Amit Levy, brother of 19 year-old Israeli hostage Naama Levy and Shay Dickman, cousin of Israeli hostage Carmel Gat, visit the experiential display of a “hostage tunnel”, in Geneva’s Place des Nations on Monday.

Shay Dickmann stood stoically as the recorded screams of a woman pierced the darkness of the sealed metal container, followed by shouting and screams, the sounds of gunshots and a baby crying. 

A narrow tunnel led to a tiny room with a single lightbulb and a dirty mattress on the floor. On the wall, a projector played through the before and after images of Israeli women kidnapped to Gaza during the Hamas-led incursion into Israeli communities near the enclave on 7 October. There were photos of the women smiling, at home and at ease before “Black Saturday,” and frames of the same women culled from Hamas video posts of their capture or captivity, their faces bloodied, fearful, and wane. 

“I think I heard the voices of the terrorists who took away my aunt and killed her, in the tape they were playing,” Dickmann said after emerging from the mock hostage “tunnel”  back into the bright winter sunlight of Geneva’s Place des Nations. 

Dickmann, along with the Israeli families of 10 other Israeli hostage women were in Geneva Monday and Tuesday for a series of meetings with World Health Organization and other UN agency officials, as well as a session at UN headquarters with representatives from some 35 countries interested in hearing their stories. 

A handful of diplomats, including US Permanent Representative to the Human Rights Council Michèle Taylor also visited the tunnel display,  which offers just a five-minute glimpse of what the 100 or more hostages still in captivity have been going through for 122 days.  

Shay holds up photos of her cousin and Israeli hostage Carmel Gat, 39, on the right, and her aunt, 67-year-old Kinneret Gat, being led away from her home by Hamas gunman – she was later shot to death on the sidewalk.

Dickmann’s 67-year-old aunt, Kinneret Gat, was killed by gunmen just outside of the family’s home on Kibbutz Be’eri on the morning of 7 October  as Hamas-led forces invaded nearly two dozen Israeli communities close to the Gaza border in a surprise attack early on a holiday morning.  

Shortly after killing Kinneret, the Hamas gunmen returned to the house and took her  39-year-old daughter, Carmel Gat, hostage. Some time later, Carmel’s brother, Alon, his wife Yarden, and their 3-year-old daughter Geffen were captured from a hiding place, after the family’s ‘safe room’ began filling up with smoke from grenades and nearby house fires; they were placed in a Hamas vehicle bound for Gaza.  

Alon managed to break away and escape with the toddler after an Israeli tank crossed the path of their kidnappers’ vehicle, creating a brief window of opportunity for the family to leap out of the car. 

Yarden Roman-Gat was chased down and recaptured, but then released on 29 November as part of an week-long cease-fire and hostage exchange deal between Israel and Hamas, brokered by Qatar.  That deal saw the release of about 110 hostages, of the estimated 240 originally taken captive by Hamas on the 7 October incursion, in which some 1,200 Israelis, mostly civilians, also were killed.  

The fragile cease-fire and hostage exchange deal broke down just a day before Carmel Gat, an occupational therapist was supposed to have been released as well, Dickmann recalled.

Instead, Carmel continues to be held in Gaza. She remains there along with another 14 women presumed to be alive – although time is running out, the families warn. 

In Geneva pleading for the release of female hostages

Simona Steinbacher, mother of 30 year-old hostage Doron Steinbacher, in front of Geneva’s UN headquarters. Doron has a “serious medical problem” that requires daily medication, but she said she has no idea if Doron is receiving treatment.

“We heard the first sign of life from Carmel from two other hostages who were released in November,” Dickmann told a briefing of diplomats at the UN’s headquarters in Geneva on Monday at the start of their two-day mission.   

“For more than 50 days we didn’t know if she is dead or alive, as there was no footage of her released on social media,” she added. 

 “Then, after 50 days, two hostages that were released told us that Carmel was kidnapped with them and that she was the one to keep their spirits up throughout the difficult times. They said that Carmel managed to find her inner strengths and practiced yoga with them.

“Now, since then, for two months, we haven’t heard anything again.”

Speaking to diplomats from some 35 national missions during a meeting at Geneva’s UN Headquarters, Dickmann and other hostage family members described their fears for their cousins, daughters and sisters – some as young as 19, and including women who sustained injuries on 7 October and others who have chronic medical needs.  

Naama Levy, one young female hostage portrayed in a Telegram video with her hands tied and her pants bottom covered in blood as she was being taken prisoner; she suffered leg wounds, apparently from sharpnel. When she was last seen in a tunnel two months ago by another Israeli hostage, since released, the leg was still swollen and disfigured.  She walked with difficulty.

“We know [from released hostages testimony] that she wasn’t treated for the injuries, even two months later,” said her aunt, Orit Mansur Levy, who was in Geneva to represent her in the meetings.  

Simona Steinbacher, mother of 30-year-old Doron Steinbacher, told diplomats that her daughter has a “serious medical problem that requires medication daily – but no one gives her the medicine.” 

On 26 January a video depicting Doron and two others female hostages was released by Hamas. “You can  see how pale and thin she looks,” said her mother, displaying a frame from the video of her daughter in captivity.

Among the 136 hostages still held in Gaza, as many as 32 are now believed to have died. Those surviving include an estimated 14 women and 88 men. Along with the women, a number of the men are elderly, ill and in desperate need of life-saving healthcare. In mid-January, a Qatar-brokered deal was supposed to insure deliveries of medicine to the hostages in exchange for Israeli agreement to step up humanitarian aid to beleaguered Palestinian hospitals in northern Gaza. Weeks later, however, there is no confirmation from Hamas that the medications were ever received or administered.  

Families aim to raise the profile of vulnerable women still held as hostages  

Videos of Israel’s female hostages held in Gaza run in a loop inside the hostage tunnel. On the right is Karina Ariev as she was hauled away in a truck after being captured by Hamas-led forces on October 7.

The meetings in Geneva included sessions with Volker Türk, UN High Commissioner for Human Rights; Mike Ryan, WHO Executive Director of Health Emergencies; and Mirjana Spoljaric Egger, President of the International Committee of the Red Cross. 

It was the first large-scale visit by hostage families to the UN and WHO headquarters in Geneva since the collapse of the first November cease-fire.

Although WHO and UN officials have repeatedly issued calls for the release of the hostages in their official statements, Gaza’s expanding humanitarian crisis, in which more than 27,000 Palestinians have been killed, has been the overwhelming focus of UN statements and relief efforts. Horrific stories of Palestinian women and children trapped in by bombings, evacuation orders and Israeli-Hamas crossfire have surged through the global media as Israel faced allegations of genocide in the International Court of Justice. 

Against that wave, the Israeli families of hostages feel that their appeals for more forceful humanitarian intervention, including women who are particularly vulnerable in captivity, have been largely pushed aside. 

Ashley Waxman Bakshi, cousin of 19 year-old Agam Berger, an Israeli hostage in Gaza – the UN should address the humanitarian crises of the Israeli hostages as well as that of Gaza civilians.

 “It should be spoken about, the humanitarian crisis in Gaza. But it should be done so alongside the humanitarian crisis of the hostages,” said Ashley Waxman Bakshi, cousin of 20-year-old hostage Agam Berger, whose capture by Hamas was documented in a Telegram video on 7 October, where she was seen being led away to a vehicle while still in her pajamas. 

“I think it’s important to say that as an Israeli, I find it tragic when I see innocent Palestinians suffering,” declared Waxman Bakshi.

“There’s no balance when you look at the numbers, but you have to look at the balance in humanity, and Israel didn’t start this war,” Waxman Bakshi asserted. “The war started with October 7 and the massacre and the taking of the hostages.  And so I just ask for balance – to see the humanity on both sides. ”  

That’s a contention that is hotly disputed by many Palestinians, who say that Israel blockaded Gaza for nearly 20 years before Hamas launched its war. Israelis, on the other hand, contend that Hamas managed to muster millions of dollars in resources to transform the enclave into a military fortress, rather than investing in human development. 

