The crowded WHA meeting room where the pandemic discussions are taking place

GENEVA – A powerful lobby, including the US, Germany and New Zealand, are pushing for the amendments to the International Health Regulations (IHR) to be adopted by the close of the World Health Assembly (WHA) on Saturday. 

Weaknesses in the IHR, the only global rules guiding countries’ conduct in international public health emergencies, were exposed during the pandemic, prompting a two-year process to amend them.

Agreement is close, with some outstanding issues particularly on definitions, according to the report on the IHR negotiations to the WHA by World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus.

“My appeal here is let us focus on the IHR so we have this success as this is already providing much better protection for the world,” said Germany’s Health Minister Karl Lauterbach. 

Strong positive signal

The European Union (EU) echoed this sentiment, describing progress on IHR amendments as “remarkable”.

“The adoption of these amendments within the very short timeframe of only two years will send a very positive signal to the outside world about the ability of the WHO and its membership to take concrete action to improve the global health architecture,” said the EU.

“Such adoption will also send very positive signal for the future of the INB [Intergovernmental Negotiating Body] process.”

The INB was charged with negotiating a pandemic agreement but member states have failed to reach agreement by the WHA deadline. The most recent pandemic agreement draft shows significant areas of disagreement remain.

The EU acknowledged that some IHR amendments still need to be resolved and urged all partners to “redouble efforts” to finalise the work and adopt the changes by 1 June.

Dr Ashley Bloomfield, co-chair of the Working Group on amendments to the IHR, told the WHA that the committee is “very close to completing an agreed package of amendments”.

“There is both momentum and an aspiration among states parties to complete the task,” said Bloomfield. “Adopting a package of IHR amendments during this assembly would be a significant milestone and achievement and we believe in a very important stepping stone to successfully concluding the pandemic agreement negotiations later.”

France, Indonesia, Kenya, New Zealand and Saudi Arabia have prepared a resolution to adopt the IHR amendments in anticipation of agreement being reached in the next few days.

Pandemic agreement process unclear

It is unclear whether the African region will support completing the IHR amendments this week if its demand for the speedy conclusion of the pandemic agreement by the end of this year is not accepted.

At a packed WHA meeting of Committee A on Tuesday afternoon, there was intense discussion and some disagreements over the way forward for the INB process on a pandemic agreement.

First off, there were two resolutions on the floor, one from the 47 WHO African member states and another from a group of countries that have often played a conciliatory role in talks – Australia, Brunei, Canada, Norway and Pakistan.

Both spoke to the time frames for further talks, while the second resolution called for a new structure to take forward the pandemic agreement negotiations.

South Africa’s Ambassador Mxolisi Nkosi.

Expressing disappointment on behalf of the African region that a pandemic agreement was not agreed on, South Africa’s Ambassador Mxolisi Nkosi called for negotiations to be completed by the end of this year, followed by a special WHA.

Botswana expressed its support for the speedy resolution of the IHR during the session, but Kenya – on behalf of the Africa region – linked the IHR amendments and the pandemic agreement, and simply said the region was ready to reach consensus.

However, US Ambassador Pamela Hamamoto called for an extension of “one to two years”, explaining that “fundamental differences remain on core issues central to the agreement”.

She described these differences as “complex technical issues that require extensive deliberation and carefully crafted workable solutions, inspired by a common vision and supported by all member states”.

Ironically, if Donald Trump wins the US presidential election at the end of the year, his administration is unlikely to support the pandemic negotiations – or even the WHO.

The WHA’s Committee A resolved that a single drafting group co-chaired by one INB member and one WGIHR member, will convene on Wednesday morning. It will be open to all member states and its task will be to consider all three draft resolutions and propose a process for adopting the IHR amendments and the timing, format and process to conclude the pandemic agreement.

These proposals will have to be submitted to the WHA as the mandates for both the WGIHR and the INB have expired.

The 77th session of World Health Assembly underway in Geneva, Switzerland.

The World Health Organization plans to make climate change and its impact on health a major focus in the coming years, along with strengthening health systems, improving health equity and access, and preventing disease, according to the organization’s plan for its general program of work from 2025 to 2028.

The four-year plan, known as GPW-14, also prioritizes mental health, gender equality, migrant health, food safety, digital health, and artificial intelligence. It was developed through an extensive 10-month consultation process involving member countries, UN organizations, and civil society organizations.

“This document will act as our canvas, articulating our collective aspirations and strategic priorities in global health for the coming four years,” said Dr Saia Ma’u Piukala, the WHO’s regional director for the Western Pacific, as discussions on the plan concluded Tuesday morning, the second day of the ongoing 77th World Health Assembly.

Dr Piukala added that the plan “reflects the learning from the Covid-19 pandemic and response to shared issues like climate change, ageing, migration, evolving geopolitics, increasing spillover events and rapidly advancing science and technology.”

The World Health Assembly approved the draft GPW-14 following Tuesday’s discussions, but funding remains a concern. The GPW-14 program has a price tag of $11.1 billion, with WHO member states’ assessed contributions covering just over a third of the cost at $4 billion. The WHO is still looking for $7 billion in flexible funding, which it will attempt to raise at an investment conference in late 2024.

Focus on Climate Change

In recent years, the impact of climate change on health, particularly non-communicable diseases, has become increasingly clear. The WHO has warned that severe weather events, pollution, and climate-sensitive diseases are becoming more frequent worldwide, with vulnerable areas like small island developing states bearing a disproportionate impact.

The GPW-14 also notes that human migration and displacement have reached unprecedented levels, with an estimated one billion people choosing to migrate or being forcibly displaced due to various factors, including economic, environmental, political, and conflict-related issues – with dire consequences for health.

“The pace of climate change and environmental degradation has accelerated, emerging as a major threat to human health in the 21st century,” the GPW-14 warns. “Increasing inequities within and between countries, which were exacerbated by the COVID-19 pandemic, are leading to a growing divide in health, social and economic outcomes between those with financial resources and those without.”

Countries like Japan and the United States praised the WHO for its growing focus on climate and health. Member states acknowledged that health-related Sustainable Development Goals are not on track, and Turkey drew attention to attacks on health facilities and disruptions to essential health services, calling it a “man-made crisis.”

“GPW-14 includes the measures to address climate change in the primary objective,” the representative from Japan said. “Now, the world is facing a huge impact of climate change on health. And we affirm the importance of disaster management, especially in the healthcare field.”

Dr Saia Ma’u Piukala, Regional Director for WHO’s Western Pacific region.

Civil Society Warns WHO Plan is Incomplete

Civil society groups have pointed out several shortcomings in the WHO’s GPW-14 plan, despite its ambitious goals to address climate change and health equity.

The NCD Alliance, an organization focused on fighting non-communicable diseases (NCDs), criticized the plan for not adequately addressing NCDs, which account for 74% of global deaths. The lack of specificity on NCDs in the GPW-14 comes despite the increasing burden of disease from climate and environmental factors like heat and air pollution.

