treatments, aducanumab and lecanemab, and is currently reviewing a third, donanemab. These therapies are designed for early stages of AD, including mild cognitive impairment or mild dementia, and require confirmation of amyloid plaques in the brain before starting treatment.

Anti-amyloid treatments help by targeting and removing beta-amyloid, a protein that forms plaques in the brain. Each therapy works uniquely, targeting different stages of plaque formation.

The team wrote in its paper that because Amyloid PET and CSF tests have limitations and aren’t easy to scale up, BBM tests are likely to become the primary method for diagnosing Alzheimer’s. They said that BBM tests are more convenient and accessible and can quickly increase in number to meet the rising demand. They can also be used in primary care (like your regular doctor’s office) and secondary care (specialist clinics), making them a practical option for more widespread testing and treatment.

“The backdrop that’s important to understand here is that the current state of the Alzheimer’s disease diagnostic pathway has at least two primary bottlenecks, including long wait times to see brain health specialists, made worse by overwhelmed primary care providers who lack the practical tools, operational support and standardized assessment process to triage patients effectively,” Tim MacLeod, director of the Healthcare System Preparedness Program of the Davos Alzheimer’s Collaborative (DAC), told Health Policy Watch.

“Traditional diagnostic inputs to inform an Alzheimer’s diagnosis are typically expensive and not readily accessible. Current methods may include lumbar puncture to collect cerebral spinal fluid and imaging such as positron emission tomography or magnetic resonance imaging.

“Blood biomarkers are a promising tool that could help make the diagnostic pathway more time and resource-efficient,” he continued, commenting in general and not on the new Nature report specifically.

The BBM Workgroup recommended that a BBM test have a sensitivity of ≥90 percent, with a specificity of ≥85 percent in primary care and ≥75–85% in secondary care, depending on the availability of follow-up testing.

The CEOi BBM Workgroup, which includes 90 stakeholders from healthcare, academia, non-profit, government, venture capital, industry, and patient advocacy, said its performance standards can be used for any test and does not endorse any specific BBM test. Its standards reflect an expert consensus, marking the first time stakeholders have united to establish a common framework.

The group said that “by adhering to these performance standards, high-quality BBM tests have the potential to revolutionize Alzheimer’s diagnosis, enabling more patients to receive the timely and accurate assessment of whether they may wish to consider using newly approved disease-modifying treatments.”

“A delayed diagnosis to a later stage of the disease will effectively deny access to current and promising disease-modifying treatments,” commented George Vradenburg, founding chairman of the DAC. “Diagnosis delayed will mean treatment denied.”

Health care 'ecosystems'
George Vradenburg participates in a private Davos panel discussion on building better health “ecosystems”

‘Significant Challenges’

However, MacLeod said, “Unsurprisingly, as we watch health systems plan, we’re observing that while specialty sites of care may have a diagnostic pathway, there are significant challenges in making those pathways scalable through the addition of primary care.”

He said, for example, that figuring out how primary care teams can identify patients who need a blood test is a widespread challenge. This process demands significant operational changes and better cooperation across different practice areas. Additionally, there are practical issues like limited access to specialists and long referral wait times. In some cases, providers within their system are skeptical about the availability and effectiveness of treatment and support options, further complicating the efforts of primary care providers to address cognitive complaints.

To address these challenges, the DAC has launched a new initiative across health systems in five countries. This initiative uses BBMs and confirmatory diagnostic testing to improve the timely and accurate diagnosis of Alzheimer’s disease and related dementias (ADRD). Managed by the DAC Healthcare System Preparedness (DAC-SP) team, the Accurate Diagnosis project is the first global research program to explore the integration of blood biomarkers in the ADRD diagnostic process.

“This program – implemented in both primary and specialty care centers – will help us understand the barriers to implementing blood biomarkers and the ways in which blood may help drive efficiencies in the diagnostic process,” MacLeod told Health Policy Watch.

Healthcare systems in Germany, Japan, the Netherlands, the United Kingdom and the United States will implement, evaluate, and share insights on using BBMs and confirmatory Alzheimer’s pathology testing. This project aims to integrate these tests, typically used in research, into routine clinical practice, speeding up the adoption of validated tools for timely patient care.

Sites were chosen based on their scientific and clinical expertise and their ability to reach diverse patient populations in terms of age, race, ethnicity, education, socioeconomic status, and geographic location, DAC said. The initial sites include:

  • University of Kansas Alzheimer’s Disease Research Center
  • Icahn School of Medicine at Mount Sinai
  • Wake Forest University School of Medicine
  • Alzheimer Center Amsterdam at Amsterdam UMC
  • Imperial College London and Imperial College Healthcare NHS Trust
  • Ludwig-Maximilians University (LMU) Hospital Munich – Alzheimer’s Therapy and Research Center
  • Tokyo Metropolitan Institute for Geriatrics and Gerontology

“The project sites are just beginning … to get patients enrolled this summer and hope to have results to share in 2026,” MacLeod shared. “One of the primary aims of this program is to make implementation easier for other health systems that want to implement this type of program.

To that end, we will co-design a blueprint with site leaders informed by our research learning that will help translate lessons learned and effective implementation strategies into pragmatic, actionable tools that can be harnessed by health system leaders.

“Additionally, by using implementation science methods, we are uniquely positioned to learn as we go,” MacLeod continued. “We are already seeing learnings emerge in the start-up phase that we expect will be of great benefit to future health systems wanting to use blood biomarkers in their practice. And by bringing the site leaders together for a monthly community of practice, they have the unique benefit of being able to share their learnings with one another and get creative as they navigate common challenges in their project planning.”

MacLeod stressed that “the stakes are really important here” as an accurate diagnosis is a necessary first step toward receiving interventions such as lifestyle modifications, pharmacological treatments, education, support, practical care and legal planning.

“As new treatments become available, pinpointing the patients who can benefit most from them will be essential since current treatments and interventions are effective when administered at earlier stages of the disease,” MacLeod said. “This is the first time [an implementation study of BBMs] has been done. Our goal is to speed up research and get directly to the patient faster.

“This is a very optimistic time for the field.”

Image Credits: Photo by Steven HWG on Unsplash, John Heilprin.

Mpox lesions

Seven cases of “severe Mpox” have been confirmed in South Africa, and two of those diagnosed have since died.

