14 June 2010 – Dhaka, Bangladesh – A mom and her new born baby at the Maternal & Child Health Training Institute for medically needy in Dhaka: Maternal mortality ratio remains a very serious concern in Asia and the Pacific – especially in South and South-West Asia, which has one third of the world’s maternal deaths. Only 5% of births in Nepal and 19% in India were attended by skilled personnel in 2006. (UNESCAP 2009)

Postpartum haemorrhage (PPH), a blood loss of 500 ml or more within 24 hours of birth, is the leading cause of maternal mortality worldwide, according to the World Health Organization. Around 14 million women die a year, said Metin Gülmezoğlu, executive director of the Concept Foundation. Yet, PPH is mainly preventable. Some 99% of PPH deaths have been eliminated in high-income countries, and 99% occur in low- and middle-income countries – specifically in sub-Saharan Africa and South Asia.

Why do we have these deaths in 2023, and what can be done to prevent them?

This was the topic of a recent Geneva Graduate Institute/Global Health Centre event: “Dying for Life: Are Mothers Still a Global Health Priority?” The November 27 event was moderated by Claire Somerville, director of the Geneva Graduate Institute’s Gender Centre.

Gülmezoğlu said that there is a general lack of research and development around new solutions for PPH, in addition to a challenge of being able to implement the results of those studies that do happen in lower-income countries where women may be giving birth outside of hospitals or other traditional healthcare facilities. According to Gülmezoğlu, countries sometimes do not have up-to-date guidelines nor sufficient political support to fund them. Other times, the challenges are related to pharmaceuticals around adequate supply chain systems and quality issues.

Postpartum Haemorrhage: The role of gender inequality

There is also a question of whether the situation would be different if it were men, not women, who were dying from PPH. Gülmezoğlu said that “the issues of maternal health, contraception and safe abortion are rarely just issues of health or clinical care. They have very strong relations with access to health care, inequalities, and specifically gender inequality.”

“I suppose if this had been an issue that impacted men more broadly, or more directly, that it might be prioritised differently,” said Shirin Heidari, a senior researcher in the Gender Centre of the Geneva Graduate Institute and Founder and director of GENDRO. She said that while there is no way to prove that the situation would be different if this were a male versus a female issue, “there are indications that that would be the case. You wouldn’t speculate looking back at the history of medicine, research, and broader health agenda. We have seen a trend that issues that are related to women’s health and women’s rights have often slid down in the global health priority agenda.”

She quoted Prof Mahmoud Fathalla, who passed away earlier this year: “Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.”

However, Heidari noted that in more recent decades, women’s rights and health have gained more significant and broader attention.

PPH roadmap aims to fast-track progress toward Sustainable Development Goal target 3.1

To that end, the WHO recently completed a roadmap to combat postpartum hemorrhage between 2023 and 2030. More than 130 stakeholders developed the roadmap, which includes four strategic areas: research, guidelines, implementation and advocacy, explained Femi Oladapo, head of the Maternal and Perinatal Health Unit in the WHO’s Department of Sexual and Reproductive Health and Research, who also spoke at the event.

Specifically, the roadmap aims to fast-track progress toward Sustainable Development Goal target 3.1: To reduce the global maternal mortality ratio to less than 70 per 100,000 live births.

The WHO stated that the roadmap is designed for key figures in public health and all parties involved in the broader maternal and child health ecosystem. This includes the global community, funding entities, researchers, innovators, industry representatives, professional associations, guideline developers, health ministries, and, importantly, the general public, focusing on women.

“Postpartum haemorrhage is something everybody wants to do something about. So, it wasn’t really difficult finding the audience and attracting people around the table,” Oladapo said. He said that the team followed the traditional WHO process of engaging stakeholders, prioritising issues, and building consensus to make the roadmap. The WHO developed an 18-person steering committee that was geographically- and gender-balanced, as well as included people with expertise from various sectors: innovators, NGOs, advocates and more.

“We made sure that everybody’s voice who needed to be there was around the table from the start,” Oladapo said. In addition, surveys, work groups and virtual meetings culminated in a three-and-a-half-day in-person event in March in Dubai.

“Even after the summit, we continue to engage regularly,” Oladapo added, noting that the roadmap does not belong to the WHO but is a roadmap that was done for all key stakeholders and that holds multiple people and entities accountable.

“We set up an accountability platform where you can see all of these key activities or milestones from now to 2030,” Oladapo described. “There is a call to action in the last chapter of the roadmap that calls on different stakeholders” – women, women’s groups, civil society organisations, professional associations, the research community and the government. “There’s something for everybody to do, and there’s a separate chapter on calls to action, on what each group should do to ensure that the goals of their roadmap are realised.”

Mamtesh, 24, has just given birth to a healthy daughter. Nearly three years ago, Mamtesh suffered antepartum haemorrhaging during her first pregnancy and her son passed away shortly after birth. This pregnancy and delivery, which took place in a government hospital, had no complications. She is happy with the hospital and the normal delivery.