“We regret the missed opportunity to ensure comprehensive outcome indicators for NCDs,” said a representative for the NCD Alliance. “The absence of answers to indicators hinders prioritization for achieving agreed targets.”

Other civil society groups noted the plan’s lack of specific references to maternal health indicators and provisions to address the vulnerability of women in the health workforce, despite women constituting 70% of healthcare professionals globally.  However, the healthcare workforce and ways to improve equity were mentioned in the plan several times.

“Integrating gender-responsive approaches into health workforce planning and management can help address gender disparities in health outcomes and advance progress towards achieving universal healthcare,” said a representative from the Global Health Council in a constituent statement.

The absence of gender-responsive provisions in the GPW-14 is likely due to opposition from conservative countries to the terminology. Countries like Russia, Egypt, and Iran objected to any references to “gender” on religious and political grounds during closed-door negotiations, Health Policy Watch reported.

Despite these criticisms, several member states thanked the WHO for the extensive consultations carried out before finalizing the draft plan.

“We particularly applaud the Secretariat for extensive and inclusive consultation through various platforms with member states, various organizations and partners in the drafting process,” the representative from Botswana said.

Image Credits: Twitter, Twitter.

A panel discussion at the "Ensuring continuity of care at different stages of the migration process" session of the Gevena Health Forum. From left to right: Alexios Georgalis of the National and Kapodistrian University of Athens, Reinaldo Ortuno Gutierrez of Médecins Sans Frontières, Rebecca Marcussen-Lewis of SOS Méditerranée and Sanjula Weerasinghe, a representative of the International Federation of Red Cross.
A panel discussion at the “Ensuring continuity of care at different stages of the migration process” session of the Gevena Health Forum. From left to right: Alexios Georgalis of the National and Kapodistrian University of Athens, Reinaldo Ortuno Gutierrez of Médecins Sans Frontières, Rebecca Marcussen-Lewis of SOS Méditerranée and Sanjula Weerasinghe, a representative of the International Federation of Red Cross.

As the world grapples with a migrant and refugee crisis of unprecedented scale, with 281m international migrants and 3.5m refugees globally, according to UN agencies, experts are turning to technology, particularly artificial intelligence, in search of solutions.

The potential for AI and technology to foster a more equitable and sustainable world has been recognised by international organisations. Last year, the World Health Organization, World Intellectual Property Organization, and International Telecommunication Union formed the Global Initiative on AI for Health to facilitate the implementation of AI in healthcare. During the 2024 World Economic Forum, specialists underscored both AI’s transformative potential and the associated risks, emphasising the necessity of cooperation and ethical guidelines to harness its benefits responsibly.

With record numbers of people on the move worldwide, can technology help tackle the migrant and refugee crises? Four experts addressed the question at the Geneva Health Forum on Monday during a day focused on migration and health equity.

The Geneva Health Forum, convened by the University of Geneva and partners on the first three days of the 2024 World Health Assembly, brings together key global health scientists and policymakers with medical practitioners and other field actors.

Here are their insights. 

Alexios Georgalis, who co-authored the Boys on the Move life skills curriculum – a UNICEF initiative that guides unaccompanied male adolescents displaced by conflict and poverty – believes that although AI cannot fully resolve the refugee crisis, digitalizing and gamifying interventional packages could have a substantial impact. His work focuses on educating young male migrants about exploitation and trafficking, as well as providing mental health support.

“Almost every refugee has a smartphone,” Georgalis noted, indicating that digital tools could serve as a “gateway into their psyches and their hands.”

Reinaldo Ortuno Gutierrez of Médecins Sans Frontières (MSF) recommended developing geotargeted technologies to help migrants find healthcare wherever they are. MSF already uses QR codes that can be scanned with a smartphone to provide a map of care sites, from primary care to psychiatric care. Gutierrez also mentioned secure referral systems that allow patient files to travel safely via smartphone, ensuring continuity of care. “It would be ideal to have some kind of passport for everyone, but at the moment, it is very limited,” he said.

Sanjula Weerasinghe, a representative of the International Federation of Red Cross (IFRC), highlighted the potential benefits of digitally-carried medical records, allowing migrants to “take responsibility and control of their own data.” However, she noted that while efforts to generate this type of record-keeping are underway, no such technology currently exists. Weerasinghe, like Gutierrez, pointed out that some international organisations have developed apps to help migrants locate and access services.

Rebecca Marcussen-Lewis, SOS Méditerranée.
Rebecca Marcussen-Lewis, SOS Méditerranée.

In contrast, Rebecca Marcussen-Lewis of SOS Méditerranée, a search and rescue NGO operating boats tasked with rescuing drowning migrant vessels, highlighted the challenges of digitalization in her work on the Mediterranean Sea.

“We don’t have connectivity, so everything being digital and online is not so easy for us, and if everything moves in that direction, we run the risk of losing the ability to do our work,” she said.

However, Marcussen-Lewis acknowledged that telemedicine could be helpful, allowing her team to reach out to a network of experts when faced with unfamiliar medical situations at sea. With a team of four serving over 630 people on a 69-meter boat, “being able to have a network that we can reach out to when we have a presentation that none of us has come across before is fantastic,” she said.

Image Credits: Maayan Hoffman, Courtesy of Geneva Health Forum, Geneva Health Forum.

contaminated tumeric with lead
Lead has been found in contaminated turmeric and other spices, creating another route of exposure to the heavy metal

Four well-known heavy metals and chemical pollutants – lead, asbestos, arsenic and cadmium- continue exact a heavy toll on the lives of those in low- and middle-income countries  – with lead named a factor in as much as 5 million premature deaths annually from cardiovascular disease, according to one recent estimate. Asbestos, arsenic, and cadmium round out the top four, claiming hundreds of thousands of lives every year.

While much recent media attention has been focused on the health impacts of newer industrial compounds such as dioxins, phthalates, and endocrine disruptors, these heavy metal “silent killers” need renewed attention in the environmental health arena, experts say.  

This was one key message from a day-long session on Health and Environment, the featured theme on the opening day of this year’s Geneva Health Forum, 27-29 May. The session highlighted the pressing threats of environmental pollution from plastics and lead to endocrine disruptors and ambient air pollution.

The Geneva Health Forum, organized by the University of Geneva on the sidelines of the World Health Assembly brings together the global scientific community with health practitioners and field actors from around the world.

Migration, health and equity and malaria are other key themes

GHF themes of environment, migration, and malaria
The Geneva Health Forum highlighted three key themes on opening day.

This year’s Forum, running on the sidelines of the World Health Assembly, brings together hundreds of scientists, policy experts and member state representatives on three key themes – including migration, health and equity; and malaria elimination – each the focus of a full-day session. There are also a host of side events on issues ranging from One Health to Climate resilience and elimination of neglected tropical diseases such as Chagas disease and Noma. 

While panellists highlighted the higher profile of air pollution in recent years and successes with air quality regulation in higher-income countries, air pollution remains a serious and even growing problem in low- and middle-income regions. 