“My daughter  is a symbol of the innocent lives taken,” declared Amanda Damari, mother of Emily Damari, a 27-year-old British-Israeli kindergarten teacher from kibbutz Kfar Aza, near the Gaza border. “She’s being held in tunnels built with milions of dollars of aid donated for humanitarian causes, tunnels built under UNRWA schools and hospitals. Everyday that passes, her life is more in danger.”

 ‘The citizens of the kibbutzim are peaceable people’

WHO Health Emergencies executive director Mike Ryan meets in Geneva on Tuesday with family members of Israeli hostages still held in Gaza by Hamas.

Paradoxically, the Gaza-area Israeli communities that suffered the brunt of the Hamas attack on 7 October were known for their liberal and even left-wing views.

Some of the same kibbutz members who were murdered or taken hostage spent considerable spare time in peace movement activities, including ferrying sick Palestinian children to Israeli hospitals for treatment that they couldn’t obtain in Gaza.  While the Israelis display solidarity abroad, at home, many of the hostage families have also been highly critical of Israel’s hard-right government for failing to push aggressively enough towards a  hostage exchange deal – even one involving major concessions.  

“Türk empathized with our stories,” reported Dickmann, after the meeting with the UN High Commissioner later Monday evening. “He declared Hamas actions on October 7 as war crimes, and condemned them saying they are unacceptable. 

“Knowing that the citizens of the kibbutzim were peaceful people, he shared his wish that we won’t lose the hope for living Israelis and Palestinians in peace on the day after,” she said, adding that he had also affirmed that any cease-fire in Gaza should be “conditioned” on the hostages’ release.  

Ryan also described the events of 7 October as “a war crime and every day they are held there a war crime is still going on,” related Dickmann, saying he promised to stress the need for the hostages’ access to medical care. 

“He said WHO is looking after the lives and the health of every human being who is vulnerable, both Palestinian and Israeli.” 

UN Special Envoy for Sexual Violence concludes visit to Israel

The visit of the hostage delegation to Geneva also coincides with rising concerns about sexual violence to which female Israeli hostages may have been subjected while in captivity. On Monday, the UN Envoy for Sexual Violence, Pramila Patten concluded a week-long mission to Israel and the occupied West Bank, “to gather information on sexual violence reportedly committed in the context of the attacks of 7 October 2023 and their aftermath,” according to a statement from her office.

She urged victims of sexual violence who are still alive to “break your silence”. At the end of her visit she was widely quoted by media saying “things happened here that I have never seen before.”

At a  public session of the British Parliament last week, Israeli first responders, police and forensics experts also provided detailed, first-hand testimony about the evidence they had gathered of the rape and genital mutilation of female victims of the October 7 massacre, testimony widely reported in the international media.  

Waxman Bakshi, who also testified at the parliamentary session, well recalls the grisly accounts she heard there:  “First responders described how they saw the bodies of women who had been shot in the back and also had semen on them, females stripped from the waist down….  I mean, clear, obvious signs of of rape.. and testimony from the Nova music festival by women and men who saw gang rapes and mutilation.”

Amongst the hostage families visiting Geneva, several familiy members also expressed fears that their daughters, nieces and cousins are similarly at risk. But so far, only “partial testimony” has been gathered, about the hostage victims, Waxman Bakshi said. 

“I had to translate [into English] for a released hostage her story,” she told Health Policy Watch. “she spoke of girls telling her in the tunnels that they had been raped at gunpoint, that they were touched, that they would be taken advantage of in moments like going to the bathroom or when they would cry. 

“But I also know that this is super, very, very sensitive. And so what released hostages have told the authorities is not necessarily what they’re saying in the media.  And I don’t blame these women. It’s hard enough for the victims of rape to come up and speak about it in general, let alone when an entire is waiting to hear if you were raped.

“What we know is that these things happened on October 7. Whatever happened on October 7, can no longer be reversed,” Waxman Bakshi concluded. “But what we know is that we still have women there. These women are still at risk, they can still be saved.”

Despair and hope in the tunnels 

Shay Dickman with her yoga mats outside the experiential display of a Gaza “hostage tunnel” in Geneva, preparing for a yoga session in the name of 39 year-old Carmel Gat, her cousin being held hostage in Gaza.

Even as the delegation’s visit took place, hopeful reports last week that a new ceasefire and hostage exchange deal might be in the offing seemed to be fading against the backdrop of hardline statements by both Hamas and Israel’s government.

Dickmann refuses to give up hope. 

After emerging from the darkness of the mock hostage tunnel into the bright winter sunlight of Geneva’s Place des Nations, she unrolled a yoga mat that she carries with her on every mission on behalf of the hostages.     

Her next act of protest, she said, would be a yoga session on the plaza, in the name of Carmel, herself an avid practitioner who had just returned a few days before from a trip to India, before being taken hostage. 

Carmel Gat practicing yoga in India, just before returning to her family’s home in Kibbutz Be’eri, where she was taken hostage.

“Carmel, my cousin, apparently is doing yoga in captivity,” said Dickman. “For me, that’s not only a sign of life from her, to hear that she is doing that. It’s a sign that Carmel is choosing life. She has the power inside her to keep going, to keep her hopes up, to get others hopeful as well and take care of them. 

I hope that she keeps her spirits up.. I want to tell her ‘Carmel, we’re coming to get you.’ ”  

Image Credits: E. Fletcher/Health Policy Watch, E Fletcher/Health Policy Watch , Israeli Mission to the UN in Geneva , Family Roman-Gat.

COP10 on WHO Framework Convention Tobacco Control. President Zandile Dhlamini (Eswatini) during the opening ceremony

“Tobacco [is] the biggest public health threat the world has ever faced. […] Together we have made great progress. We have saved lives,” the World Health Organization’s (WHO) Director-General Dr Tedros Adhanom Ghebreyesus stated at the opening of the 10th Conference of the Parties (COP10) on the Framework Convention Tobacco Control (FCTC) in Panama on Monday. 

The biennial convention acts as a governing body to supervise FCTC implementation, and the 183 parties to the FCTC will meet first to discuss the next steps for tobacco control policies.

From 12-15 February, the third Meeting of the Parties (MOP3) will discuss progress on the special Protocol to Eliminate Illicit Trade in Tobacco Products.

Since the convention was adopted in 2005, there have been major improvements for tobacco regulation.

“Two decades ago, the idea of tobacco-free bars and restaurants was unthinkable, but now this has become the norm,” stated Jarbas Barbosa, director of the Pan American Health Organization.

The number of smokers worldwide is decreasing, both as a proportion of the adult population, from 33% in 2000 to only 22% presently, and in absolute numbers despite the population growth, said Dr Adriana Blanco Marquizo, the WHO FCTC’s Secretary, in her opening statement.

Marquizo outlined three key concerns for the meeting: FCTC’s  slow implementation, new nicotine and tobacco products gaining popularity and the industry’s continuous interference in countries’ tobacco control efforts.

Participants at the COP10 opening ceremony

One of the major concerns of participants is the growing popularity of emerging products, including heated tobacco products and e-cigarettes. 

 As the WHO has warned, the tobacco industry often markets these specifically to the young generation, using attractive flavours or cartoon characters as part of their design.

Industry lobbyists claim that e-cigarettes, or vapes, are a less harmful alternative to traditional cigarettes that help people to quit smoking. But the WHO contests this, arguing that they neither help people to quit smoking nor are harmless.

Tobacco industry produces “alternatives that are equally addictive” and provides misleading information about them, stressed Barbosa. Thus, regulating the emerging products is one of the main challenges for the meeting parties.

Meanwhile, big tobacco companies are up and running with their own campaign to discredit the convention, as the University of Bath research confirms.

In a leaked email published by The Guardian, Philip Morris International senior vice-president of external affairs Grégoire Verdeaux described the summit as “nothing short of a systematic, methodical, prohibitionist attack on smoke-free products”.

He also expressed his outrage at the fact that the industry was excluded from the talks.

But according to WHO, “there is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests”, while Marquizo describes them as an “industry that profits from suffering and death.”

