Dr Tedros with Cabo Verde Prime Minister Ulisses de Pina Correia e Silva at the ceremont to mark the country conquering malaria.

Cabo Verde was certified as malaria-free on Friday by the World Health Organization (WHO), only the third African country to have achieved this milestone.

The country, an archipelago of 10 islands off the West African coast near Senegal, joins 43 countries including African countries Mauritius and Algeria in eliminating malaria. 

Its last indigenous malaria case was recorded in January 2018.

“WHO’s certification of Cabo Verde being malaria-free is testament to the power of strategic public health planning, collaboration, and sustained effort to protect and promote health,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. 

Certification is granted when a country has shown “with rigorous, credible evidence” that the chain of indigenous malaria transmission by Anopheles mosquitoes has been interrupted nationwide for at least the past three consecutive years, and that the country has the capacity to prevent the re-establishment of transmission, according to the WHO.

“The certification as a malaria-free country has a huge impact, and it’s taken a long time to get to this point,” said Cabo Verde Prime Minister Ulisses Correia e Silva. “In terms of the country’s external image, this is very good, both for tourism and for everyone else. The challenge that Cabo Verde has overcome in the health system is being recognised.”

Collaboration

Cabo Verde included the elimination of malaria in its national health policy in 2007. A strategic malaria plan from 2009 to 2013 focused on expanded diagnosis, early and effective treatment, and the reporting and investigating all cases. 

To stem the tide of imported cases from mainland Africa, diagnosis and treatment were provided free of charge to international travellers and migrants.

Even during the COVID-19 pandemic, the country focused on improving the quality and sustainability of vector control and malaria diagnosis, strengthening malaria surveillance –   particularly at ports, airports, in the capital city and areas with a risk of malaria re-establishment.

The Ministry of Health worked with other government departments focused on the environment, agriculture, transportation, and tourism. The inter-ministerial commission for vector control was chaired by the Prime Minister and ensured collaboration, including  from community-based organisations and NGOs.

“This is an extraordinary accomplishment, a beacon of hope at a time when climate change threatens to slow down our progress in the global fight against malaria,” said Peter Sands, Executive Director of the Global Fund, which has assisted to fund the country’s anti-malaria efforts.

“What’s now crucial is that we do not lower our guard, and that we help Cabo Verde sustain this achievement and prevent the reintroduction of malaria. With this aim in mind, we will continue to fund vector control interventions and ensure quality case management and disease surveillance for another three years.”

Sands also called for use of new products that have proven to be safe and effective – such as next-generation insecticide-treated nets, insecticides, diagnostics, treatments or vaccines. 

“At the same time, it is crucial to build the supply chain, human resources for health and disease surveillance systems to support quality service delivery,” said Sands.

The Global Fund provides 65% of all international financing for malaria programs and has invested more than US$17.9 billion in malaria control programs as of June 2023.

Marion Koopmans addresses the WHO consultation

The World Health Organization (WHO) launched a series of consultations with the scientific community this week aimed at building consensus about how best to identify and address the pathogens most likely to cause epidemics and pandemics.

The first consultation kicked off on Tuesday, with some of the world’s top scientists addressing how to develop a scientific framework for epidemics and pandemics.

Hosted by the WHO’s Research and Development (R&D) Blueprint, it is one of four planned consultations to be held over the next few weeks as the WHO prepares to release an updated list of priority pathogens that pose epidemic and pandemic threats.

The priority pathogen list was last updated in 2018 and the WHO has indicated that it will publish a new list in the first half of this year.

Since November 2022, the WHO has focused on entire classes of viruses or bacteria rather than individual pathogens that pose threats in a process chaired by US virologist Dr Barney Graham from Morehouse School of Medicine in Atlanta.

“Over 200 scientists from 53 countries are independently evaluating the evidence related to 30 viral families, one core group of bacteria, and “Pathogen X” – an unknown pathogen with the potential to trigger a severe global epidemic,” according to WHO. 

“This new approach will also help identify representative viruses (or prototypes) within a viral family as a pathfinder in generating evidence and filling knowledge gaps that may then apply to other viruses of threat in the same family.”

Priority list ‘almost finished’

Dr Marie Paule Kieny, chair of the working group on Rhabdoviridae viruses, told Tuesday’s consultation that the WHO was “almost finished” prioritising the 30 viral families for their pandemic potential and whether there are medical countermeasures to stop their spread.

“From early 2024, WHO will start phase two, which will be a public health prioritisation [of the pathogens] with a process involving a prioritisation advisory committee with 40 to 50 experts where the output is expected to be the final shortlist of viral and bacterial families with pandemic potentials, including prototype pathogens,” said Kieny.

“It is absolutely indispensable that trials to demonstrate the efficacy of medical countermeasures are integrated into the outbreak response,” she added.

Once the list had been finalised, it would enable the “scaling up of a scientific approach to pandemic preparedness and will unravel a number of scientific opportunities,” said Kieny. 

Rapid research to stop outbreaks

British virologist Dr Peter Daszak offered a view from the field, showing how rapid research could prevent outbreaks.

Daszak’s team has identified a virus with similar properties to SARS CoV2 in caves in China frequented by bats and humans collecting their faeces to fertilise their crops.

“Here we have a virus in bats right now in a cave that’s used by people who are highly exposed to faeces and this is a virus that shed in bat faeces,” said Daszak.

“It has real potential for emergence. But the good news is, because we could do serological assays and we have a lot of access to human sera from the region, we know that most people in the region have either had COVID or have been vaccinated and that will provide really good protection, we think against this virus.”

By encouraging people to wear PPE and working with them to understand the risks, the scientists and local health authorities could reduce the potential for this virus to spill over, he added.

“If we target our surveillance, if we use the right technological approaches, we can discover really interesting and important new evidence of potential spillover of pathogens and do something about it, try and prevent that from becoming an outbreak,” concluded Daszak.

Bringing research and public health together

Renowned Dutch virologist Dr Marion Koopmans told the meeting that “the evolving global pathogen surveillance network” offered a huge opportunity for collaboration on “building surveillance and sequencing capacity for the common pathogens”.

However, she added that every region has its own pathogen hotspots and priorities.

“We need sampling designed that bears in mind the likely disease emergence scenario in each region. Do I want to be able to detect it pre-emergence, for instance, for vector-borne diseases going forward… or do I want to develop it into an early warning surveillance including, for instance, wastewater surveillance,” said Koopmans.