Focus on pollutants with the highest impacts on death and disease

Lead and CVD graph
A recent study implicated lead with 5.5 million premature deaths

Meanwhile, age-old problems of heavy metal and mineral pollutants such as lead and asbestos also need much more attention, also in LMICs.   

“We need to deal with key priorities, country by country, of what’s causing the most damage,” said Richard Fuller, founder and former chair of the Global Alliance on Health and Pollution, who recently participated in an assessment ranking the burden of disease from key WHO “chemicals of concern.”

“There was one chemical issue that caused millions of deaths – and then four issues that caused hundreds of thousands of deaths,” he said, referring to lead, asbestos, highly hazardous pesticides, arsenic, and cadmium. “The one that caused the majority of deaths was our old friend lead, which is responsible for 1.5 -2 million deaths per year.”

Lead may account for as many as 5.5 million premature deaths from CVD 

A man melts lead metallic wastes used in the production of cooking pots, at a recycling warehouse in Koumassi, Abidjan, Ivory Coast.

A 2023 paper published in The Lancet, supported by the World Bank, estimated that lead exposure may cause up to 5.5 million premature deaths annually, with 95 per cent of those deaths attributed to cardiovascular diseases. The analysis draws on emerging evidence linking lead exposure to atherosclerosis, alongside its known effects on reduced IQ, the central nervous system, and other organs.

Mr. Fuller noted that the “lead problem,” once associated with pipes, paint, and gasoline, has evolved in affected low-income regions, but its impact remains just as devastating. “It turns out to be all sorts of activities going on in low- and middle-income countries, including [fabrication of] pots and pans and [contamination] of turmeric,” he explained.

“The ones that are less impactful … are things like dioxins, phthalates, brominated flame retardants, PFAS, endocrine disruptors, PCBs, and PAHs,” Mr. Fuller noted, emphasizing that these pollutants are “simply the noisier part of the agenda, but not necessarily the most impactful part of the agenda.”

“Should we be focusing on the ones that have the most impact, not just the most noise?” he added.

John Ji, an environmental epidemiologist at the Tsinghua University Vanke School of Public Health, told the forum he initially thought his 2013 dissertation on lead would be one of the last.

“Then Flint happened,” he said, referring to the water crisis in Flint, Michigan, which brought the issue of lead contamination back into the spotlight.

Air pollution remains a driver of poor health

From left: Hon. Fernando Espinosa, Richard Brown, Nino Kuenzli
From left: Mexican Ambassador to Geneva Fernando Espinosa; Nino Kuenzli of the Swiss Tropical Instiute and John Ji of China’s Vanke School of Public Health.

With the World Health Organization attributing 13.7 million deaths to chemical and pollutant exposures, the Forum called attention to the need for global collaboration, research, and policy to tackle pollution-related health effects. 

“Clean air is possible, yet in some cities in the Asian and African continents, air pollution is getting worse,” said Nino Kuenzli, former Swiss Tropical and Public Health Institute professor. He acknowledged that air pollution regulation is part of a broader environmental health success story, citing the significant increase in air quality in Europe and North America in the past decades.

“The Swiss mountain town I grew up in had worse air quality than the Swiss urban centres today,” said Kuenzli, adding that this drastic improvement was built upon decades of scientific victories.

“We cannot just call for action and policy without a knowledge [of the science] and it is really fascinating to see how the science to understand the health effects of air pollution has evolved over the last 35 years. It’s incredible. Progress is enormous.” Advances in environmental epidemiology, and newfound ways for collaboration among basic scientists and toxicologists, have paved the way for these air quality improvements.

Addressing global air pollution inequalities and replicating much of the successes of higher-income countries means “leapfrogging” intermediate policies and technologies, argued Ji. For example, one of the largest sources of indoor air pollution comes from burning biomass fuels, yet countries often transition to gas stoves, which still produce air pollutants. Instead, countries could support a transition directly from biomass to electric, he said.

Air pollution
Air pollution levels have continued to go up in most countries across the world despite rising awareness of its harms.

Plastic pollution: a new and growing threat

Plastics, now ubiquitous in the environment, are another kind of new, and growing pollution concern for soils, waterways, and air, when incinerated.

“By 2050, there will be more plastic than fish in the oceans,” remarked Fernando Espinosa, the Mexican Ambassador to Switzerland.

Plastic pollution got a brief nod on opening day following last month’s fourth Intergovernmental Negotiating Body in Ottowa, Canada to develop an international legally binding instrument on plastic pollution, including in the marine environment. While the negotiations did reach some conclusions, like developing a list of chemicals of concern, they did not agree to reduce the production of new plastics, most likely due to ongoing pressure from the fossil fuel lobby and their state backers, such as Saudi Arabia, Russia and the United States.

Climate adaptation and resilience in the healthcare system

The Forum also brought together experts to discuss the often negative environmental contributions of healthcare systems in lower- and middle-income countries. The sector has increasingly produced contaminated waste, greenhouse gas emissions, and other pollutants – causing upwards of five per cent of global greenhouse gas emissions. These emissions come from hospitals themselves, but also from the manufacturing of medical products.

Yet remarks from panellist Habib N’Konou, founder of an innovative biomedical waste company, during a later session demonstrated the disproportionate environmental impacts of the health sector in lower-and-middle-income countries. Senegal, he noted, produces upwards of 21,000 tonnes of medical waste per year, much of which is inadequately processed. “It’s an alarming situation. When I came back to Senegal, there was waste on the coasts, in neighbourhoods.”

Looking to the successes of other countries could pave the way for better biomedical waste management, N’Konou noted. Morocco and Tunisia both have government-mediated partnerships between waste facilities and hospitals, something N’Konou champions for Senegal and surrounding countries. Even when regulations exist, they are hard to enforce. 

Despite the environmental challenges facing LMICs, the climate crisis is an opportunity to rethink how healthcare systems operate, according to Sonia Roschnik, executive director of the Geneva Sustainability Centre. 

“This is where I really hope that some of what we do to respond to climate change is going to help us leverage more innovative ways of looking at healthcare that actually deliver better population health, but also help the planet.”

 

Image Credits: Prchi Palwe , EPA/L. Koula, Geneva Health Forum, Geneva Health Forum.

WHA76
The World Health Assembly in progress.

GENEVA – Conservative countries have objected to the use of the terms “gender responsive” and “advancing gender mainstreaming” in behind-the-scenes negotiations on several resolutions before the World Health Assembly (WHA), according to a wide variety of sources.

There have also been some objections to the use of “gender equality” and “sexual” in some instances – alongside a long-standing objection to the use of “rights” when referring to sexual and reproductive health.

“Gender” references have already been stripped from the World Health Organization’s (WHO) draft pandemic agreement. At least five other resolutions have become bogged down by objectives from conservative member states, particularly Russia, Egypt, Iran and Nigeria.

These include resolutions on mental health, emergency preparedness, the economics of health, climate and social participation.

In the case of the economics of health resolution, Nigeria initially objected to the use of both “gender equality” and “advancing gender mainstreaming”, one source said.

Another source told Health Policy Watch that Russia even wants “sexual” to be removed from the standard term, “sexual and reproductive health”.