Opening the convention, COP president Zandile Dhlamini commended “the commitment and passion we all have for […] developing solutions to continuously protect present and future generations from the devastating effects of tobacco”.

Image Credits: WHO/FCTC/Yuscar Duarte, WHO / FCTC / Yuscar Duarte.

Stella Kyriakides, the European Commissioner for Health and Food Safety, at the AU-EU meeting in Addis Ababa.

Europe’s Health Emergency Response Agency (HERA) has pledged €6 million to assist the  Africa Centre for Disease Control (ACDC) to scale up sequence-based disease surveillance and laboratory capacity on the continent.

This was announced by Stella Kyriakides, the European Commissioner for Health and Food Safety, at the start of a three-day meeting between the African Union and the European Union in Addis Ababa on Monday to address health and humanitarian issues.

Belgium’s development agency has also signed a memorandum of understanding with the ACDC aimed at strengthening Africa’s pandemic preparedness, said Caroline Gennez, Belgian Minister of Development Cooperation and Major Cities.

Belgium holds the EU presidency and one of its aims to accelerate equal access to health and strengthen the Africa-EU partnership on Global Health. 

To this end, Belgium is hosting a high-level event on health with the African Union on 20 March.

Africa CDC Deputy Director General Dr Ahmed Ouma welcomed the agreements, saying that they would improve global health security by “building [African] countries’ capacity to detect and respond to health emergencies”.

The agreements focus on three main issues, he added: supporting Africa CDC’s role as the continent’s health implementer, the growing resistance to antibiotics, and building the continent’s One Health capabilities. This is particularly crucial on a continent with a high level of zoonotic diseases.

Kyriakides said that “when it comes to health, there are no continents and borders”.

She added that Africa was a “key priority” for the EU.

Gennez said that the pandemic accord negotiations at World Health Organization (WHO) were a recognition that “all big challenges are global”.

“Team Europe supports the decentralisation of vaccine and medicine production,” added Gennez.

Meanwhile, Minata Samate Cessouma, the African Union’s Commissioner for Health, Humanitarian Affairs and Social Development, said that the meeting would also discuss cooperation on Africa’s humanitarian needs, especially in the Horn of Africa.

“Climate change is now starting to displace more people than conflicts now,” Cessouma noted.

Working Group on Amendments to the IHR (WGIHR) co-chairs Dr Ashley Bloomfield and Dr Abdullah Assiri, alongside WHO head of emergencies, Dr Mike Ryan, at the start of the seventh meeting.

With only 10 official negotiating days left, the Working Group on Amendments to the International Health Regulations (WGIHR) is under pressure to reach agreement on changes to the rules that govern global health emergencies.

The seventh WGIHR meeting which began on Monday officially kicked off the 2024 pandemic ‘season’ negotiations at the World Health Organization (WHO) in Geneva.

It’s a short, intense season though, with the grand finale for both the IHR amendments and the pandemic accord set for the May World Health Assembly.

As Eswatini pointed out, the WGIHR only has 10 official negotiating days left until May, and by Friday, this time will be halved. 

Addressing the equity-related gaps in health emergencies should be prioritised, stressed Eswatini, speaking for the 47 African member states and Egypt (part of WHO’s Eastern Mediterranean region).

Malaysia, representing the Equity Group (a cross section of over 30 countries), stressed that articles to “operationalise equity” – particularly Articles 13, 13A, 44 and 44A, alongside annexures 1 and 10  – need to be prioritised.

“It is important for the IHR amendments to enable us to better prepare for future pandemics and other health emergencies, and this can only be achieved through concrete provisions that effectively operationalise equity,” said Malaysia.

“Hence, we look forward to more concrete engagements and conclusive discussions on equity related provisions before we can agree on the full package of proposed amendments,” it added, appealing to the WGIHR Bureau co-ordinating the negotiations to “make every effort to facilitate the informal consultations as much as possible in order to make headway”.

Sincerity of developed countries?

Bangladesh appeals for reciprocity from developed countries.

Bangladesh, which had made a similar appeal at the last WGIHR meeting, was more forthright: “It is a fact that, in many cases, equity-related proposals have fallen apart despite the strong demand of a large number of countries.”

“Developing countries have sincerely engaged in all proposals submitted by the developed countries. Reciprocity to that is not a demand rather a cause that once motivated us to conceive the idea of amending IHR 2005,” said Bangladesh. 

“We are confident that the developed countries have the capacity to deliver on them and towards that we all need to demonstrate our real intent and commitment.”

Avoid ‘complexity’

Dr Mike Ryan, WHO head of health emergencies, appealed to negotiators to ensure that any amendments were clear and simple to enable efficient implementation.

Ryan summed up the IHR thus: “We protect each other and our communities by committing to provisions to make our borders safe, to make sure that we have good surveillance systems in place, that we manage information in a way that allows others to be alerted when there’s a problem, and  commit to helping others when they have a problem.”

“I would only ask you in what is already a very complicated instrument, and it is very difficult for the Secretariat to meet those provisions and carry out those provisions in an efficient way, not to bring complexity that results in inefficiency, despite the intent. 

“Sometimes in life, especially in an emergency situation, the more complex the action, the more likely it is to fail at a time of critical pressure.”

Malaysia appealed for measures to operationalise equity.

‘Optimism is high’

Despite the daunting week ahead, Dr Abdullah Assiri, the working group’s co-chair, said that “the optimism is high”. 

“We have had ample time to deliberate with our capitals and therefore we can take swift positions on the proposed text. We have several articles and annexes of which consensus could be reached in this meeting,” said Assiri.

Thanks to meetings with the Intergovernmental Negotiating Body (INB), which is developing the pandemic accord, there was also “more clarity on common issues”.

 “For example, you correctly believe that surveillance and the definitions of health alerts all the way to the pandemic definition are mainly IHR related issues. At the same time, you made it clear that equity and finance need to be addressed in both instruments,” said Assiri.

Collaboration, capacity building and financing

The WGIHR Bureau suggests that the meeting begins with text proposals relating to “collaboration, capacity building and financing”. 

These are the articles proposed by Malaysia (13,13 A ,44, 44A) as well as Annex one and a new Annex 10. 

The outbreak continuum – from issuing a public health alert up until the WHO Director General declares a Public Health Emergency of International Concern pandemic – (Articles 6, 7, 10, 11,12, 48 and 49), will be next. 

Then the meeting will address articles related to “governance, monitoring and oversight”, said Assiri. 

“Here we suggest that the proponents – African Group, European Union and the United States of America – work with the Bureau to develop updated text proposals which can be reviewed during the week.”

However, in response to concerns about time, Russia suggested that it might be necessary to implement the amendments in stages.

Misinformation

Dr Ashley Bloomfield, the other co-chair, raised the “well coordinated campaign to try and undermine this process and the INB process and indeed, to try to undermine the work of the WHO”. 

“It’s very important in our work that we provide confidence, both on the importance of the work, and the fact that it is a member state driven process and that the sovereignty of countries is not threatened by this process,” stressed Bloomfield.

“Rather, the sovereignty of each country can be enhanced by us all working collectively,” he added.

“We will be working hard to make sure there is a public profile for this work and that it does address the myths and disinformation that has been targeted at our process. I’m sure you’re aware of it. You’re probably facing your own battles back in your countries with those WHO wish to undermine the process and we must of course not let that happen. There is too much at stake.”

Raising its own concerns about misinformation, Japan proposed that the WGIHR releases an updated draft of the proposed amendments so the public could see that the process is member state driven.

The WGIHR will hold a public update on this week’s negotiations on Friday afternoon.

Healthworker administers polio vaccination in Pakistan’s sensitive northwestern region.

ISLAMABAD – As Pakistan heads towards general elections on Thursday, February 08, leaders of its polio programme are hoping that improved political stability and a more stable security situation could help make 2024 the year for final eradication of the crippling disease from the country.

Pakistan and Afghanistan, neighbouring countries sharing a porous border, are struggling to completely eradicate the wild poliovirus from their countries.

