Sudanese women are being targeted by soldiers using rape as a weapon of war.

The “weaponization of sexual violence” during conflicts is a major challenge facing the health sector, and it needs the serious attention of the international community, said World Health Organization (WHO) Director General Dr Tedros Adhanom Ghebreysus.

Tedros broke down  while recounting that his own cousins had been raped and his uncle had been killed during recent violence in Tigray in Ethiopia as gender-based violence has become an instrument of war.

“Tens of thousands of women have been raped during that conflict, and there is no capacity in the region or within WHO to handle it. But you see it not only in Ethiopia, but you see it in DRC, you see it in Haiti, you see it in Sudan. You see it everywhere,” said Tedros during a  high-level dialogue with UN High Commissioner for Human Rights Volker Türk in Geneva on Monday – a day after International Health Day and the WHO’s 76th anniversary.

Tedros admitted that addressing gender-based violence was “beyond the capacity” of the WHO.

“I say beyond our capacity, or beyond the capacities of any player I know in conflict,” said Tedros.  “Many thousands of women haven’t received any services whatsoever – nothing, zero – and it’s the same in many countries where there is active conflict,” said Tedros.

“The magnitude is so high, and the international community should take it seriously,” he stressed, adding that women didn’t just need medical services, but psychosocial support.

Strategic dialogue with OHCHR

UN High Commissioner for Human Rights Volker Türk recalled that a number of countries, including Sudan, denied that their soldiers were involved in rape “but it happens in every army”.

Türk proposed a strategic dialogue between his Office – known as OHCHR – and the WHO to address human rights in the health sector and how to secure the right to health.

The two organisations have a framework of cooperation, said Türk, but they hadn’t been able to “bring it to the next level” during the pandemic.

“I think it would be good to take stock, and look strategically at how both worlds can be much closer together on a number of fronts,” he proposed – with Tedros immediately agreeing to a meeting during the course of the year.

 

The two leaders also raised the deliberate targeting of health facilities during conflict and the impact of this on health workers, and the high fatality rates of civilians in current conflicts. The WHO has documented the destruction of 300 health facilities and the deaths of 742 health works in this year alone.

Türk said that after “two massive world wars, after atrocity crimes, horrible war crimes, the Holocaust, and the Great Depression, there was a real recognition that, when it comes to health in conflict, hospitals and medical personnel are sacrosanct”.

But this has been replaced by a “flagrant blatant disregard for the laws of the war when it comes to hospitals and medical personnel”, he added.

In Syria, Ukraine and Gaza, there had been an almost deliberate targeting of hospitals and of health personnel, said Türk, who described what is happening in Gaza as “an unmitigated disaster” with “hardly any health facilities working”.

“We need to regain the space of the normative values that go back to the origins of why it is important to protect healthcare personnel, and health infrastructure in all situations around the world. I mean, we are talking about 55 active conflict situations,” he added.

‘Target fossil fuel’

The two leaders also raised the impact of changing climate on health, with Tedros supporting the focus on phasing out the use of fossil fuels, which is responsible for “70% of greenhouse gases.

“Because of climate change, asthma is on the increase. Cardiovascular diseases are on the increase. Vector borne diseases like malaria, dengue are actually invading places they have never been known before,” said Tedros.  

Dr Tedros Adhanom Ghebreyesus

“Universal health coverage is a question of rights, and it has to influence the budgetary decisions that states make, and which brings us to the issue of the human rights economy,” said Türk. 

“If there was any lesson to be learnt from a COVID pandemic, it is precisely that it is that you need to have universal health coverage in order to be able to deal with the big challenges or the stress factors that a pandemic can unleash,” he added.

“We want to be sure that we’re prepared for whatever comes next, and universal health coverage is absolutely critical, both in terms of rights, but also in terms of sustainable development for any country in the world.”

Image Credits: CC.

WHO and UN agency officials survey the ruins of Al-Shifa’s Emergency Department during a visit Friday, April 5.

Speaking out on World Health Day, WHO Director General Dr Tedros Adhanom Ghebreyesus decried the destruction of Gaza’s Al-Shifa hospital and blamed Israel for the devastation, saying that the “atrocity” of the Hamas attacks on Israeli communities 7 October, did not justify “the horrific ongoing bombardment, seige and health system demolition by Israel in Gaza.”

He made his remarks Sunday, two days after the first WHO visit to Shifa Hospital following the 1 April withdrawal of Israeli forces from the hospital compound after a fierce two-week battle with Hamas forces in and around it.

“It has been six months since the brutal attacks in #Israel by Hamas and other groups, in which 1,200 people were killed, many more injured and hundreds abducted,” Tedros said in a post on X, of the 7 October events that triggered the war. 

“@WHO once again condemns this barbaric act of violence and demands the release of remaining hostages. However, this atrocity does not justify the horrific ongoing bombardment, siege and health system demolition by Israel in #Gaza, killing, injuring and starving hundreds of thousands of civilians, including aid workers.

“The deaths and grievous injuries of thousands of children in Gaza will remain a stain on all of humanity…. The denial of basic needs – food, fuel, sanitation, shelter, security and healthcare – is inhumane and intolerable,” said the director general. 

Images of the hospital taken during the UN inter-agency visit, which included WHO, OCHA and other relief organisations, highlighted the degree of damage done, with the hospital’s emergency surgical and maternity departments, in particular,  reduced to unrecognisable shells.

“As WHO marks World Health Day … under the theme ‘My health, my right,’ this basic right is utterly out of reach for the civilians of Gaza,” said a WHO statement shortly after the mission took place, noting that prior to the beginning of the war, Shifa had been the largest and most important referral hospital in Gaza.

“Of the 36 main hospitals that used to serve over 2 million Gazans, only 10 remain somewhat functional, with severe limitations on the types of services they can deliver,” said the WHO statement, noting that “access to health care in Gaza has become totally inadequate, and the ability of WHO and partners to help is constantly disrupted and impeded.

“The proposed military incursion into Rafah can only result in further diminution of access to health care and would have unimaginable health consequences.  The systematic dismantling of health care must end.”

The WHO comments on Shifa triggered a sharp reaction from Israel’s ambassador in Geneva, Meirav Eilon Shahar, who accused WHO of “complicity” in its silence over Hamas militarisation of the hospital that Israel says triggered the two-week invasion in which several hundred Hamas gunmen, including a number of senior Hamas leaders, were reportedly killed.

“It’s not just the 133 men, women and children which are held hostage by Hamas, it’s the entire Palestinian civilian population and their infrastructure including hospitals and schools,” said Shahar in an X post.

“Hundreds of terrorists in Shifa. Silence. Hostages taken to hospitals on October 7. Silence. Weapons found in incubators. Silence. Rockets founds in wards. Silence. The last 6 months. Silence from @WHO on Hamas, and its abhorrent strategy. Silence is complicity.”

World Health Day, celebrated every year on 7 April, marks the anniversary of the founding of the World Health Organization in 1948.

Image Credits: OCHA .

Ukrainian family flees over the border on foot in March 2022, following Russia’s invasion of the country.

Victims of conflict face a double or triple whammy when trying to cope with mental health challenges. Even the most resilient may begin to experience symptoms of anxiety, anger and sleeplessness during wartime that last decades. And those with pre-existing conditions are forced to cope with the acute trauma provoked by experiences of death, destruction and displacement at the same time as any chronic condition, for which they may be unable to get medications or support. 

The issue was the focus of a recent online event “No Peace of Mind” organised by the Global Health Centre of Geneva’s Graduate Institute and the UK-based charity Beyond Conflict, in which experts with experience dealing with ongoing conflicts in Ukraine, Kashmir and the Palestinian West Bank and Gaza spoke about the myriad of challenges they faced. 