All cases involve men in their thirties living with co-morbidities – most notably HIV. Five of the seven identified as “men who have sex with men,” according to the South African Department of Health.

None of the confirmed cases had travelled to countries with ongoing Mpox outbreaks.

The country is waiting for a consignment of Mpox vaccines to arrive as well as the treatment, tecovirimat, according to Health Minister Dr Joe Phaahla. 

“These vaccines will not be procurements but donations co-ordinated by the World Health Organization (WHO) and Gavi,” Phaahla told a media briefing.

Once these arrive, the health department intends to offer free vaccinations to four  groups it regards as most at risk: men who have sex with men, sex workers, health workers and laboratory workers.

The seven patients’ known contacts are also being monitored for 21 days.

“The cases in South Africa were only detected in very sick individuals, highlighting that the epidemic is probably much bigger and that we need more diagnosis and contact tracing,” according to Professor Tulio de Oliveira, director of the Centre for Epidemic Response and Innovation (CERI) at the University of Stellenbosch in South Africa.

The cases were confirmed by South Africa’s National Institute for Communicable Diseases (NICD). Available sequence data from three cases revealed the circulation of Clade IIb, the Mpox strain that led to the largest multi-country Mpox outbreak in 2022.

“We are committed to supporting South Africa in securing the necessary doses of Mpox vaccines, and building capacity for event-based surveillance focusing on community and health facility,” said Dr Jean Kaseya, the Director General of the Africa Centres for Disease Control and Prevention after meeting South Africa’s health minister.

“An Mpox outbreak anywhere is a threat everywhere. We call for swift and urgent action to increase access to Mpox diagnostics, vaccines and therapeutics for all affected African countries.” 

Since January, seven African countries have reported Mpox, with a total of 8,479 cases and 401 deaths as of 14 June. The vast majority of cases – 97% – are from the Democratic Republic of Congo.

Image Credits: Tessa Davis/Twitter .

WHO is working with countries to scale up oxygen access, particularly in low- and middle-income countries but the requirement is a mystery.

The COVID pandemic brought into focus the life-saving role of medical oxygen – but the stock of oxygen is still severely limited in low- and middle-income countries, and many don’t know how much oxygen they need.

Despite wide-ranging efforts to improve access to oxygen and oxygen delivery devices over the past four years, services in low- and middle-income countries remain severely limited, according to a study by the World Health Organization (WHO), published in October 2023.

WHO investigators estimate that non-invasive advanced respiratory support is needed for around 1% to 3% of patient beds, and for 2%–25% of those on ventilators, depending on the region. The world health body has cautioned that these are preliminary trends and not the final findings.

But basic oxygen and the oxygen delivery devices remain severely limited in many countries, as is data about needs and gaps.

“Pre-pandemic oxygen needs and post-pandemic oxygen needs are likely to be similar with appropriate adjustments for population growth over time,” Lisa Smith who leads the Market Dynamics programme at the global health non-profit PATH, told Health Policy Watch.

“Oxygen needs to continue to be a central focus of reliable healthcare access. Initiatives that promote its improved access mustn’t slow now that the pandemic is passed. Instead, there should be sustained investment that ensures countries are resilient in the face of efficient spread of disease and with that, unexpected fluctuations in oxygen demand,” she said.

The WHO convened a three-day meeting in May in Dakar, Senegal, where participants shared best practices and gaps that the pandemic period revealed, and the challenges in scaling up their national plans. WHO aims to come up with a template that will allow member states to develop their own evidence-based national plans.

Discussions at the meeting addressed the need for technical support for countries to improve their safety standards to prevent accidents and fires. They also covered issues such as sustainable financing, better workforce planning, and public-private partnership potential to improve access.

Lack of data on the need

The key issue highlighted was the lack of understanding of just how much oxygen is needed, and where the need is.

“The data just almost doesn’t exist,” said Nahreen Ahmed, Medical Director of non-profit MedGlobal that works in crisis and conflict zones. “And there’s almost always a shortage of human resources. And because of that, there isn’t somebody that’s actually allocated to collect this data and then there isn’t like a system that it goes. I think if there was a general registry of some kind that was always available for this information to enter into, I think that would probably help,” she said.

She also highlighted that just as the pandemic where the need for oxygen went up dramatically, in conflict zones the need fluctuates wildly depending on whether it is a period of stability or conflict.

“It’s a two-part question, really, what’s the baseline use? And then what is the anticipated need when there is an escalation of something whether it’s a natural disaster, epidemic, conflict, something like that,” Ahmed said.

A representative from India shared that the multiple platforms developed to gauge oxygen use during the pandemic are no longer used as hospitals don’t feel the need to spend time entering the data. He added that multiple platforms meant that the data was duplicated – highlighting not just the need for better technology but also better coordination.

As of 2024 an estimated 200,000 cubic meters of oxygen a day is required for oxygen needs in all low-and middle-income countries, according to a PATH tracker, established during the pandemic.

The trackers developed during the pandemic are no longer helpful now.

“The needs tracker does not estimate oxygen requirements for all treatment indications (it is currently COVID-19-specific). If it did, the total figures would be higher, however the trend in need since the pandemic would still show a decline until it levelled off/returned to typical fluctuations due to disease seasonality,” Smith told Health Policy Watch about the PATH tracker.

During the pandemic, WHO officials made the case to re-think oxygen as a health tool that requires a sustainable supply at the country level, as Health Policy Watch reported earlier.

Power cuts, fire hazards

Representatives of developing countries highlighted how the lack of basics like a reliable power source affects an oxygen plant’s ability to supply high-quality oxygen.

“If we expect to have an uninterrupted supply of medical oxygen we have to have an uninterrupted supply of power in order to produce it,” said Jim Stunkel, Vice President of Technical Services at global non-profit Assist International. He added that the solutions might have to be beyond the traditional grid. “Grid may not be it. I was so impressed by those that are innovating, looking forward to green solutions and solar solutions,” he said.

Across the world health facilities have been employing green solutions to run basic facilities, and while the usage for oxygen plants is currently limited, the meeting shone light on the potential to expand access of green energy sources.

Another challenge is the fire hazard posed by a sudden scale-up of oxygen in a health facility, and the need for improved safety protocols. During the pandemic, several catastrophic fires broke out in health facilities around the world, killing hundreds of people.

The WHO Access to Oxygen Initiative provides technical and operational support to Member States.