Experts predict that wild poliovirus could be eradicated globally within the next three years, if all goes well. What happens in Pakistan and Afghanistan are central, however, is central to making that happen.   

According to the Pakistan Polio Eradication Program, six wild poliovirus cases were reported in the country in 2023 – another six in Afghanistan. While several imported cases of wild poliovirus were also detected in Mozambique and Malawi in 2022, those were deemed to have been imported from Pakistan, and no further cases have been reported over the past 15 months. 

In Pakistan, no wild poliovirus cases have been confirmed so far in 2024 – putting the country on track for ending wild poliovirus soon, if not this year. 

First national anti-polio drive of 2024 was hit by militant attacks

Site of an attack by gunmen who shot and killed a polio programme coordinator in the Bajaur district of northwestern Pakistan, near the border with Afghanistan, on Jan. 19, 2024.

However, Pakistan’s first national anti-polio drive, which kicked off last month to immunize 44.3 million children, suffered a notable setback, with two militant attacks in the country’s turbulent northwestern region bordering Afghanistan within a space of just a few days.

As a result of these attacks, which occurred in the same region of the country, a senior health official coordinating anti-polio efforts and at least seven security personnel were killed.

Pakistan’s current caretaker government, as well as previous governments, have always expressed their resolve to provide security to polio campaigns.

However, the recruitment of police personnel providing teams with security, has remained a challenge in the ultra-conservative tribal region of the country – ever since a fake Hepatitis B vaccination campaign was carried out by the CIA in the Pakistan border region in order to obtain the DNA of Osama bin Laden and identify his location in hiding, finally leading to his assassination in 2011.

The country’s polio eradication program and its global partners, Rotary International, have welcomed Pakistan Law Enforcement Agencies’ (LEAs) role in supporting polio team security.  However, polio vaccinators and local political leaders  say that polio vaccination teams still need more support.  

More security still needed

Door-to-door campaigns, a critical part of Pakistan’s polio eradication strategy, are a challenge in districts rife with insecurity.

Shahzeb Malik, a polio vaccinator in the northwestern region of Khyber Pakhtunkhwa told  Health Policy Watch that security teams accompany the polio workers in anti-polio drives but there must be better operational coordination on both sides.

“Polio workers and police personnel have been targets of the militants in recent  years, so we need an improved version of the security with this polio program,” he said.

There is no doubt about the strong administrative resolve for ending the polio in the country, he asserted, even in remote regions of Pakistan like his own, he asserted. 

But this year’s  first polio campaign also coincided with election campaigns – a time in which health workers, including polio staff, are also supporting the set up of voting stations and other preparations for the big election day. 

Overcoming the ‘trust deficit’ amongst tribal leaders

The CIA’s operation against Bin Ladin left a lasting legacy for Pakistan’s polio program, resulting in an ongoing ‘trust deficit’ with regards to vaccination campaigns, Dr. Humayoun Mohmand, chairman of  Pakistan’s Senate Standing Committee on National Health Services, told Health Policy Watch. 

He expressed hopes, however, that a new government could begin to bridge the gaps, bringing great political stability and focusing on local solutions to a broad range of problems facing rural tribal communities.

“Absence of political stability and lack of coordination between federal and provincial governments does impact the polio program,” said Mohmand.

Hailing from the tribal region of Pakistan, himself, Dr. Humayoun emphasized the need to engage local ‘Jirga’, referring to local tribunals administered by mosques and Imams [religious leaders] in polio vaccination drives.

“We have to incentivize these institutions and provide financial assistance to include them in the fight against polio,” Mohmand stressed.

Rotary International plays a key role in polio eradication 

Administering a polio vaccine in a door-to-door campaign

Religious leaders, including Imams and Islamic scholars, can also play a vital role in reassuring hesitant parents within their communities about the safety and effectiveness of vaccinations, in line with Islamic principles, asserted Aziz Memon, the chair of Rotary’s International’s PolioPlus national Pakistani committee, in comments to Health Policy Watch. 

Rotary International has been a key player in the global campaign to eradicate polio, committing more than $2.7 billion over the decades to the effort through a funding partnership with the Bill & Melinda Gates Foundation,

In Pakistan, Rotary also supports ulema workshops to build community trust and confidence in vaccines, through the Gates-funded Global Polio Eradication Initiative (GPEI). In addition to engaging trusted religious and community leaders, GPEI partners provide communities with desired (complementary) health services alongside polio immunization.

“Challenges to polio eradication in Pakistan include politicization of the polio program and in some cases, vaccine refusals,” Memom observed. 

“The risk of international spread of poliovirus remains a Public Health Emergency of International Concern”, he added, referring to the longstanding WHO declaration of a global polio health emergency for the virus, which was reaffirmed in December 2023. 

“That’s why Pakistan is implementing and deploying tactics to strengthen essential immunization, better target high-risk areas, and integrate basic health services to complement polio immunization activities including leveraging the capacity of female health workers and religious leaders to build community trust and improve vaccine acceptance.

He said the polio programme prioritizes the safety of the healthcare and frontline workers, and works closely with local governments and authorities to protect these individuals.

“Specifically, the government of Pakistan provides security teams to accompany frontline workers during immunization activities,” said Aziz Memon.

GPEI in Pakistan has also been active in working with political leaders at the national, provincial, and district levels, including during this time of political transition, Memon addded.

“When a new government is established, that advocacy will continue to minimize the impact on the programme,” he predicted.

Insecurity leads to rushed campaigns or campaign postponement

Administering a polio vaccination

Pakistans polio programme has the full support of law-enforcement agencies, from the police to the army, that provide security cover to teams in each campaign, agreed Dr. Shehzad Baig national coordinator of Pakistan’s Polio Eradication Programme..

Even so, insecurity still contributes to “rushed campaigns or campaign postponement in security-compromised areas, which means we are unable to reach the children who need the vaccine the most,” he admitted.

Political instability has been a particular problem in the tribal areas of polio endemic southern districts, such as Khyber Pakthunkhwa, as well as in Pakistan’s northwestern region.  

The Programme also has built a “robust communications strategy in place across the country, including digital and on-ground social behavior change strategies, to build trust in communities,” Baig added. 

“In places where we see vaccine hesitancy and refusals for whichever reason, we enlist the help of local influencers, tribal elders, social workers, and religious leaders to engage with communities and increase the threat perception of polio,” he said.

Still, it remains difficult, if not entirely impossible, to conduct quality house-to-house campaigns in conflict-prone areas.

“In areas where some children are inaccessible to our teams, we implement a ring-fencing vaccination strategy to vaccinate people going in and out of the area to prevent the virus from spreading and give the population some protection from the virus,” he observed..

As for the impacts of political rhetoric and administrative re-shuffling during election season, Baig asserted that it had not really hindered vaccination efforts. 

“With the upcoming general elections, we have a full strategy in place for interaction and advocacy with the incoming government to ensure polio remains a priority,” said Baig.

“Even as the elections are near, all District Commissioners and health department staff supported throughout January 2024 the national immunization drive to ensure that we reach over 44 million children with the vaccine.” 

Image Credits: Pakistan Polio Eradication Program , VOA/Google Maps.

Modupe Famodun, 40, and her eight-year-old son, Tiolu, who lives with cerebral palsy.

In resource-restricted countries like Nigeria, parents of children with special needs, particularly mothers, bear the entire burden of care.

In an unexpected turn of events in early 2015, Modupe Famodun’s baby son was diagnosed with cerebral palsy.

A neurologist at the Federal Neuropsychiatry Hospital (FNPH) in Lagos in South-West Nigeria, had been strolling down the hospital corridor when an unusual, shrill cry pierced the air, immediately drawing her attention. Her instinct, sharpened by years of experience, led her to believe something was wrong.

 Upon inquiry, she found out that the crying child was Tiolu, Famodun’s then two-month-old son.

Filled with empathy for the young mother, the neurologist rallied a team within the hospital to conduct a series of laboratory tests for little Tiolu without charge.

