Construction workers are particularly vulnerable to heat stress.

Hundreds of migrant construction workers are likely to have died of heat stress while building soccer stadiums in the Qatari desert for the recent Fifa World Cup.

But people’s exposure to extreme heat – temperatures of 38°C and higher – is becoming widespread as climate-related temperatures soar.

“Billions of people are already exposed to dangerous heat at work, elevating their risk of heat stroke, dehydration, kidney disease and other serious illnesses,” Dr Rüdiger Krech, World Health Organization (WHO) director of Environment, Climate Change and Health, told a media briefing on Thursday.

“In agriculture, construction and other physically demanding sectors, we’re seeing a clear rise in heat stroke, dehydration and long-term kidney and cardiovascular damage due to dangerous working conditions,” added Krech during the launch of a new report on heat stress, published by the WHO and the World Meteorological Organization (WMO).  

“The workers keeping our societies running are paying the highest price. These impacts are especially severe in vulnerable communities with limited access to cooling health care and protective labour policies.”

WMO director Johan Stander told the media briefing that the past 10 years are the hottest on record and 2024 was the hottest year ever.

Extreme heat has “accelerated” in Europe, Africa, North America and Asia, where new record temperatures were recorded, he added.

“In the Middle East, we’ve seen temperatures in the region of 50°C, and areas in Europe have topped around 40°C.”

The report defines workplace heat stress as “increased heat storage in the body of a worker as a result of excessive heat exposure in the workplace”. This can be due to hot environmental conditions, increased metabolic heat from performing physically demanding tasks; and/ or the requirement to wear heavy protective clothing, which limits the body’s ability to dissipate heat (for example, health workers wearing PPE in hot climates during disease outbreaks).

It describes heat stroke as “a life-threatening condition defined by profound central nervous system dysfunction”, including severe disorientation, seizures, coma.

Outdoor construction and agricultural work during the hot season are considered the highest-risk occupations for experiencing morbidity and mortality associated with workplace heat stress.

The WMO’s Johan Stander, WHO’s Rudiger Krech and Joy Shumake-Guillemot, lead of the WHO/WMO Joint Office for Climate and Health

Safe working environments

The International Labour Organization (ILO)’s Joaquim Pintado Nunes told the briefing that it is mandatory for the 187 countries that are ILO members “to promote safe and healthy working environments”.

“More than 2.4 billion workers are exposed to excessive heat, and this represents 71% of the world’s total working population,” said Nunes, the ILO’s head of Occupational Safety and Health and the Working Environment.

Heat exposure causes more than 22 million occupational injuries and almost 19,000 deaths each year, according to an ILO report published last year. In 2020, there were an estimated 26.2 million persons living with chronic kidney disease attributable to workplace heat stress.

The ILO report found that workers in Africa (92.9%) and the Arab states (83.6%) had the worst heat exposure, but the fastest changing working conditions are in Europe and Central Asia, with the proportion of workers affected rising by 17.3%, almost double the global average increase.

“Heat exhaustion and sometimes fatal heatstroke have been repeatedly reported among coal miners, surface miner workers and gold miners, as well as workers in agriculture and construction workers in the United States of America,” according to the WHO-WMO report.

“Climate change is reshaping the world of work,” said Nunes. “Without bold, coordinated action, heat stress will become one of the most devastating occupational hazards of our time, leading to a significant loss of life, significant loss of productivity and with catastrophic effects in the future of work.”

Joaquim Pintado Nunes, chief of Occupational Safety and Health and the Working Environment, International Labour Organization (ILO)

Data about workers’ conditions is often hard to come by. To establish the cause of death of the migrant workers in Qatar, researchers triangulated the mortality data of Nepalese migrants in Qatar, interviews with returning migrants about their working conditions, and temperatures.

Most of the migrant workers were young men aged 25 to 35. Globally, this group usually only records a 15% death rate from cardiovascular disease (CVD). But 22% of the Nepalese migrants who died while working in Qatar died of CVD in the cool season and 58% died in the hot season – which the researchers concluded to be likely due to “extreme heat stress”.

Clear recommendations

The report, the first on the subject since 1969, offers guidance to governments, workers, employers, local authorities and health experts to mitigate heat stress.

Recommendations include occupational heat-health policies with “tailored plans and advisories that consider local weather patterns, specific jobs, and worker vulnerabilities”.

Those most vulnerable to heat include middle-aged and older workers, people with chronic health conditions and lower physical fitness.

The report also recommends educating all stakeholders on how to recognise and treat the symptoms of heat stress – particularly essential for subsistence farmers, who are not part of organised workplaces and may not understand what is happening to them.

Krech told reporters that the threshold for the human body is 38°C, over which it is dangerous to work.

Professor Andreas Flouris from the University of Thessaly in Greece said that there is “ongoing discussion” in Europe on “moving towards thresholds of environmental limits where workers can safely work”.

Cyprus, Spain, Belgium already have such thresholds defined in legislation, added Flouris, who was the report’s editor.

“The report provides the evidence that policy makers can use to convince both the employers and the workers that it’s in their best interest for both in terms of health but also productivity, to move to such solutions,” said Flouris.

Image Credits: Shraga Kopstein/ Unsplash, WHO-WMO.

By examining excess mortality data during the COVID-19 pandemic, public health officials were able to see which groups and areas were most affected by the virus.

Thinking back to five years ago, during the height of the COVID-19 pandemic, I was living around the corner from the Brooklyn Hospital Center. Each day, I’d take a walk through the neighborhood, but those walks became hauntingly different as I started passing refrigerated trucks parked outside – temporary morgues, there to handle the overwhelming number of lives lost to the virus. This sight became a constant, sobering reminder of the scale of the loss just a few steps away from where I lived.

As the virus surged and deaths spiked, news reports and government communications started using the public health term to capture what was happening with those trucks: “excess mortality”. 

This measure reflects the increase in the number of deaths during a period of time compared to what would be normally expected and was often presented as graphs displaying large peaks in deaths. While the term itself can sound cold or even morbid, its purpose is to convey the full scale of a tragedy that individual case counts often fail to capture.

Unlike official COVID-19 death tallies, which only included those who tested positive and were formally diagnosed, excess mortality accounted for all deaths, including those who may have died from COVID-19 without being tested, as well as those who succumbed to other causes indirectly linked to the outbreak, such as overwhelmed health systems or delayed care. 

Clearer picture

By digging deeper into these data by age, location, race and ethnicity, public health decision-makers saw a clearer picture of the pandemic’s toll. They saw that nursing homes were especially hard hit, or that certain neighborhoods in New York were suffering from higher death rates. Using mortality data, policymakers could develop the most effective plans to target the spread of COVID-19 and save as many lives as possible. 

But the value of mortality data doesn’t end with COVID-19. If we’re serious about addressing the world’s most pressing health challenges, mortality data must remain a global priority. During the pandemic, excess mortality estimates exposed the staggering scale of loss—over 14 million excess deaths by the end of 2021, according to the WHO—laying bare the limits of health systems and the deep inequities between and within countries. 

Importantly, this figure wasn’t derived from official death counts alone. In many countries, especially those with limited reporting infrastructure, deaths weren’t recorded in real time or at all. 