Image Credits: Unsplash, PATH, WHO, Twitter.

From a luxury good to a part of daily diets, sugary drinks pose a growing risk to health in developing as well as developed countries.

In a first for healthier diets, WHO has issued a “strong recommendation” that countries tax sugar-sweetened beverages as part of a wider effort to combat the powerful health impacts of the industrial foods industry – whose marketing of sugar, sodium and fat-laced, processed foods is linked with millions of deaths annually.

WHO also issued more “conditional” recommendations in favor of the taxation of unhealthy foods and the subsidizing of healthier options, in its new guidelines on “Fiscal Policies to Promote Healthy Diets,” launched Friday. 

The first-ever WHO recommendations on food pricing policies comes only days after a scathing report by WHO’s European Region, that found unhealthy foods amongst the top four commercial products that cause some 19 million deaths annually worldwide, including 2.7 million deaths in the WHO’s European Region. 

“We need more comprehensive policies,” said Francesco Branca, head of WHO’s Department of Nutrition, at a Friday launch event. 

The guidelines are the result of a painstaking process of evaluation of dozens of studies on taxation policies as they affect foods – in line with stringent WHO requirements.   

Ample evidence from studies looking at sugar sweetened beverages led to a strong recommendation for more taxation of the drinks that are associated with Type 2 diabetes and other noncommunicable disease conditions, Branca and other experts at the event stated. 

WHO recommendations on tax policies for other types of healthy and unhealthy foods, containing excessive fat, salt or processing were more “conditional” due largely to the smaller range of studies on those linkages. 

Sugar sweetened drinks 

Taxes on unhealthy foods and sugary drinks, by country.

While some 115 countries do impose taxes on comparable international brands of sugar-sweetened drinks, the tax rate is “really low at 6.6% of the beverage price,” Branca said. 

And nearly half of the countries that impose such taxes “also include unsweetened beverages like mineral water, which is not unhealthy,” said Branca – effectively canceling out any financial incentive to switch to healthier alternatives. 

Only 25% of country specifically target sugar sweetened drinks, as such, he said, concluding that  “the value is low, the modalities of the tax are not ideal.”

Taxing unhealthy foods 

Nutrition
Between 1975 and 2016, southern Africa saw the world’s highest proportional increase in child and adolescent obesity – 400% per decade. Ultra-processed foods and sugary drinks have been named as a key factor in the rising rates.

Meanwhile, only about 41 countries impose taxes on unhealthy foods that contain excessive levels of  saturated fats, trans-fatty acids, free sugars, salts and are highly processed, the analysis  found. 

Such foods are associated with a wide-range of non-communicable disease conditions from added risks of high blood pressure (in the case of salt), to cardiovascular conditions, in the case of saturated fats, and cancers (in the case of processed meat). 

Although the WHO recommendation about taxing such unhealthy foods is more “conditional,” the report still rebuts a key argument against taxes against unhealthy foods as well as unhealthy beverages, saying:  

“The regressivity of a food tax is a common argument used by opponents of such taxes. However, this argument is based solely on the tax burden incurred by consumers and does not consider the health and economic harm caused by excessive consumption of foods that do not contribute to a healthy diet. 

“While considering the financial impact on lower-income populations, policymakers should strive

to design tax structures that target foods that do not contribute to a healthy diet, encouraging a shift towards healthier options,” the report concludes. “This approach aims to strike a balance between safeguarding affordability of foods that contribute to a healthy diet for all income groups, while discouraging foods the consumption of which is associated with negative health outcomes.”

Subsidizing healthier alternatives 

NCD
Shifts from traditional diets based on local fresh foods to ultraprocessed foods is a driver of the worldwide rise of NCDs.

In terms of subsidizing healthy foods, WHO’s conditional recommendation was based on “evidence form a subset of targeted food subsidies that provide price incentives to consumers at the retail level, including through rebates, tax breaks, discounts, coupons or vouchers, on targeted foods. 

Such subsidies should be applied to foods that are “nutrient-dense, rich in naturally occurring

fibre and/or unsaturated fatty acids, low in saturated fatty acids, trans-fatty acids, free sugars and/or salt, free of non-sugar sweeteners, and/or the consumption of which is associated with positive health outcomes,” WHO recommended. 

Insofar as low-income groups often suffer anyway from food insecurity, food subsidies for healthier foods also can help reduce nutrition related inequalities – for a dual health benefit, the WHO report concludes. 

Even though the body of health-related evidence is insufficient to recommend “specific policy design elements,” the WHO recommendation is supported by evidence about the “probable acceptability and feasibility, probably favourable cost-effectiveness, and the potential for the intervention to increase equity and support human rights,” the guideline’s authors concluded. 

Additionally, they note that unrelated to health, there is ample evidence that “price changes that affect the cost of food can influence decisions on food purchases. So it stands to reason that a subsidy on foods can provide an incentive to purchase.”

Country scorecards

Mexican media campaign warning consumers of the health risks of sugary drinks.

The guidelines also recommend more careful study and monitoring of national food policies – to determine better what works and what doesn’t in terms of taxes, pricing and incentives.  

An interactive WHO global database on food and nutrition action (GIFNA), is being developed and updated to provide ratings and scorecards of national performance on key food related nutrition indicators.  

This data base includes global mappings as well as national “scorecards” on policies vis a vis dietary risk factors like  sugary drinks, phase out of trans-fats, high sodium content, and taxes on unhealthy foods overall.   

Image Credits: Bloomberg Philanthropies, Heala_SA/Twitter, WHO, Dr Alexey Kulikov/Twitter, WHO.

Lydia Zigomo, the Regional Director of UNFPA East and Southern Africa during a press conference Tuesday stressed the need for more funding to support women and girls in during crises.

As many as 65 million people in over a dozen Southern and Eastern African countries from Mozambique to Ethiopia are facing unprecedented challenges with food security, extreme weather events and conflict, UN officials say.

The crises disproportionately affect women, who are already in a more vulnerable situation due to their gender, said Lydia Zigomo, UN Population Fund (UNFPA) Regional Director at a Geneva press conference Tuesday. As “they find themselves displaced far from family planning clinics and national healthcare, the risk of violence soars and unintended pregnancies become a harsh reality,” Zigomo said. 