 “What is cerebral palsy?” Famodun recalled asking the neurologist after she disclosed the test result. Cerebral palsy is the medical term for a group of disorders that affect balance, movement and muscle tone. And now her son, Tiolu, has been diagnosed with it.

Unable to come to terms with her son’s cerebral palsy diagnosis, Famodun repeated the test at the Lagos University Teaching Hospital (LUTH) two months later.

 She was desperate for a different outcome, but reality soon hit her. The result was no different from the first.

“This was the moment that brought me to tears because I was completely unprepared,” she said, her voice quivering as she fought her emotions.

In resource-restricted countries like Nigeria, parents of children with neurological disorders bear the entire burden of care. The impact is even more profound on mothers, who assume greater caregiving responsibilities.

A study conducted by Andrew Olagunju, a Nigerian psychiatrist and researcher, highlighted that the severity of the child’s disability can have a significant impact on the caregiver’s psychological well-being.

Emotional roller-coaster

In the months following her son’s diagnosis, Famodun would grapple with overwhelming anxiety as she contemplated the chances of her son ever living a normal life.

“I shut myself in and cried endlessly, hoping on God for a miracle,” she shared.

During the initial two months of her self-imposed isolation, she could barely bring herself to touch her son except when she needed to breastfeed him. Her husband took on all the duties.

“I was lost, totally lost,” she admitted, harbouring guilt for Tiolu’s condition and blaming herself for the events surrounding his early days.

Three days after Tiolu’s birth in 2014, Famodun suspected he had jaundice but a senior family member played down her fears. By the fifth day, when she finally sought medical help, it was already too late. In fact, he was presumed dead at the hospital. Eventually, the doctor resuscitated him but hinted at possible brain damage.

The medical confirmation of Tiolu’s cerebral palsy brought back those painful moments from 2014. She wrestled with regrets, guilt, and sorrow all at once, and it felt like her pain had no end. “I felt responsible for his suffering,” she said.

Famodun had initially hoped that her son would reach developmental milestones like walking, sitting, and talking, just like other children. However, she later learned from the doctor at LUTH that his development is unpredictable.

After Famodun’s supervisor at work learned about her situation, she granted her a year’s paid leave. This period allowed her sufficient time to recover from the emotional turmoil and adapt to her new role as a caregiver.

Her husband helped her through this life transition. “My husband offered counsel on several occasions and taught me how to efficiently manage my time, ensuring I could care for Tiolu before leaving for work,” she shared.

However, as she grew stronger in her role, her husband’s support waned. Four years later, he lost his contract job and eventually stopped returning home, choosing instead to live in the church for the next few months.

Feeling abandoned, Famodun slipped back into depression. She was now left alone to cater for the family’s well-being and shoulder Tiolu’s medical expenses.

Cost of care

Stella Igbokwe, a young mother whose only child was diagnosed with hydrocephalus — a condition in which excess cerebrospinal fluid builds up within the fluid-containing cavities of the brain — disclosed that she spends more money on her child’s care than she earns from selling fruit on the street.

“I spend over 50,000 naira ($37) every month on my son, Stanley. Registering him at Flora’s Trust Centre [a formal caregiving home] costs 20,000 naira ($14.7). The rest covers his medications, diapers, special diet and transportation. It is not easy,” she lamented.

In his research, Olagunju noted that in countries with limited resources, caregivers not only play a crucial role in the well-being of these children but often bear the primary responsibility for their treatment.

He attributes this to the unequal distribution of healthcare resources and limited health insurance coverage in these countries, leading to high out-of-pocket expenses for families.

It is estimated that public spending on support for people with disabilities (PWD) in low- and middle-income countries is below 0.3% of GDP. This is in stark contrast to high-income countries, where allocations for such support can exceed 1.4% of GDP.

Weak policies

According to Article 28 of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) and its Optional Protocol, which Nigeria ratified in 2010, effective social protection policies must take into account the additional costs faced by people with disabilities from low-income backgrounds.

In a report by the Office of the High Commissioner for Human Rights (OHCHR), eight Nigerian states were recognized for adopting regional disability laws. However, only five of these states allocated funds in their 2023 annual budget for the implementation of these laws, with Lagos State, the focus of this report, being one of them.

Remarkably, the budget for the Lagos State Disability Fund, aimed at enforcing the 2011 Lagos State Special People’s Law (LSSPL) to safeguard the rights of people with disabilities in the state, was greater than the combined budgets of the other four states.

The LSSPL fails to make provisions for financial assistance for children with disabilities and their families living in poverty, as recommended in the CRPD, but it faces criticism mostly for its poor implementation.

In early 2023, allegations of fund misappropriation were made against the general manager of the Lagos State Office of Disability Affairs (LASODA), the agency charged with implementing the LSSPL and managing its funds.

Following the accusation, the then general manager of LASODA, Dare Dairo, failed to respond to the allegations, simply saying that his office lacked the authority to withhold funds. He also noted that the agency was working with local government officials to enhance healthcare access for PWDs. However, access to free healthcare remains an unfulfilled promise for people with disabilities in the state, as out-of-pocket expenses for treatment remain the norm.

Expressing her discontent with the governing board, Tobiloba Ajayi, a lawyer living with cerebral palsy who contributed to the development of the LSSPL, said, “The law is comprehensive and beautifully written. We put in all the work to get the law passed, and yet, implementation has continued to be lacking.”

Some respite for caregivers – but at a cost

The privately owned Flora’s Trust Centre was established by Chikaodili Ugochukwu, a 55-year-old mother with a teenage son living with cerebral palsy. Her decision was influenced by the challenges she faced in finding a suitable caregiving home for her son close to their place of residence in Lagos.

In Nigeria, the number of formal caregiving homes is limited and unevenly distributed. Quite a number of the well-maintained ones are owned by individuals or non-governmental organisations (NGOs).

 Mothers interviewed for this report have expressed disappointment with government-owned caregiving homes, citing poor living conditions and low staff-to-child ratios, leading them to dismiss these homes as viable options.

Stella Igbokwe, 27, visits her son at Flora’s Trust Centre.

When Ugochukwu began the centre in 2018, it was exclusively dedicated to children living with cerebral palsy, but it was impossible for her to turn her back on mothers raising children with other neurological disorders. “Disability management is a herculean task,” she said.

Ugochukwu felt obligated to take in Igbokwe’s son to ease the burden on the young mother, who does not receive support from her partner.

“Once I drop him off at the centre, I feel a sense of relief, knowing I can focus on my work. My primary concern now is ensuring that I have enough money to pay for another month,” Igbokwe said. 

An unsustainable practice

Although there have been instances where children were admitted to the caregiving home  without paying the enrollment fee, Ugochukwu soon found that this practice was not sustainable.

 “We are non-profit, but in the meantime, we require parents to pay subsidised fees to cover our operational expenses until we can attract more sponsors,” she explained.

Ugochukwu revealed that it costs no less than 800,000 naira ($590) to keep the centre running. This covers their overhead costs and enables them to employ the services of professionals to offer physiotherapy, speech and occupational therapy for the children.

On the centre’s lemon-coloured wall, a whiteboard displayed the names of enrolled children. There were 11 names, although only five children were present at the time of this report.

Drug and food charts for some of the children enrolled at the centre.

Among the absentees was Ifedayo*, a 12-year-old girl living with cerebral palsy. Her mother, Ayomide*, a 49-year-old single parent, had not renewed tuition for that month because Ifedayo’s older brother was on holiday and would be supporting her at home.

When her husband was alive, Ayomide never considered caregiving centres because he effectively supported her at home, even at some point becoming Ifedayo’s primary caregiver.

“After my husband passed away, I was really under pressure,” said Ayomide, who became the sole breadwinner of the family.

 She said that it was impossible to make ends meet while providing round-the-clock care for her daughter. “I was struggling to meet deadlines at work, and not all my clients were understanding.”

 She stumbled upon Flora’s Trust Centre by chance and decided to enrol Ifedayo after learning about the centre’s weekly boarding services. This meant parents could drop off their children on Monday mornings and pick them up at the end of the week.