“the opportunities are there, the tools are there. They need to be further developed for routine implementation and that to me is the next step. What that requires in terms of collaboration is much closer connection between the more research type work in clinical settings and public health settings, rather than setting up separate data and sample collection studies for emerging diseases,” she added.

The next two consultations take place next Thursday and Friday, with the fourth to be held in February.

Wounded people wait to be treated at Al Shifa Hospital in Gaza City. Al Shifa is barely functioning due to lack of staff and supplies due to Israel’s closure of the area.

The World Health Organization’s (WHO) Director General has appealed to Israel to permit it to deliver more medical supplies to Gazan health facilities, particularly in northern Gaza, after Israel refused to allow WHO convoys to travel to the area seven times in the past two weeks.

“We call on Israel to approve requests by WHO and other partners to deliver humanitarian aid,” Dr Tedros Adhanom Ghebreyesus said at the global body’s first press conference of the year on Wednesday.

“We have the supplies, the teams and the plans in place. What we don’t have is access. WHO has had to cancel six planned missions to northern Gaza since 26 December, when we had our last mission because our requests were rejected, and assurances of safe passage were not provided. A mission plan for today has also been cancelled,” said Tedros.

He said that the situation in Gaza was “indescribable” with almost 90% of the population of 1.9 million people being displaced.

“People are standing in line for hours for a small amount of water, which may not be clean or bread, which alone is not sufficiently nutritious. Only 15 hospitals are functioning even partially. The lack of clean water and sanitation and overcrowded living conditions are creating the ideal environment for disease to spread,” he added.

“This Sunday marks the 100th day of the conflict in Israel and the occupied Palestinian territory,” Tedros noted. 

“We continue to call for the release of the remaining hostages, and we continue to call on all sides to protect health care in accordance with their obligations under international humanitarian law. Health care must always be protected and respected it cannot be attacked and it cannot be militarised.”

Dr Tedros Adhanom Ghebreyesus

Gaza laboratories destroyed

However, the WHO is unable to say what diseases are spreading as there is no way of diagnosing diseases because the facilities of Gaza Central Public Health Laboratory are no longer functional, said Dr Mike Ryan, WHO’s head of health emergencies.

The Central Public Health Laboratory had been in place for the last 40 years, providing “very high quality, environmental and human health sampling systematically across Gaza”, Ryan added.

“We are trying to make arrangements for samples to be taken out of the country and tested, and in other places to bring in mobile labs,” said Ryan. “And these are the trade-offs when you talk about access. Do you replace a truck of food with a truck of lab supplies? Which truck has more priority? Do you bring in water testing equipment or bring in water?”

Declaring WHO’s readiness to assist in Gaza, Ryan hit out at those criticising UN agencies for not doing enough.

“If you continue to destroy infrastructure, if you continue to draw destroy services at this rate, and then you blame the people who are trying to come in and support and help and provide life-saving assistance, who’s to blame here?” Ryan asked.

“Is it the people who are destroying the infrastructure and destroying the livelihoods and destroying the services? Or is it those who are trying to help restore those services under intense bombardment, under the threat of violence?”

Meanwhile, Dr Rik Peeperkorn, WHO’s Jerusalem-based representative for the Occupied Palestinian Territory, added that 16 out of 21 other planned United Nations humanitarian convoys carrying food, fuel and water to areas of northern Gaza that are now under Israeli military control had also been refused entry Gaza in January alone.

Peeperkorn also expressed concern that hostilities and evacuation orders were intensifying in southern Gaza close to Nasser and Gaza European Hospitals in Khan Younis, the only operational referral hospitals there, as well as Al Aqsa Hospital, in Gaza’s central region  – which together serve around two million people.

Image Credits: @alijadallah66 /Al Andalou News Agency, WHO .

Air pollution data for 2023 across seven cities in India, including its capital Delhi, shows air pollution levels either remained the same or worsened in winter months despite a national programme to improve air quality.

PUNE, India – India’s National Clean Air Programme (NCAP) was launched five years ago and has provided budgets to 131 Indian cities to respond to air pollution.

But over half of this money had not been used by the end of 2023, according to the latest figures released by the government, while the programme’s impact on reducing pollution has been “mixed”. This is according to an analysis of air pollution levels since NCAP was initiated, conducted by Climate Trends.

The NCAP’s initial target was to reduce two key air pollutants – PM10 and PM2.5 (ultra-fine particulate matter) – by 20 to 30% by 2024, but in September 2022, this target was revised to a 40% reduction by 2026.

“In 49 cities, PM2.5 data was available for all five years. Out of these, 27 cities recorded improvements in PM2.5 levels from 2019 to 2023,” according to the report.

“Similarly, for PM10, data across five years was available for 46 cities. Of these, 24 cities saw an improvement in their PM10 levels.”

The most significant improvement in air pollution was seen in Varanasi, the home constituency of India’s Prime Minister, Narendra Modi, where PM 2.5 air pollution was reduced by 72% and PM10 by 69%, according to government data.

However, IQAir still shows “unhealthy” levels of air pollution in Varanasi. The improvement the government data shows does not always match those by independent monitors and concerns have been raised in the past by advocates and activists about the government figures.

Several cities experienced increases in PM2.5 from 2019 to 2023. These include Navi Mumbai (46% increase), Ujjain (46%) and Mumbai (38%).

“Such marginal and short-lived improvements show that we need a science-based, well-planned, and comprehensive action plan which takes into account sources of pollution and meteorological factors,” said Aarti Khosla, Director of Climate Trends.

Around 99% of the world’s population breathes in air that exceeds the pollution standards set by the World Health Organization (WHO).

But the Indo-Gangetic plain that stretches from Pakistan in the west to Bangladesh in the east is home to some of the world’s most polluted cities like Lahore, Delhi, Kolkata and Dhaka. The region is a plain bordered by the Himalayas in the north which makes air flow difficult, causing pollution to remain in the air over some of the most densely populated cities in the world.

Addressing other sources of pollution

A lot of the conversation in Delhi around its air pollution has been focussed on stubble burning in neighbouring states as farmers clear their fields for the next planting season. While stubble burning has reduced, other sources of pollution have not.