El Niño led to floodings and  worst drought in 40 years

In a region that is already “no stranger to adversity,” fourteen countries have been exceptionally affected by the recent El Niño season which led to droughts of more than 50 days in most places, marking this period as the driest in 40 years, she noted. 

Among those are Angola, Botswana, the Democratic Republic of the Congo, Malawi, Mozambique, Namibia, Zambia, and Zimbabwe.

But El Niño also caused historic flooding, said Liesbeth Aelbrecht, WHO’s Incident Manager for the Greater Horn of Africa during the same press briefing. After a four-year drought, the Horn of Africa region was hit by torrential rains and floods affecting about 1,6 million people across Burundi, Ethiopia, Kenya, Rwanda, Somalia, and Tanzania. 

The floods also have a significant health toll, from direct effects like injury and infection to cholera outbreaks as a result of water contamination or prolonged mental health impacts. New cholera outbreaks have been reported in Kenya and Uganda (313 and 32 cases in 2024, until the end of April, according to the WHO), along with an increase in cases in other countries, reaching over 80 000 cases in 14 countries this year. Floodwaters are also a breeding ground for mosquitoes, which in turn exacerbates the risks for malaria, dengue or Rift Valley Fever.

Gender based violence haunts Ethiopia 

In Northern Ethiopia, the number of people at risk of gender-based violence has risen to 7.2 million, compared to 6.7 million in 2023. The recent conflict in the Tigray region has left only 3% of its healthcare facilities fully functioning in 2022, which is still affecting the local health system, Zigomo said.

Tigray refugees on the move over the past year to escape Ethiopan and Eritrean forces

The UNFPA response network includes mobile clinics staffed with midwives and health professionals that service remote areas with reproductive health services as well as services for those experiencing gender based violence – including HIV testing, family planning and psychosocial support.

Zigomo appealed for more funds to secure those operations – which otherwise would have been slashed by half or more by the end of the year. So far, UNFPA has reached only about 20% of its global fundraising goal of $1.2 billion for 2024, Zigomo said, saying the global community should consider this not only as a plea for help, but also an opportunity to “turn the tide” and ensure protection of reproductive health as well as an adequate gender based violence prevention.

“Resilience lies within our grasp,” persuaded Zigomo, as she appealed for more donations. “Today, I want to emphasize hope, hope that stems from our collective efforts,” she added.

Image Credits: © UNFPA/Sufian Abdul-Mouty.

Despite the growth of renewable energy, the number of people worldwide without electricity access increased in 2022, for the first time in over a decade.

Progress on household electricity access suffered a setback for the first time in a decade – with 10 million more people lacking access in 2022 as compared to 2021, according to the 2024 Energy Progress Report released this week.

As many as 685 million people were without electricity access in 2022. Some 2.1 billion people continued to rely on polluting fuels like charcoal and biomass for household cooking – with shifts to cleaner, more modern alternatives largely stalled over the past year.

Overall, the world is far off course to achieve the Sustainable Development Goal (SDG)-7 for access to affordable, sustainable energy by 2030, according to the report, whose co-authors included the International Energy Agency, World Bank and World Health Organization.

Most of those lacking electricity access are in Sub-Saharan Africa

Worldwide, some 91% of people worldwide have electricity access as compared to 78% in the baseline year of 2000.  But over 80% of the global population without access to electricity live in sub-Saharan Africa – some 570 million people in the region,

A combination of factors contributed to the setbacks, including the global energy crisis, inflation, growing debt distress in many low-income countries, and increased geopolitical tensions, the report states.

The analysis highlights some promising trends in the rollout of decentralised energy solutions, largely based on renewable energy that is helping more rural areas gain electricity acces. However, most new investments are going to developed countries and not developing ones, worsening the inequity in energy access. Only 1% of PV solar capacity is in Africa.

“Air pollution and energy poverty are claiming lives, inflicting suffering and hindering development. Transitioning more rapidly to clean energy and cooking technologies is essential for protecting the health of the 2.1 billion people without access, and the health of the planet on which all life depends,” Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO).

SDG-7 seeks to ensure access to affordable, reliable, sustainable and modern energy. It includes reaching universal access to electricity and clean cooking, increasing efficiency, and substantially increasing the share of renewables in the global energy mix.

Attaining these goals will help reduce the toxic levels of air pollution inside homes as well as outdoors, which together kill an estimated 7 million people a year, according to WHO.

Nearly 685 million people were without electricity access in 2022 globally.

The report was produced by the International Energy Agency (IEA), the International Renewable Energy Agency (IRENA), the United Nations Statistics Division (UNSD), the World Bank, and the World Health Organization (WHO).

It comes a few weeks after the WHO released its latest report on health statistics that found that the world is off course on achieving health-related SDGs as well, as reported by Health Policy Watch.

Billions without clean cooking

Around 2.1 billion people still live without access to clean cooking fuels and technologies, with the number remaining largely unchanged compared to the 2023 report that looked at trends for the year 2021.

Lack of access to clean cooking contributes to 3.2 million premature deaths each year, according to the report that calls for renewed political commitment on the issue.

Improving access to clean cooking would have a deep impact on people’s health, especially women’s health as they are the ones disproportionately burdened with the task of cooking for the family.

“To achieve Sustainable Development Goal 7, we will need much more investment in emerging and developing economies to expand access to electricity and to clean cooking technologies and fuels. Today, only a fraction of total energy investment is going to the countries where the problems of electricity access and clean cooking are critical, not least in Sub-Saharan Africa,” said Fatih Birol, Executive Director at the International Energy Agency.

Around 2.1 billion people continue to rely on health harmful biomass and solid cooking fuels globally.

Renewables are growing but so is inequity

The growth of renewable energy was seen as an encouraging sign.  Renewable electricity consumption grew by more than 6% year-on-year in 2021, bringing the share of renewables in global electricity consumption to 28.2%. Installed renewable energy-generating capacity per capita reached a new record in 2022.

But developed countries have 3.7 times more capacity installed than developing countries.

And even though the cost of renewable energy has plummeted, less than 1% of installed solar PV capacity is in Africa,  according to another recent IEA report.  Almost 80% of the investments in renewable energy remains concentrated in just 25 countries in 2022, according to the report released this week.

A key reason for this is that banks see investments in underserved regions where infrastructure may be sorely lacking as “high risk”, further increasing the vicious cycle of “energy poverty.”