Even after she found that this would cost her 60,000 naira ($44.2)—significantly higher than the centre’s non-boarding services—she still went ahead with her decision.

“It’s not that I could afford the money, but commuting daily to the centre would cost almost double the amount,” she explained, referring to the mobility challenges she experiences when going out with her daughter, whose condition confines her to a wheelchair.

False hope

At first, Ayomide thought that diligently following her daughter’s treatment plan would help her recover. “But there seems to be no end,” she said.

Like those who came before her, she would realise that caring for children with special needs is a journey, not a sprint. 

“Many of these children will rely on their parents throughout their lives,” said Lillian Akuma, a physiotherapist at the Child and Adolescent Centre of the FNPH. She has been working with children and adolescents living with neurological disorders for 12 years now.

“What I often observe is that many caregivers are unprepared for the transition from childhood to adolescence and eventually adulthood,” she continued. She noted that health professionals who provide care for these children were partly to blame.

Lillian Akuma during a physiotherapy session.

“In a bid to comfort parents, we give them the impression that it’s just a phase the child will outgrow. But that’s not always the case,” she explained.

These parents, clinging to this prognosis, become anxious to witness their children reach important milestones. “They hope to see their children stand, but after two years, if the children haven’t even achieved neck control, the parents become depressed,” she said.

“I have conducted research on caregiver’s burden and discovered that when they are in this mental state, they no longer put in their all to support their children,” Akuma said.

 “When caregivers fail to fulfil their roles effectively, we can’t expect positive treatment outcomes for the children,” she concluded.

A safe place

An empty hallway in the Child and Adolescent Centre. The building has brightly coloured interior walls and adorned with vivid drawings to appeal to the children.

The Child and Adolescent Centre, an annexe of the FNPH, where Famodun’s son was first diagnosed, is one of the few facilities offering medications for children with neurological disorders.

However, it holds significance far beyond being just a healthcare institution for many of these mothers.

“The Child and Adolescent Centre is like a family house for me,” said Wemimo Akinwunmi, a 39-year-old mother of a son living with cerebral palsy. Her son, Ayomikun, had earned the endearing nickname “Ambode” from fellow parents at the centre, which was a nod to a former governor of Lagos State whose first name was also Akinwunmi.

Akinwunmi recounted when she ran out of money for her son’s medication and the other parents rallied to provide the outstanding amount. On days when she had enough, she returned the favour to other parents in need.

The centre has gained immense popularity for two key reasons: first, its specialised treatment for children with neurological disorders, and second, as a safe space where their parents feel genuinely understood.

Wemimo Akinwunmi, 39, and her son, 7, Ayomikun, going out for a walk. She considers the Child and Adolescent Centre, of the Federal Neuropsychiatry Hospital “a family house.”

Famodun disclosed that the centre played an important role in restoring her confidence. ‘In 2016, I was transferred to the pharmacy section of the Children and Adolescent Center, where I met numerous mothers who shared similar experiences. I learned so much from them,” she said. She also benefitted from the return of her husband, whom she described as supportive.

 These days, when parents visit the clinic, the nurses frequently turn to Famodun to address their concerns. “I went from being quiet to becoming an activist for my son,” she said, smiling proudly.

*Chikaodili Ugochukwu lost her teenage son some months after this interview was conducted.

*Some names have been changed to protect their identities.

*Naira exchange rates used were based on the time of report

This story was produced with the support of the Women Radio Centre and the MacArthur Foundation.

Image Credits: Samuel Okoro., Samuel Okoro, Kate Okorie.

Dr Adriana Blanco Macqueso, Head of the Secretariat of the WHO Framework Convention for Tobacco Control

New tobacco and nicotine products and the tobacco industry’s extensive lobbying of governments are likely to be in the spotlight when country representatives meet next week to discuss the implementation of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). 

The 10th Conference of the Parties (COP10) starts in Panama on Monday (5 February) after being postponed from last November because of unrest in the host country.

“Tobacco is, and continues to be, a threat. It is a threat to human life. It is a threat to human health, but also a threat to the health of the planet,” stressed Sabina Timco Lacazzi, WHO’s Legal Officer working on FCTC implementation.

WHO FCTC, signed by 182 parties, entered into force in 2005, and the biennial COP and Meeting of the Parties (MOP) acted as governing bodies working on implementing the treaty.

The Convention is the first international treaty to take into account not only human health but also the impact on animals and the planet, as Lacazzi proudly stated. “It’s really important that parties and the public in general remember this very important reason why we work […] to take stock of tobacco control measures and to continue to push for progress in this regard.”

Tobacco’s health cost

Over a fifth of the world’s population uses tobacco, with four out of five smokers living in low- and middle-income countries, according to the WHO.

Smoking is the cause of over eight million deaths annually, 1.3 million of which are a result of mere exposure to tobacco smoke from other smokers.

Even though the number of tobacco product users is declining, it still amounts to a substantial burden of cancer, stroke, heart and lung disease, says the CDC.

Deadly health effects of cigarettes and similar products are widely known and yet, the tobacco industry is often successful in its lobbying for fewer regulations or discouraging information campaigns.

New products, investment fund to be discussed

The upcoming meetings is also likely to focus on the regulation of emerging nicotine and tobacco products as well as details of a new investment fund covering implementation of the treaty, stated Dr Adriana Blanco Macqueso, head of the WHO tobacco regulation treaty secretariat in a press conference.

But Macqueso could not say what direction the will parties take on heated tobacco products and e-cigarettes. 

“With 162 parties, we may have 162 different positions on this,” she said, but stressed that countries agree that the new commodities “should be regulated,” as traditional ones are.

Lobbying tactics

According to the WHO, “there is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests”.

Despite that fact, many governments fail to resist the persisting lobbying pressure. The industry’s tactics involve many practices, including intimidation, claiming a public health role, influencing scientific research or even undermining existing laws.

A selection of lobbying tactics used by the tobacco industry, as presented by Sabina Timco Lacazzi, WHO Legal Officer working on implementing the tobacco regulation treaty

In Cameroon, for instance, the health authorities had a secret working session with the tobacco industry, according to Vision for Alternative Development (VALD) Ghana, a health-focused NGO.

Even COP meetings have struggled to eliminate the intrusive tobacco industry’s presence. During the last meeting in India, for example, one of the country delegates “actually spoke at the floor, saying tobacco is not addictive,” said Akinbode Oluwafemi, Executive Director of Corporate Accountability and Public Participation Africa based in Nigeria. 

Measuring industry influence

In response to a variety of lobbying practices, the Global Center for Good Governance in Tobacco Control has developed the Tobacco Industry Interference Index which classifies countries based on how independent they are from tobacco companies’ influence.

Tobacco Industry Interference Index scores for a selection of African countries, as presented by Labram Musah from Vision for Alternative Development

Botswana and Ethiopia emerged with the lowest scores (least influence), while Zambia, Tanzania and Cameroon were the most heavily influenced.

Countering industry pressure at COP

Similar to the climate summit in Dubai, where the presence of fossil fuel companies undermined some ambitions for a phase-out, the tobacco regulation COP might face industry pressure, highlighted Oluwafemi.

But the FCTC “represents one of the most effective public debt instruments in the world”, he added.

Former WHO Chief Scientist Dr Soumya Swaninathan

Dr Soumya Swaminathan is returning to the international stage after leaving the World Health Organization (WHO) in late 2022, just as the world was recovering from the COVID-19 pandemic.

She became the agency’s first Chief Scientist just before the pandemic, a position that propelled her to become a widely-known global voice for WHO, analyzing and communicating the latest information on the pandemic.

Now, the 64-year-old is co-chairperson of Our Common Air (OCA), a new global commission that has been launched by Clean Air Fund (CAF) in London, and the Council on Energy, Environment and Water (CEEW) in New Delhi. The other co-chair is Helen Clark, former Prime Minister of New Zealand.