In the resolution on climate and health, for example, there was an impasse over the use of “gender-responsive” policies – apparently because conservatives believe that this opens the door to engagement with LGBTQ groups although they have never unpacked their objection. Countries have eventually settled on a reference to “gender equality”.

Objecting to these particular phrases is new. All UN member states including Russia agreed by consensus to the language of the global Sustainable Development Goals (SDGs), which refer to sexual health and gender.

Concerned parties close to the talks stressed the importance of “stopping the backsliding” against established terms and rights for women and other groups in the face of the relentless campaign.

Experts call for SRHR space to be protected

A few days ago, 43 of the foremost global experts in sexual and reproductive health and rights (SRHR) in the UN called on the WHA to protect advance in this hard-won space in an article published by Health Policy Watch.

The experts, who work in various UN expert committees, described progress on SRHR as “fundamental for human rights and dignity, national economies, sustainable development, and a healthier planet”. 

They added that while SRHR includes “services needed to prevent unwanted pregnancies, unsafe births and avoidable sexual or reproductive illness, injury or dysfunction, it is much broader. 

“Vitally, it includes the positive enjoyment of consensual sexual intimacy and pleasure, the development of mutually respectful and loving relationships, as well as the affirmation of individuals and families in all their diversity,” they added.

“Sexual and reproductive health and rights flourish only where its emotional, mental, and social dimensions are also enabled, free of coercion, discrimination, and violence.”

A repeat of 2022?

The Saudi delegate in heated WHA debate over sexual rights and terminology at the WHA in 2022.

Two years ago, the entire WHA was delayed for days over conflict related to a global strategy on HIV, hepatitis B and sexually transmitted infections, primarily because of a glossary on sexual health and target populations for HIV treatment.

While the language was standard for HIV treatment and care, the Saudi Arabian delegate – speaking for WHO’s 22-member state Eastern Mediterranean Region (EMRO) – objected to the terms “sexuality”, “sexual orientation”, “sexual rights”. 

He also objected to “men who have sex with men” being designated as a target population for HIV treatment.

Although the WHO works by consensus, the strategy eventually went to a vote late on the last night of an extended WHA, and narrowly passed with many absentions.

 

The 77th World Health Assembly is underway in Geneva.

GENEVA — As the 77th World Health Assembly (WHA) opened on Monday, global leaders pressed World Health Organization (WHO) member states to conclude a pandemic agreement, despite failing to meet the original deadline for reaching a consensus.

The WHA, a week-long gathering that sets the agenda for the WHO, was initially expected to mark the completion of both the pandemic agreement and amendments to the International Health Regulations (IHR), which govern global disease outbreaks. However, negotiations on both fronts remain unfinished, although talks on the IHR are reportedly nearing a conclusion.

On Tuesday, the assembly will deliberate on the path forward for these crucial discussions, with potential options including extending the talks by days (in the case of the IHR), months (until the end of the year), or even years (possibly until the 2025 or 2026 WHA).

In a video message, United Nations Secretary-General Antonio Guterres called on member states to “bring [the pandemic agreement] to fruition and to support the amendments to the International Health Regulations, boosting our ability to respond to emergencies.”

Guterres described the pandemic agreement as a “once-in-a-generation opportunity to ensure the global health system can respond more quickly and equitably when the next pandemic strikes.”

Ursula von der Leyen, President of the European Commission, reaffirmed the EU’s commitment to “concluding a pandemic agreement that makes a real difference on the ground.”

WHO Director General Dr Tedros Adhanom Ghebreyesus praised the negotiators, some of whom worked until 4am, and expressed optimism that an agreement on responding to future pandemics could still be achieved, emphasizing that the process now lies in the hands of the WHA.

“Of course, we all wish that we had been able to reach a consensus on the agreement in time for this health assembly and cross the finish line,” said Tedros. “But I remain confident that you still will because, where there is a will there is a way… now it is for this World Health Assembly to decide what that way is.“

Preventing emergencies

The WHA’s theme, ‘health for all, all for health,’ stands in stark contrast to the reality on the ground. Tedros noted that “at least 4.5 billion people, more than half of the world’s population, are not fully covered by essential services, and 2 billion people face financial hardship due to out-of-pocket health spending.”

“Outbreaks, disasters, conflicts, and climate change are all causing death and disability, hunger, and psychological distress,” he added.”Outbreaks, disasters, conflicts, and climate change are all causing death and disability, hunger, and psychological distress.”

Tedros said that the WHO responded to 65 graded emergencies last year, including outbreaks of cholera, dengue, diphtheria, hepatitis E, Marburg, measles and mpox. He also highlighted the establishment of the Pandemic Fund, which has already disbursed $338 million to 37 countries, and the launch of the International Pathogen Surveillance Network and WHO BioHub System.

“While our work responding to emergencies often makes the headlines, our work supporting countries to prevent and prepare for emergencies is less visible but equally important,” said Tedros.

He also drew attention to the increasing attacks on health facilities, stating that in 2023, the WHO verified “1,510 attacks on health care in 19 countries, with 749 deaths and more than 1,200 injuries.” He called for immediate ceasefires in Gaza, Sudan, and Ukraine.

Secretary-General Guterres, deeply troubled by the unrelenting attacks on health facilities in conflict zones worldwide, described the situation as “unprecedented” and “beyond anything” he had seen throughout his tenure as the UN’s top official.

Image Credits: WHO.

The 2021 data was released later than usual as experts continue to grapple with the pandemic’s impact on global health data collection and analysis.

GENEVA — Six of the ten leading risk factors for premature deaths and years of healthy life lost due to disability are within an individual’s control, according to new data from the Global Burden of Disease Study 2021.

The study, the most comprehensive effort to quantify health loss worldwide to date, aims to identify and eliminate disparities in health systems. Its findings were discussed on Monday at the Geneva Graduate Institute’s Global Health Centre during a side event of the 77th World Health Assembly.

“In the absence of a major health innovation, these factors are predicted to remain relevant over the next several decades,” said Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, which conducted the study. “If we intervene, we can change the global burden of disease.”

Of the top 10 risk factors identified in 2021, high blood pressure, tobacco use, dietary risks, high blood sugar, obesity and high cholesterol, are often, although not always, related to behavioural choices such as food choices and physical inactivity, Gakidou and other experts on the panel pointed out.

Similarly, behaviour also drives other leading risks considered in the analysis, including those related to high alcohol use, unsafe sex, poor hygiene [in cases were safe water is available]; drug use, and physical inactivity. 

Malnutrition ranks first, with air pollution second, in a Global Burden of Disease analysis of aggregated risk factors (level 2), in the IHME analysis.

Precise risk factor ranking depends on how you group the data

While it’s clear that a huge burden of deaths and disease could be controlled through individual lifestyle and behaviour changes, economic and social conditions, as well as policy choices are also major drivers.

And the precise ranking of risk factors also depends on how you group the data. For instance, a Lancet report on the same IHME Global Burden of Disease Study, published by Health Policy Watch on 25 May, cited air pollution as the leading risk factor for global disease burden, followed by hypertension.