As a result, these global estimates relied heavily on statistical modeling to fill the gaps left by weak or incomplete data. The most reliable and sustainable source of mortality data is a country’s civil registration and vital statistics (CRVS) system, which records life events like births and deaths.

 Yet despite its critical role, investments in CRVS systems remain fragmented, and political attention is waning. Without sustained commitment, we risk losing the very evidence needed to guide policy, target resources, and save lives.

Lessons from Peru, Shanghai and Colombia

Take Peru, for example. In 2018, the Ministry of Health published a groundbreaking national mortality report analyzing 30 years of data , exposing stark inequalities across socioeconomic and geographic groups. 

One critical finding—a high number of fatal lower respiratory infections among older adults—led to the launch of a nationwide pneumococcal vaccine campaign. Without these mortality data, the program might never have been implemented, leaving seniors at risk of a deadly but preventable disease.

Similarly, in Shanghai, officials became concerned about the rising number of e-bike collisions in 2017. By turning to mortality data, they discovered the alarming extent of the problem—road deaths and injuries among e-bike riders were on the rise, and only 11% of riders wore helmets. In response, the city passed a helmet law in 2021.

By the end of the year, local police reported that over 90% of riders were wearing helmets, a dramatic shift in behavior that is helping to save lives and make the roads safer for everyone.

An extract from a public health video aimed at encouraging Shanghai residents to wear helmets when riding ebikes.

These life-saving interventions would not have been possible without robust mortality data. Yet too often, ministries of health rely solely on data from those who passed away in health facilities. 

While useful, this approach misses a critical truth: in many parts of the world, a large share of deaths happen beyond the reach of the formal health system. In some low- and middle-income countries, 70% or more deaths occur outside of hospitals, often in rural or underserved areas, where they risk being uncounted, unregistered, and ultimately invisible. This gap is especially dangerous in countries with weak CRVS systems. 

In Colombia, over 90% of deaths are registered in the CRVS system but among the unregistered, most occur in rural, indigenous and poor communities. In 2021, the government launched an initiative to engage hard-to-reach tribal communities with varying cultural practices and languages in the Amazonas. 

Through this effort, the government is now able to provide a more complete picture of the population, including the number and causes of deaths, and can develop more inclusive health and social policies. Investments in mortality and CRVS systems are starting to show progress across the globe. In the Asia-Pacific region, more than 1 million additional deaths are recorded each year through improved systems. 

Data-driven interventions

As seen in Colombia, Peru, Shanghai and beyond, mortality data serve as a powerful compass, guiding life-saving interventions and exposing the true toll of public health crises. 

Yet despite its vital role, mortality data are not always easy to obtain.  Although it may seem like a simple measure, recognizing when someone has died and understanding why is a complex process that depends on strong systems and sustained investment. 

To build healthier futures for all, we must prioritize and invest in strengthening mortality and CRVS systems around the world. 

A robust CRVS system includes timely and universal registration of deaths, accurate certification of causes of death by trained professionals, digitized systems for timely collection and analysis of the data, and the integration of this information into national databases for analysis and policymaking. It also requires coordination across government agencies, legal frameworks that mandate registration, and public trust and accessibility, especially in marginalized communities. 

Without these building blocks in place, many deaths go uncounted, leaving gaps in the data that hinder effective health planning. As funding for alternate sources of mortality data are reduced or under threat, strengthening mortality data systems in the health and civil registration sector is a smart choice. This isn’t just an investment in infrastructure—it’s an investment in dignity, in visibility, and in making every life count.  

Farnaz Malik is a Senior Technical Advisor at Vital Strategies working under the Bloomberg Philanthropies Data for Health Initiative. She partners with country governments in Asia and sub-Saharan Africa using evidence-based policymaking to improve population health. Malik holds an MPH in Epidemiology from the University of Michigan School of Public Health and a BA in Integrative Biology from the University of California, Berkeley.

 

 

Image Credits: Vital Strategies, Vital Strategies.

The US Centers for Disease Control and Prevention in Atlanta, which a gunman recently attacked.

US Health and Human Services Secretary Robert F Kennedy Jr has been given until 2 September to stop spreading anti-vaccine information by hundreds of current and former staff members from the Center for Disease Control and Prevention (CDC), the National Institutes of Health (NIH) and the HHS.

In a letter released by “Save HHS” on Wednesday, over 750 staff – about half of whom opted to remain anonymous – say that they are gravely concerned about “America’s health and safety” following an attack on the CDC early this month, when a man opposed to COVID-19 vaccines fired hundreds of bullets at the institution. A police officer was killed in the attack.

“The attack came amid growing mistrust in public institutions, driven by politicised rhetoric that has turned public health professionals from trusted experts into targets of villainization – and now, violence,” according to the letter, which has been sent to Kennedy and Members of the US Congress.

Lukewarm response to CDC gunman

In a media release accompanying the letter, the staff described Kennedy’s response to the shooting as “delayed and cursory”. He also “failed to take accountability for his role in the denigration of HHS employees and his decades of anti-vaccine rhetoric that reportedly contributed to the shooter’s motives”.

In an interview shortly after the attack, Kennedy criticised the CDC’s response to the COVID-19 pandemic.

The staff accuse Kennedy of being “complicit in dismantling America’s public health infrastructure and endangering the nation’s health by repeatedly spreading inaccurate health information”.

They say he has sown public mistrust, including by calling the CDC a “cesspool of corruption”, falsely claiming mRNA vaccines “failed to protect effectively” during the COVID-19 pandemic and subsequently cancelling $500 million in contracts for mRNA vaccine development, “possibly our best line of defence against another respiratory virus pandemic”.

They also cite his disbanding of the US Advisory Committee on Immunization Practices (ACIP) as part of his anti-vaccine activity.

They also accuse the health secretary of falsely claiming the measles vaccine has not been “safety tested” and that protection “wanes very quickly” while “promoting inappropriate prevention measures like vitamin A even as US measles case numbers are at their highest in more than 30 years”.

Finally, they say Kennedy has misused data to “falsely claim childhood vaccines are the cause of autism despite decades of research demonstrating otherwise”.

‘Dangerous and deceitful’

Describing these Kennedy statements as “dangerous and deceitful”, the letter gives the HHS Secretary until 2 September to “cease and publicly disavow the ongoing dissemination of false and misleading claims about vaccines, infectious disease transmission, and America’s public health institutions”.

It also asks him “acknowledge and affirm that CDC’s work is rooted in scientific, non-partisan evidence focused on improving the health of every American” and “guarantee the safety of the HHS workforce”.

Dr Anne Schuchat, former Principal Deputy Director of CDC, said that “an attack on a U.S. government agency should be a moment in time when we come together”. 

“Instead, Secretary Kennedy continues to spread misinformation at the risk of American lives,” she added.

Dr Ian Morgan, an NIH scientist and steward of NIH Fellows United, said that the attack on the CDC  on the death of the police officer should have been a “wake-up call” for Kennedy and NIH Director Jay Bhattacharya.

“Yet, we’ve seen them persist in the same antivaccine and anti-science rhetoric that led to the shooting, endangering the lives of HHS workers and the American public. This dangerous rhetoric from HHS leaders must stop,” said Morgan.