“We bring complementary strengths,” Dr Swaminathan told Health Policy Watch, referring to Clark’s international political connections and her own scientific credibility. She was speaking just ahead of a closed-door meeting in Bellagio, Italy, with leaders of the new initiative, OCA, which aims to raise the political and financial investment in air pollution.

The OCA aims to drive more funding from governments, developmental, and the private sectors to cut down air pollution globally. Air pollution causes 8.3 million deaths a year –  almost 16 deaths a minute – whereas it received only 1% of international development funding, a study by CAF shows.

“We want to raise that profile of air quality as an important determinant of health, as well as bring attention to the actions that individuals, as well as companies, communities, cities, and governments, need to take urgently in order to address this big huge global problem,” said Swaminathan.

Air pollution has short-term and long-term impacts on health, many studies have shown. These range from heart attacks, diabetes, and strokes, and in pregnancy it increases the risk of low birth weight, stillbirth, and miscarriage due to long-term exposure.

Short-term exposure over a few hours or days to high pollution can affect lung function, worsen asthma, and increase hospital admissions related to respiratory and cardiovascular conditions.

A study backed by CAF and the Confederation of Indian Industries (CII) showed pollution is estimated to have cost India $95 billion or about 3% of its GDP. This includes loss of the workforce to deaths, loss of productivity by employees not fully functioning at work because of the effects of pollution, lower attendance at markets on high pollution days, and the stunting of crops among other things.

“What business leaders have to understand is that some of the impacts of climate change – air pollution, heat, food, and nutrition and security – is really going to impact their productivity,” Swaminathan told Health Policy Watch.

Despite spending on air pollution, India’s air quality has continued to deteriorate in the past decade.

Air pollution’s cost-to-company

Despite all the science and data, there is little funding for air pollution control measures. Philanthropic funding between 2015 and 2022 was $330 million. The biggest chunk, about 35%, of philanthropic pie, went to North America, while Europe and India got 15% each and China 15%. Just 2% went to Latin America and 1% to Africa.

Swaminathan admits that OCA has an uphill task. Their targets are not just governments and donor organizations but also businesses.

“There’s enough evidence out there. What will it take, ultimately, to convince I don’t know. When you’re talking about globalization, and companies having employees all over the world, employees will be very much more reluctant to relocate to places where the air quality is poor, they may ask for extra compensation and things like that.

“I’ve seen this happening with some diplomats, for example. They don’t want postings in places with poor air quality. It’s not just a reputational issue, but it becomes a real issue when it comes to getting the work done.”

Pollution is a double whammy for developing countries

Swaminathan describes air pollution as a “double whammy” for developing countries: “It is one of the most important risk factors for non-communicable diseases, which, of course, are on the rise worldwide, as well as in India, and the developing world. So it’s a double whammy because the burden is increasing because of the risk factors. And because care, diagnosis, and treatment are not accessible to everyone, then we’ll also have a higher mortality.”

One of the first major successes she recalls soon after she joined WHO was over air pollution. As Deputy Director General of Programmes, she had a “huge scope.”

This enabled her “to address some very obvious disconnects, which I found, which perhaps had not been addressed in the past because of the siloed nature of WHO.” Air pollution and non-communicable diseases (NCDs) were handled by different teams despite the pollution being a critical risk factor for NCDs like heart disease, strokes, and chronic lung disease.

“By bringing (the two teams) together, we were able to say air pollution is the fifth major risk factor for non-communicable diseases and it goes into the documents. And it then went to the high-level political event in New York in 2018, as one consolidated set of recommendations rather than separately.”

A core focus area for Swaminathan has been tuberculosis. When she was appointed Chief Scientist, it allowed her to make an impact on guidelines. “I was able to put in place improved and more forward-looking and futuristic ways of doing our norms and standards, moving away from individual opinion base to a much more systematic way of synthesizing evidence, including the use of artificial intelligence.”

Proportion of premature deaths from leading NCDs attributable to air pollution according to WHO data.

‘Politically driven’ attacks

Swaminathan is frank about her WHO tenure during COVID-19 when she was targeted by, among others, the US Food and Drug Administration (FDA) during the Trump administration, and the Indian Bar Association. In both cases, she and the WHO were proven right, she points out.

The WHO and Swaminathan were critical of the US FDA’s decision to give emergency approval to Remdesivir as a COVID treatment based on limited evidence, whereas the WHO’s Solidarity Trial found no measurable benefits for the drug’s use.

She dismisses the second attack – over her comments against the use of Ivermectin as a treatment for COVID – as one by a “fringe group” and points out that the WHO was proven right by numerous studies.

“There were extreme views on things during the pandemic, a lot of it was politically driven. But there were also people out there who just wanted to create trouble and wanted to spread misinformation and had some very strange beliefs about things like vaccines and drugs,” Swaminathan said.

“That was very surprising for me – to face that kind of criticism and opposition, but it was also difficult to handle because of the visibility that I had, and the social media presence that I had, and it’s very easy to harass you on social media.”

Former WHO Chief Scientist Soumya Swaminathan

‘Learned to live with criticism, harassment’

“I would not say that I would do anything differently based on that experience because I think, difficult as it was, it was something that I learned to live with. I would say, it did not impact my work and didn’t impact the work of the organization. And in the end, I think we got credit for having stuck to the science.”

Swaminathan says she had the backing of WHO Director General Dr Tedros Adhanom Ghebreyesus, who told her he would back her if she could defend what she said: “To that extent, I had full freedom.”

“It was DG Tedros who was actually facing the most attacks, including from the President of the United States and from various other quarters. So compared to that, I think the attacks on me were minor. But I did have his backing and the backing of the WHO because, before we said anything, we would discuss it internally.”

When she’s away from the international stage, Swaminathan is busy running the MS Swaminathan Research Foundation back home in Chennai. It was set up by her legendary father, Professor MS Swaminathan, in the late 1980s. He and his foundation have made a huge contribution to food security in India through research on plant genetics, agricultural research and development, and the conservation and enhancement of natural resources.

Her new challenge perhaps presents an opportunity to create a similar legacy.

Image Credits: BreatheLife/WHO.

During humanitarian crises millions of people struggle to manage a range of non-communicable diseases (NCDs).

The United Nations estimates that 363 million people are currently impacted by humanitarian crises driven by increasing fragility and conflict, the climate crisis and widening inequality. Around 108.4 million people were forced to flee their homes in 2022, meaning one in every 74 persons globally.

Humanitarian crises, such as those occurring in Ukraine, Gaza, Libya, Somalia and Sudan may vary in nature and scale but they all share population displacement, the destruction of infrastructure and the disruption of supply chains and services.

Health is one of the first casualties. Increasingly, healthcare facilities and supply chains are directly targeted in conflict. Restricted or impeded access to hospitals, health services and staff and life-saving medicines and technologies, as well as food and water shortages, make life precarious.

Much media attention during crises understandably tends to focus on overwhelmed hospitals and what that means for women giving birth, vulnerable newborns and war-wounded people needing life-saving surgery.

Access to medication in crises

Outbreaks of infectious diseases such as measles and cholera also make the headlines. Yet the parallel reality is that during humanitarian crises millions of people struggle to manage a range of non-communicable diseases (NCDs) such as diabetes, hypertension or cardiovascular illness. Access to their essential medications and health professionals may be non-existent.

Policymakers are now being forced to take an ‘all hazards approach’ to emergency planning and response, together with an inclusive health and humanitarian response that leaves no one behind.

There are plenty of factors to consider: increasing fragility, widening inequality, uneven economic growth, a fragmented geopolitical landscape, inadequate financing, the potential for new pandemics, and climate crisis encroaching on and shifting the way societies produce, eat and live.

Of course, the degree to which countries are able to respond to health emergencies will depend on the scale of the crisis they face at any given time, the financial situation, preparedness, and how resilient the health system is.

Many low- and middle-income countries have fragile health infrastructures to begin with, and when faced with crises, they are much more vulnerable. But the success of an emergency response is more likely if established models of care and strong partnerships between government and civil society are already in place.

The International Committee of the Red Cross headquarters in Geneva, Switzerland.