Mental health alongside physical care in emergency settings

Mariana Duarte, Médecins Sans Frontières (MSF)

Panellists emphasised the need for health and humanitarian relief organisations to recognise the need to provide mental health support to conflict-affected populations, along with other emergency health services. 

In prolonged conflict settings, long-term investments in culturally sensitive and accessible care are important, they stressed. Building awareness about self-care as well as more training for family practitioners in the identification and treatment of mental health conditions can help overcome the dearth of resources, as well as building more resilient community services that also counter-balance the historical focus on hospital-based care.  

“We cannot allow a lack of resources to be an excuse for neglecting the basic needs of people who are suffering,” said Mariana Duarte, a mental health advisor to Médecins Sans Frontières (MSF). 

“Integrating mental health into emergency response requires collaboration amongst various sectors including health, social services, education and community organisations,” she stressed. 

At the same time, she added, the responsibility of health actors does not end with the provision of services.

“We must also address the underlying cause of armed conflicts and work tirelessly to promote peace, justice, and reconciliation.” Duarte said. “Only by addressing the roots of conflict, can we hope to create a world where mental health is protected and valued.”

Addressing mental health after the conflict ends  

Edna Fernandes, co-founder Beyond Conflict

If war- related traumas are not resolved, then they continue to create illness long after the hostilities have ended, noted Edna Fernandes, the co-founder of the charity Beyond Conflict and moderator of the session. 

She helped found the organisation after  life-changing interactions with two refugees from Iraq who fled Islamic State in 2016.  One was a young woman that she met at an IDP conference in the United Kingdom who had escaped sex trafficking but remained “full of rage.” 

“When I asked her privately what was the one thing that would make a real difference, she surprised me because she said ‘we simply need more psychiatry.’”  

The second was an 10 year-old boy who had escaped ISIS and after three months in an IDP camp, barricaded himself into a room with two small children ages 2 and 3, which he then hanged.  

“So the 10-year-old was repeating the cycle of terror and violence that he had learnt from ISIS,” she said. “Through these two refugees, we first learnt about the lack of mental health support for victims of war and conflicts around the world.”  

Since being founded in 2018, the charity has worked with Rohingya refugees from Myanmar living in Bangladesh;  Ukrainian refugees, and since January, a project for Palestinians in the West Bank and for Israeli young people who were traumatised by the 7 October Hamas attack on the Nova Music Festival.  

“In all cases, we support expert partner organisations on the ground who know the cultural landscape inside out”,” she said. “Yet despite growing awareness and an understanding of the long term cost of failure to address more related trauma, the huge demand for mental health support remains largely unmet.”  

Psychiatric conditions exacerbated during acute crises  

Displaced Palestinians walk from the north of Gaza towards the south in January 2024 after Israel ordered their evacuation during its war on Hamas.

Expert panellists from Ukraine; Jammu and Kashmir, and the Palestinian West Bank, provided their insights into mental health trauma in three conflict-ridden parts  of the world.  

“Presently, the only psychiatric hospital in Gaza has been ravaged by war,” said Mohammad Marie, an assistant president at An-Najah’s College of Medicine in the West Bank city of Nablus. He described the urgent challenges faced in an active conflict setting, where life-threatening threats to physical health create new mental health scars that add to those previously experienced.  

“Psychiatric patients in Gaza are living without medication,” he declared. “But in addition, children’s [limbs] are being amputated without anaesthesia; women are undergoing caesarean sections. 

“This catastrophic situation leads to death, or people live with mental health scars for the rest of their life,” he said. “There is no mental health care in Gaza. There is no medication, especially psychiatric medication. In Gaza. In addition to that, there is no food, no clean water.” 

And even amongst Palestinians in the West Bank, where Marie lives, the war has changed their lives, as the Israeli military occupation around them tightens its grip. 

“I live in Nablus, for example, and personally I have been unable to move outside of my city for the past six months. I feel suffocated, unable to travel,” he said.  

In both the West Bank and Gaza, decades-long waves of conflict, along with the accompanying feelings of helplessness and hopelessness,  have left people in an unending cycle of intergenerational trauma, he added. 

“And each trauma is more difficult or more severe than in the past.” 

When the bombs stop falling the real struggle of people starts 

Saiba Varma, bottom left, describes particularly vulnerable population in the Jammu Kashmir context.

Sometimes it can feel very difficult to talk about mental health in the context of conflicts, added Saiba Varma, an associate professor of psychological and medical Anthropology at the University of California, San Diego.  

“It makes you sometimes question why is this important given what people are going through?  But I have to always remind myself that it’s what happens after the bombs stop falling,” Varma said. “That’s when, in many ways, the real struggle of people starts. And as an anthropologist, when I’m thinking about the relationship between mental health and war and occupation.” 

In complex and ongoing long-term conflicts, the “war on the psyche” persists even if bombs are not falling every day, she explained. 

“It is a war that targets people’s perceptual reasoning, decision making and behavioural capacities. It is very explicitly a war that does not only target soldiers and combatants, but ordinary citizens,” Varma continued. “For example, in the region of Jammu and Kashmir, the Indian government does not see it as an ongoing occupation. It does not see it even as a war. It sees it as a place of terrorism, whereas when you talk to people from Jammu and Kashmir they will name this as a war, as an occupation.

“So even the ways in which we name these conflicts are imbued with ambiguity. That, I think, is a sort of psychic assault on people’s ability to reason and make sense of their world. That’s where it really begins, in terms of the mental health challenges that are particular to Kashmir but certainly not unique.”

Varma noted that a lot of research on trauma and PTSD is based on people who have fled places of violence. However, in places like Kashmir, the population continues to live in the traumatic environments.

“Amongst the vulnerable populations in Kashmir, as in other conflicts, we’re seeing very high rates of substance use in children and youth,” Varma said. “In women, we’re seeing increased rates of self harm.  And  particularly what we’re seeing more recently are the ways in which political activists, journalists, medical professionals and others are being criminalised for speaking out and they’re actually called narrative terrorists by the Indian government. So that has a unique kind of set of mental health challenges as well.”

And care is either deliberately targeted or eroded over time due to the effects of militarisation, she added.

“In terms of, you know, who can access a hospital, what kinds of medications are available? Is there a curfew, is there a strike?”

Challenges faced by humanitarians 

WHO officials in northern Gaza mission in early March – attending to the physical needs of people trapped in conflict tends to overshadow mental health.

The complex of issues leaves humanitarian organisations with huge challenges in terms of how critical they choose to be about the underlying political or conflict dynamics while also trying to gain access to conflict settings where help is most needed. 

And even when services might be available, relief organisations must address stigma around getting care for mental health issues, Varma added.  

“There’s a lot of apprehension people have towards particularly biomedical Western medical psychiatric care that has to do with histories of abuse in psychiatric institutions.  It was only in 2001 that the Indian Supreme Court banned the use of restraints in psychiatric hospitals. So that’s very recent, and people remember those histories and that contributes a lot to their apprehension and seeking care.”

Finally, she said, humanitarian mental health care is inevitably limited in scope. 

“It’s not always able to provide health and mental health in the way in which local populations understand it. And in the case of Kashmir as with many other places in the world, people define health much more broadly than just being about the absence of symptoms. For them health has a social dimension, moral, spiritual, psychological and political. 

“I think the thing that I heard most often from people while I was doing my research was this idea that we will not be healthy until the conflict leaves us.”

At the same time, intervention strategies need to include more focus on the cultivation of positive survival skills, she said. 

“I think we need a lot more focus on the positive aspects of how people living in these contexts survive. So some of the things that I heard from people in Kashmir were for example, patience, cultivating patience, forbearance, hospitality, these are kind of critical coping skills that I think need a lot more attention…  So, all of those dimensions will also require attention from humanitarian organisation.” 

Countering stigma in Ukraine

Ukrainian child with his dog, displaced by war, in a refugee camp on the Moldova-Ukrainian border.