“Year after year, renewables prove to be a leading player in increasing energy and electricity access through steady expansion of renewable power capacity,” said Francesco La Camera, Director-General of the International Renewable Energy Agency. “But distribution disparity remains stark, as reflected in the international public financial flows in support of clean energy. The rebound in the flows does indicate a positive signal, but it is nowhere near the needed amount to achieve SDG7.”

Progress on electricity access remains slow and inadequate to meet the SDG-7 targets by 2030.

Current rate of growth remains inadequate

New global targets pledged by over 130 countries in the UAE Consensus reinforce the objectives of SDG 7 by aiming to triple renewable generating capacity and double the rate of energy efficiency.

“There are solutions to reverse this negative trend, including accelerating the deployment of solar mini grids and solar home systems. The World Bank is actively working to support this acceleration, and jointly with the African Development Bank we have committed to providing electricity to an additional 300 million people by 2030,” said Guangzhe Chen, Vice President for Infrastructure at the World Bank.

Yet at the current rate of growth 660 million people will be without electricity access and around 1.8 billion without access to clean cooking technologies and fuels by 2030.

“Deployment of renewable electricity is on a growing trend, whereas other kinds of renewable are lagging, and energy efficiency improvements seem to have reached a bottleneck. Time is running short and more focused policies and investment are fundamental to ensure the provision of sustainable energy for all by 2030,” said Stefan Schweinfest, Director, United Nations Statistics Division.

The report will next be presented to top decision-makers during the High-Level Political Forum (HLPF) on Sustainable Development in July.

Image Credits: Unsplash, 2024 Energy Progress Report.

A group of trainee midwives receiving training from a Seed Global Health educator at the School of Midwifery Makeni Lab in Sierra Leone.

Africa’s health worker shortage is projected to reach more than six million by 2030 – and the weaker the system, the more likely health workers are to leave as poor working conditions erode their morale. 

The non-profit organisation, Seed Global Health works to address this shortage by investing in long-term training and support for health workers in four countries – Malawi, Sierra Leone, Uganda, and Zambia – via partnerships with health ministries.

For Seed, long-term means “for as long as our partners will have us”, says CEO Dr Vanessa Kerry, who is also the World Health Organization’s (WHO) Climate Envoy.

Seed launched its 2030 strategic plan last week, an ambitious programme that requires the organisation to raise at least $100 million.

“The 2030 strategy is a reflection of what we see as a deep need in the world today, which is to build the health workforce of the future and to position the workforce as a global priority,” says Kerry in an interview with Health Policy Watch.

“The workforce is the frontline of any response, whether it is managing existing disease burdens, pandemic preparedness, or our response to climate change.”

She stresses that Seed is not “pivoting to any new flashy moment” but rather “doubling down on what we’ve done always, which is focusing on education, practice and policy, to ensure that we have a skilled workforce that can provide definitive care for those in need.”

“The mission is simple. It’s a just equitable and healthy world. The mission is to expand access to quality care and improve health outcomes for all. We do this by training health workers and we really believe that can be transformative across any number of sectors.”

Not a ‘fly-in, fly-out’ model 

Vanessa Kerry, CEO of Seed Global Health.

Seed “embeds” its educators with partners for at least a year to build trust, understand the context, learn from colleagues, and apply their skill set to support the problem.

“A lot of folks will create a curriculum, or they’ll teach through Zoom or they’ll feel like they can just come, teach, leave,” says Kerry.

“We’re not a fly-in, fly-out model. We are about integrating into communities and being in service to the priorities of our partners.”

The challenges are immense. All four partner countries are on the World Health Organization’s (WHO) list of countries with critical health worker shortages.

A woman giving birth in Malawi is 28 times more likely to die than a woman in the UK; a Zambian newborn is 24 times more likely to die than a Norwegian newborn and Uganda has four doctors per 100,000 people while Switzerland has 440.

Sierra Leone has one of the world’s highest maternal mortality rates (MMR). Malawi’s MMR is also high, Uganda struggles with high rates of injuries, mostly from traffic crashes, and Zambia has been trying to move to universal health coverage but it does not have staff trained in family medicine.

All four countries are affected by rapidly changing climates, including floods, droughts and migration.

Seed has found that the best way to support health workers is by day-in, day-out mentoring at patients’ bed sides.

“I’m a physician. Medicine, nursing and midwifery require apprenticeship and learning. You cannot memorise an algorithm on hypertension and think you’re going to walk into a patient’s room and know how to care for that patient in the right way,” says Kerry.

“Every patient brings a different background, a different pattern to their diseases, a different combination of diseases.”

Country selection

Kerry founded Seed in 2011, and its flagship programme, the Global Health Service Partnership (GHSP) with  Peace Corps sent US health professionals abroad to train others, including to Malawi and Uganda. 

But when the GHSP wrapped up after more than a decade, “we weren’t done”, says Kerry.

Both Malawi and Uganda wanted Seed to continue helping to train health workers to tackle their health challenges.

Malawi has a maternal mortality rate (MMR) of 349 deaths per 100,000 live births. It aims to reduce this to 70 per 100,0000 by 2030.

Uganda’s leading causes of death and illness are acute childhood illnesses, injuries (driven by road traffic injuries), and maternal health conditions. Non-communicable diseases account for 40% of the disease burden.

Then in 2018, Zambia asked for help to launch a Family Medicine programme to provide the core of its primary healthcare system.

A Seed Global Health midwife educator assessing a pregnant woman at Makeni Hospital in Sierra Leone.

In 2019, the government of Sierra Leone called Kerry, asking for help to address its MMR, one of the highest in the world with 717 women dying per 100,000 live births.

Seed supports health ministries’ training goals rather than developing their own separate agendas, says COO Andrew Musoke. 

Some of its achievements are astonishing. Since it started working in Sierra Leone in 2020, for example, there has been a 60% reduction in maternal mortality in the districts where it has been working.

Human rights challenges

Post-partum haemorrhaging is the leading cause of maternal mortality in Uganda and Malawi, sometimes caused by backstreet abortion as  abortion is illegal in both countries.

Before becoming Seed’s COO, Musoke was country director for Clinton Health Access Initiative (CHAI) in Uganda, and acknowledges that “especially during COVID, we saw a lot of teenage pregnancies and rising abortion mortalities”. 