Collaboration to deliver better NCD care

Partnering for Change – a collaboration between humanitarian organisations, the International Committee of the Red Cross (ICRC) and the Danish Red Cross (DRC), and the private sector company, Novo Nordisk – was launched to identify best practice to support people living with diabetes and hypertension in humanitarian crises. They have partnered with academia, the London School of Hygiene and Tropical Medicine (LSHTM) in research initiatives to design, evaluate and improve models of care.

Since 2020, the ICRC has supported a primary health care service run by the local NGO Chabab Al Ataa Al Jazeel Association (CAJA) in Bireh in Northern Lebanon. Initial research from P4C with patients, caregivers and service providers highlighted patients’ multiple care needs and the huge burden families faced in navigating a fragmented care system.

Improving the patient-centeredness of care by integrating cardio-metabolic disease management with mental health and physical rehabilitation services with defined referral pathways, and a joint patient management system was seen as a potential solution. An adapted integrated model was developed and is currently being implemented. In parallel, an evaluation is being conducted for a better understanding on how to implement, sustain and scale up this type of integrated model for NCD care in humanitarian settings.

Outside of Partnering for Change, the Danish Red Cross is supporting the Somali Red Crescent Society, one of the biggest health care providers in Somalia, in its efforts to integrate screening and management of diabetes, hypertension and asthma as well as mental health and psycho-social support into already existing health programmes.

They have until now mostly focused on maternal and child care but decided to include NCD care and prevention based on needs assessments. As well, Somali Red Crescent Society are seeking to include focus on health-promoting behaviour, NCD prevention and awareness of risk factors through community engagement and community health committees.

Trucks carrying humanitarian aid wait to cross into Gaza from Egypt through the Rafah border point.

Integrate care in humanitarian settings

A recent report on the financing of NCD care in humanitarian settings has pointed to the essential role of community-engagement in reaching people early, before conditions become serious and require costly hospital-level care.

These kinds of interventions are hopefully a window into the future, further building on what already exists. The idea of integrated care across the non-communicable and infectious disease spectrum has slowly been gaining traction: both the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund now include NCDs in their HIV and tuberculosis financing portfolios.

Yet more evidence is still needed to adequately demonstrate that integration is cost-effective. To address this gap, a recent report has looked into how integrated NCD care can save resources for both patients and health systems. Patients benefit the most – about 85 per cent of the total savings. From a health-system perspective, the extra cost to integrate these programmes are relatively small compared to the positive health outcomes they generate.

While delivering these integrated care services in humanitarian settings logistically still remains a leap into the unknown, the rationale for financing them is clear – if we are to achieve Universal Health Coverage, NCD services must be integrated into community services and primary healthcare facilities to ensure that people living with these chronic diseases have access to quality services across the continuum of care and during disruptions in care from disasters or conflict.

We’ve heard the growing calls for health services to be protected during conflicts. We’ve seen first-hand the growing alignment of climate change and health agendas at the recent COP 28 meeting. Now, we need to see political will that better responds to an uncertain future for the growing number of people living with NCDs and that guarantees their right to health.

Micaela Serafini is head of the health unit at the International Committee of the Red Cross.

Katie Dain is CEO of the NCD Alliance.

Nicolai Haugaard is Vice President and Global Head of Health Equity, Novo Nordisk

Image Credits: Unsplash, Flickr – US Mission Geneva, © UN Photo/Eskinder Debebe.

Patients undergoing chemotherapy for cancer.

New cancer cases are projected to increase by a massive 77% between 2022 and 2050 – mainly as a result of tobacco, alcohol, obesity and air pollution.

Ageing and population growth are also factors pushing new cases from 20 million in 2022 to an expected 35 million in 2050, according to the Global Cancer Observatory  released by the International Agency for Research on Cancer (IARC) on Thursday.

The IARC research, published every two years, covers 185 countries and 36 cancers with data drawn from countries themselves.

Lung cancer was both the most common cancer and the leading cause of cancer deaths in 2022 – likely because of “persistent tobacco use in Asia”, according to the IARC, which is the World Health Organization (WHO)’s cancer agency .

There were 2.5 million new lung cancer cases (12.4% of total cases) and 1.8 million deaths (18.7% of total) in 2022 – with men being more likely to succumb than women.

Breast cancer ranked second (2.3 million cases, 11.6%), followed by colorectal cancer (1.9 million cases, 9.6%), prostate cancer (1.5 million cases, 7.3%), and stomach cancer (970 000 cases, 4.9%).

However, colorectal cancer was the second biggest killer (900 000 deaths, 9.3%), followed by liver cancer (760 000 deaths, 7.8%). Breast cancer, which is the biggest killer of women, was the third highest cause of cancer mortality with 670 000 deaths (6.9%), closely followed by stomach cancer (660 000 deaths, 6.8%). 

Absolute numbers of cancers per continent in 2022

Low-income countries face doubling of deaths

In terms of the absolute burden, wealthier countries with a high human development index (HDI) – a measure of life expectancy, education rates and income – are expected to experience the greatest absolute increase in incidence, with an additional 4.8 million new cases by 2050 compared. 

Yet the increase in incidence is most striking in low HDI countries, which face a projected 142% increase, and in medium HDI countries (99%). Cancer deaths are projected to almost double in 2050.

“Those who have the fewest resources to manage their cancer burdens will bear the brunt of the global cancer burden,” says Dr Freddie Bray, IARC’s head of the cancer surveillance told a media briefing this week. 

Bray also called for better cancer data, as a number of countries do not have cancer registries.

Global cancer burden 2022

 

The Global Cancer Observatory was released alongside a WHO survey on cancer care on the eve of World Cancer Day on 4 February.

Only 39% of 115 countries surveyed covered the basics of cancer management as part of their financed core health services for all – ‘health benefit packages’ (HBP) – according to the WHO survey.

People living in poorer countries had much worse outcomes thanks to later diagnosis and often unaffordable treatment

In countries with a very high HDI, one in 12 women will be diagnosed with breast cancer in their lifetime and one in 71 women die of it.  But in countries with a low HDI, only one in 27 women will be diagnosed and one in 48 women will die from it.

“Women in lower HDI countries are 50% less likely to be diagnosed with breast cancer than women in high HDI countries, yet they are at a much higher risk of dying of the disease due to late diagnosis and inadequate access to quality treatment,” explains Dr Isabelle Soerjomataram, IARC’s deputy head of cancer surveillance.

Meanwhile, cervical cancer was the eighth most commonly occurring cancer globally and the ninth leading cause of cancer death. It is the most common cancer in African women with significant mortality although it can be eliminated as a public health problem through the scale-up of the WHO Cervical Cancer Elimination Initiative.

Female cancer mortality: Africa compared to Europe

“Despite the progress that has been made in the early detection of cancers and the treatment and care of cancer patients, significant disparities in cancer treatment outcomes exist not only between high and low-income regions of the world, but also within countries,” says Dr Cary Adams, head of the Union for International Cancer Control.

“Where someone lives should not determine whether they live. Tools exist to enable governments to prioritise cancer care, and to ensure that everyone has access to affordable, quality services. This is not just a resource issue but a matter of political will.”

Unaffordable treatment

WHO’s global survey of health benefit packages also revealed significant global inequities in cancer services. 

Lung cancer-related services were four to seven times more likely to be included in standard health benefits in high-income than lower-income countries. On average, there was a four-fold greater likelihood of radiation services being covered in a HBP of a high-income than a lower-income country. The widest disparity for any service was stem-cell transplantation, which was 12 times more likely to be included in a HBP of a high-income than a lower-income country.

“WHO’s new global survey sheds light on major inequalities and lack of financial protection for cancer around the world, with populations, especially in lower income countries, unable to access the basics of cancer care,” said Dr Bente Mikkelsen, WHO’s Director of Noncommunicable Diseases (NCDs). 

“WHO, including through its cancer initiatives, is working intensively with more than 75 governments to develop, finance and implement policies to promote cancer care for all. To expand on this work, major investments are urgently needed to address global inequities in cancer outcomes.”

Image Credits: Roche.