Study co-author Michael Brauer told Health Policy Watch that the difference in the list is based on how risks are aggregated.

If maternal, neonatal and early childhood nutrition risks, related to a diverse range of intestinal and respiratory diseases, as well as poor maternal nutrition and poor breastfeeding practices, are considered separately, as was the case in The Lancet publication, then air pollution is No. 1. If, however, these various maternal and child “malnutrition” risks are aggregated, they become number 1, with air pollution as number 2.

Significantly, unhealthy diets becomes number 5 in the aggregated analysis. These risks include high consumption of red and processed meats, salt and sugar and low consumption of fruit, vegetable, seeds, polyunsaturated fats – which are largely, although not always, within an individual’s control.

“In the GBD there is a hierarchy for the risk factors,” Brauer explained. “We have four levels of risk factors. The first is just environmental/occupational, behavioural, metabolic. The level two aggregation is what Emmanuela presented, the level three and four are much of the focus of the [Lancet] publication.”

Air pollution ranks as the first health risk factor among 88 considered in the new IHME Global Burden of Disease study, published by IHME in The Lancet.

Study examined data from over 12,000 researchers in 163 countries

The GBD 2021 study examined 459 health outcomes from 88 risk factors, drawing on data from over 12,000 collaborators in 163 countries and territories. It utilised a total of 316,737 data sources, including government reports, surveys, and health sector data.

The 2021 data was released later than usual due to the pandemic’s impact on the organisation’s work. Dr. Gakidou stressed that the report not only tackles the pandemic-induced backlog but also highlights the growing challenges in collecting data from conflict zones, an increasingly significant issue as global conflicts persist.

Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation
Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation

“We struggle to get data from countries in conflict and on populations that are displaced by conflict or have natural displacement, and we know there are conditions that get exacerbated by conflict,” she said. “This is an area of huge interest and a massive data gap.” 

IHME aims to release 2023 data by December 2024 and 2024 data by November 2025, she noted.

The latest report’s results have “profound implications for future thinking of how [countries] should be organizing their health systems [and] social sectors.”

“This is a graph of hope,” Gakidou remarked as she displayed a graph of the leading risk factors. “Things can be done [to reduce] many of them.”

Life Expectancy Disparities Persist Despite Global Gains

“We forecast that life expectancy improvements will be larges in sub-Saharan Africa than in any other super-region between 2022 and 2050,” the study said.

The GBD study revealed that COVID-19’s impact on life expectancy varied across the globe. Yet, even when adjusting for the pandemic’s effects, disparities in life expectancy improvements remain evident among different regions.

From 1990 to 2021, life expectancy rose by 8.3 years in Southeast Asia, East Asia, and Oceania, while Central and Eastern Europe and Central Asia saw a mere 2.1-year increase. 

Sub-Saharan Africa, despite a 7.8-year improvement driven by advancements in treating diarrhoea, pneumonia, and communicable diseases, as well as reducing neonatal mortality, still lags behind with the world’s lowest life expectancy. The gap between this region and others has not significantly narrowed in the past three decades.

Kalipso Chalkidou, head of finance at the Global Fund to Fight AIDS, Tuberculosis and Malaria, pointed out that just 15 countries, accounting for about 5% of the global population, are responsible for 40% of the worldwide decline in mortality. Diseases such as tuberculosis, AIDS, and malaria contribute to nearly half of this figure.

Dr. Gakidou also emphasized that the lack of progress in addressing non-communicable diseases is a significant factor in the regions struggling to keep pace with life expectancy improvements.

More Deaths Than Births in Many Countries

“By 2100, fertility rates will not be high enough to sustain population growth in 97% of countries,” the study found.

Over half of the countries in the study are now “below replacement level,” with more deaths than births. Nearly all countries are projected to face this reality by 2100.

By 2100, over 30% of births will occur in regions classified as low-income by the World Bank, while births in middle- and upper-income countries will decrease by 20%.

“This has significant implications for where these babies are born, what they will need to do well and thrive, and could have implications on migration and other trends around the world,” Gakidou said.

A new global health landscape?

From left: Richard Horton, editor-in-chief of The Lancet; Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington; Kalipso Chalkidou, head of the Department of Finance for the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Haidong Wang, unit head of the Division of Data, Analytics and Delivery for Impact at the World Health Organization
From left: Richard Horton, editor-in-chief of The Lancet; Emmanuela Gakidou, co-founder of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington; Kalipso Chalkidou, head of the Department of Finance for the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Haidong Wang, unit head of the Division of Data, Analytics and Delivery for Impact at the World Health Organization

The discussion on the data concluded with a vision of an emerging global health landscape. What does this new landscape look like?

Chalkidou, speaking on a panel alongside Gakidou, Richard Horton, editor-in-chief of The Lancet, and Haidong Wang, unit head of the Division of Data, Analytics and Delivery for Impact at the World Health Organization, pointed to the need to change the global health “architecture.” 

“I think we need to change the way things are hardwired to get different results,” she concluded. 

Wang, meanwhile, said that to envision a new landscape, “we need to remind ourselves how fragile the gains in population health are.”

“Just in two years of the pandemic, we lost a decade,” he said, alluding to the importance of sustaining investment in public health.

As the session drew to a close, Gakidou struck a more optimistic tone. 

“People value health over everything else. I think that the global community has demonstrated that very visibly,” she said. “I think the new global health landscape … is one where health continues to be valued as the most important component of well-being and we take care of our populations globally – regardless of their age, where they live and what they do.”

Image Credits: Maayan Hoffman, IHME , IHME.

Dr Tedros and Barbados Prime Minister Mia Mottley

GENEVA – The World Health Organization (WHO) is seeking $7-billion in flexible funding for its four-year programme of action (2025-2028), and will hold an investment conference towards the end of the year – but the launch of this quest was celebrated at an event at its Geneva headquarters on Sunday evening.

The four-year programme will cost $11.1-billion to implement and little over a third – $4-billion – will come from WHO member states’ membership fees, referred to as “assessed contributions”, said WHO Director General Dr Tedros Adhanom Ghebreyesus.

“Let me put that into context for you,” added Tedros. “Last year, the world spent $717-billion on cigarettes.

“It’s about ensuring WHO is fully funded and improving the quality of the funding we receive. Much of the funding we receive is unpredictable, reactive, and tightly defined,” he added.

The WHO currently manages over 3,000 granted for earmarked projects, which did not allow for quick responses in times of crisis, he explained. In addition, because so much of its income was tied to specific projects, many WHO staff were on 60-day contracts.

“When the funding we get is flexible, then we will have the opportunity to prioritise based on the countries’ situation,” he said, adding that it would also boost morale.

“A lot of people invest their time – including directors – managing grants, mobilising resources  instead of focusing on the programmes.”

The launch, on the eve of the 77th World Health Assembly, “marks the start of a year-long series of engagements and events, co-hosted by countries, where member states and other donors will be invited to contribute funds to WHO’s strategy for 2025 through 2028 and show high-level political commitment to WHO and global health,” the WHO noted.