Seed COO Andrew Musoke

These were often difficult for health workers to deal with as women and girls came to health facilities very late in the process with heavy bleeding. 

“While trying to improve emergency medical services, we have recognised that some of the gaps relate to the referral pathways, as well as health workers’ ability to address the issues,” says Musoke.

Ensuring speedier referrals and more skilled health workers has helped to reduce deaths from haemorrhaging. 

A year ago, Uganda passed its draconian Anti-Homosexuality Act, which introduces harsh punishment for same-sex sexual activities. In reaction, many civil society organisations called on international programmes to stop channelling money through the country’s health ministry.

Kerry acknowledges that human rights issues pose challenges for Seed in “a really complicated world with very complex politics”.

“I can look to my own country, the US, and I can look to Uganda. Every country is struggling to figure out our values and how we are going to move forward in this world, politically. When you see human rights issues in countries, it’s very difficult. 

“But the end of the day, we are a health organisation. I’m a physician. We are driven to care for patients with dignity, with respect, and to ensure that they have access to services.”

She adds that Seed’s partners all acknowledge the need for patient care to be driven by science.

“We stay focused on trying to raise awareness about how, for example, anti-homosexuality policies can actually be detrimental to the progress we’ve made in HIV and the progress we’ve made in primary care, and to raise awareness on that and to really help provide education.”

Climate resilience

Another component of Seed’s training is to assist health workers to address daily impacts of climate change, says Kerry. 

“Pick an aspect of disease, people are being impacted by climate change,” she adds. 

Zambia is in the midst of a drought which has caused a massive cholera outbreak. Malawi has had cholera from the effects of Cyclone Freddy. Sierra Leone, a coastal country, has seen the salinisation of its water sources and it is worried about rising sea levels. Changes in Uganda’s weather patterns have negatively affected livelihoods, particularly in agriculture and fisheries.

Recent research shows that, for 1° Celsius increase in temperature over 23.9°C, there’s a 22% increase in infant mortality. If midwives understand this, they can counsel women with high-risk pregnancies on how to stay cooler in extreme heat to prevent infant mortality. 

Indirect effects of climate include migration, projected to effect up to 1.2 billion in the next decade. And in some countries, women who have to walk farther for water are more prone to sexual assault. 

“Focusing on building strong resilient health workforce is our primary ability to respond,” says Kerry.

The REACT team from Katakwi District Hospital in Uganda

Rich countries’ poaching of health workers

One of the hazards facing partner countries is wealthier countries recruiting their skilled health workers.

While Kerry says it is a human right for health workers to be able to move, Seed tries to address the “push” factors related to job satisfaction.

“Health workers may want to stay in their country, their communities, their contexts, their families, but also don’t want to be demoralised every day because they’re watching someone die because there isn’t blood available for transfusions, for example,” she says.

“So the degree that we can help shift the system by building advocates and changing health outcomes can go a long way to promoting retention. And we’ve seen that places that were working, such as the emergency medicine graduates we have trained staying in Uganda. When there’s a change in morale, retention can be promoted.”

South Africa is leading an initiative, through the African Union COVID-19 Commission headed by President Cyril Ramaphosa, to develop a health workers’ compact that would enable health workers to work abroad on training exchange programmes.

“What the compact will do is create the economic case and roadmap for countries to be able to understand their health workforce needs and training, and also think about how to train enough health workers to be in service to the world as well as their home country. 

“What that allows is job creation and remittances. It builds an economy around healthcare workers, and it solves multiple problems at once. The population of Africa is growing so there is a workforce that can be in service for the world. So we’re trying to be very ambitious in thinking about how to solve these problems.”

Image Credits: Seed Global Health, Seed Global Health.

Avian influenza is spreading among US cattle, and milking machines are likely to be one source of infection.

Global surveillance of influenza viruses in animals needs to be intensified to “rapidly detect any changes to the virus that could pose a greater threat to humans”, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyessus told a media briefing on Wednesday.

He also urged the media to ensure that the humanitarian crisis in Sudan, one of the worst in the world, was not forgotten.

The outbreak of H5N1 avian influenza in US dairy herds has almost tripled in the past five weeks, now affecting 92 herds in 12 states. The number of human cases has increased from one to three, and 500 people are being monitored after exposure to infected cattle.

The US H5N1 clade affecting the cattle derives from Eurasian geese and is the same clade that has affected wild birds, commercial poultry flocks and “sporadic infections in several species of wild mammals and neonatal goats in one herd in the US”, according to the American Veterinary Medical Association.

“Collaboration, communication and information sharing between the animal and human health sectors is essential in all countries. This is the meaning of One Health,” Tedros urged.

However, the WHO continues to assess the risk to public health as low because of its limited spread in humans.

“Since 2003, there have been 893 reported infections of H5N1 in humans, including 11 so far this year: five in Cambodia, three in the U.S., and one each in Australia, China and Viet Nam. In that time, the virus has not shown signs of having acquired the ability to spread easily among humans,” said Tedros.

“In recent years, H5N1 has spread widely among wild birds, poultry, land and marine mammals on several continents,” said Tedros.

Timely investigation of every human case

“WHO recommends that anyone working with any infected animals, in any country, should have access to, and use, personal protective equipment”, and urged systematic follow-up, testing and care of people exposed to the virus.

“Early medical care and support, and thorough and timely investigation of every human infection is essential to evaluate and interrupt potential onward transmission between humans.”

Dr Wenqing Zhang, head of the WHO’s Global Influenza Programme

Dr Wenqing Zhang, head of the WHO’s Global Influenza Programme, said that previous large avian flu outbreaks in seals had been contained and had not spread to humans.

While it was “too earlier” to predict the trajectory of the US cattle infection, Zhang said it was possible that it could be eliminated.

However, Dr Maria van Kerkhove, the WHO’s director of  epidemic and Pandemic preparedness and prevention, said that the WHO is concerned about the geographic spread of H5N1 and the fact that it is infecting new animal species, and put more people at risk.

“We need to be able to rapidly assess the viruses that are circulating, any changes in those viruses that are circulating, to make sure that the system that is in place so we can react as quickly as possible, should we need to produce vaccines,” she added.

“We’re not in that situation yet.”

She stressed that a lot of work needs to be done at a local level with communities using this One Health approach.

“The stronger the biosecurity we have within the farms, the earlier that we can mitigate any potential spillover into human populations and potential onward spread.”