Ukraine, as well, also faces historical and cultural barriers to mental health care, with stigma persisting amidst a historical lack of resources, observed Dmytro Martsenkovsky, assistant professor at the  Department of Psychiatry of Bohomolets National Medical University, Kyiv. 

“Ukraine has inherited a Soviet-based type of mental health care, and it was very institutionalised,” he said. 

So basically, if people needed mental health services, hospitals were almost the only place people could access support, he said. 

But with civilians under heavy bombardment and confined to shelters, accessing hospitals became logistically more difficult, even as mental anxiety and related disorders grew exponentially. Moreover, more than 10 million people were displaced, saw family members killed, or experienced torture and imprisonment under various waves of Russian occupation.    

In addition, there is a lack of “mental health literacy” in Ukrainian society, with considerable stigma, he said.   

“It has some historical roots, but also a lot of people are afraid because, for them, seeking mental health services is showing that you’re weak, that you’re not able to cope with your conditions on your own,” Martsenkovsky said. 

Countering that, Ukraine’s First Lady, Olena Zelenska, has championed a more open approach to mental health treatment, supported by a broad-based mass media campaign. 

An online “How are You” platform has been developed that provides basic information on mental health and self-care techniques. 

“And this can help people who are feeling anxious or fear to seek professional care, to receive at least basic interventions to try to cope with their conditions,” he said. 

Martsenkovsky is also working with the Ministry of Health to provide more education to family doctors on basic mental health interventions. 

“And this is one of the core priorities because we had a lack of human resources even before the war,” but with the invasion most of the specialists, especially those who were women, were either displaced or left the country with their own children seeking safety and shelter.”

Recovery may take decades

Whether it’s Gaza, Ukraine or elsewhere, panellists all agreed that it typically takes “decades” for people to recover from the psychological trauma of war, particularly when the conflict also persists with no end in sight.  

“We are talking about … creating the possibility to enjoy life again, to have proper sleep, to not wake up from nightmares, to work for the prosperity of families and communities and to have a stable belief in a safe future,” Martsenkovsky said. “Because the longer the conflicts go on, fewer and fewer people are able to see a future for themselves and their children. It becomes more difficult for them to cope with everyday challenges.

“I’m not talking about the challenges of war, but about conflicts in families, financial difficulties that all of us face at points in time. And this will affect those who are traumatised by war for many decades … sometimes for generations.” 

Image Credits: © UNRWA/Ashraf Amra, People in Need, WHO , UNICEF/UN0599222/Moldovan.

Microplastics have been found in the arteries .

Doctors and scientists are concerned about the impact of plastics, not only on the environment but on human health – and new research has found a potential link between microplastics and heart attacks and strokes. 

When plastics enter the environment, humans may inhale or ingest them. Moreover, just as plastics can take centuries to break down on earth, plastics do not easily break down within our bodies, potentially leading to accumulation over time.

Multiple studies have already detected microplastics in various organs, from the lungs to the placenta.

The newest study, published in the New England Journal of Medicine last month, involved more than 250 people who had carotid artery disease and were having surgery to remove the build-up of plaque from their carotid arteries, the main arteries that supply the brain with blood, located in the neck. 

More than half (58%) of these patients had microplastics or even smaller nanoplastics in a main artery, and those who did were 4.5 times more likely to experience a heart attack, a stroke or death in the approximately 34 months after the surgery than were those whose arteries were plastic-free.

The researchers collected plaque samples from 257 patients during their surgeries and performed a chemical analysis on them. They found that 150 had microplastics and nanoplastics in their arterial plaque, mainly polyethylene (in all 150 people) and polyvinyl chloride (in 31). 

These are two of the most commonly used plastics in the world; the researchers looked for 11 plastics.  

Polyethylene is usually used for packaging, such as plastic bags or containers. Polyvinyl chloride is a more versatile plastic used for anything from medical devices to window frames and flooring.

In addition to the increased risk of heart attack or stroke, the researchers also found that those with microplastics in their plaque samples had higher levels of biomarkers for inflammation.

However, the researchers pointed out that individuals with microplastics in their plaque also exhibited other risk factors such as smoking, high cholesterol, diabetes, and heart and circulatory diseases, all of which elevate the risk of heart attack and stroke to begin with. 

Moreover, since all of the study participants were already undergoing carotid artery surgery and were known to have carotid artery disease, it is too early to tell whether the results of this study can be generalized to a broader population. 

In addition, the researchers stressed that the study does not prove that microplastics cause heart attack or stroke, only that there is a potential relationship. 

Dr Steve Nissen, a heart expert at the Cleveland Clinic, told The Independent that while “the study is intriguing,” it has “substantial limitations.” 

He said, “It’s a wake-up call that perhaps we need to take the problem of microplastics more seriously. As a cause for heart disease? Not proven. As a potential cause? Yes, maybe.”

Cardiac function 

This is not the first study to examine the link between plastics and human health. A similar, separate study published earlier this year in Environment International also examined the effect of microplastics and nanoplastics on the cardiovascular system, finding that these plastics “affected cardiac functions and caused toxicity on (micro)vascular sites.”

Effects included abnormal heart rate, cardiac function impairment, pericardial edema, and myocardial fibrosis, as well as hemolysis, thrombosis, blood coagulation, and vascular endothelial damage. 

This latest study comes as global representatives, led by the United Nations Environment Programme (UNEP), are working to finalize a plastics treaty to help eliminate plastic pollution by the end of the year.

The fourth session of the Intergovernmental Negotiating Committee to develop an international legally binding instrument on plastic pollution, including in the marine environment (INC-4), is scheduled to take place from 23- 29 April in Ottawa, Canada

Image Credits: University of Oregon.

The Lady Health Worker programme in Pakistan have helped to double the child vaccination rate.

Each woman in the health workforce is powerful, capable of transforming individual lives, communities, and nations when supported in her role. Women health workers deliver care to approximately five billion people, mostly as nurses, midwives, and community health workers. They contribute $3 trillion to global health annually, half in unpaid work. 

Despite constituting 70% of the global health workforce, they often serve in low-status jobs, with little or no pay. Men hold 75% of health leadership roles and, on average, earn 28% more than women. Investing in these women is a smart move, offering an estimated 9:1 return on investment and contributing to women’s economic empowerment.

This World Health Worker Week (1-7 April), and ahead of the Africa Health Workforce Investment Forum in May, we call on governments and the global health sector to recognize the transformative contributions of women in the health workforce by developing and implementing policies to ensure their protection, pay, and promotions.

Immense potential of women in health

Women health workers play a dual role, improving health outcomes while advancing gender equality by serving as role models in societies where women’s participation is limited.

 Studies indicate that promoting gender equality within communities not only fosters economic growth but also enhances access to contraception and reduces child mortality. Moreover, these workers significantly contribute to economic prosperity by serving as frontline caregivers in rural areas with inadequate health infrastructure, promoting sexual and reproductive health and rights, and investing in the health and education of their families.

The World Economic Forum predicts that by 2050, the climate crisis will result in 14.5 million more deaths and $12.5 trillion in economic losses, with an additional $1.1 trillion in costs to health systems.  

Women and children will bear the biggest burden, highlighting the urgent need for women health workers to play a crucial part as part of a broader multidisciplinary effort in educating communities, supporting the delivery of healthcare in challenging conditions, and advocating for policies that mitigate the health impacts of climate change. As most of the health workforce, they can respond to climate-induced health emergencies like the rise in infectious diseases, the effects of extreme heat on pregnant women, and the rise in waterborne disease. 

Saving lives in Pakistan and Nigeria

Women health workers can help achieve universal health coverage, and foster stable, prosperous societies through global health security. This potential holds true everywhere.

For example, Pakistan and Nigeria – despite their unique cultures, politics, and economies – face similar challenges such as rapid urbanization, weak rural health care, high maternal and child mortality, extreme vulnerability to climate change, and gender inequalities. Ensuring we protect, support, and invest in women health workers is a high-impact solution.