The investment round will culminate in November with a major pledging event to be hosted by Brazil around the G20 Leaders’ Summit.

“It’s about ensuring WHO is fully funded and improving the quality of the funding we receive. Much of the funding we receive is unpredictable, reactive, and tightly defined,” said Tedros Adhanom Ghebreyesus. “The Investment Round aims to change that, by generating funding that is more flexible, predictable, and resilient.”

Sea change

Barbados Prime Minister Mia Mottley told the event that there needs to be “a sea change in the global governance architecture of our international financial institutions”.

“There can be no first class and second class citizens of the world, particularly as it relates to access to pharmaceuticals, and access to medical care,” she added.

“Unless we begin to internalise that the balance sheets of most multinational corporations, in fact, dwarf more than half of the world’s states, we will not be able to get to the point where we need to get,” said Mottley, who received a Global Health Leaders Award for lifetime achievement from Tedros.

“And if we accept that public funds are getting more and more difficult to find, then it means that we can only rely on states to be at the core of funding the global public goods.”

“There can be no first class and second class citizens of the world, particularly as it relates to access to pharmaceuticals, and access to medical care. If we get that right, then the missing part of the equation can be found and what is the missing part of the equation? It is political will,” concluded Mottley.

Norwegian Health Minister Jan Christian Vestre

“Global problems need global solutions, and no other organisation has turned out to be in a better position to provide us a chance to come to global solutions,” Brazil’s Minister of Health Nísia Trindade said in a video address. “We will use the convening power of G20 to help mobilise efforts to make the Investment Round a success.”

Qatar Minister of Health Dr Hanan Mohamed Al Kuwari announced a contribution of $4 million in fully flexible funds to the Investment Round, and an intention to contribute further.

“Health care is a fundamental human right and we must continue to invest in the World Health Organization to safeguard our health. Unity is the key to our success,” Al Kuwari said.

France, Germany, and Norway announced that they would serve as co-hosts for the Investment Round.

Norwegian Health Minister Jan Christian Vestre said that his country was proud to co-host the investment round “which will be an important step in securing the organisation a more sustainable financing”. 

However, he said that “more steps are needed, including an increase in assessed contributions”. Two years’ ago, the WHA resolved that 50% of the WHO’s funds should come from by 2030.

“The increase in assessed contributions will not only make WHO more efficient, but also more democratic, as the organisation will be in a better position to follow the priorities that are decided in the assembly instead of following donor earmarked financing,” said Vestre.

Ashley Bloomfield, co-chair of the Working Group on amendments to the International Health Regulations and Precious Matsoso, co-chair of the Intergovernmental Negotiating Body (INB) for a pandemic accord, speaking on the eve of the World Health Assembly.

Although a draft pandemic agreement may take weeks or months longer to conclude, there are moves underfoot to try to quickly wrap up negotiations and get final member state sign-off on amendments to the 2005-era WHO International Health Regulations  (IHR) at the this week’s World Health Assembly (WHA), said the co-chair of the working group on amendments to the IHR, Ashley Bloomfield, of New Zealand.

He was speaking at the Geneva Graduate Institute‘s Global Health Center, on the eve of the opening of the WHA, which will grapple with an agenda that is perhaps one of the most complex, divisive and also potentially impactful, in the Organization’s 75 year history.

The week-long Assembly will be taking up resolutions and decisions dealing with a new four-year strategy to WHO; it’s new funding appeal to raise some $7 billion more over that period in voluntary funds from donors; the humanitarian crises related to wars in Ukraine and Gaza; as well as a host of other vital health themes – from a new resolution on climate and health to the status of efforts to eliminate malaria, tackle chronic disease as well as head off a wave of drug resistant pathogens and disease, to name just a few.

Amidst all of that, while two-years of negotiations on a proposed new pandemic agreement ended Friday without final agreement on a draft, the committee negotiating parallel amendments to the IHR, the pre-existing set of WHO emergency rules approved in 2005, have moved closer to the end goal with an agreement in principle over its contents.

And out of 34 articles in the IHR amendments, 17 are fully approved, while another 17 remain to be finalised, Bloomfield said.  As a result, he said the group would be sharing the document-in-progress with the assembly, but asking for the go-ahead to continue negotiations during the WHA.

“We will put forward a draft resolution asking the Assembly to continue the work this week, and hoping that it will be adopted by the Assembly before the week is over,” he said.

“I think there is a really strong intent by us to seize the moment,” he added, noting that language advancing more “equity” between countries during health emergencies are among the “significant inclusions” to the draft  IHR amendments – although he did not elaborate.

More predictable financing for disease threats

Many nations imposed strict border controls during the pandemic, contrary to the International Health Regulations call to ensure free movement of people and goods.

The IHR equity achievements include stronger commitments by high-income states, such as the European Union, to support more predictable and sustainable financing for all countries in outbreak prevention, preparedness, other sources told Health Policy Watch.

That, in turn, should help support more robust surveillance of pathogens which pose outbreak, emergency and ultimately pandemic risks, particularly in low- and middle-income countries that lack the tools and resources to track and identify them quickly.

Other elements of the amendments on which the working group is close to an agreement, include an official definition for a “pandemic.” This would be a trigger for WHO to declare a higher level of emergency beyond the current designation of a “Public Health Emergency of International Concern” (PHEIC).

That would activate the more far-reaching provisions of a future- pandemic accord, should that new legal instrument be finally approved and ratified by countries. During the COVID pandemic, no actual “pandemic” designation existed and so when WHO declared that the world was facing a pandemic, on 11 March 2020, moving beyond language for the PHEIC that had been declared in late January, it was more of a symbolic step, rather than one with any legal implications.

Another element of the IHR amendments, also close to conclusion, would involve creation of a mechanism for indpendent monitoring of how countries implement the IHR’s key provisions – to strengthen what one negotiator called “the collective oversight” of the readiness process.

WHO’s new global health strategy and the $14 Billion ‘Ask’

On left: Bjorn Kummel, German Ministry of Health, makes the case for a new approach to WHO funding.

Another key feature of this year’s WHA will be the launch of a first-ever WHO “Investment Round,” which seeks to raise an additional $7.1 billion in voluntary contributions from member states for the four-year, 2025-2028 period, on top of regular asssessed contributions, which are expected to amount to $4 billion.

“The 7.1 billion seeks to expand the envelope to cover what is not covered by the assesssed contributions of WHO,” said senior WHO advisory Bruce Aylward.

While WHO has always sought and received voluntary contributions from member states and philanthropies, the idea is to systemize the giving, allowing the organization to more flexibly allocate funds to agreed-upon priorities and enjoy more “predictability” in its funding cycles.

“The idea is to really lobby at the highest levels, presidents and prime ministers for funding for WHO,” said Bjorn Kummel, a senior official in Germany’s Ministry of Health, who led moves last year to increase assessed member state funding to WHO.  “Most of the funding [now] comes in highly earmarked,” he noted.  Additionally, significant organizational resources from various departments, are expended courting to donors individually and reporting to them. 