Neither Kennedy nor the HHS had responded to the letter by the time of publication.

An examination of 51 studies has assembled more evidence that exposure to air pollution is linked to a higher risk of dementia.

Air pollution, specifically the tiny particles known as PM2.5, is linked to higher rates of dementia, according to a recently published study in The Lancet.

Nitrogen dioxide (NO2) and black carbon, which is the black soot left behind when combustion is incomplete, have also been linked to higher risk of dementia in the study, which is headed by researchers at UK’s Cambridge University.

“What this means is that cleaner air policies, including those targeting diesel, could help protect brain health, not just lung and heart health. Dementia is a devastating disease, and while we wait for a cure, we need to act on modifiable risk factors. Air pollution is one of the biggest,” Haneen Khreis, one of the authors of the study, told Health Policy Watch.

Researchers reviewed 51 existing studies across several countries up to October 2023 to arrive at this conclusion.

PM2.5 is 1/28 of the width of a human air and much of it is released during the burning of gasoline, oil, diesel or wood. PM10 particles are relatively larger, though still invisible to the naked eye.

“PM2.5, or fine particulate matter, can cross the blood-brain barrier, resulting in inflammation and disruption of brain function. There is also evidence to suggest that fine particles can travel through the olfactory nerve into the brain,” Pallavi Pant, who is the head of global initiatives at Health Effects Institute told HPW.

“Exposure to air pollution may also have impacts on brain development and functioning in children, including an increased risk for neurodevelopmental disorders like autism and psychological disorders like anxiety and depression,” Pant pointed out.

The dangers of PM2.5

A comparison of the sizes of PM2.5, PM10, human hair and fine beach sand.

Air pollutants are categorized by their sizes. There is PM2.5 and there is PM10. Evidence does not yet link PM10 with higher rates of dementia, but the number of studies looking closely at PM10 were small, the researchers concluded.

Gases like NO2, and particles the size of PM2.5 or less, are dangerous because they are small enough to enter the bloodstream from the lungs after being inhaled.

Once inside the body, they can travel from head to toe, according to Palak Balyan, research lead at Climate Trends, headquartered in New Delhi.

There are two ways patients can develop dementia, a broad term describing a decline in mental abilities severe enough to interfere with a person’s everyday life, says Balyan.

One is a natural consequence of ageing, while the other is caused by blockage in the brain – including by air pollution.

“These small particles (PM2.5) block a lot of arteries, veins or small capillaries in our brain. That also leads to dementia,” she said.

Black carbon

While PM2.5 and PM10 do get some attention, black carbon does not.

“Most studies have focused on PM2.5 and NO₂, but we need much more attention on black carbon, given its major role in both health harms and climate change. These pollutants mainly come from car exhaust, power plants, industry, and diesel engines,” said Khreis, who added that black carbon or soot is sometimes smaller than PM2.5 and sticky.

“If that small sized black carbon particle sticks inside your lung or inside any other capillary in your body, that can create more damage than any other bigger sized particle,” Balyan explained.

Limited evidence from Global South

Most of the world’s population breathes in polluted air.

Of the 51 studies that were examined, 20 (39%) were done in Europe and 17 (33%) in North America, representing more than half of the overall evidence.

“Most of the data comes from high-income countries, and often from White, urban populations. That means we’re missing critical evidence from low- and middle-income countries, and from groups that face the highest exposures because of structural inequalities,” Khreis said.

She added that the global burden is probably underestimated and the risk in some groups within urban areas is concealed.

“It is likely that the deleterious impact of PM2.5 on dementia risk is mediated by other factors such as overall health status, specific co-morbidities, exercise and nutrition. Hence it is important to generate data from geographically and socioeconomically diverse populations across the world to develop a more customized and holistic framework for risk reduction interventions,” said Vaibhav A. Narayan, PhD, head of innovation and strategy for the Davos Alzheimer’s Collaborative, which is supporting a “Global Cohorts Programme” with other research partners to generate such data in low-resourced settings.

A majority of the world’s most polluted cities are in the developing countries. In 2024, 49 of the world’s most polluted cities were in Asia and one in Africa, according to data from IQAir, a Swiss air monitoring company.

But only 12 studies (24%) from Asia were included and none from Africa or Latin America. Two (4%) others were from Oceania (both in Australia).

Some of the earliest studies linking air pollution and impacts on the brain were conducted in Mexico City. Dogs living in polluted environments in Mexico City had more neurodegeneration than dogs living in cleaner environments outside Mexico City, according to one study. Similar studies were also done with children going back to 2008.

Evidence from India also suggests that those using polluting sources of cooking fuel were at a higher risk of cognitive impairment, especially rural women, given that they tend to have higher exposure to polluting cooking fuels like firewood.
“A majority of studies are currently from Europe or North America, or China, and we need a broader global evidence base representing other regions,” Pant said.

“Having said that, with the available evidence, the case for addressing air pollution to help reduce the dementia burden at the population level is strong,” she added.

A ‘modifiable risk factor’ for dementia

WHO’s outgoing director of the Department of Environment, Climate Change and Health, Dr Maria Neira, is widely credited with increasing awareness about air pollution.

The Lancet Commission has included air pollution as a modifiable risk factor for dementia in 2024, as it is possible to improve air quality.

Balyan sees some positive trends in addressing air pollution, including more awareness, more funding for research on air pollution and more collaboration.

“Now engineers and doctors are collaborating, they are working together. So that kind of collaboration has also increased which is leading to more number of studies. International collaboration has also increased because of this easy to work online system,” she said.

Dr Maria Neira, the outgoing director of the World Health Organization’s (WHO) Department of Environment, Climate Change and Health since 2005, is widely credited with increasing awareness about the impact of air pollution on health.

Image Credits: WHO, U.S. Environmental Protection Agency (EPA), WHO, US Mission Geneva .

China’s representative at the World Health Assembly in May.

China has suggested that the access pharmaceutical manufacturers get to information about dangerous pathogens should be “contingent” on their home country being a party to the Pandemic Agreement recently adopted by the World Health Assembly (WHA).

This will encourage World Health Organization (WHO) member states to ratify the agreement in their respective countries, but it is also a dig at the United States, which has pulled out of the WHO, under whose auspices the agreement was negotiated.

China’s proposal is part of a list of suggestions by WHO member states ahead of a meeting of the Intergovernmental Working Group (IGWG) on 15 September.

At its first meeting in July, the IGWG appealed to member states for suggestions about what should be included in the major outstanding issue of the agreement – an annex on a pathogen access and benefit sharing (PABS) scheme.

Disagreement about PABS has long been the main obstacle to the pandemic agreement – so much so that it was kicked down the road by the WHA in May. The WHO has entrusted the new body, the IGWG, to thrash out how the scheme will work before the next WHA in 2026. 

Once this has been done, the pandemic agreement will be complete and ready for country ratification.

Essentially, the PABS scheme will regulate how the genetic sequencing and other information about “pathogens with pandemic potential” is shared. Many countries, particularly in the global South, want any sharing that they do to be on condition that they get benefits from products that manufacturers make as a result.