Lady Health Workers (LHW) and community midwives in Pakistan, through initiatives like the Pathfinder ‘building healthy families’ program, provided critical support during the 2022 floods when a third of the country was under water. 

LHW canvassed districts in Sindh Province, reaching communities with 20,000 dignity kits for safe pregnancies, and information on nutrition, hygiene, and health, easing the floods’ toll. 

Midwives delivered babies at birthing stations that replaced flooded health clinics.  LHWs also played a crucial role during the COVID-19 pandemic, providing vital information on infection prevention and supporting isolated women at risk with information on gender-based violence services. 

Since 1994, when the LHW program began, these workers have contributed to the number of fully vaccinated children nearly doubling. They have helped to cut maternal and newborn deaths and increase family planning access.

A Nigerian mother and her baby who benefited from the Saving Mothers Giving Life programme

Similarly, Community Health Extension Workers (CHEWs), nurses, and midwives in Nigeria—mostly women—have saved numerous lives, through programs like Saving Mothers Giving Life. 

In Cross River State, CHEWs provided emergency obstetric and newborn care services in rural communities and referred complicated cases to higher-level health facilities leading to a 66% decrease in maternal mortality in supported health facilities over three years. 

In Akwa Ibom state, CHEWs learned how to offer clinical contraceptive methods—injectables and implants—at local health facilities, and within two years of the training, uptake of modern contraceptives doubled while the number of women with contraceptive implants tripled.

What we need to do now

Investing in women in the health workforce fosters health, development, and prosperity. To maximize this investment, we must protect, pay, and promote women, formalizing their roles within health system strategies, plans and budgets, and providing adequate training and mentorship from higher level providers. 

We must elevate women into leadership positions, ensuring they are involved in budget planning and on emergency response committees, and support them with woman-friendly policies like maternity leave, childcare support, and protection against workplace harassment and discrimination. We must ensure they receive a fair wage. Without these investments, the power of women in the health workforce will be a missed opportunity.

Dr. Tabinda Sarosh is Pathfinder’s President in South Asia, Middle East, and North Africa. She is accountable for the impact and performance of Pathfinder’s programs in Bangladesh, India, Egypt, Jordan, and Pakistan. 

Dr. Amina Aminu Dorayi is Pathfinder’s Country Director in Nigeria. She has extensive experience designing and managing health system and sustainable development programs seeking to improve the health of women, girls, and communities.

 

Image Credits: Women Deliver, Pathfinder.

Afghan opium poppy cultivation sustains many rual communities – and keeps many in the adiction vicious cycle

The ‘forgotten crisis’ of Afghanistan has exposed more and more young Afghans to mental health problems and drug abuse amid dwindling donor support and crumbling healthcare under the Taliban regime, said experts at a high-level side event at the recent meeting of the Commission on Narcotic Drugs in Vienna Austria.

Since the Taliban imposed a drug ban in April 2022, opium poppy cultivation in the war-ravaged country has dropped by around 95%, according to the United Nations Office on Drugs and Crime (UNODC). 

But experts claim that drug abuse, particularly among the youth, is getting worse – and is being compounded by a lack of treatment.

The WHO estimates that around 2.9 million people abuse drugs in the country, while nine million have mental health issues in a population of around 38,3 million.

Holistic approach

At the side-event on “Mental health and substance use disorders in Afghanistan”, hosted by the World Health Organization (WHO), UNODC, the European Union (EU) and the Japanese government, stakeholders said the rapidly deteriorating socio-political environment in the country poses new challenges that require a more holistic approach and engagement with the Taliban authorities to save millions of lives. 

Jean-Luc Lemahieu, UNODC’s director of policy analysis and public affairs, said that many youngsters trying to escape the Taliban’s oppressive system of governance are vulnerable to drug abuse and exploitation, including radicalization.

To confront those threats, a system of community-based programmes anchored around existing primary health care services, should be developed, he and other experts speaking at the session emphasized. Those need to address both drug addiction and offer “active livelihood support and vocational skill training.”

Opium poppy farming in Afghanistan dramatically decreased after a 2022 drug ban.

UN officials noted that the “near-total contraction of the opiate economy is expected to have far-reaching consequences” for rural communities who relied on income from cultivating opium.

“Farmers’ income from selling the 2023 opium harvest to traders fell by more than 92 per cent from an estimated $1,360 million for the 2022 harvest to $110 million in 2023,” according to UNODC.

The WHO estimates that 23.7 million Afghan people will need humanitarian assistance this year as economic conditions in the country deteriorate. In addition, 9.5 million people have no or very limited access to healthcare.

Experts at the event warned that mental health and drug addiction can have far reaching public health consequences, including higher mortality rates, infectious diseases like HIV, hepatitis as well as diminished productivity.

Social tensions

Raffaella Iodice, Chargée d’Affaires and deputy head of the EU Delegation to Afghanistan, told the conference that mental health issues and drug addiction can trigger social tensions and negatively influence stability in communities. 

“Investing in drug demand reduction and mental health, quality, evidence-based and comprehensive treatment and prevention can pave the way for more sustainable and resilient communities that are critical for advancing the overall economic situation,” she said.

The EU is supporting a 100-bed Female and Children Drug Addiction Treatment Centre (DATC) in Kabul, which was established in December 2023.

It assists mothers and children up to the age of 17, offering “child counselling sessions that surpass conventional education, acting as a crucial pillar of support for young minds navigating the complexities of addiction”, according to a report from the WHO EMRO region. 

Expanding outpatient services at primary health care level

Abdul Hakim, who was enrolled in a drug addiction treatment centre in Kabul eight months ago after 20 years of drug addiction,  told Health Policy Watch that the easy availability of drugs was one of main reasons why many return to addiction after treatment and recovery.  

“If the authorities collect the drugs and dealers from the market, we will recover and stop using drugs,” he said.

Kabul city resident Gholam Ali, whose son became addicted to drugs eight years ago, told Health Policy Watch that his son has been treated several times, but easy access to drugs has made him addicted to it again. 

“There was no clinic left that I did not take my son to. He is treated for one or two months in each clinic, but when he leaves the clinic, there are drug addicts and drugs available outside, and he turns to drugs again,” said Ali.

Anja Busse, a UNODC programme officer working on prevention, treatment and rehabilitation,  said that the treatment model that exists in Afghanistan right now, based around clinics in large cities, is unable to meet the needs in the sprawling country, where rural needs are neglected. 

“The outpatient services in the community would need to be widely expanded and to be integrated in the community based health care approaches to have a continuum of care,” said Busse.

“ The reduced availability of previously widely used opioids at local markets has potentially increased risks for people with drug dependence due to increased levels of police interactions.”

Afghanistan’s health system system has been struggling to meet mounting demands amid dwindling aid and restrictions. Stigma is also a problem.

“Whether we are facing a mental health patient or substance use disorder client, we are facing a major stigma issue and most of the communities,” said Dr Vail Al-Raas, the mental health and psychosocial support coordinator at the International Medical Corps in Afghanistan.

She suggested the mental health treatment programs should be integrated into existing public health primary care programmes to use existing infrastructure and resources. 

“This can give [these programmes] a good chance to expand and be implemented on the ground, and interest has recently been shown by some donors.”

Image Credits: Resolute Support Media, UNODC.

The new generation of obesity drugs have reached sky-high popularity – and command high prices.

Demand for diabetes drugs such as Wegovy, Ozempic, Rybelsis and Trulicity has soared since they have been clinically proven to help weight loss – but they are massively overpriced in the US and unavailable in most low- and middle-income countries (LMIC), according to Médecins Sans Frontières (MSF).

The mark-up for these drugs – called glucagon-like peptide 1 agonists (GLP-1) – in the US is almost 40,000%, according to a paper published in JAMA last week authored by Yale University’s Dr Melissa Barber and MSF’s Dr Dzintars Gotham, Dr Helen Bygrave and Christa Cepuch.