‘Ministries of health have a central role to play’

Oladapo also stressed that politics plays a crucial role in ensuring the roadmap’s success and women’s health in general. He said it is also funded in countries where maternal health is prioritised, and health outcomes improve.

“Ministries of health have a central role to play,” Oladapo stressed. “So, in the development of the roadmap, we brought [representatives] around the table” from around 20 ministries of health.

These ministries are critical, for example, in ensuring research is funded and in building the infrastructure to allow for innovations. Moreover, sometimes, there is a disconnect between global evidence-based recommendations and what people are doing on the ground, and the ministries can play a central role in terms of the adoption and adaption of these recommendations, as well as ensuring that staff – at least at the hospital level – are adequately trained.

“In Nigeria, there are no user fees for maternal health, and maternal mortality has plummeted,” according to Oladapo. “In other places, where you have to pay for every little thing, women continue to die. So this is all within the hands of the ministry.”

Image Credits: UN Photo/Kibae Park/Flickr, Children's Investment Fund/Flickr .

From left to right: Martin Raiser, World Bank Vice President for South Asia, Dr Farhna Ahmed, Secretary, Ministry of Environment, Forest and Climate Change and Anna Wellenstein World Bank Regional Director, Sustainable Development, East Asia and Pacific

Air pollution and climate change have never received as much combined attention, at such a high level, as at COP28 in Dubai. The UN’s 28th Conference of Parties on climate change has seen top-level participants from the World Health Organization (WHO), the UAE presidency, and noted expert bodies discuss the estimated 7-8 million deaths annually linked to air pollution.

The nexus of air pollution and climate change is also receiving increasing attention in the development sector, as evidenced by a World Bank-hosted discussion on Friday featuring top officials from China and Bangladesh.

At the event, Zhao Yingmin, China’s Vice Minister of Ecology and Environment, described how the country has reduced the most health-damaging pollutant, PM 2.5, by as much as 55% in the past decade in prefecture-level cities across the country, administrative centers that rank second only to provincial capitals.

He and other officials at the event emphasized how China’s experience could serve as an inspiration for South Asian countries currently grappling with some of the world’s highest pollution levels.

South Asia’s air pollution claims two million lives annually

Zhao Yingmin, Vice Minister at China’s Ministry of Ecology and Environment, and Dr Farhna Ahmed, Secretary of Bangladesh’s Ministry of Environment, Forest and Climate.

Excessive air pollution across South Asia is estimated to cause the deaths of approximately two million people each year, making it one of the most polluted regions worldwide. The region is home to 37 of the 40 most polluted cities in the world.

In densely populated areas of the Indo-Gangetic Plain, which stretches from Pakistan to Bangladesh and across the Himalayan foothills of southern Nepal, PM2.5 levels in many locations exceed 20 times the World Health Organization’s recommended annual guideline of 5 micrograms per cubic meter of air (µg/m3).

World Bank Vice President for South Asia Martin Raiser highlighted the potential “triple wins” of reducing annual air pollution levels to the World Health Organization’s interim air quality target of 35 µg/m³ of PM2.5.

These benefits include a 25% reduction in emissions of CO2, carbon dioxide, and methane, a gas 28 times more potent than CO2 in terms of its global warming potential. Additionally, emissions of black carbon, another short-lived climate pollutant that accelerates Himalayan glacier melt, would be reduced by 80%. Furthermore, methane emissions could be further reduced by 25%.

“These are huge co-benefits and create a great potential for triple wins,” said Raiser. “The challenge is that to address the issue of air quality we need to work on several sources of pollutants at the same time.”

Chinese Vice Minister: How we cut air pollution

Air pollution over Shanghai, China.

China’s experience in curbing air pollution can serve as an inspiring example for other Asian nations, according to Zhao.

Zhao attributed China’s success to a multi-pronged approach implemented systematically across various sectors, including industry, transportation, and building heating and cooling.

He highlighted the replacement of old coal furnaces with energy-efficient electric heat pumps, often augmented by natural gas when economically viable, as a key strategy in the residential sector.

The World Bank also played a significant role in catalyzing early action, providing China with a $1 billion loan a decade ago to address air pollution in Beijing.

“With a modest public investment, we discovered that they could leverage more from the private sector,” Zhao noted.

Cooperation on air pollution mitigation can lower costs 

Air pollution knows no borders, making both urban-rural and regional cooperation crucial to addressing the issue, the World Bank’s Raiser stressed.

Last year’s “Striving for Clean Air” report identified six key South Asian airsheds and developed scenarios for reducing average PM 2.5 levels to the World Health Organization’s interim air quality target of 35 µg/m³.