Restricted access

China proposes that the annex defines the scope of eligible participants in PABS and the modalities of their engagement. For manufacturers, the annex should “specify qualification criteria, boundaries of liability, and both financial and technical benchmarks, and make these contingent on whether their home state is a party to the Pandemic Agreement”, says China.

It also proposes that the WHO establish a “tracing and tracking mechanism” for PABS materials based on “transparency and traceability”. 

However, it suggests restricted access to high-risk information with “a mechanism that tracks both the chain of custody of biological samples and the linkage to associated data”, based on the Influenza Virus Traceability Mechanism (IVTM).

Russia also wants restricted access as some pathogens which could become “weapons of mass destruction”. It suggests that “pathogens with pandemic potential” should not be transferred to countries that lack “national biosafety and biosecurity regulations and certified laboratory facilities and personnel”.

Legally binding contracts

The Africa Group’s proposal reiterates its longstanding position that the scheme should be based on both “rapid and timely access” to PABS materials and sequence information and the “rapid, timely, fair and equitable sharing of benefits” arising from this information. 

Africa envisages that the WHO will have individual legally binding contracts with manufacturers that join PABS, the terms of which will be public.

During a “pandemic emergency”, these manufacturers will make available to the WHO “20% of their real-time production of safe, quality and effective vaccines, therapeutics, and diagnostics for the pathogen causing the pandemic emergency”. At least 10% of this will be free, and the remaining 10% at “affordable prices”.

Australia, the United Kingdom, Norway, Canada, and New Zealand also support the 20% allocation to WHO.

Africa also wants the contracts with manufacturers to include annual monetary contributions to the PABS system “to support initiatives for transfer of technology and know-how, research and development, scientific and research collaborations, and laboratory capacity strengthening”.

Pandemic simulation exercise

The European Union’s proposal simply notes five areas that PABS needs to cover, with the “benefit-sharing parameters” based on contracts with participating manufacturers that demarcate issues such as the “set-aside quantities” and donations (to the WHO) of vaccines, therapeutics and diagnostics developed.

Japan submitted a diagram that succinctly presents issues to be covered.

Switzerland, in collaboration with the WHO Collaborating Centre at the Spiez Laboratory, proposes to organise “a simulation exercise to support the negotiations of the annex”. 

The one-day exercise would test the “practical feasibility and operational functionality of a potential PABS Mechanism by simulating a realistic pandemic emergency scenario”. 

An informal IGWG meeting is planned for 12 September, with the next formal meeting from 15-19 September.

The IGWG Bureau, the administrative body overseeing the talks, is also compiling a list of experts to assist with negotiations. These will also be circulated to member states.

Experts are essential for this part of the talks, which are complex given that the annex will need to harmonise with several international agreements covering intellectual property and trade, as well as the Nagoya Protocol, which determines how to share the benefits arising from the utilisation of genetic resources fairly and equitably.

Indian Prime Minister Narendra Modi at the launch of the government health insurance scheme in 2018. However, the scheme has run into problems over non-payment to private hospitals.

ROHTAK (Haryana), India – When 22-year-old Sunita* rushed her father to a private hospital in for a cardiac emergency earlier this month, she expected her government health insurance scheme, Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (known as PM-JAY), which promises to cover hospital expenses up to ₹5 lakh (around $5,725) per family, would spare her family from crushing debt.

Instead, she was told that the hospital in Haryana State had stopped admitting scheme patients over months of unpaid dues from the government. The facility is one of 650 private hospitals across Haryana that have suspended all PM-JAY services in protest over ₹490 crore ($59 million) in pending reimbursements. 

According to the Haryana Health Department, the unpaid dues date back at least six to nine months. The abrupt halt has cut off up to 18 million low-income residents from private-sector surgeries, dialysis, cancer care and other critical treatments.

Sunita’s family, who earn barely ₹10,000 ($114) a month from farm labour, had to admit her father to a smaller facility with limited cardiac services. 

“We had no choice but to borrow money,” she said. The bill ran into several thousand lakhs, “an amount my father or any of my relatives had never seen together in our lives.”

National promise under pressure

 The suspension in Haryana is the latest stress fracture in India’s flagship public health insurance programme, launched in by President Narendra Modi 2018 to provide cashless secondary and tertiary care to the poorest 40% of the population. Nationally, the scheme claims to cover more than 500 million people, with over 25,000 member hospitals.

It also comes as a recent Swiss Re Institute report warns that India faces one of the world’s largest health protection gaps, with out-of-pocket expenses accounting for over half of total health spending. 

The report cautions that without reliable public health financing, millions could fall into poverty due to medical costs  directly undermining the government’s universal health coverage goals. 

A recent Indian study found that nearly 28% of households incurred “catastrophic expenditure” on inpatient healthcare alone in 2024. This is defined as health spending that is over 10% of household’s capacity to pay. 

Haryana’s deadlock with private hospitals highlights a deeper problem: while PM-JAY has been touted as the world’s largest government-funded health insurance scheme, its rollout across states has been uneven, plagued by delayed reimbursements, under-enrolment of private providers, and allegations of fraud.

A private hospital in Rohtak, India. Some 650 hospitals in Haryana State have suspended services to government health insurance members over non-payments.

And the cracks are not limited to Haryana. In Jammu and Kashmir, where healthcare infrastructure is weaker and private hospitals are fewer, delayed claim settlements and restrictive empanelment rules have left many patients travelling hundreds of kilometres for treatment, sometimes across state lines.

The region has fewer than 130 empanelled private hospitals compared to Haryana’s 650.

Months of unsuccessful negotiations

In Haryana, the private hospitals and representative bodies began their refusal to accept members with the government insurance scheme in early August after months of unsuccessful negotiations with the state health department over pending dues, the Indian Medical Association (Haryana) told the Hindustan Times. 

Hospitals say they cannot sustain payroll, utilities, medicine purchases and consumables when reimbursements are delayed for six to nine months.

Dr Suresh Kumar, a doctor based in Haryana, said private facilities could no longer sustain operations without timely reimbursements. 

“We have to pay salaries, electricity bills, buy medicines and consumables — all on time,” he told Health Policy Watch. “If the government delays payments for six to nine months, we simply cannot function.”

Hospital administrators also argue that  the national Health Benefit Package (HBP) rates for procedures under AB-PMJAY are often outdated and may not match rising input costs. 

The Health Benefit Package documents list package prices for procedures, while the audits show that actual costs for complex surgeries frequently exceed package rates in many private hospitals, creating a shortfall for providers

The state health agency, however, has accused some hospitals of inflating bills and submitting dubious claims. Officials say they are conducting audits to weed out fraud before releasing payments, which has contributed to the delays.

Patients in limbo

While the standoff drags on, patients are bearing the brunt.

Ramphal*, a 56-year-old construction worker in the Rohtak district, had postponed a hernia surgery for three months because the nearest government hospital has a waiting list and private options are off-limits. 

“The pain is constant,” he said. “But without Ayushman, I can’t afford the operation.”

For Sunita’s father, the consequences were immediate and severe. The smaller hospital where he was admitted lacked advanced cardiac care, forcing a risky makeshift treatment. The family borrowed from relatives and neighbours, sinking into debt that could take years to repay.