The authors modelled the manufacturing costs of a variety of diabetes medications and added a modest profit margin.

“MSF’s study estimates that GLP-1s for diabetes could be sold at a profit for just $0.89 per month, compared to the price of $95 per month charged in Brazil, $115 per month charged in South Africa, $230 charged in Latvia and at least $353 charged in the US [based on Medicare price], which is a 39,562% markup over what the estimated generic price could be,” according to MSF’s press release. In fact, the US drug costs are usually much higher, reaching as much as about $1000 monthly.

Novo Nordisk makes both Ozempic and Wegovy (which contains a higher dose of the active ingredient, semaglutide, than Ozempic), while Eli Lilly makes Trulicity. Some are oral pills and others are injections.

US Senator Bernie Sanders has called on Novo Nordisk to lower the price of Ozempic Wegovy in the US to no more than what they charge for this drug in Canada.

“The American people are sick and tired of paying, by far, the highest prices in the world for prescription drugs while the pharmaceutical industry enjoys huge profits,” said Sanders in a statement.

“As a result of a major grassroots movement, Novo Nordisk did the right thing by recently reducing the price of its insulin products by some 75% in America. Novo Nordisk, a company that made nearly $15 billion in profits last year, must now do the right thing with respect to Ozempic and Wegovy,” added Sanders, who chairs the US Senate Health, Education, Labor, and Pensions Committee.

FDA approval for weight management

While GLP-1 drugs were made to treat diabetes, in 2021 the US Food and Drug Administration (FDA) approved Wegovy for weight management in people with a body-mass index (BMI) of over 30, or a BMI of over 27 with underlying conditions such as high blood pressure.

“Novo Nordisk and Eli Lilly are the only producers of these GLP-1s today, and their intellectual property barriers on the drugs and injection devices block any generic manufacturing that could help drive prices down,” MSF notes.

“The corporations have not even announced a price for low- and middle-income countries, nor have they licensed these drugs so that generic manufacturers could make them, which would help to meet global demand and drive prices down,” MSF says, noting that because they are now being used for weight loss in high-income countries, the companies are “unable to meet the massive demand”.

Co-author Christa Cepuch, pharmacist coordinator at MSF’s Access Campaign, describes the new drugs as “an absolute game changer for people living with diabetes”, but cannot be accessed by people in LMICs.

“Eli Lilly and Novo Nordisk can in no way supply the world with the amount of these medicines needed to meet global demand, so they must immediately relinquish their stranglehold and allow them to be produced by more manufacturers around the world,” said Cepuch.

The steep price of the drugs is hampering access even in the US, although the country’s federal health insurance programme, Medicare, recently struck a deal with Novo Nordisk, to cover the cost of Wegovy – but strictly for preventing heart attacks and strokes not for weight loss, Reuters reported. 

“The American people are sick and tired of paying, by far, the highest prices in the world for prescription drugs while the pharmaceutical industry enjoys huge profits,” said sen. Bernie Sanders, Chairman of the Senate Committee on Health, Education, Labor, and Pensions on the US cost of GLP-1s.

“Ozempic has the potential to be a game changer in the diabetes and obesity epidemics in America. But, if we do not substantially reduce the price of this drug, millions who need it will be unable to afford it,” he continued.

Obesity’s heavy burden

The GLP-1 drugs stimulate insulin production and feeling of satiety (fullness), promote weight loss, lower blood pressure and cholesterol, improve blood flow in the heart and uptake of glucose in the muscles, according to the US National Institute of Health.

Side effects can include commonly nausea, diarrhea, vomiting, constipation, stomach pain, headache or stomach flu, and less often, depression with suicidal thoughts or kidney failure.

Doctors warn that they need to be taken alongside a healthy diet and exercise.

The US accounts for almost three-quarters of the sale of Novo-Nordisk’s Ozempic, Wegovy and Rybelsus, according to Pew Research Center. The country has an adult obesity rate of 42%, according to the American CDC, one of the highest in the world.

Despite steep prices and side-effects, GLP-1s have become wildly popular in the last few years, especially in the US. 

Obesity is a growing problem worldwide, affecting 890 million adults – 16% of the global population – in 2022, according to the World Health Organization (WHO). The prevalence of this condition more than doubled between 1990 and 2022.

Global costs of obesity and overweight are predicted to reach $3 trillion per year by 2030 and more than $18 trillion by 2060 at the current rate.

In relation to obesity, World Health Organization (WHO) Director General Dr Tedros Adhanom Ghebreyesus recently stressed that the private sector “must be held accountable for the health impacts of their products” as Health Policy Watch reported – a reference to the impact of products such as ultra-processed food and sugary drinks on obesity.

Being overweight and obese increases people’s risk for type 2 diabetes, heart disease and cancer, WHO highlights, also affecting bone health and reproduction and increase the risk of certain cancers.

Both conditions can be affected by gene composition, but are mostly a result of an imbalance of energy intake (diet) and energy expenditure (physical activity). As such, are largely dependent on the options the environment offers. 

“Obesity is a societal rather than an individual responsibility, with the solutions to be found through the creation of supportive environments and communities,” WHO says.

The analytics platform, Airfinity, argues that it would be beneficial for public health to administer Wegovy to not only to diabetics type 2 patients, as the current Medicare deal allows, but to all people in the US with a BMI over 40. 

If 60% of people living with obesity and 40% of those of a BMI above 35 received the drugs, this could prevent as many as 300 000 heart failures in the US by 2030, according to Airfinity

World distribution of obesity. Safe the extreme numbers for small populations (on the right), some Middle Eastern countries and the US show highest percentages.

The demand for the Novo Nordisk drugs has more than quadrupled between 2019 and 2021, reaching 8.2 million prescriptions.

In fact, the demand was so high that it caused many months of shortages in the US, making it difficult for many to obtain their doses, Reuters reports.

Even those who do not have any medical reason to take GLP-1s often ask their doctors for a prescription. The drugs, seen as a miraculous way to achieveachieve wards a perfect body shape, feed hope that impossible beauty standards can be attained with a weekly injection.

Despite the surge in demand for these drugs, it’s important to recognize that they alone cannot address the societal challenges associated with obesity. 

According to the WHO website, “Stopping the rise in obesity demands multisectoral actions such as food manufacturing, marketing and pricing and others that seek to address the wider determinants of health (such as poverty reduction and urban planning).”

“While we are unaware of the analysis used in the [MSF] study, we have always recognized the need for continuous evaluation of innovation and affordability levers to support greater access of our products,” said Novo Nordisk in a statement. “We continue to support greater health equity to those in need of diabetes treatment and care.”

Image Credits: Chemist4u, Pew Research Center.

A diabetic patient with kidney complications receiving dialysis treatment at the Muhimbili National Hospital in

Non-communicable diseases like hypertension and diabetes have emerged as serious health crises in developing countries, as HIV was a decade ago. New models of primary health care that combine NCD and HIV care are catching on – and Tanzania is implementing this approach.

DAR ES SALAAM, Tanzania – Lying on a neatly made bed at Muhimbili National Hospital (MNH), Zaituni Kashozi is recovering from surgery to amputate her gnarled toes that were infected by diabetic ulcers. 

Wrapped in iodine-stained bandage, her left foot dangles on a string attached to an aluminium bar that helps to propel her feeble blood circulation.

The 74-year-old, who has grappled with diabetes for three decades, woke up to a grim reality a year ago when insidious infections took root, forcing her to go under the surgeon’s scalpel.

“I don’t feel any pain on my feet. All the sense of touch is gone. Even if you prick me with a needle, I won’t feel it. What a terrible disease,” Kashozi laments.