“In Delhi, it is important to mention that fire counts (stubble burning events) decreased considerably in Punjab and Haryana in this season of October and November, which contributes a significant portion to the emission of PM2.5,” said S K Dhaka, Professor in the Department of Physics at Delhi University’s Rajdhani College.

“Despite the fact that the pollution level remains high in November, and remains similar in December, there is a need to address other sources of emissions such as transport, construction, and operation of thermal power plants in Delhi NCR,” Dhaka says.

A significant part of India’s air pollution comes from the energy sector. The country’s coal usage to generate energy has continued to grow, despite climate commitments at the international level. Coal is a highly polluting source of energy and its use has doubled in the past ten years to meet the demands of a growing population as well as the industrial sector. India’s pollution numbers reflect the emissions that have not changed much.

Kolkata’s air pollution has been on the whole lower in both 2022 and 2023 which suggests that efforts to control and manage pollution have been effective.

Some cities like Kolkata have shown improvements compared to the national average that show strategies when implanted effectively can deliver results. Kolkata was one of the few cities that used most of the budget it received from the NCAP to address air pollution.

Data across the past five years has found that some cities experienced increases in pollution concentrations, underscoring the complexity of achieving air quality targets.

Increased advocacy has led to an increase in air quality monitoring in most cities, with a significant number seeing an increase in active monitors, according to Climate Trends.

No progress in the past year

Meanwhile, air pollution levels in most major cities in India either remained the same or worsened in the winter months of 2023 in comparison to 2022.

This is according to an analysis of data from India’s Central Pollution Control Board (CPCB)  from seven Indian cities, Delhi, Chandigarh, Lucknow, Varanasi, Patna, Kolkata and Mumbai.

“Comparing monthly average pollution levels between 2022 and 2023 shows some improvements, especially in Lucknow and Varanasi, but at the same time in the winter months, where air quality matters more than other months due to fog and temperature drop, we see that cities of Delhi and Chandigarh are either the same across years or worse off,” says Climate Trends director Khosla, who conducted the analysis.

The data underscores the need for targeted interventions to address the specific seasonal challenges.

In 2023, Delhi experienced a surge in winter pollution compared to 2022 that has been attributed to factors like meteorological conditions and increased emissions.

Image Credits: Unsplash, Climate Trends, Unsplash.

COVID
The WHO has urged countries to continue to sequence COVID-19 samples to monitor variants.

The JN.1 COVID-19 variant is completing its global takeover, with the number of new cases having increased by 52% during the 28 days leading up to the end of the year, according to the World Health Organization (WHO). 

In the United States, JN.1 accounts for more than 60% of COVID-19 cases, according to the Centers for Disease Control and Prevention – and all of this on top of rising influenza and Respiratory Syncytial Virus (RSV) waves. 

“The pandemic is far from over,” stressed American scientist Eric Topol in an opinion piece in the Los Angeles Times. 

What is JN.1?

JN.1 is a derivative of the BA.2.86 Omicron subvariant of SARS-Cov-2 but with more than 30 mutations. Israeli variant trackers first discovered it in August. WHO first spoke about JN.1 at a press conference on 19 October press as a variant “to keep a close eye on.” Last month, it named JN.1 a “variant of interest” (VOI) but nit the more serious “variant of concern” (VOC). 

According to Topol, “by wastewater levels, JN.1 is now associated with the second-biggest wave of infections in the United States in the pandemic, after Omicron.” He said the level indicates that around two million Americans are infected with JN.1 daily.

Although many people are carrying the virus and CDC data shows that US COVID-19 hospitalizations have continued to increase in the last two months, JN.1 has not caused the surge of hospitalizations seen in Omicron. 

This is also the case in other countries, including Israel, where it was first discovered, according to Cyrille Cohen, the head of the field of life sciences and medicine for the Israel Science Foundation and a professor at Bar-Ilan University. He said the country is seeing 10 to 20 cases of severe COVID-19 disease in hospitals on any given day, compared to as many as 1,400 two years ago. 

At the same time, studies are starting to show that the updated COVID-19 vaccines developed by Pfizer, Moderna and others are eliciting antibodies against JN.1 – at least in vitro, according to Cohen. 

For example, Kaiser Permanente recently released a report that showed a vaccine booster conferred approximately 60% protection against hospitalization for JN.1 and other recently identified variants. 

However, Cohen cautioned that it can be challenging to determine the impact of COVID-19 vaccines today as people have had so many shots at different intervals and of different versions. Moreover, most people have either been exposed to or are sick with COVID-19. 

The other issue is that vaccine uptake is deficient. CDC data as of 5 January showed that only 8% of eligible children and 19.4% of eligible adults had received the updated 2023-24 COVID-19 vaccine. The percentage jumped to around a third (38%) among adults over 65. 

Many more people are opting to take the influenza vaccine: 44% of children and 45% of adults, including 70% of adults over 65. 

Evaluating JN.1: What to ask

Whenever there is a new variant, you need to ask three questions, explained Peter Chin-Hong, a professor of medicine and infectious disease at the University of California, San Francisco: Is it more transmissible? Do the vaccines work? Does it cause more severe disease?

Is it more transmissible?

Chin-Hong told Health Policy Watch that the data indicates JN.1 is more transmissible “because it is rising to the top of the charts very quickly.” He said that at the beginning of November 2023, JN.1 accounted for between 5% and 8% of all US cases, and today it is the most common variant. 

Can it evade vaccines?

The answer here, Chin-Hong said, is generally no. He said the studies show that the vaccine works as long as people are newly inoculated. He recommended the vaccine for immuno-compromised people with pre-existing medical conditions and those over the age of 75. For these people, he said, “just being infected a year ago and getting the first two shots will not be enough.”

Does it cause more severe disease?

According to Chin-Hong, there is no evidence that JN.1 has caused more severe diseases so far and no evidence that it will. This is true in the countries currently experiencing a rise in the variant, and also from data in Singapore and other countries where JN.1 has been the predominant variant for longer, he said. 

In those countries, the variant did not seem to cause more people to be hospitalized. 

Moreover, he added that antiviral drugs such as Paxlovid and Remdesivir continue to work to curtail the severity of the virus. 

Instead, he said his concern is that JN.1 will exploit the world’s COVID-19 complacency. The majority of countries have not kept up testing or vaccination, and given its high price tag, many low- and middle-income countries do not have access to drugs like Paxlovid. 

“Those are the vulnerabilities that JN.1 will exploit,” Chin-Hong said. 