Public hospitals, meanwhile, are reporting a surge in patient load since the suspension, with longer wait times and overstretched staff.

A rural hospital in Paud in western India.

Parallel crisis in Jammu and Kashmir

In Jammu and Kashmir, the AB-PMJAY rollout has faced its own hurdles – even without a mass suspension.

The region, which joined the scheme in December 2018, has only a limited number of empanelled private hospitals, most in the Kashmir Valley.

The majority of private clinics are not part of the programme, citing cumbersome empanel procedures and low reimbursement rates.

Patients in rural districts often travel to Srinagar or even to Punjab for eligible treatments. Delayed claim settlements — sometimes taking more than six months — discourage providers from participating.

 Dr Parvez Ahmad, who runs a mid-sized poly-clinic in Baramulla, said the uncertainty has forced private hospitals  to limit the number of Ayushman patients. 

“The paperwork is heavy, the payments are slow, and the rates don’t match actual costs,” he said. “We want to help poor patients, but we can’t run at a loss.”

For patients like 45-year-old Naseema from Kupwara, the gaps in coverage are stark. She was diagnosed with breast cancer last year but had to travel over 100 km to Srinagar for surgery under PM-JAY, a trip that drained her savings and left her physically exhausted.

Fragility of public-private model

Health economists say the twin crises in Haryana and Jammu and Kashmir illustrate the fragility of India’s public-private partnership model in healthcare.

“PM-JAY is heavily dependent on private hospitals, but the government’s purchasing power is undermined when reimbursements are delayed,” said public health expert Dr Indu Bhushan. “Without a predictable payment system and periodic rate revisions, private participation will keep shrinking.”

The Swiss Re Institute’s analysis echoes these concerns, warning that India’s heavy reliance on out-of-pocket payments – currently about 50% of total health expenditure – risks reversing poverty reduction gains. It estimates that the health protection gap could reach $200 billion by 2033 if current trends continue.

In Haryana, the government has promised to clear dues by October and review package rates, but private hospitals remain sceptical. In Jammu and Kashmir, officials say they are working to streamline empanelment and speed up claims processing, but no concrete timeline has been announced.

High stakes for Universal Health Coverage

India’s 2017 National Health Policy sets a target of reducing catastrophic health expenditure to 25% of households by 2025. But reality suggests that, without structural fixes to schemes like AB-PMJAY, that goal may be out of reach. 

According to a 2024 meta-analysis, the pooled incidence of catastrophic health expenditure stands at 30% of Indian households – 5% higher than the 25% policy target.

Moreover, a 2024 study of inpatient healthcare found that 28% of households incurred catastrophic health expenditure. 

On average, inpatient care accounted for 11% of monthly household consumption, underscoring how deeply hospital costs strain family budgets.

While government spending on health is gradually rising, out-of-pocket payments remain stubbornly high. 

Recent National Health Accounts data shows that government health expenditure rose from 1.13% to 1.84% of GDP between 2014–15 and 2021–22, but still leaves households shouldering a significant burden.

Together, these figures paint a stark picture: the policy target of reducing catastrophic burden to 25% by 2025 is not being met, and public financing remains limited despite slow gains.  This means that households are still paying a major share of healthcare costs themselves, raising serious concerns about the financial protection that the scheme offers.

For Sunita’s family, the lofty targets mean little compared to the daily reality of debt and uncertainty. “If Ayushman doesn’t work, where will poor people go?” she asked.

As the impasse in Haryana continues and patients in Jammu and Kashmir remain underserved, the larger question looms: can India’s flagship health insurance programme truly deliver universal health coverage, or will it remain a patchwork safety net that frays when it is needed most?

*Patients asked for their surnames not to be used.

Image Credits: PMO India, Disha Shetty.

Ahmad, 15, and his younger brother Sahil, 12, at the Torkham border between Pakistan and Afghanistan with their family, after returning from Pakistan.

Afghanistan’s fragile healthcare system is at breaking point under the strain of hundreds of thousands of Afghans deported from Iran and Pakistan over the past few months, many in urgent need of medical care.

This follows the decision by both Pakistan and Iran to repatriate Afghans, even those with refugee status in the case of Pakistan. Earlier this year, the UN High Commission for Refugees estimated that there were over 3,5 million Afghan refugees in Iran and 1,7 million in Pakistan.

Between January and 13 August, some 1.86 million Afghans have been returned from Iran and over 314,000 from Pakistan, bringing the total returns to over two million people over the past eight months alone.

Over eight million Afghans have fled their country over decades of war, but those in Iran and Pakistan are being deported to an uncertain future.

At Afghanistan’s Islam Qala border crossing with Iran, the human cost is stark: toddlers with sunken cheeks and dehydrated skin, elders bent over in coughing fits, heavily pregnant women staggering through the dusty camps, some giving birth amid chaos.

For the past many months, overwhelmed border Afghan health teams have confronted the same cycle of illnesses almost daily. Health workers say the illnesses surging through the camps are a predictable fallout of forced displacement colliding with an already overwhelmed healthcare system.

“Commonly reported health issues among returnees include trauma, malnutrition, infectious diseases such as acute watery diarrhoea and acute respiratory infections, and mental health problems,” according to the World Health Organization (WHO).

The sweltering camp for deportees reeks of over-flowing latrines and antiseptic, a grim reminder that these makeshift checkpoints have become the country’s first, and often only, line of defense against disease outbreaks.

In a torn tarpaulin’s thin shade, Zaher Qayumi, a father of five from Badghis Province, shields his children from the relentless sun. Just 10 days earlier, after five years in Iran, his nine-member family was abruptly expelled from Tehran. His children suffer from diarrhea and dizziness, their faces flushed with heatstroke.

“The situation here is terrible. Medicines, even for simple pain or diarrhea, are almost impossible to find,” Qayumi told Health Policy Watch. 

“Iranian authorities are expelling everyone. The elderly and children suffer the most. People have no means and resources. Everyone is sick.”

It is extremely difficult and complicated to navigate for returnees to access what little public health services there are, and Qayumi’s words reveal the human face of the slow-motion public health emergency playing out across the desert border.

A WHO-supported disease surveillance support team conducts a health education session for returnees at Islam Qala border crossing.

Plea for immediate assistance

Stephanie Loose, UN Habitat head for Afghanistan, told a recent press briefing in Geneva that families are arriving after days of travel in blistering heat, enduring overcrowded tents and nights without enough food, water, or shelter. 

“The real challenge is still ahead of us… people need access to basic services, to water, to sanitation, and overall, they do need livelihood opportunities for having a long term perspective and for also allowing them to, you know, lead their lives in dignity and to support their families,” said Loose.

Afghanistan’s humanitarian system is in free-fall. The country’s 2025 aid plan, valued at around $2.4 billion, is only 12% funded, according to the UN.

Aid agencies warn they are already cutting food, health, and shelter support, leaving millions at risk. UN officials are urging donors to act immediately, stressing that without swift contributions, lifesaving operations could collapse, plunging vulnerable communities into further desperation.

“At [Islam Qala’s] zero-point clinic, returning families arrive dehydrated, malnourished, and sick with respiratory and diarrheal diseases,” said Dr Noor Ahmad Mohammadi, head of the WHO-supported clinic. “We treat hundreds of children daily, most never vaccinated. Immediate action is critical to prevent rapid outbreaks.”