Within the walls of this 1,500-bed medical facility, the toll of diabetes is strikingly evident. Ward after ward echoes with the woes of chronic foot ulcers even blindness – a reflection of the toll diabetes is taking on the urban populace.

Diabetes, a chronic metabolic disease, poses a serious health threat that can affect the heart, blood vessels, eyes, kidneys and nerves. An estimated 12.8% of the population had diabetes by 2021 – up from around 2.8% in a decade.

However, cardiovascular disease such as strokes and heart attacks – often driven by hypertension – is the biggest NCD killer in the country. Many people are unaware that they have either hypertension or diabetes until very late.

The elderly, like Kashozi, bear a huge burden of NCDs, and around 90% of those aged 50 and above navigate the labyrinth of health challenges without the safety net of health insurance, forcing them to dart between hospitals frantically seeking elusive medical care.

HIV and NCD management under one roof  

On the other side of the city, Halfani Ali, a 53-year-old father of five, is struggling with the dual challenges of HIV/AIDS and diabetes.

Since his HIV diagnosis in 2003, Ali has been receiving care and medication at various health centres across the city. However, in 2013, Ali’s life took an unexpected turn when he was diagnosed with diabetes.

This dual burden of disease has presented a complex challenge, forcing him to juggle HIV and diabetes appointments at two different health centres.

Recognizing the struggles faced by individuals like Ali, the Temeke Regional Referral Hospital in Dar es Salaam (TRRH) integrated health care for NCDs within the ambit of HIV services in 2023.

Now individuals like Ali can manage coexisting conditions like diabetes and hypertension under the same roof.

“I am very happy because I get all my medication at Temeke Hospital. I don’t have to travel all the way to Kariakoo to see a diabetes specialist,” says Ali, reflecting the relief he has experienced with the integrated approach.

Taking blood samples
A health worker takes blood sample from Sultani Ally Kessy to test for diabetes during a diabetes camp at Temeke Regional Referral Hospital.

Maria Bitwale, a senior oncologist at Temeke Hospital, says many HIV patients with diabetes are now seeking treatment, and the integrated approach is helping to deter potential health crisis triggered by diabetic complications.

On a bright Saturday morning, Ali approaches the physician’s desk where his examination unfolds meticulously.  Bitwale, armed with a patellar hammer, probes the nuances of his nerves, safeguarding against the perils of diabetic complications.

 Ali’s eyes light up as he recounts the doctor’s advice on nerve function control and a prescribed diet, ensuring he remains in robust health.

In this amalgamation of medical expertise and personal resilience, Ali’s story is testimony to the success of integrated healthcare approach for killer diabetes, HIV and hypertension – diseases which previously could have led to a death sentence, alone or together. 

HIV is an entry point for NCD care 

In Tanzania, over 1.4 million people out of the country’s 61 million population are living with HIV. Of these, an estimated 29% have hypertension and 13% have diabetes.  And it is these latter diseases that are now the main causes of death in Tanzanians living with HIV today.  

Integrating up NCDs care into HIV services, which are widely available at the primary health care level, is the one new model being used to diagnose, prevent and manage leading chronic diseases in a cost-effective manner. 

John Njingu, Tanzania’s Permanent Secretary at the Ministry of Health, emphasises that integration of NCDs into primary healthcare facilities nationwide, extending to HIV-targeted clinics, where the screening and management of NCDs are offered to people with or without HIV under one roof.

“We want to bring better health care services to the people at lower cost to the service providers and the patients themselves,” he told Health Policy Watch in an interview. 

The NCD response in Tanzania took a major leap forward in 2019 on World Diabetes Day, when a new National NCD Prevention and Control Programme was launched by Tanzania’s Prime Minister, Kassim Majaliwa.

The NCD strategy has been rolled out in 700 primary health care clinics in 26 regions across Tanzania, 245 of them in the first stage. These PHC centres have been provided with basic NCD diagnostic equipment, and over 3,000 health care staff working at the centres have been trained in basic NCD care.

The new programme builds on several years of effort by the Ministry of Health and national stakeholders to establish the necessary platform for NCD services to reach communities. 

The new strategy has been supported by a range of national as well as international partners, including World Health Organization (WHO), the Global Fund, the US President’s Emergency Fund for AIDS Relief (PEPFAR), and UNAIDS.

The WHO guidelines call for HIV-NCD service integration across the continuum of care as does the 2021 Political Declaration of the UN General Assembly High-Level Meeting on HIV and AIDS. 

But there is still a long way to go, as the country has a total of 8,549 primary, secondary and tertiary heath facilities, according to the Ministry of Health.

‘Unprecedented’ in sub-Saharan Africa 

“What we have seen unfolding in Tanzania with basic NCD services for very common conditions such as diabetes and hypertension now reaching primary care across the country at this scale is arguably unprecedented in a sub-Saharan African context,” says Bent Lautrup-Nielsen, head of global advocacy at the World Diabetes Foundation (WDF).

WDF began supporting NCD interventions in the country two decades ago, and has played a key supporting role in the new NCD programme launch.  

“With the strong results on NCDs achieved by the Ministry of Health, the President’s Office for Regional Administration of Local Government and key national partners such as Tanzania Diabetes Association and Tanzania NCD Alliance, the prospect of integrated primary care with NCDs becoming part of routine services everywhere alongside HIV, TB and maternal and newborn care are now quite promising,” said Lautrup-Nielsen.

The INTE-Africa research team and stakeholders in Tanzania

New research findings demonstrating the benefits of integration also have helped pave the way for broader change. In a ground-breaking study dubbed INTE-Africa, conducted in Tanzania and Uganda in 2022, scientists documented the benefits of merging and decentralising services for HIV, diabetes, and hypertension in terms of disease management and cost-savings. 

The study, published in The Lancet in 2023, found that integrated management resulted in a 75% higher rate of retention in care for people with HIV and one or more NCD conditions; did not adversely affect viral suppression rates among people with HIV; and was cost-saving in terms of the health services provided. 

The researchers randomly allocated 32 health facilities (17 in Uganda and 15 in Tanzania) serving 7,028 eligible patients, to integrated care or standard care groups.  

In the integrated care group, participants with HIV, diabetes or hypertension, were managed by the same health workers, used the same pharmacy, and had uniform medical records, registration and laboratory services. In the standard care group, patients attended separate standalone clinics for each condition, following the standard practice in sub-Saharan Africa.

Data collection was conducted at baseline, as well as months six and 12. Retention was assessed through routine clinic attendance and track-and-trace procedures.

Roadmap for policymakers 

The study’s findings lay out a roadmap for policymakers, not just in Tanzania and Uganda, but more widely across Africa for scaling up integrated care for conditions such as HIV, diabetes, and hypertension, saving money while providing effective care.   

The idea of anchoring such care in HIV clinics is based on the success in providing HIV patients with steady care, resulting in dramatic suppression of viral load. The death toll for this group has plunged from a peak of two million annual deaths in the early 2000s to fewer than 500,000 deaths in 2022, researchers say.

Inspired by the INTE-Africa trial, Tanzania, which had for many years embraced infectious diseases as its priority in health policy and resources allocations, is undergoing a seismic shift in its primary health care services to address the new NCD crisis. 

The integration of HIV, diabetes and hypertension services has earned global recognition, as reflected in the NCD Alliance’s Spending Wisely report, which also found “evidence is strong that integrated services can deliver health impact.”  

The shift in Tanzania’s policy also aligns with the evolving strategy of the Global Fund dubbed Prioritization Framework Supporting Health Longevity Among People Living with HIV, which articulates the opportunities and priorities for integrated investments to prevents, identify and managed advanced HIV disease and NCDs, among other diseases, for the period of 2023-2025.

The strategy calls for integrating NCD services into other services designed for people living with HIV, especially those over the age of 50. 

Countries are encouraged to align services with the WHO package of essential NCD disease interventions for primary health care focusing on cardiovascular and chronic respiratory diseases, diabetes and early diagnosis of cancer.