‘Forgotten and ignored’ Sudan 

Tedros also drew media attention to Sudan, noting that this is the war the world has “either forgotten or ignored”.

“Sudan is the world’s largest humanitarian crisis, with 12 million people displaced – 10 million internally, while two million have fled to neighbouring countries.”

“More than 70% of hospitals in conflict-affected states, and 45% of health facilities in another five states are not working, and the remaining ones are overwhelmed with people seeking care,” he noted.

“Critical services, including maternal and child health care, the management of severe acute malnutrition, and the treatment of patients with chronic conditions, have been discontinued in many areas.”

He noted that insecurity and operational hurdles, such as the current break in telecommunication services, were disrupting WHO’s ability to deliver supplies and services.

A WHO team member providing nutrition support to internally displaced children in Gedaref state, Sudan, in August 2023.

Famine in Gaza

Turning to Gaza, Tedros said that the WHO welcomes the UN Security Council resolution adopted on Monday, which calls for a full and immediate ceasefire, the unconditional release of all hostages, a permanent end to hostilities, and the reconstruction of Gaza.

We urge all parties to take steps to implement the resolution immediately, and bring a permanent end to the suffering of millions of people.” said Tedros.

“A significant proportion of Gaza’s population is now facing catastrophic hunger and famine-like conditions,” he noted. “Over 8,000 children under five years old have been diagnosed and treated for acute malnutrition, including 1,600 children with severe acute malnutrition.

“Our inability to provide health services safely, combined with the lack of clean water and sanitation, significantly increase the risks for malnourished children. There have already been 32 deaths attributed to malnutrition, including 28 among children under 5 years old.”

However, due to insecurity and lack of access, only two stabilization centres for severely malnourished patients are operational, he added.

 

Image Credits: WFP/Ala Kheir, Josh Kelahan, WHO.

Monu Kumar Yadav, a street vendor sells juice at a busy Delhi road. Peak temperatures here have been hovering between 40-49° for several weeks.

A wave of record-setting heat waves, beginning in March, have led to new Government guidelines for emergency cooling including measures like heat stroke rooms. Even so, public health  experts are only beginning to grapple with the multiple ways in which heatwaves can kill – and map out mitigating measures for both healthy people as well as the more vulnerable, including people with chronic diseases. 

Under a mid-day blazing sun on a busy Delhi road, Monu Kumar Yadav tends to his cart. There’s little shade. He’s selling bael sharbat or stone apple juice, a popular summer drink. It’s 41°C but Yadav, who says he’s here from 8am to past 5pm daily, says it’s bearable. It was far worse a week ago, he says.

There have been a series of heatwaves in almost every part of the country since March and these are forecast to continue in the north throughout June. Temperatures have been as much as six degrees or more above normal and touched 50°C in several places. The capital, New Delhi, hit a record high of 49.9° C at two stations. 

Heatwaves coincided with India’s general election held across April, May and June. Hundreds of deaths have been reported, several of these related to the election. Some 33 polling staff died from the heat on the last day of voting in Bihar, Uttar Pradesh and Odisha states, according to Reuters.

Experts in the government had forecast the heatwaves and prepared response plans. This is in addition to the heat action plans in dozens of Indian cities. But local administrations and communities were seemingly caught unaware. 

Climate scientists have calculated that heat waves will only get worse with the record amount of carbon dioxide and other greenhouse gases being emitted. 

The heat wave alerts began as early as February. From early March onwards, forecasts warned temperatures could be more than 5° C above normal in parts of the country. The Indian Meteorological Department (IMD) has also warned of hotter temperatures and longer heatwaves this year.

A fortnight later the Election Commission of India announced the longest voting schedule in decades lasting 44 days; longer, if the campaign and counting days are included. 

India’s longest heatwave?

In Kishan Kunj, New Delhi, Razia splashes water on the jute bags that she has covered her roof with before she leaves for work every day. She hopes that the room below remains bearable for her two sons during the summer months.

April’s heat was alarming with a rare heatwave alert in the southern coastal state of Kerala. In eastern India, deaths began to be reported. But it was about to get a whole lot worse in May, in the north. 

A new study by ClimaMeter, a global group of scientists who provide a climate context for weather extremes, shows May’s heatwave was 1.5°C hotter than any other ever recorded in India. 

Delhi’s power demand touched a record high, its water supply ran low. The local government announced it would fine anyone wasting water, for instance washing cars with water pipes or letting tanks overflow.

Separately, the IMD told Health Policy Watch that several states in north India saw an unusually long stretch of heatwave days. The normal for May is three days for places like Delhi, and a few more for places like the desert state of Rajasthan and Madhya Pradesh in central India. 

IMD forecast the number of days could be as much as four to eight days above normal. But it turned out to be far more at about 15 days. Officials that HPW spoke with couldn’t recall a similar event in recent years though they are yet to analyse whether this is the longest stretch ever on record.  

The spell was broken by some storms and rain in early June but the heatwaves are forecast to continue in north India. 

With hotter nights, the danger is shifting indoors. The human body gets little chance to recover from the day’s heat and cool down which hits health and productivity at a “very large scale,” Sharma adds. 

Heat and NCDs

Differentiating between heat exhaustion and more dangerous heat stroke.

Extreme heat may be a direct trigger for fatal conditions, even in the healthiest person.  The most direct impacts involve deaths from heat stroke – when the body’s core temperature shoots up beyond normal temperatures of 36.8°C . If temperatures cross 42°C or 107.6°F, cellular damage and cardiac, respiratory and kidney failure begin to occur. 

But heat can also can exacerbate pre-existing noncommunicable diseases in older people, other groups with chronic conditions, and newborns lacking poor heat regulation, also leading to death. At least 605 people died of heart attacks out of almost 25,000 “suspected” heat stroke cases in India between March and May according to government data. 

In earlier years, experts have pointed out that heat-related deaths have been under-reported, insofar as many of those who perished also suffered from other types of non-communicable diseases (NCDs), such as cardiovascular or respiratory conditions – to which their deaths were attributed.

But this season the number of heat-related deaths being reported has been frequent and high -signalling at least a new awareness of the ways in which heat can exacerbate pre-existing NCDs. Several of these have been reported from the election. However, the data remains plagued by discrepancies and confusion – which are understandable in light of the complexity of the diverse impacts of heat on healthy and more vulnerable groups.  