COVID-19: ‘a new era’

But Cohen said he believes the world and COVID-19 are “in another era” since WHO ended the virus’s official pandemic status in May 2023. He noted that COVID-19 is not the same threat as at the pandemic’s beginning or even during Delta. 

“With the Omicron era that started exactly two years ago, the infection decreased in intensity,” Cohen said. Moreover, “since most of us were exposed to COVID at least once in our lifetime, there is also some kind of protective [herd] immunity.”

That does not mean, however, that the medical and scientific community should not be taking JN.1 or COVID seriously, Chin-Hong stressed. He said WHO should hurry to give the variant a Greek letter name, such as Pi, to “allow governments and people to mobilize” and fight the virus. 

“Right now, people are fed up with COVID,” Chin-Hong told Health Policy Watch. “Giving it a letter will give something to people to latch onto: let’s vaccinate against Pi, get medicines, and have a global talk about sequencing.

“These things have trickle-down effects,” he continued. “Giving it a name would also help the everyday person believe he still has something to pay attention to.”

Chin-Hong and Cohen said that information remains crucial and that countries should continue to sequence to identify variants of concern. 

“We need to monitor those variants because it is not the end of COVID,” Cohen said. Just like with flu, which has an intense strain every 10-20 years, he said that COVID-19 could also once again have a more dangerous strain.”

As Topol wrote in the LA Times: “Inevitably, there will be another strain in the future that we are not at all prepared for and will lead to yet another very big wave across the planet.”

Image Credits: Photo by Mufid Majnun on Unsplash.

Vaccine
Health workers prepare a vaccine

The rising number of US citizens declining vaccinations is threatening population immunity to certain diseases, according to two US Food and Drug Administration (FDA) leaders.

“The situation has now deteriorated to the point that population immunity against some vaccine-preventable infectious diseases is at risk, and thousands of excess deaths are likely to occur this season due to illnesses amenable to prevention or reduction in severity of illness with vaccines,” according to FDA Commissioner Dr Robert Califf and Dr Peter Marks, director of the FDA’s Center for Biologics Evaluation and Research writing in the journal, JAMA.

They cite a recent measles outbreak in central Ohio involving 85 children, 36 of whom (42%) had to be hospitalized for complications.

High-income parents ‘prefer social media’

“It is sobering to note that vaccine hesitancy to childhood vaccines, such as the measles, mumps, and rubella vaccine, has been found to cluster in middle- to high-income areas among parents with at least a college degree who preferred social media narratives over evidence-based vaccine information delivered by clinicians,” they note.

In addition, only 35% of people older than 65 have had the updated COVID-19 vaccine (XBB.1.5 monovalent), which is about half the rate in this age group in the UK.

“Contrary to a wealth of misinformation available on social media and the internet, data from various studies indicate that since the beginning of the COVID-19 pandemic, tens of millions of lives were saved by vaccination. The benefits of these vaccines in prevention were largest in older individuals. However, studies show that people of all ages who are up to date on vaccination benefit and have a lower risk of developing long COVID,” they note.

Mortality per Million Individuals From COVID-19 in the US Depending on Vaccination Status

Uptake of the influenza vaccine amongst US citizens over 65 is also inadequate. 

“Vaccination rates against these respiratory pathogens are inadequate, and this is most distressing in older individuals in whom the benefits of vaccination in reducing hospitalization and death are eminently clear.”

Califf and Marks urge the clinical and biomedical community to “redouble efforts to provide accurate plain-language information” about the benefits and risks of vaccination. 

“We believe that the best way to counter the current large volume of vaccine misinformation is to dilute it with large amounts of truthful, accessible scientific evidence,” they argue.

Clinicians who provide care are the most trusted source of information about health decisions, while retail pharmacists perform this role for people who lack a primary care clinician or who are uninsured.

“All those working in health care, while being straightforward about the risks, need to better educate people regarding the benefits of vaccination, so that individuals can make well-informed choices based on accurate scientific evidence,” they urge.

Ironically, 2024 is the fiftieth anniversary of the World Health Organization’s Expanded Programme on Immunization (EPI), which aimed to ensure equitable access to life-saving vaccines for every child, regardless of their geographic location or socioeconomic status. 

Texas case against Pfizer 

The FDA leaders’ appeal comes shortly after Texas Attorney General Ken Paxton launched court action against Pfizer late last year for “false, deceptive, and misleading acts and practices” relating to its COVID-19 vaccine.

“The pharmaceutical company’s widespread representation that its vaccine possessed 95% efficacy against infection was highly misleading,” according to Paxton in a media release.

Paxton, who is seeking more than $10 million in fines, claims he is “pursuing justice for the people of Texas, many of whom were coerced by tyrannical vaccine mandates to take a defective product sold by lies”.

In response, Pfizer has applied for the case to be moved to the Northern District of Texas, saying that the case has no merit. It also claims that it is immune from liability under federal and state law in terms of the Public Readiness and Emergency Preparedness (PREP) Act for Medical Countermeasures Against COVID-19 passed in 2020.

“The FDA … is in the best position to resolve questions concerning the accuracy and propriety of statements Pfizer allegedly made concerning the COVID-19 vaccine, which the FDA itself vetted, authorized, and approved,” according to Pfizer in its legal filing.

Paxton’s court action has been hailed by anti-vaxxers on social media, many of whom are supporters of Donald Trump, in a country where uptake of vaccinations have become politicised, particularly during the pandemic. Republican supporters are significantly less likely to be vaccinated against COVID-19 than Democrats and died in greater numbers during the pandemic.

Image Credits: WHO Afro region, JAMA.

Al Aksa Hospital, the largest hospital in central Gaza, overwhelmed by casualties as fighting between Israel and Hamas in area intensifies.

Médecins Sans Frontières (MSF) and two other international relief agencies all said that they are withdrawing emergency medical teams from Al Aqsa Martyrs Hospital in central Gaza after intensified fighting around the hospital area made it impossible for staff to continue emergency care functions. 

“After days of artillery fighting in Gaza’s Middle Area, Israeli forces dropped flyers with evacuation orders in the neighborhoods around Al-Aqsa Hospital,” said MSF in a statement on Saturday. “Over the last couple of days, drone attacks and sniper fire were just a few hundred meters from the hospital, and yesterday, a bullet penetrated a wall in the ICU.” 