The clinic provides outpatient care and polio vaccinations, seeing roughly 200 patients and vaccinating 100 children under 10 each day. But with thousands crossing daily, their modest resources are overwhelmed.

UNHCR has expressed concern that many Afghans, regardless of status, “face serious protection risks in Afghanistan due to the current human rights situation, especially women and girls”.

Forgotten crisis

Afghanistan’s health system, hollowed out by decades of conflict, chronic underfunding, and the exodus of medical professionals following the Taliban’s rise to power in 2021, was already on the brink of collapse before the deportations began.

“Afghanistan is facing a deepening humanitarian crisis fuelled by a deteriorating human rights situation, prolonged economic hardship, recurring natural disasters and limited access to critical services. The large-scale returns of over 2.1 million Afghans from Iran and Pakistan in 2025 have further exacerbated the situation,” said UNHCR in a statement.

Aid agencies warn that as many as three million Afghans could be pushed back by the year’s end, raising the risk of a preventable public health disaster without urgent scale-up of clean water, vaccinations, and emergency care.

“The crisis is forgotten by much of the world,” said Nicole van Batenburg of the International Federation of Red Cross and Red Crescent Societies in a statement. “Local health systems are simply not equipped to cope.”

Many families were given mere hours to leave homes in Iran or Pakistan, abandoning belongings, medication, and any sense of security. Children arrive with fevers, diarrhea, scabies, and trauma; parents carry the weight of uprooted lives.

By spring 2025, more than 200 health facilities across Afghanistan had closed or suspended services due to lack of funds, the WHO reports. 

Dr Edwin Ceniza Salvador, WHO’s Afghanistan representative, warns that 80% of supported health services could shut down without fresh funding.

“Mothers are unable to give birth safely, children missing lifesaving vaccines, and more preventable deaths every day,” he said.

In a corner of the border camp, Zohra*, a 28‑year‑old pregnant woman, lay on a thin mat, clutching her stomach. She was seven months pregnant when her six-member family was forcibly expelled from Mashhad in Iran.

“We were told to leave within hours. I couldn’t procure the medicines I needed even before this ultimatum as I feared arrest going to the hospitals,” she said in a faint voice. “The journey was long and hot. I thought I would lose my baby on the road.”

By the time she reached the Afghan border, Zohra was severely dehydrated and showing signs of early labour. Border clinic staff managed to stabilise her, but they warned that complications could turn deadly if she cannot access a proper hospital in time.

“I wish my daughter comes to this world alive and healthy, but I worry what kind of place my children would live and grow in Afghanistan”, Zohra said.

An earlier wave of deportations from Pakistan has already strained the Afghan healthcare system. Since late 2023, tens of thousands of Afghans, many of whom had lived in Pakistan for decades, have been forced to cross back to Afghanistan with little more than what they could carry.

The UN estimates that in this year alone, at least 314,000 Afghans had been returned from Pakistan by the end of July, often arriving with untreated chronic conditions, respiratory infections, and severe malnutrition, while vaccination records are frequently missing.

No medicine or food

Halima Bibi, an elderly diabetic woman, had lived as a refugee in Pakistan for years before she was expelled from the outskirts of Islamabad with her son’s 10-member family. Her health situation embodies the health crisis in Afghanistan.

“My feet are swollen, and I can barely stand,” she said. “I haven’t had my medicine or proper food for days. We had to wait anxiously for days to get an extension for our stay in Pakistan, but they forced us to leave without any consideration or time to prepare.” 

Across Afghanistan’s border, in provinces like Nangarhar where Bibi lives, clinics and hospitals are swamped, lacking the resources to meet the urgent needs as well as management of chronic diseases like diabetes. 

Halima is fearful that insulin medicine would not be easily available for her in Afghanistan and this will cause her serious health complications. 

The Taliban’s deputy minister for refugees and repatriation, Abdul Rahman Rashid, has publicly rebuked host countries for the mass expulsions, describing the removal of Afghans as a “serious violation of international norms, humanitarian principles, and Islamic values.”

“The scale and manner in which Afghan refugees have been forced to return to their homeland is something Afghanistan has never before experienced in its history,” Rashid told a press conference in Kabul last month.

Back at Islam Qala border crossing, the transit clinic operates 24/7 where the returnees arrive with health conditions that are manageable in a well-resourced hospital, but often life-threatening here. Women and girls face particular concerns over movement restrictions and access to healthcare.

As summer heat intensifies and thousands continue to arrive daily, aid workers warn the window to prevent a full-blown humanitarian and public health catastrophe is closing fast.

Image Credits: UNHCR/ Oxygen Empire Media Production, UNHCR, WHO Afghanistan.

A protest against closure of the US Agency for International Development (USAID) in February

US non-profit groups have vowed to fight on after losing their court bid this week to compel the Trump administration to restore Congress-approved foreign aid it had stopped in January.

A three-judge panel of the US Court of Appeals ruled 2-1 to overturn a District Court ruling that compelled the US government to restore some $10 billion in foreign aid authorised by Congress for fiscal year 2024, before Trump assumed office.

According to Wednesday’s ruling, only the Government Accountability Office, Congress’s independent watchdog, can challenge the president’s actions in court in terms of the Impoundment Control Act.

But Judge Florence Pan issued a scathing dissenting opinion: “A President defies laws enacted by Congress without any legal basis, and the court holds that he has merely violated a statute, that the Constitution is not even implicated, and that there is no judicially enforceable cause of action to challenge his conduct. 

“By failing to rein in a President who ran roughshod over clear statutory mandates, the court evades its constitutional responsibility to delineate the obligations and powers of each branch of our government,” added Pan.

She also accused her colleagues, Judges Karen Henderson and Gregory Katsas, of derailing “the ‘carefully crafted system of checked and balanced power’ that serves as the ‘greatest security against tyranny – the accumulation of excessive authority in a single Branch’.” 

‘Seek permanent relief’

On 10 February, Public Citizen filed the lawsuit on behalf of AVAC, a global HIV advocacy group, and the Journalism Development Network, seeking emergency relief from a funding freeze put in place by an executive order issued the day that Trump took office. 

Public Citizen attorney Lauren Bateman described the ruling as “a significant setback for the rule of law and risks further erosion of basic separation of powers principles”. 

Bateman said the lawsuit “will continue as we seek permanent relief from the administration’s unlawful termination of the vast majority of foreign assistance”, adding that “countless people will suffer disease, starvation, and death from the administration’s unconscionable decision to withhold life-saving aid from the world’s most vulnerable people.” 

AVAC executive director Mitchell Warren said in a statement that the court ruling “hands the administration another victory in their intentional effort to destroy decades of progress in global development, diplomacy, public health and human rights”.

“Time and again, this administration has shown their disdain for foreign assistance and a disregard for people’s lives in the US and around the world,” added Warren.

“More broadly, this decision, which we will appeal to the extent possible, further erodes Congress’s role and responsibility as an equal branch of government, and the majority opinion makes the court complicit.”