Heatstroke may affect both people with chronic conditions as well as healthy people, as a result of over-exertion or exposure to extreme weather conditions.

As of 1 June, the National Centre for Disease Control (NCDC) reported 56 deaths. But that excluded Uttar Pradesh, a northern state with a population larger than the UK, France, and Germany combined, where 166 deaths had been reported as of May.

About 141 deaths suspected to be heat-related were reported from the eastern, coastal state of Odisha as the polls ended. However, officials said post-mortems and investigations had shown less than a fifth to be due to heatstroke, as such.  

The capital, Delhi, too saw many deaths (24) in the last week of May, and over 120 in Rajasthan. There, in one city, newborn babies were put on dialysis because of dehydration leading to an increase in sodium levels. 

With such a devastating impact, Rajasthan’s top court called for heatwaves to be categorised as “national calamities” which would enable emergency relief as with other natural disasters, though there’s no decision on that yet.  

‘Cooling, cooling, cooling’

The response to the heatwave crisis has broadly been at two levels. Met and health experts within the government have been putting out warnings and advisories. 

Health advisories include detailed guidelines, webinars, social media posts and other outreach efforts; there was even a meeting held by Prime Minister Narendra Modi where he called for a whole of government approach and hospitals to be adequately prepared. 

Health is a state subject in India, which means that the central government can put out advisories but the states decide their policy and what to implement. One such advisory titled ‘Emergency Cooling for Severe Health Related Illnesses’ was released in March 2024. 

In February, the National Disaster Management Authority held a workshop where preparations for this year’s heatwaves were discussed by health, disaster management, met, and climate experts in the government. It showed how training had begun as early as January, that there should be a decentralised approach involving local communities and health infrastructure should be strengthened, for instance establishing cooling centres in public buildings and spaces. 

For the first time this year, such advisories called for heat stroke rooms. These are essentially places set up at healthcare centres to rapidly cool a person suffering from heat stroke, a potentially fatal condition. Doctors point out the main treatment for heat stroke or heat exhaustion is “cooling, cooling, cooling.” 

The mortality rate for delayed treatment is about 80%, but with early identification and rapid cooling, it can be as low as 10%. Symptoms of a heat stroke include a temperature of 40.5°C/104.9°F or more, throbbing headache, no sweating, and red hot dry skin among others. 

The idea is to bring the body temperature down to 39°C/102.2°F as quickly as possible. The methods prescribed include immersing a person in an ice bath or very cold water, placing ice packs on them, using wet towels, and rushing them to the hospital. 

But to what extent have these guidelines and advisories been implemented at the grassroots level? There is little data available about how many health centres, the most basic and widely spread health care facilities, in rural and urban areas were equipped to identify and treat heat stroke patients. The heat stroke room was proposed last year and implemented this season, according to a source. It is meant to be set up at all healthcare facilities but it’s unclear how many were done. 

Towards the end of May, the central health ministry asked states to take “proactive measures to prevent devastating incidents caused by extreme heat.” A substantive press note was issued two days after the election result. 

Assessing heatwave risks to health

At least three types of temperature readings may be considered for hyperlocal responses. An understanding of these can help people and authorities work out what to do in a house, in schools or offices, at construction sites, in marketplaces, and of course at public gatherings.

The first is the conventional meterological temperature. Several places and meteorological stations in the arid plains of India have crossed 50°C. Around this time, swathes of the north were forecast at 45-50°. Such temperatures, even for one day, can be fatal, depending on the person’s age, co-morbidities, and other factors. 

The scond is urban heat island temperatures. A study done in April used a thermal camera and it shows how built-up or paved areas can be much hotter than the official temperatures. In vivid visuals, these illustrate what climate scientists including the IPCC have called the urban heat island effect. If the temperature was about 40°C according to standard, official readings, it could be as high as 50-59°C depending on concrete or tarred places that trap heat.

The third is the ‘feels like’ temperature. Experts warn of another danger, particularly for low-income households.

Anshu Sharma is co-founder of SEEDS, which works with people, particularly in vulnerable communities, to build their resilience to disasters and climate change impacts. He warns that wet bulb temperatures – a factor of heat and humidity – must be monitored to provide relief.

“While temperatures will drop once the Monsoon arrives, the suffering will not go away. Indexed heat, with the addition of humidity, will make it feel worse than the current dry heat, with indexed temperatures expected to go well above 50°C,” says Sharma.

“This year’s heatwaves, characterised by hotter days, much hotter than normal nights, and longer duration of heatwaves have hit people harder than usual. Nights, especially during power cuts, are particularly unbearable for those who cannot afford air conditioning and power backups.”

Many causes or one main cause?

In eastern India, the heatwaves may have been exacerbated by anti-cyclonic circulation and the absence of thunderstorms during April, and in the northwest, the absence of western disturbances (bringing storms and rain) during May. The El Nino phenomenon has also been blamed. This is the Pacific climate pattern which tends to cause hot and dry weather in Asia and heavier rain in parts of the Americas. 

The biggest cause, however, is climate change. World Weather Attribution (WWA), at the Grantham Institute in Imperial College London, says that the heatwaves in the last two years became 30 times more likely and hotter because of human-induced climate change. 

April mean temperature 2024. The blue outline shows the region with the most extreme heat in South Asia.

Dr Mariam Zachariah, a WWA Researcher, told HPW, “While it is likely the additional heat from El Nino, a naturally occurring climate phenomenon, helped push summer temperature extremes in some regions of India to cross 50C, such episodes will become more frequent in India as the climate warms, regardless of El Nino.” 

Monu Yadav doesn’t know what makes the heat worse than earlier years but out on the roads for eight to 10 hours a day, he knows for sure that it’s hotter than anything else he’s experienced in Delhi. 

With greenhouse gas (GHGs) emissions rising faster than ever to record levels, heatwaves will get worse, but the response needs to be better. Cutting GHGs is vital, as are SOS cooling solutions for people.

Image Credits: Chetan Bhattacharji, Webinar/Ministry of Webinar on Clinical Aspects of Heat-Related Illnesses – National Programme on Climate Change and Human Health, MoHFW., Webinar on Clinical Aspects of Heat-Related Illnesses: National Programme on Climate Change and Human Health, MoHFW., World Weather Attribution.