“The other challenge is predicability,” Kummel added.  “You may notice that there are many in WHO on short-term contracts, and this is due to the way that we are funding WHO through unpredicatable finances.”

Additionally, he noted, the aim is to broaden the base of voluntary giving to include more countries that have moved up the ladder of economic development and could now shoulder a share of the burden.

“It’s been the same 18 key donors  [for voluntary contributions] over the past 50 years,” Kummer said.  “That can’t continue.”

Geopolitical and cultural divides deeper than ever

Against all of the complexity, the WHA convenes in a period where geopolitical and cultural divides are deeper than ever.

Two residents stand in the ruins of homes in Borodianka in the Kyiv region.

Two more resolutions on the humanitarian situation in Ukraine following Russia’s 2022 invasion may come before the assembly, said Gian Luca Burci, WHO’s former chief legal counsel and now a senior faculty member at the Geneva Graduate Institute.  That follows divisive debates in 2022 and 2023 over previous WHA resolutions, initiated by the European Union and its allies, on the Ukraine situation.

And the health and humanitarian emergency in Gaza, triggered by Israel’s war against Hamas, following the bloody 7 October 2023 Hamas incursion into Israel, will be the focus of a dedicated resolution that member states will debate alongside a perennial resolution and debate on the health conditions in the Occupied Palestinian Territories, including the West Bank.

That latter resolution, however, has taken on added significance since the war began, insofar as West Bank Palestinians also have faced tough Israeli military lockdowns and curtailment on routine movements, including to obtain health care.

In addition, there may be moves afoot to enhance Palestine’s status at the WHA, where it is now merely an observer, like the Vatican:  “There may be an initiative to adopt a resolution giving Palestine … rights of member states,” Burci said, referring to a similar move recently taken by the UN General Assembly.

The UN GA resolution greatly expanded Palestine’s rights before the body, although it stopped short of giving it the right to vote, or allowing it to posit its candidacy for the UN Security Council, rights that only the UN Security Council may bestow.   Finally, he said that there could be moves afoot to curtail Israel’s eligibility to serve on WHO’s governing body, the 34-member Executive Board, although that would have little immediate meaning as Israel recently completed a three-year EB term.

Gender inclusion and sexual and reproductive health rights

Another flashpoint that has been the focus of gathering stormclouds is the issue of gender inclusion and sexual and reproductive health rights.

Standard language about those issues was traditionally a part of most resolutions and decisions on topics ranging from HIV/AIDs to maternal and child health, as well as environmental health. But increasingly an alliance of conservative countries have sought to have such references watered down or removed, not only from WHA-approved resolutions but even from WHO Secretariat reports.

Pascale Allotey
Pascale Allotey

“There’s really a much more fundamental question that is happening within the lines of gender equality as a shared value,” said Pascale Allotey, a Ghanaian public health researcher who is now director of WHO’s progamme on Sexual and Reproductive Health (SRH) and its joint programme on Human Reproductive Health (HRP).

“We hear a lot now of the use of the term ‘gender ideology’  – this idea that it’s just about imposed concepts,” she said. “But this agenda isn’t about imposed concepts or about concepts at all. It’s really just a …framework for understanding the realities of people’s lives – the ways in which your lack of power and agency restricts people’s capacities and opportunities in unjust ways.” 

Image Credits: The National Guard/Flickr, Matteo Minasi/ UNOCHA.

Most air pollution-related deaths are due to cardiovascular diseases, according to the latest report by the World Heart Federation.

Almost 70% of the 4.2 million deaths attributed to ambient (outdoor) air pollution in 2019 were caused by cardiovascular diseases, notably ischaemic heart disease (1.9 million deaths) and stroke (900,000 deaths), according to a new report by the World Heart Federation (WHF).

The report highlights the outsized impacts air pollution is having on the worldwide epidemic of cardiovascular diseases (CVDs).

Meanwhile, air pollution has become the leading risk factor for global disease burden, overcoming even hypertension, according to a recently published Lancet study, in a ranking of 88 environmental and health risk factors across 204 countries and territories. The analysis was a part of the Global Burden of Disease (GBD) study 2021, conducted by the Seattle-based Institute of Health Metrics and Evaluation (IHME).

The GBD study is published once every two years but publication of the 2021 data was delayed until now, due to the pandemic. It considered risk factors ranging from environmental and occupational hazards, such as air pollution, to behavioural factors such as tobacco use, physical inactivity, unsafe sex and poor nutrition.

Air pollution was also one of the leading risk factors in the last GBD study published in 2020, but as the disease burden was calculated separately for ambient and household pollution, which have overlapping mortality, it did not rank as the highest.

But in the 2021 Lancet report, malnutrition risk factors, largely related to low birth weight, child growth failure and suboptimal breastfeeding were ranked separately. If those were ranked together, then malnutrition [primarily neonatal, newborn and early childhood] becomes the Number 1 risk, with air pollution, second and hypertension third, said Michael Brauer, lead author of the study for the Institute for Health Metrics and Evaluation (IHME), in a comment to Health Policy Watch.

Air pollution ranks as the first health risk factor among 88 considered in the new IHME Global Burden of Disease study, published by IHME in The Lancet.

Cardiovascular – not lung disease – associated with the lion’s share of air pollution-related deaths

However, among the diseases most closely associated with ambient (outdoor) air pollution-related exposures, cardiovascular disease is responsible for the lion’s share according to the new WHF report. And that is a striking new finding.

“Most people, when they think of air pollution they think of someone coughing, they think of lung conditions like asthma and pulmonary disease. But actually, it is the cardiovascular conditions which are probably the most concerning,” Dr Mark Miller of the University of Edinburgh, and the WHF’s Chair of the Air Pollution and Climate Change Expert Group told Health Policy Watch.

“This report essentially is like a reappraisal of the most recent World Health Organization (WHO) data to emphasize how bad the cardiovascular effects of air pollution are,” he said.

The report titled ‘Clearing the Air to Address Pollution’s Cardiovascular Health Crisis’ was launched during the World Heart Summit underway this weekend in Geneva, Switzerland. It represents one of the most sweeping reports, to date, by the global federation on a risk factor that many cardiologists have failed to fully acknowledge.

In terms of household air pollution – the link to CVD is also clear – if not quite as pronounced.

Amongst the 3.2 million deaths attributed to household air pollution in 2019, 53% was attributable to CVDs – including one million deaths from ischaemic heart disease and 700,000 from stroke.

Seen from the disease perspective, some 37% of all CVD deaths globally were attributable to air pollution in 2019, including 22% of deaths from ischaemic heart disease and 15% from stroke, according to the report.

Air pollution – the greatest single environmental health risk

The report calls air pollution “the greatest single environmental health risk.” In some regions air pollution is over ten times the recommended limit by the WHO, the report noted.

Air pollution levels have remained stagnant in many parts of the world, or even increased slightly, despite increased awareness of its harms.