On Sunday, two other relief agencies, the International Rescue Committee and the UK-based Medical Aid for Palestinians said that their Emergency Medical Teams also had been “forced to withdraw and cease activities” from the hospital in Deir Al Balah, which remains the only functioning hospital in Gaza’s “Middle” area. 

Speaking Sunday from Al Aqsa Hospital, WHO’s Sean Casey, WHO EMT Coordinator, described chaotic scenes where doctors struggled to provide trauma care to people who had been victims of bombardment and explosions. 

“The hospital is operating with about 30% of the staff that it had just a few days ago,” Casey said. “They are seeing hundreds of casualties in a small emergency department. They are treating children on the floor. The hospital director spoke to us, and his one request was that this hospital be protected, that they not be evacuated, that they are able to continue functioning,” Casey said. 

Meanwhile, a planned WHO mission to Al Awda Hospital in northern Gaza was cancelled Sunday for the fourth time since 26 December, “because we did not receive deconfliction and safety guarantees,” according to WHO’s Jerusalem-based Office for the Occupied Palestinian Territory on X (formerly Twitter). 

“The mission planned to move urgently needed medical supplies to sustain the operations of five hospitals in the north, including Al-Awda, said WHO. “It has now been 12 days since we were last able to reach northern Gaza. Heavy bombardment, movement restrictions, and interrupted communications are making it nearly impossible to deliver medical supplies regularly and safely across Gaza, particularly in the north.

Lacking adequate access, staff and supplies, doctors are being forced to perform more amputations on people who were unable to reach medical care, and now have severely infected limbs, Dr. Mohamed Obied, an orthopedic specialist at the hospital was quoted as saying. “And doctors are forced to amputate limbs more frequently, performing “above the knee, rather than below-knee amputations.”

Gaza amputee – above knee amputations becoming more frequent Palestinian doctors say.

Last Thursday, WHO’s Director General Dr Tedros Adhanom Ghebreyesus also deplored an Israeli attack on a Palestinian Red Crescent training center inside the Al Amal Hospital Complex in Khan Younis city in Southern Gaza, which reportedly killed five civilians including a newborn.  Some 14,000 displaced people are sheltering on the hospital grounds, Tedros noted.  

Growing hunger and risk of famine 

Nareman Abu Al-Soud, holds her newborn in the shelter of an IDP camp in Rafah, after fleeing her home during Israeli-Hamas fighting in Gaza.

Along with the conflict, per se, the growing specter of extreme hunger, and looming famine, are amongst the other risks faced by Gaza Palestinians in the new year, said the UN’s Martin Griffiths, in a statement on Friday.

A fresh report by UN Secretary General to the UN Security Council further warned that “widespread famine looms”. More than half a million people, a quarter of the population face extreme hunger, stated the bleak summary, published on X by Al Jazeera’s UN corespondent ahead of its formal release.

“People are facing the highest level of food security ever recorded… famine is around the corner,” echoed Griffiths, UN Under-Secretary General for Humanitarian Affairs and Emergency Relief Coordinator, also writing on X.   

Bereft of food, shelter and warmth, the conditions for disease spread are also ripe, he underlined.

“Families are sleeping in the open as temperatures plummet.  Areas where civilians were told to relocate for their safety have come under bombardment…  

“A public health disaster is unfolding. Infectious diseases are spreading in overcrowded shelters as sewers spill over, he added. “The humanitarian community has been left with the impossible mission of supporting more than 2 million people, even as its own staff are being killed and displaced, as communication blackouts continue, as roads are damaged and convoys are shot at. 

“Meanwhile, rocket attacks on Israel continue, more than 120  people are still held hostage in Gaza, tensions in the West Bank are boiling, and the specter of further regional spillover of the war is looming dangerously close. Hope has never been more elusive… We continue to demand an immediate end to the war.” 

Displaced people walk from the north of Gaza towards the south, as ambulances head in the other direction.

Israel under international pressure

Israel has come under increasingly intense international pressure, including charges of genocide, for its conduct during its invasion of Gaza, which began after Hamas gunmen entered some 22 Israeli communities around Gaza in the early morning hours of 7 October, killing 1200 people, mostly civilians, in their homes. 

Israel’s has since killed some 22,000 Palestinians, displaced 80% of the area’s 2 million residents, and turned northern Gaza City into an apocalyptic landscape of sand, rubble and blown out buildings during one of the most intense aerial bombing campaigns in history.   

After claiming “operational control” last week of most of northern Gaza, Israel’s military has now moved into central and southern areas of the densely-populated enclave, which is only 365 square kilometres in all, waging fierce battles there against Hamas fighters who are bunkered down in underground tunnels and still holding over 100 Israeli hostages, including the elderly, women and children. 

Speaking to the Times of Israel, the Israeli military spokesman said Hamas “systematically operates in the hospitals in the Gaza Strip and in the areas adjacent to them, using the residents as human shields and exploiting the hospital’s infrastructure, including electricity and water.”  

“Entire neighborhoods in the Gaza Strip have been converted into “fighting complexes” for Hamas, which include “ambushes, command and control apartments, weapon depots, combat tunnels, observation posts, firing positions, booby-trapped homes and explosives in the streets,” another Israeli military source was quoted as saying. 

Although Shifa’s hospital’s alleged Hamas underground “command and control” complex did not turn out to be as massive as Israeli military analysts originally had projected, significant evidence about Hamas military infrastructure under and around Gazan hospitals has been gathered and presented by Israel during the war. Several groups of Israeli hostages, mainly women and children, were also held in Gaza hospitals during part of their captivity, according to testimony by former Israeli hostages released in late November during a brief humanitarian pause and prisoner exchange.  

Image Credits: Democracynow.org, WHO , WHO , © UNRWA/Ashraf Amra.

Krakow skyline. Eight of the European Union’s 10 most polluted cities are in Poland. But an initiative to swap out polluting coal and wood furnaces/boilers could change that.

An ambitious Polish state policy that aims to replace 50% of the country’s coal and wood household furnaces/boilers with electric heat pumps or natural gas could dramatically improve air quality in a country with some of the worst ambient air pollution levels in the European Union, says a new assessment by the European Clean Air Centre (ECAC). 