The Trump administration has closed the US Agency for International Development (USAID), attempted to slash the budget of the President’s Emergency Plan for AIDS Relief and withdrawn from the World Health Organization.

The US Senate recently agreed to exempt PEPFAR from a planned $400 million cut, proposed as part of a $9.4 billion rescission package put forward by Trump.

But this relief is likely to be short-lived as US State Department officials are developing a plan to transform PEPFAR from an entity that tackles HIV to one that is broadly focused on protecting and promoting “American interests”, according to the New York Times.

The new entity would be based on bilateral agreements with low-income countries focused on diseases that could threaten the US.

Dr Jirair Ratevosian, a global health expert at Duke University and previous PEPFAR chief of staff, said that the Trump administration has “made it very clear that they want to carry on with aggressive transition planning” for PEPFAR.

“Transition planning is not a bad idea, but it must be done right, with timetables, developing indicators, matching government buy-in, getting community input, etc,” Ratevosian said.

Warren said that the court decision “exacerbates an already grave humanitarian crisis” and urged policymakers and the courts to “act urgently to reverse this dangerous precedent”.

“The health and lives of millions – not to mention the underpinnings of our democracy – hang in the balance.”

Image Credits: Reuters Youtube.

At 7am Friday morning, the plastics negotiations were called off in Geneva after countries fail to reach agreement on the basics. No advances in the text were made over the 12-day talks.

GENEVA — Negotiations over a United Nations (UN) treaty to combat the plastic pollution crisis ended in failure early Friday morning, as 183 nations were unable to bridge vast divides over production limits, toxic chemicals and financing after three years of diplomacy.

Norway officially announced the failure at 7am Geneva time after a final overtime negotiation session lasting over 24 hours.

Denmark, co-chair of the High Ambition Coalition supported by around 100 countries, said it was “truly sad to see that we will not have a treaty to end plastic pollution here in Geneva”, adding that the coalition has “clearly and repeatedly stated that we need an international, legally binding instrument that effectively protects human health and the environment from plastic pollution.”

A treaty that is able to fulfil this mandate must “at a minimum address the full life cycle of plastics, the “unsustainable consumption and production of plastics” and include “global measures and criteria on plastic products and chemicals in products,” added Denmark, which also raised the possibility of voting.

The talks were themselves an extension following December’s failed summit in Busan, South Korea. Rules requiring unanimous agreement kept the process in stalemate throughout the 12-day session.

Both draft texts presented by negotiation chair Luis Vayas Valdivieso of Ecuador were rejected by all parties. The chair’s approach, predicated on placating the lowest-ambition nations, proved insufficient even for those countries.

The petrochemical producing bloc (which calls itself the “like-minded countries”) led by Saudi Arabia and flanked by the United States (US), Russia, India, Malaysia and others, rejected even hollowed-out texts that had angered high-ambition countries by removing all mentions of chemicals, production limits, health, climate emissions, and mandatory finance. 

Further negotiations will reconvene at an undetermined date and location, based on the draft text from Busan, leaving the agreement no closer to completion than six months ago. 

Many delegates questioned the purpose of the Geneva talks, as the outcome appeared predetermined with no apparent strategy to break the deadlock. If the rules of engagement requiring unanimous agreement remain unchanged, it is uncertain whether high-ambition nations or civil society will attend future talks.

Defeat for multilateralism

UNEP executive director Inger Anders, speaking after the collapse of the talks in Geneva.

Speaking outside the assembly hall after the collapse, Inger Andersen, executive director of United Nations Environment Programme (UNEP) said: “Tell me of a treaty that has been done, in a shorter time, and then we can discuss. Would I have liked this in two years? Absolutely. 
At this point, it is critical that we take some time first to sleep and then to reflect and then to regroup. In the end, this is a member state’s lead process, and we from the United Nations are here to support it.

“I believe that everybody is very disappointed. However, multilateralism is not easy. What I can say about the future, I can’t say, we literally just walked off the floor.”

The breakdown represents a significant defeat for multilateralism at a time when its capital, Geneva, is facing mounting challenges to its value as a global diplomatic capital. 

It is also a blow for UNEP, which spent millions organising the talks but serves only as a mediator without the ability to sway outcomes, which are decided by nation-states.

“We cannot hide that the European Union and its member states had higher expectations,” EU Environment Commissioner Jessika Roswall said in a statement. 

“We came to conclude a global plastics treaty here in Geneva. We have confidence in the science that impels us, confidence in the people that pushed us, confidence in a majority of countries of both developing and developed that are aligned.

“That is what we fought for. We have not managed to get there.” 

The failure exposes a fundamental rift in visions for global plastics governance between more than 130 countries seeking legally binding measures to curb plastic production and the powerful bloc of oil-producing states intent on protecting the financial benefits of the plastics boom.

With plastic production expected to triple by 2060, according to OECD projections, and 99% of plastics made from fossil fuels, the sector represents a crucial revenue stream for petrostates as traditional energy demand shifts toward renewables.

“I am disappointed, and I am angry,” said French Environment Minister Agnès Pannier-Runacher following the collapse. “A handful of countries, guided by short-term financial interests rather than the health of their populations and the sustainability of their economies, blocked the adoption of an ambitious treaty against plastic pollution.”

Plastic
Most plastics that are produced end up in landfills in poorer countries.

“This was never going to be easy – but the outcome we have today falls short of what our people, and the planet, need,” said Surangel Whipps Jr, President of Palau and chair of the Alliance of Small Island States (AOSIS), many of whom are overwhelmed by plastic pollution and stand to lose much of their territories to climate-related rising sea level.

“Still, even after six rounds of negotiations, we will not walk away. The resilience of islanders has carried us through many storms, and we will persevere – because we need real solutions, and we will carve pathways to deliver them for our people and our planet.”

The global petrochemical industry, valued at $638 billion in 2023, is expected to be worth $838 billion by 2030. Saudi Aramco, the state-owned oil company, plans to channel about one-third of its oil production to plastics and petrochemicals by 2030. Petrochemicals make up 82% of Saudi foreign exports critical to its government budget. 

“The scientific and medical evidence is overwhelming: plastic kills. It poisons our oceans, our soils, and ultimately, it contaminates our bodies.”

Production off the table 

The central battle throughout negotiations centered on whether the treaty would address plastic production or focus solely on waste management and recycling, as advocated by the petrochemical bloc and its allies.

These nations insist that the plastics crisis can be solved through better waste management, despite technological limitations that have kept global recycling rates below 10% after decades of research and billions spent to improve recycling technologies. 

The nations pushing recycling as the solution have failed at it themselves. Saudi Arabia recycles just 3-4% of its plastic waste, Russia between 5-12%, and the US only 5-6%, according to OECD data.

The like-minded nations successfully blocked any mention of plastic production limits in the draft texts. They also removed references to climate change, emissions, fossil fuels, and petrochemicals, despite plastic production releasing more than two gigatons of CO2 annually.

If the plastics industry were a country, it would be the world’s fifth-largest greenhouse gas emitter. At projected growth rates, plastics alone could consume a quarter of the remaining carbon budget to meet the Paris Agreement’s 1.5°C target.