Global Fund specialist Dan Koros told Health Policy Watch that the Fund’s support for NCD Integration into HIV programs in Tanzania began in January 2024 with a grant of $115,075 – primarily for carrying out baseline assessment, developing protocols and training healthcare workers for the period of 2024-2026.

The Global Fund investments aim to support integrated diagnosis and treatment of HIV positive adults over the age of 40 and on antiretroviral treatment, who are also receiving treatment for one or more NCD, including cardiovascular disease, hypertension, diabetes, obesity, and mental health conditions.

Two women at a hospital in Tanzania
Anna Mlengu, who suffers from diabetes, consults a doctor at Hindul Mandal Hospital in Dar es Salaam.

NCD’s – highest premature mortality is in LMICs

Globally the NCDs are the leading cause of death, killing 41 million people each year-equivalent to 71% of all deaths worldwide.  And the highest rates of premature mortality – that is deaths before the age of 70, are in low- and middle-income countries, particularly Africa. 

Across the WHO’s African region, patients suffering from diabetes and hypertension are neglected, with less than half remaining in care one year after diagnosis, leading to approximately two million deaths each year, medical researchers say.

And when their disease condition is addressed later in life, it also makes treatment much more complex. Many elderly patients like Kashozi,  suffering from diabetic ulcers and related complications, do not always get access to specialised care.

“The ageing process affects immune function and slower wound healing, making the treatment of diabetic foot ulcers even harder,” says Zawadi Chiwanga, senior endocrinologist and lead surgeon in Kashozi’s case. 

“Diabetic ulcers can be particularly insidious, often manifesting silently without the knowledge of a patient until they reach an advanced stage,” Chiwanga told Health Policy Watch.

Diabetes affects younger people too

While traditionally Tanzanians perceived diabetes as a disease that primarily haunts the elderly, the city of Dar es Salaam, one of Africa’s  fastest growing urban areas, bears witness to a different reality. 

From Tandale, a labyrinthine slum, to the upscale enclave of Masaki, favoured by Western diplomats, and further to Kariakoo, a business hub replete with fast- food joints, youth obesity is on the rise – accompanied by an alarming surge in diabetes cases. 

Out of the 613,210 patients screened for diabetes at MHN in the last six months, an estimated 165,566 individuals (27%), were diagnosed with diabetes, hospital records show. Along with the toll of co-infections, this silent crisis is attributed to poor dietary choices and lack of physical activity.

In the suburb of Upanga in Dar es Salaam, 38-year-old Pragash Gupta, who was diagnosed with diabetes three years ago, routinely checks her blood glucose levels by pricking her fingers.

Gupta, weighing 125kg and also recently diagnosed with high blood pressure and heart fibrillation, struggles to heed doctors’ call to make lifestyle changes, including adjusting her diet.

“I check my blood glucose every morning and every night,” she says “I am supposed to do it four times, but sometimes my fingers hurt and I don’t do it as often.”

Irene Masanja, an infectious diseases specialist at Bagamoyo district Hospital in Tanzania’s coastal region, says that the rising incidence of diabetes and hypertension, among HIV patients as well as in the general population, is alarming. 

 “Early detection and intervention are key. We must empower healthcare providers and equip them with appropriate skills and knowledge to address interconnected health problems effectively,” she says.

Image Credits: Courtesy Public Relations Department Muhimbili National Hospital, Muhidin Issa Michuzi, INTEAfrica.

WHO Director General Dr Tedros Adhanom Ghebreyesus

WHO’s Director General Dr Tedros Adhanom Ghebreyesus on Wednesday decried the deaths of seven aid workers by Israeli fire while delivering food aid to Palestinians in besieged northern Gaza, demanding a major revamp of “deconfliction” procedures so that aid missions could proceed safely and predictably. 

“WHO is horrified by the killing of 7 humanitarian workers from World Central Kitchen in Gaza on Monday.  The work they were doing was saving lives, providing food to thousands of starving people,” said the director general at a press briefing. 

Responding to a blast of international criticism, Israel’s top military and political leadership expressed deep regret for the incident in which air force drones deliberately picked off, one by one, three cars carrying the seven aid workers affiliated with an organisation widely recognised even by Israelis as a neutral partner. The country pledged a high-level investigation of the incident. 

But Tedros said that the incident reflects systemic problems faced by virtually every agency mission WHO has conducted in Gaza in coordinating missions with Israel’s military through areas of Gaza that it now controls. Those problems are also putting its aid workers at risk almost daily from combat fire, as well as taking the lives of other innocent people in the past six months of war, Tedros and other senior WHO officials said.

“The DG rightly highlights why we are all appalled by the killings of our colleagues, in clearly marked vehicles in a deconflicted area. It clearly shows that the  deconfliction mechanism is not working,” said Richard Peeperkorn, head of WHO’s Jerusalem-based Office in the Occupied Palestinian Territory (OPT).  

“What is needed is an effective, transparent and workable deconfliction and notification mechanism. The UN has to be assured that convoys and facilities are not targeted. It means that assuring movement of aid in Gaza, including through checkpoints, is predictable, expedited, etc. That roads are operational and cleared.”

Fraught with cancellations, delays and uncertainties 

Dr Richard Peeperkorn, head of WHO’s Jerusalem-based office for the Occupied Palestinian Territories.

In particular, WHO relief missions to northern Gaza, which Israel nominally controls although heavy pockets of fighting with Hamas continue – have been fraught with cancellations, delays and other uncertainties for months, Peeperkorn complained. 

“We see too many missions delayed or denied. It’s also making the missions which are delayed, and I’ve been on quite a few myself, more arduous and dangerous. You sometimes return at 11 o’clock at night, or past midnight. So it becomes unnecessarily dangerous.” 

“Even today, who my team was in an mission to the north, again, to deliver a few medical supplies, food and water, to Al-Ahli Hospital and Al-Sahabah Hospital in the north… They were, as was planned and agreed on, between 6 and 7 a.m. ready to go,” he recounted. 

“They went to the checkpoint, and just before the checkpoint, they’ve been waiting and waiting and waiting up till now. Now they had to return back to their to their guest houses.”

Not an isolated incident 

Shell of WCK car that came under drone attack, with the NGOs identity clearly marked on its roof

Along with the blast of international criticism, the WCK attack has been deplored widely inside Israel, where the organisation has been praised for having also delivered food aid to Israelis displaced by the Hamas attacks on Jewish communities around the perimeter of Gaza on 7 October. 

While the Israeli army has sought to portray the killings as a tragic, but isolated incident, critics say it reflects more systemic problems related not only to poor coordination of aid, but an expanding culture of “shoot first ask questions later.”

Peeperkorn underlined that the attack also wasn’t an isolated incident for UN and WHO operations. 

“We shouldn’t forget that already in December, January, we have seen, unfortunately, attacks and sometimes the shooting at the UN vehicles,” he said. 

This included a mission to the north in which he participated in early December, he recalled. 

“There was an airstrike 150 meters from our car. The truck delivering medical supplies was shot at, the PRCS (Palestinian Red Crescent Society) people were shot at. And PRCS staff were actually arrested and detained for a while.” 

Painstaking detail for every mission prepared 

Nasser Medical Complex in Khan Younis, in southern Gaza. Each WHO convoy to southern Gaza, and northward, requires painstaking preparation.

Detailed planning is required for every mission WHO or its partners prepare. For WHO missions, not only international and local health workers, but also a security officer and an ordnance expert are typically included in the team as well. 

“It’s an enormous amount of work, and every mission that gets delayed, impeded or denied, that other missions cannot take place,” Peeperkorn said.

“All of those details – the timing, the people on the missions, are shared through Israeli counterparts, and then there is agreement that the mission can take place at this hour,” he stressed. 