The policy could save 21,247 lives a year in Poland, increase the number of people breathing clean air 15-fold, and help Poland reach new, and much stricter, EU air quality standards, according to the assessment, published in late December. New EU standards aim to align more closely with WHO clean air guidelines for PM2.5, the most health hazardous pollutant, with negotiations underway now about a timeline for implementation.  

The Polish national programme involves replacing half the country’s 2.7 million wood and coal-fired heating systems with natural gas furnaces or even more efficient heat pumps by 2030 – a rate of about 6000 weekly. 

Polish example may show a way to move faster

Today, only about 2 million Poles live in areas with PM2.5 air pollution levels of 10 micrograms/m3 or less – the envisioned EU air quality standard for 2030.
By 2030 nearly 30 million people would live in areas that meet the new EU air quality guidelines, if retrofits continue at the current rate.

The European Commission has proposed rules by which countries would need to meet a new PM2.5 target for ambient air pollution of 10 micrograms/m3 annually by 2030. That’s half of the current EU limit of 20 μg/m3 –  although at 5 μg/m3, the WHO guideline is even stricter. But some member states still have questioned the feasibility of the 2030 deadline to meet the new EU Air Quality Directive.

Yet, results from an assessment of Poland’s experience demonstrate that reaching the new standard on a tight schedule is feasible, even in nations with higher levels of air pollution, says the ECAC. 

Air pollution is the number one environmental health risk in the WHO’s 53-member European region, according to the World Health Organization. In 2019 alone, it accounted for 569 000 premature deaths. In the 27-member state European Union, the European Environent Agency (EEA) estimates that about 300,000 people die prematurely from air pollution-related conditions – including over 40,000 in Poland.

According to the EEA, eight out of ten most air-polluted EU cities are located in Poland. A key pollution source, to quote the Polish-language version of the ECAC report, is single-family houses using biomass and low-quality coal for heating.  Nearly 90% of Europe’s coal for household heating is burned in Poland.

For the past ten years, the sector has received much attention from legislators on local and country level. A decade of civil society activism in Kraków led the region to become the first in banning polluting coal furnaces/boilers. In 2019 a national programme subsidizing retrofits with modern electric systems was launched – and the results are potentially transformational.

“Poland’s coal boiler replacement programme is an example of what ambitious environmental policy can mean for normal people. Our analysis shows that 2.7 million households will replace their heating source and with refurbishment of buildings, this will lead to a more secure, cheaper and cleaner energy source across the country, a triple win.” Łukasz Adamkiewicz, ECAC’s lead researcher, told Health Policy Watch.

Ambient air pollution’s health effects

According to the WHO, tiny particles of PM2.5 or smaller penetrate deep into lung tissue, also entering the bloodstream and infiltrating into almost every organ of the body, causing systemic inflammation and carcinogenicity. Worldwide, between one-third and one-quarter of premature deaths involving heart attack, stroke, respiratory diseases, and cancers are attributable to air pollution. 

Right now, approximately 41 000 people die prematurely every year in Poland, as a result of ambient air pollution exposures.  Experts also note that the estimate is probably under-valued insofar as poor air quality has many indirect health effects, especially for more vulnerable populations such as children, pregnant women and the elderly. With European society aging, the health burden of pollution is likely to grow even more.

More efficiency, less CO2 emissions

Furnace retrofits would also reduce CO2 emissions from the household sector by 33% by 2030, the ECAC study estimates

Along with reducing air pollution, the revolution in heating sources also will have an impact on greenhouse gas emissions – reducing CO2 emissions from the household sector by 33%, the ECAC study projects.

While some households have replaced coal furnaces with gas boilers, heat pumps so far have comprised 50-60% of the retrofits. Both represent a significant reduction in CO2 emissions, insofar as gas is much more efficient and releases far less CO2 that coal when burned.

Heat pumps are even better, achieving efficiency rates three-to four times that of other heating systems, according to the MIT Technology Review. This means the heat they produce is three-to-four times the electricity used. 

Additionally, heat pumps can, and are, being integrated with rooftop solar panels amongst some households in Poland with support from other state and national subsidy programmes. When a rooftop solar array powers the heat pump during daytime hours, this reduces further demand on coal power plant generation – traditionally Poland’s dominant electric power source.   

Growing share of renewables in the Polish energy mix. From left to right: share of electricity sources through time (grey – coal; blue – natural gas; green – renewable sources) and renewable energy production in TWh (yellow – photovoltaics, blue – wind green – biomass, brown – bio gas, grey – water).

Thanks to the gradual shift, more than a quarter of electricity produced in Poland now comes from renewable sources. According to the European Network of Transmission System Operators for Electricity data, PV solar panels produced a record 17% of the country’s energy in July 2023.

That said, solar panel systems are still too expensive for many households and in many areas. And in many areas, the uptake of PV panels has already outstripped the capacity of the power grid to absorb the power thus generated.  This leaves further growth in the solar sector uncertain until the new Polish government sets a policy direction, said Adamkiewicz.

Continued subsidies essential to implementing the initiative 

The continuation of state-sponsored subsidies for furnace/boiler conversions is critical to maintaining the current pace of change; the subsidies are projected to support about 87% of the heating system modernisations over the coming years, the ECAC report notes.

Luckily for air quality, Poland’s new climate minister, Paulina Hennig-Kloska, plans on sustaining the subsidy programme, which is investing a total of €25 billion into the clean heating system retrofits.

Additionally, electricity tariffs need to be made more affordable and attractive so as to encourage consumers to move to more efficient heat pumps, as compared to gas, researchers and activists state. 

“When compared with gas, the replacement with heat pumps has dropped from 60% in 2020 to 48% now as a share of the types of boilers being replaced, said Adamkiewicz. “A further decline will occur if the government does not prepare a special tariff and other regulations,” he warned. 

Poland sets example in the midst of trilogue negotiations

The Polish policy trends come at a crucial time for the EU Parliament.  The proposed EU Air Quality Directive (AAQD) is not only more rigorous in terms of air quality standards, it also would introduce an option for citizens to go to court over the health effects of excessive air pollution.

The final shape of the new Directive is currently under discussion between the European Commission, the European Council and the European Parliament in complex “trilogue” negotiations to hone down details of the new rules. As Parliament has already voted in favour of sweeping revisions, it is now up to the Council, which includes representation from all member state governments, to make the next step.

“Trilogue negotiations between the Commission, Council and Parliament are ongoing, and the legislation needs to be finalised by mid-February in order to become law before the European Parliament elections,” noted the ECAC in a press release.