Health impacts sidelined, science ignored 

The infiltration of plastics and microplastics into air, rain, oceans, ecosystems and human organs has been linked to cancer, infertility, cardiovascular disease and hundreds of thousands of premature deaths annually.

A Lancet study released during the talks estimated the cost of just three plastic chemicals at $1.5 trillion per year across 38 countries. One chemical of the 16,000 used in plastics, BPA, was associated with 5.4 million cases of heart disease and 346,000 strokes in 2015. 

“Toxics and microplastics are poisoning our bodies, causing cancer, infertility, and death, while corporations keep profiting from unchecked production,” said Giulia Carlini, senior attorney at the Center for International Environmental Law (CIEL). “The science is undeniable. Yet here, it has been denied and downplayed.”

Complete safety information is missing for more than two-thirds of the chemicals used in plastics. Three-quarters have never been properly assessed for human health impacts. Just six per cent of all plastic chemicals are regulated under multilateral environmental agreements.

Yet despite the science, petrochemical states continued to argue that health impacts fall beyond the treaty’s mandate, insisting that regulation should be governed by the WHO.

Many of the same countries arguing health is outside the scope of the plastics treaty, including Russia and Iran, held the opposite position at the latest World Health Assembly, contending chemicals should not be regulated by World Health Organization (WHO) due to UNEP’s mandate. 

“The inability to reach an agreement in Geneva must be a wakeup call for the world: ending plastic pollution means confronting fossil fuel interests head on,” said Graham Forbes, head of the Greenpeace delegation to the treaty negotiations.

“The vast majority of governments want a strong agreement, yet a handful of bad actors were allowed to use process to drive such ambition into the ground,” Forbes added. “The plastics crisis is accelerating, and the petrochemical industry is determined to bury us for short-term profits.”

Petrochemical industry influence

At least 234 fossil fuel and petrochemical lobbyists attended the Geneva talks, exceeding the combined delegations of the EU and its 27 member states. They outnumbered expert scientists by three to one.

The process itself faced criticism for its opacity, with many meetings closed even to national delegations. Chair Valdivieso, Ecuador’s ambassador to the UK, was roundly criticised for his handling of negotiations, the vast majority of which occurred behind closed doors.

Civil society groups, including indigenous peoples, waste pickers and frontline communities who travelled from around the world, found themselves actively sidelined

In the closing plenary, only the Youth Plastic Coalition was allowed to speak before the US and Kuwait cut proceedings short, silencing the rest of civil society.

“This is the real health crisis,” Kuwait’s delegation said, alluding to the long night faced by negotiators as the clock struck 9am. 

Less developed nations stood up to industry and rich country pressure that had cornered them behind the scenes with economic threats, yet even this resistance could not break the deadlock.

The consensus requirement allowed low-ambition countries to “hold the entire process hostage,” as Ethiopia’s delegation put it.

“This INC was doomed from the start,” said Andrés Del Castillo, senior attorney at CIEL. “Poor time management, unrealistic expectations, lack of transparency, and a ministerial segment with no clear purpose.”

Image Credits: Stefan Anderson, Photo by Hermes Rivera on Unsplash, UNEP.

Africa CDC Director General Dr Jean Kaseya (centre) visiting DRC to assist with its mpox outbreak

African countries worst affected by mpox have rapidly expanded their diagnostic capacity, with more laboratories and better-trained health workers, said Dr Jean Kaseya, head of the Africa Centres for Disease Control and Prevention (Africa CDC).

The Democratic Republic of Congo (DRC), the epicentre of the mpox outbreak, has increased its laboratories from two in January 2024 to 69, Kaseya told a media briefing on the first anniversary of the declaration of mpox as a Public Health Emergency of Continental Security (PHECS).

 

Mpox has compelled the DRC to rapidly expand its health capacity.

Despite mpox vaccine shortages, some 886,000 people have also been vaccinated in 12 countries, he added.

Mpox has affected 24 African countries, with over 97,000 suspected cases and almost 600 deaths. But weak diagnostics mean fewer than a third of cases( 29,849) and deaths (197) were confirmed.

Conflict and poor infrastructure are affecting the DRC’s ability to identify and treat cases, which accounts for most of the untested cases. 

Other high-burden countries – Sierra Leone, Burundi and Uganda – have been able to test almost all their suspected cases.

Africa CDC and the World Health Organization (WHO) have coordinated countries’ responses via an incident management support team (IMST), which has trained 3,000 health workers on case management.

The IMST has developed continental Mpox Preparedness and Response Plans and co-led the implementation.

“Our collective efforts have been crucial in strengthening measures for an effective response,” said Dr Otim Patrick Ramadan, WHO Africa’s programme area manager for emergency response. “It is critical to sustain what works, which includes rapid case detection, timely targeted vaccination, strong laboratory systems, and active community engagement.”

Professor Yap Boum, deputy incident manager for Africa CDC, said: “With limited resources, there is a critical need to be more efficient which means working as one team, with one plan budget and monitoring framework,” said

Mpox is declining on the continental and Africa CDC’s independent expert panel will soon decide whether to suspend the PHECS, said Kaseya.

However, challenges persist including imited access to vaccines, competing emergencies, funding gaps, inadequate access to care, and stigma and the conflict in eastern DRC, according to WHO Africa in a media release on Thursday.

“Our priorities for the next six months are to  expand community-based surveillance in high-risk areas, continue to procure and distribute essential supplies to hotspots, support the integration of mpox response into other health programs for sustainability, support targeted vaccination and advocate for more funding for vaccine deployment,” said Otim.

However, the infrastructure that has been set up to address mpox is also being used to address another health emergency: cholera. 

Twenty-three countries are facing cholera outbreaks, usually caused by a lack of clean water,  which are being fanned by “humanitarian crises and natural disasters”.

So far, over 220,000 cholera cases have been recorded this year – already close to the case load of 254,000 for the whole of 2024.

By month-end, Zambia will host a meeting on cholera to develop a common continental approach, said Kaseya.

Africa CDC is also encouraging countries to integrate their HIV and mpox responses, testing people for both diseases. People with HIV are more susceptible to mpox, which can also be sexually transmitted.

Health financing

When asked whether any African group was taking forward the proposal that tourists to the continent should be charged a tax levied via airlines to help cover the cost of healthcare, as suggested by last week’s summit on African health sovereignty, Kaseya simply deferred to Rwandan President Paul Kagame.

“The meeting in Ghana … is just a continuity of what is already done, because there is, there is nothing new that will come there if it was not discussed in AU,” said Kaseya. “Our champion for health financing is President Kagame. And in Africa, we like to respect to that. For the next steps, if there is a leader who must talk about health financing and bring other leaders together, it is  President Kagame.”

However, Kaseya reiterated that the solutions to the funding crisis lie in countries allocating more domestic resources to health; innovative solutions including the airline tax and taxes on unhealthy products ,and blended finance. The DRC is taxing all imported goods and allocating some of that revenue to health, he added.

There has been a 40% reduction in development aid to the continent in the past two years – the steepest cuts taking place over the past eight months since US President Donald Trump assumed office.

“We have a number of areas of engagement with the US , and we hope that that we can get a positive outcome from this engagement,” said Kaseya.

 

Image Credits: Africa CDC.