Cardiovascular disease kills more than 20 million people every year globally. Air pollution has the most impact on people with pre-existing cardiovascular conditions, the report said.

The report warned that without adequate policies in place, deaths and disability from cardiovascular conditions caused or worsened by air pollution is set to increase further.

“These two reports highlight how critical it is for governments to prioritise measures to rapidly improve air quality, to save lives and reduce the toll and cost of cardiovascular disease – the world’s biggest killer,” said Nina Renshaw, Head of Health at the Clean Air Fund. “The fact that air pollution is the number one risk factor driving the global burden of disease requires attention from health donors too. Efforts to tackle air pollution remain chronically underfunded, receiving only 1% of global development funding in recent years. Air pollution must quickly become a higher priority in global health.”

Why air pollution is such a CVD killer

In fact, while not intuitive, there are clear physiological reasons why air pollution, and particular fine particulates are so closely associated with heart disease and stroke.

Air pollution particles are absorbed in tissue deep in the lungs where they can cause inflammation setting the stage for chronic lung disease and cancers. But the finest particles, of PM2.5 or smaller in diameter, penetrate the lung walls and enter the bloodstream. Circulating in arteries and veins of the body and the brain, these fine particles exacerbate the build-up of plaque over time, as well as contributing to the constriction of the arteries, setting up a perfect storm of conditions for heart disease and stroke.

Air pollution-related CVD deaths increasing sharply in Southeast Asia and the Eastern Mediterranean 

The report also finds that the number of deaths from heart disease attributable to air pollution has increased in some regions by as much as 27% over the past decade.

A key reason for this is the rising air pollution levels in some countries of Southeast Asia and the Eastern Mediterranean, where average air pollution concentrations are nearly ten times the WHO – recommended levels, experts say.

The Western Pacific region saw the highest number of deaths from heart disease and stroke due to outdoor air pollution with nearly one million deaths in 2019, and the Southeast Asian Region was a close second, with 762,000 deaths.

Countries facing the some of greatest challenges with air pollution include those in the Eastern Mediterranean, with Kuwait, Egypt, and Afghanistan.

Real number of CVD deaths related to air pollution is likely higher

Moreover, the real number of CVD deaths from air pollution is in fact likely to be much higher, as currently, mortality is only assessed for a single air pollutant i.e PM2.5, and only for ischaemic heart disease and stroke, while there are a range of other cardiovascular diseases that may be exacerbated by air pollution.

“The reality is that there is a real lack of reliable and granular data, mostly due to the absence of ground monitoring systems. This is especially true in low-income settings where millions of people live in unmonitored areas,” said Mariachiara Di Cesare from the University of Essex who was involved with the WHF’s report.

“To give an example, IQAir’s 2023 World Air Quality Report provides a comprehensive overview of PM2.5 data across almost 8,000 cities in 134 countries, regions, and territories. When you look at Africa out of 54 African countries, only 24 have the capacity to monitor air quality in some capacity, with most of the existing stations concentrated in the western and southern regions of the continent,” Di Cesare said.

This makes the results of the report an underestimate, Cesare told Health Policy Watch. She said that improved air pollution monitoring in both rural and urban areas will help provide more accurate estimates of air pollution levels and trends.  

Global distribution of PM2.5 monitoring stations

WHF study relies upon 2019 data – Lancet updates that air pollution is now the top killer

Significantly, the new WHF report relies upon 2019 data regarding air pollution impacts on cardiovascular health. The latest IHME Global Burden of Disease study, published in The Lancet, provides slightly updated data – linked to 2021. Also, the WHF report focuses its analysis primarily on air pollution related CVD deaths, while the Lancet study looks at both mortality and morbidity. But the overall message regarding the killer impacts of air pollution is the same.

Over 11,000 researchers were part of the IHME GBD study. Following air pollution, high blood pressure and smoking were the second and third-ranking risk factors contributing to excess disease and disability – or Disability Adjusted Life Years (DALYS). However, if all of the dozen or so

“These are groups of risk factors where the exposure to the risk factors is increasing. And then, that is exacerbated by these demographic factors, the growing populations, the aging populations,” said Brauer in a podcast unpacking the findings.

At the same time, if malnutrition risks are aggregated together, then they become the top risk, with air pollution ranking number 2, Brauer said, noting that the original IHME GBD analysis, upon which The Lancet publication was based, considered several “levels” of aggregation of the risks that were analysed. These malnutrition risks are mainly related to poor maternal, neonatal and early childhood nutrition, including infections from parasitic and water-borne diseases, tuberculosis and other respiratory conditions. Risk factors linked to unhealthy diets, including factors like high red meat consumption, low fruit, vegetables, nuts and seeds; and high salt and sugar intake, ranked fifth in the aggregated analysis.

Malnutrition ranks first, with air pollution second, in a Global Burden of Disease analysis of aggregated risk factors (level 2), in the IHME analysis.

The 2021 Lancet study also looks at how health risks have evolved over the past two decades – comparing the most recent findings with those in 2000. That was the year that GBD study quantifying deaths and disease linked to a set of 25 environmental, occupational and behavioural health risks was published by the WHO. A comparison between the two shows risk factors that stagnated or become more significant, along with those that have moved down the list as conditions improved, notably for safe water, hygiene and sanitation.

While its ranking has varied somewhat over years, air Pollution was the leading risk factor for disease burden in the year 2000 and 2021, this graphic from the most recent IHME GBD study demonstrates.

Climate change is compounding impacts

Climate change is also turning out to be an additional stressor, compounding air pollution risks, as global temperature rise continues unabated, the WHF experts note.

This year has already seen heatwaves from Mali to India and temperatures have soared. Climate change has increased the frequency and the intensity of heatwaves, according to climate scientists. Heatwaves are also known to exacerbate underlying non-communicable diseases like diabetes and heart ailments as Health Policy Watch has reported earlier.

“That’s the sort of, that’s the sort of main message that the science is telling us now, as we’re starting to see all these environmental stressors compounding each other,” said Miller. “And you would expect that, for example, if you have heat waves that were accompanied by higher air pollution, that would make cardiovascular disease worse.”

Global air pollution-related healthcare costs are already projected to surge from $21 billion in 2015 to USD 176 billion in 2060, with annual lost working days potentially increasing to 3.7 billion by 2060. Any additional stressor will make the costs worse, the WHF report notes.

The key message, however, is that action will make a difference, Miller said. “While highlighting some really terrifying figures here, these huge numbers of deaths worldwide as well…we’re referring to them as preventable deaths, because air pollution is preventable. So, there’s an opportunity here, as well that, you know, if we can tackle these issues, and we know some of the measures to do so then hopefully, we will see improvements in cardiovascular health.”

–Updated to include reference to “malnutrition” risks and their ranking, as relates to air pollution, in the IHME analysis.

Image Credits: Unsplash, IHME, Clearing the Air to Address Pollution’s Cardiovascular Health Crisis report., Clearing the Air to Address Pollution’s Cardiovascular Health Crisis Report, IHME , Global Burden of Disease Study 2021.