Some member states in eastern and souther Europe have pushed back against the new EU rules saying that countries with a GDP below the EU average need a ten year time frame for  implementing the stricter air quality standard, rather than six years, as is now proposed. But Poland’s example shows faster implementation of clean air policies isn’t necessarily linked to income levels. 

“Poland should be seen as an example of what can be done in Europe with the right policy in place,” states Adamkiewicz.

Image Credits: Zuzanna Stawiska , ECAC , Wysokie Napięcie.

Village pharmacy in Kaga Bandoro, Central African Republic; weak drug regulatory systems still leave the door open to substandard and fake medicines in many countries.

CAIRO, Egypt -Some 70% of countries globally have weak national medicines regulatory systems. But the launch of the African Medicines Agency should help address many of the shortcomings on the African continent, said speakers at the 6th Scientific Conference on Medicines Regulation in Africa (SCoMRA), convened here in mid-December. 

The conference, organized by the African Union Development Agency-NEPAD (AUDA-NEPAD) in partnership with the World Health Organization (WHO) and the African Medicines Regulatory Harmonization programme (AMRH) examined how stronger regulatory systems can increase equitable access to life-saving medicines.

“Since its inception we can say SCoMRA over the years has been instrumental in strengthening Africa’s harmonization efforts by promoting the regulation of medical products and propelling the continent towards equitable access to lifesaving medicines,” said WHO’s Andrea Keyter, reflecting on the theme of this year’s event.

Andrea Keyter, WHO Department of Prequalification and Regulation

Despite progress made, leadership changes, sustainable financing, human resource constraints, and infrastructure deficiencies, remain key challenges, said Keyter, a technical officer in WHO’s Department of Prequalification and Regulation.  

She referred to a 2021 WHO survey published in the Global Benchmarking Tool for Evaluation of National Regulatory Systems of Medical Products that found 70% of countries worldwide with weak national  regulatory systems for health products.

“There is the need for a more efficient use of the global regulatory resources to facilitate access to quality-assured medical products and to build capacity,” Keyter emphasized 

Battling Substandard and Falsified Medical Products

Wanga Karim, Kenya Pharmacy and Poisons Board

In another WHO report cited by Wanga Karim,  head of post market surveillance at the Kenyan Pharmacy and Poisons Board, substandard and falsified (SF) medicines are on the market in every country. At least one out of 10 tested samples in low- and middle-income countries are substandard or fake.

Unfortunately, public health officials in many countries fail to appreciate the burden of SF medicines. As this is better understood, officials will be able to make more informed choices about investments in regulatory systems that watchdog medicines quality.

On the persistent challenges of substandard and falsified medical products in Africa, Karim called for a concerted effort in utilizing available resources to curb the problems of SF on the continent.  

WHO describes substandard and fake medicines as medical products that have not undergone evaluation and /or regulatory approval for the market in which they are marketed, distributed, or used.

Increase in the marketing of contaminated cough syrups

WHO alert on 5 October 2022 of contamination found in four Indian-made cough syrups consumed by children in The Gambia – some of whom later died.

In particular, the number of reported incidents of contaminated cough syrups has increased over the last 3 years, Karim said, noting. “Contaminated syrups have been detected in all regions – with exception of the WHO Region of the America.” As of Oct 2023, the highest number of reports of such incidents was in the African Region. 

According to Karim, some  22 incidents of cough syrup contamination with the chemicals diethylene glycol and ethylene glycol (DEG/EG) were reported to WHO in 18 member states involving 58 unique product batches between 2020 and 2023. Senegal, The Gambia, India and Cambodia topped the list.

In The Gambia, one of the biggest cases, DEG/EG contamination was “potentially” linked with acute kidney injury and 66 deaths among affected children, WHO Director General Dr Tedros Adhanom Ghebreyesus in October 2022.  Subsequent WHO-commissioned laboratory tests confirmed the presence of DEG/EG in four cough syrup products. The Haryana-based Maiden pharmaceuticals plant, which produced the syrups, was shut down temporarily by the Indian government as a result, while other products were recalled.  

In the period 2014 – 2023, Eritrea received about 2,400 alerts of suspected substandard or fake products, ultimately recalling more than 100, said Mulugeta Russom of the Eritrean Pharmacovigilance Centre, who presented a report on understanding, readiness and response in combating falsified medicine products in the country. 

“FS is a global threat because weak regulation and harmonization is a fertile ground for falsification hence in combating falsified medical products, understanding, knowledge and the political will is needed,” he concluded. 

International collaboration is critical 

Dr Tamer Essam, chair Egyptian Drug Authority, at the 6th Biennial Scientific Conference on Medical Products Regulation in Africa

Conference participants stressed the importance of international collaboration in the fight against substandard and fake products. 

“Unity in action is our strongest asset,” said AUDA-NEPAD’s Chimwemwe Chamdimba.   

Tamer Essam, Chairman of the Egyptian Drug Authority, highlighted the significance of improving the local legal frameworks and strengthening intersectional collaboration on the continent to maximize resources for the fight. “Improving the legal framework and strengthening intersectional collaboration are essential steps to combat SFMP effectively. We need a unified front in this battle,” he added.

Hiti Baran Sillon, a unit head in WHO’s Department of Regulation and Prequalification emphasized the crucial role of data and information sharing in the fight against fake and substandard medicines. 

“Enhancing data and information sharing on SF medical products among member states is crucial,” he said, adding, “collaboration is our strongest weapon against this menace.” 

African Medicines Agency – still waiting to begin operations

(Left-right) WHO’s Hiiti Baran Sillon, Dr Magareth Ndomondo-Sigonda, NEPAD; and Adam Mitangu Fimbo Vice Chair of the AMRH Steering Committee at the 6th Biennial Scientific Conference on Medicines Regulation in Africa.

The African Medicines Agency is expected to help intensify the fight against fake medicines – expediting the sharing of data and information between countries, participants stressed. 

Some 55 countries have signed and/or ratified  the AMA Treaty, with Tanzania as the most recent, ratifying the treaty on 31 October 2023.” 

Aimed at facilitating sustained continental-wide harmonization of technical standards and processes, the AMA Treaty, which came into force in November 2021, was built on earlier AMRH efforts in regulatory harmonization. 