“You want to start this as early as possible. For some of the food transport, it’s even better to do that at night, before sunrise. But in the case of medical supplies, food or fuel for patients, we normally start a mission around 5 or 6 in the morning. …. Because there will always be delays, and you want to be back in daylight. 

A team sets out on the road only after it has received an OK from the Israeli army. “Then, normally, there’s a holding point at military checkpoints, where you have to wait again,” Peeperkorn said. 

“Most of the missions, there were always problems.  Delays, delays, delays – and often denials in the end,” he said. 

“And the mission today was a good example – to bring a few medical supplies, food and water to those two hospitals in the north. 

“It was all agreed, they would leave at 6:30 to 7 am. First of all they don’t get a green light to go. And finally, they get a green light to go to the checkpoint…. 

“And then they waited before the checkpoint. And they wait and they wait and they wait. In the meantime, very little discussion. Nothing is going on.  

“They realize that even if they get a green light now, they can’t go to Al Sahaba anymore. They would only deliver supplies to Al Ahli hospital and then go back.” Eventually, after more waiting, they realise that “they will never be able to return [in time], and they have to cancel the mission.” 

Workable deconfliction

“So what is a workable deconfliction mechanism?” Peeperkorn asked. 

“That routes are coordinated. That it’s a predictable mechanism. That the roads are going to be clear. And anyone who knows Gaza, know that there are a number of roads, which can be easily cleared and made operational. 

“So in a way, it’s a simple mechanism, and somehow, it has never properly worked.”

Given the mass hunger that northern Gaza faces, followed by the near total destruction of Al Shifa Hospital, the area’s main health facility, over the past two weeks, those missions are needed now more than ever, Peeperkorn stressed.

“There should be 50 missions going to the north every day. Multiple [missions] of food, water, shelter, and maybe one medical mission. That should be happening everywhere, including in the south,” said Peeperkorn. 

“And even if there’s active conflict going on, then you expect that humanitarian corridors are created, where the UN partners can safely deliver their aid and do their job. And clearly the horrific attack on WCK is clearly a sign that this is not working.

“So I really do expect, whatever comes out now, that we get a functional deconfliction mechanism and a proper notification system and that the UN and partners can do their work.” 

Image Credits: AFP/TImes of Israel, WHO/EMRO.

An electronic blood sugar monitor makes it easier for people with diabetes to manage their disease.

As WHO unveils S.A.R.A.H. (Smart AI Resource Assistant for Health), its new digital health promoter prototype powered by generative artificial intelligence (AI), and available in eight languages 24 hours a day, WHO’s Regional Director for Europe writes about harnessing innovation in health to help meet critical public health challenges, both now and in the future.  

Innovation has always been a driving force behind advancements in health, revolutionizing the way we prevent, diagnose, and treat diseases. And as we navigate through a rapidly evolving health landscape, embracing health innovation has become more crucial than ever. 

From cutting-edge technologies like mRNA vaccines to AI-driven diagnostics, the potential of innovation to transform healthcare is limitless. But for too long health has often been viewed as a passive beneficiary of innovation rather than a driver of it. 

It’s time to change this mentality and harness the power of innovation. The challenges we face, from global pandemics to rising chronic diseases, from a rapidly ageing population to the effects of climate change, demand creative solutions that prioritize the well-being of populations worldwide. 

Shifting mindsets to move health innovation needle

Our sector – health – can and should be at the cutting edge of new and innovative solutions, driven by technology including AI, which is going to fundamentally change every aspect of human life over the coming century. 

In fact, the IMF predicts that 40% of jobs will be affected by AI in some shape or form over the coming years, including in health and care. Further, AI products and services are expected to contribute $15.7 trillion to the global economy by 2030, more than the current output of China and India combined.

However, while technological advancements have made significant strides in healthcare, social innovations and policies also play a crucial role in addressing the complex needs of diverse communities. Innovation in public health goes beyond technological breakthroughs; it involves harnessing creativity, collaboration, and sustainability, to promote equitable access to quality healthcare.

To foster an environment conducive to innovation in public health, leaders and decision-makers must focus on responding to the needs of communities while closing the equity gap. 

We must shift the focus from solely economic returns to the broader public health impact of innovative solutions. By aligning policies with the goal of improving health outcomes for all, we can better address inequalities in healthcare access and deliver sustainable solutions that benefit society as a whole. 

Another strategic shift requires patients themselves to be co-creators and designers of innovation because patients are experts in their own right. They know how to navigate life living with cancer or diabetes or a physical/mental disability. Involving them in the full pathway of disease management will make solutions more relevant and sustainable, and encourage innovation at scale.  

Ecosystem approach 

As public health professionals, we are not always good at articulating how innovation meets health and societal needs. That’s why we need an ecosystem approach to innovation. By fostering collaborations between healthcare providers, technology companies, research institutions, and policymakers, a holistic ecosystem can be created to drive innovation in health.

In Ireland, for example, the Health Ministry joined forces with the Department for Business, Enterprise, and Innovation to set up the Health Innovation Hub, an incubator for public health solutions. Health workers in the Health Innovation Hub spend half their time delivering care and the other half working with start-ups and health tech companies: a clear example of an ecosystem approach.   

Digital solutions to health, such as telemedicine, are already a reality in some countries.

As we embrace innovation to tackle pressing global challenges, sustainability must remain at the core of our efforts. Innovations should not only address current needs but also contribute to long-term social, economic, and environmental sustainability. 

This requires a shift towards sustainable practices, circular economy models, and responsible innovation that minimizes negative impacts on both people and planet. 

Too often people tell me that striving for health equity is at odds with our market-driven societies; that equity somehow stifles innovation. I would strongly dispute that – there is no contradiction. But unfortunately, modern economics tends to focus only on improving efficiency – for example, getting more cancer screenings for the dollar, or squeezing the last ounce of productivity out of the health system.

 Equity – leaving no one behind – is not seen as the responsibility of the commercial sector but that of the state or the non-profit sector. This mindset also needs to change. 

A Wellbeing Economy values equity and not only revenue or “productivity”. It strives to make the world a safe and just place for humanity – and this is the true challenge for innovators.

The future is already here 

Innovation for health brings together experts from diverse fields such as medicine, engineering, data science, and behavioural psychology. But as health is about where people live, love, work, and play, it’s also about transportation, urban planning, and agriculture.

This interdisciplinary approach not only catalyses breakthrough discoveries but also nurtures a culture of cross-pollination, where ideas flourish, and boundaries are transcended – precisely the kind of culture that innovation needs to thrive. 

However, the pursuit of innovation for health is not without its hurdles. From regulatory barriers to financial constraints, from ethical dilemmas to data privacy concerns, the path to innovation is fraught with challenges that require careful navigation. Nevertheless, these challenges should not deter us but rather galvanize our resolve to push the boundaries of what is possible. 

By fostering a culture of innovation, nurturing creative minds, and empowering diverse stakeholders to collaborate, we can address the most pressing challenges of our time.

Embracing emerging technologies, exploring new frontiers in science and medicine, and prioritizing social innovations will pave the way for a more equitable, resilient, and sustainable future and help countries in the hard-pressed challenge of reaching the Sustainable Development Goals by 2030.

We are well and truly in an era of ever accelerating innovation in health, bringing with it boundless possibilities for improving our collective health and wellbeing, generating jobs, and growing our economies. But health leaders are not yet fully equipped to navigate this new world, so full of exciting potential, with confidence. 

The health sector must be ready and equipped to embrace innovation across all dimensions, strengthening health and wellbeing. Or run the risk of being left behind, squandering the opportunities of today and jeopardizing the very future of health itself.  The choice is clear.

Dr Hans Henri P. Kluge is WHO Regional Director for Europe

Innovation ecosystem for public health 

Digital health – WHO/Europe

AI ethics and governance guidance

Image Credits: Uka Borrgeaard/ WHO, Juliana Tan/ WHO, WHO.