The AMA is expected to further support countries in  assessing complex medical products, provide scientific and regulatory advice in support of local pharma industry development, and expedite the removal of unnecessary technical barriers to trade in pharmaceuticals.

In June, the African Union signed an agreement with Rwanda to host the new AMA. The search for a director is meanwhile reportedly underway. But there has so far been no firm date fixed for the AMA to actually begin operations. Meanwhile three of Africa’s most powerful nations – Nigeria, South Africa and Ethiopia, have yet to sign the AMA treaty.  

The AMA is positioned not to replace but to coordinate and complement the work of national regulatory authorities and regional economic communities, stressed  Keyter.  However, in order to advance progress in regulatory strengthening, the importance of collaboration cannot be underestimated, she stressed. 

Dr David Mukanga, chair of AMRH, at the 6th Biennial Scientific Conference on Medical Products Regulation in Africa

Conference participants also  highlighted the significant role of the African Medicines Regulatory Harmonization (AMRH) initiative, in the lead-up to the AMA’s creation. Said David Mukanga, chair of ARMRH Partnership Platform, “AMRH has been instrumental in implementing the African Vaccines Regulatory Forum (AVAREF) and the African Medicines Quality Forum (AMQF)  and has contributed to improved regulatory decisions, reduced registration timelines, and enhanced regulatory capacity.”

Image Credits: Jessica Ahedor , DIFD , Jessica Ahedor, AUDA/NEPAD, World Health Organization .

Extinction Rebellion protest in London on 9 April 2022.

In early December, I was one of the nearly 100,000 delegates at COP28, the biggest climate conference ever held. As a senior health professional and campaigner for gender equity in health, I was pleased to see the adoption of the first ever COP health declaration.

Who among us can still deny that climate change is a direct threat to human health? Ours is an age when humanitarian disasters as a result of wildfires, flooding, heatwaves and hurricanes have become the norm. The WHO tells us that 3.6 billion people already live in areas highly susceptible to climate change. That’s nearly half of us humans. Between 2030 and 2050, climate change is expected to cause approximately 250 000 additional deaths per year, from undernutrition, malaria, diarrhoea and heat stress alone. We know that women and children are 14 times more likely to die as a result of a disaster than men and that women and girls are more likely to be malnourished than men and boys, so it is clear that climate risks are not equally shared.

Women and girls among the hardest hit by dual climate and health crisis

Water security
Women and children spend 200 million hours every day collecting water – an increasingly scarce resource in regions stricken by more climate-induced droughts.

Women and girls are part of the vulnerable populations hardest hit by the dual climate – health crisis. Together they represent 20 million of the 26 million people estimated to have been displaced already by climate change. Because of poverty, detrimental social and cultural norms and other such factors, they often come last in accessing vital health services. The numbers are so stark, it seems almost redundant to highlight that this is a deeply gendered injustice.

The tight link between climate, health and gender doesn’t stop here, however. The overwhelming majority of people dealing with the impacts of climate disasters within health services everywhere are – you guessed it – women.

Women make up 70% of the health workforce and 90% of frontline health workers during crisis situations, such as natural disasters or the COVID-19 pandemic. They are the ones who tend to bear the brunt of huge disruption, keeping health systems afloat – and saving lives. As we have seen in the pandemic, they work the extra shifts, put their own health at risk and do what’s needed to keep everyone safe in times of high risk  and hardship.

This alone is nothing if not commendable. But that’s not all.

Women also on frontlines of healthcare crisis

Women health workers profest protest about poor working conditions during the COVID pandemic.

In keeping all of us safe, women health workers themselves are forced to accept unsafe working conditions. Often, they don’t have basic personal protective equipment (PPE). Our own Women in Global Health research during the pandemic, documented stories of women nurses or doctors having to fashion themselves aprons out of garbage bags, or to reuse PPE because of insufficient supplies. To make matters worse, when PPE is provided, it often doesn’t fit women – and therefore doesn’t protect them, because it was made to fit a male body, which is used as the standard.

And to make their jobs and lives even more stressful, women health workers routinely experience abuse, sexual violence and harassment from male colleagues, patients and community members. This only gets worse in times of crisis. During the pandemic, for instance, women frontline workers were targeted with abuse in some contexts, wrongly accused of spreading infection and later by anti-vaccination campaigners.

This might all be different if women health workers were equally included in health systems’ decision-making. Although they represent the large majority of the health workforce, women occupy only 25% of leadership positions. In January 2020, just five women were invited to join the 21-member WHO Emergency Committee. A 2020 Women in Global Health Study found 85% of 115 national COVID-19 task forces had majority male membership. It’s high time we recognise this is not only unfair and obscenely disproportionate – but it has a cost as described in our new report ‘The Great Resignation’, which details the growing global trend of women health workers leaving, or planning to leave, the profession. And we cannot be surprised that women are leaving the health sector in alarming numbers.

Gender equity is not just a ‘nice-to-have’

When it comes to the humanitarian impacts of the climate crisis, all of this matters. Women are the first to respond during a climate-induced natural disaster, from the health frontline, but also as carers of their families and their communities. Climate change is amplifying and multiplying health emergencies.  Gender equity is not just a ‘nice-to-have’ in the face of such unpredictability, it is fundamental to all our survival. When we depend on women to keep us safe and minimise the human toll of climate unpredictability, we can’t afford to let them down.

This is why, as glad as I am – as a health professional – to see a first-ever health declaration adopted at COP28, and knowing – as a former government official of Pakistan – what painstaking negotiation is needed for any international agreement, I know we need to go much further, much faster, for the predominantly female health workforce upon whom we depend in climate unpredictability. The health declaration mentions health workers as well as women and girls only once, when they must be central to our thinking and our interventions around the climate-health intersection. Anything short of a new social contract for women in health, equity in leadership and gender transformative approaches across our health system means we risk not being able to withstand the challenges that unpredictable climate events are throwing at us. Anything less than genuine commitment and action is, frankly, hot air that we cannot afford.

Dr Shabnum Sarfraz

Dr. Shabnum Sarfraz is the Global Director for Gender and Health and Deputy Executive Director of Women in Global Health.  Before joining Women in Global Health, Dr. Sarfraz previously served at the Federal Planning Commission, Government of Pakistan, including leading Pakistan’s national COVID19 response efforts and served as the national focal person for SDGs. 

Image Credits: Roberto Barcellona, Shutterstock, UNICEF, Women in Global Health .