The report found that full coordination between Pakistan, India, Nepal, and Bangladesh would significantly lower the costs of achieving this target compared to scenarios where countries act independently.

In the best-case scenario, the cost per 1 µg/m³ reduction in average PM 2.5 levels would be $278 million. However, if countries were to act alone, costs could double or even increase tenfold, reaching $780 million to $2.6 billion per 1 µg/m³ reduction.

Dr. Farhana Ahmed, Secretary of the Ministry of Environment, Forest and Climate Change in Bangladesh, called for a deepening of regional cooperation among South Asian countries to tackle air pollution.

“We all know air pollution travels long distances, crossing national boundaries and multi-country actions are extremely important in the region,” said Ahmed. “We should encourage all the countries in the region (South Asia) to enhance knowledge sharing and good practices and exchange appropriate technical know-how.”

In 2022, the “Kathmandu roadmap” was developed to outline a plan for cross-regional cooperation between India, Pakistan, and Nepal. However, India’s Environment Minister Bhupender Yadav, who was originally scheduled to attend the World Bank discussion, did not participate. Officials at the India pavilion attributed his absence to bilateral meetings.

Despite this, India is making some progress in addressing air pollution. According to a report released today by Climate Trends and the Centre for Financial Accountability in New Delhi, 100% of project finance loans in India in 2022 went to renewable energy projects, while no such loans were provided for coal projects.

“Project finance” refers to loans typically granted by governments and others for the development of a specific project and does not include equity or corporate finance. The report’s findings do not mean that new coal power projects were unfunded by other lenders, namely equity or corporate entities.

The total amount of $2.36 billion for renewable energy finance in India represents a 45% decrease from 2021 levels, according to the report.

Finance has been one of the operative words of COP28, with over $83 billion pledged in the first five days for climate action, according to the UAE presidency.

While there are no specific funds earmarked for air pollution, per se, which is typically emitted by the same sources as climate pollutants, commitments to areas such as health, clean cooking, and renewable energy, should yield air pollution co-benefits.

‘Hard part’ of COP28 begins

As COP28 enters its final days, negotiators are entering the “hard part” of the climate summit: grappling with the critical issue of phasing out fossil fuels.

COP President Dr. Sultan Al Jaber has appointed eight ministers to facilitate consensus-building in the final stages of negotiations.

“Over the next 48 hours, this team will play a crucial role in helping bring this COP to consensus around the Global Stocktake and all other mandates as part of the agenda,” Al Jaber stated. 

The possibility of a fossil fuel phase-out being included in the outcome text from COP28 has panicked oil and gas producers. A letter leaked to the Guardian on Friday showed OPEC Secretary-General Haitham Al Ghais calling on the cartel’s member states, including COP hosts UAE, to “proactively reject any text or formula that targets energy, i.e. fossil fuels, rather than emissions”.

Ghais described the need to oppose language on the phase-out of fossil fuels as a matter of the “utmost urgency”, adding: “It would be unacceptable that politically motivated campaigns put our people’s prosperity and future at risk”.

UN Climate Executive Secretary Simon Stiell acknowledged the tension surrounding fossil fuel language, stating, “We will make sure every country has a seat at the table and can use their voices. I don’t want to see diversions and political tactics that hold climate ambitions hostage.”

The opening day of the climate summit saw more than 100 countries back a complete phase-out of fossil fuels. As COP is a consensus-based forum, far more will be required to push a final deal over the line.

COP28 concludes on December 13, but past conferences have often gone into overtime to achieve consensus. The outcome texts from previous UN climate summits have to date fallen far short of the action required to limit global warming to the Paris Agreement target of 1.5°C above pre-industrial levels.

Failure to reach this target could have devastating consequences, far surpassing the current impacts of 1.2°C warming. Alok Sharma, president of COP26 in Glasgow, warned that a failure at COP28 will “push the world into climate breakdown.”

“We are literally in the last chance saloon to save our children’s future,” Sharma told the Observer in an interview on Friday. “If you’re going to keep 1.5C alive, you’re going to have to have language on a phase-out of fossil fuels.”

“The language needs to be unequivocal,” he said. “So that anyone who reads the agreed language completely understands that what we’re talking about here is a phase-out of all fossil fuels.”

Image Credits: Photologic.

Child receiving a WHO-recommended hepatitis B vaccine

The Board of Gavi, the Vaccine Alliance has approved the establishment of a new African Vaccine Manufacturing Accelerator (AVMA), a financing instrument that is to make more than $1 billion available to support sustainable vaccine manufacturing in Africa.

The board decision marks a historic reversal of past efforts which saw the agency’s massive budget for vaccine procurement concentrated on the biggest pharma manufacturers in Asia, Europe and the Americas who could offer the lowest price-per-dose on vaccines Gavi procured due to economies of scale.

While such an approach may have seemed cost-efficient a decade ago, it also reinforced a concentration of vaccine production in certain regions of the world – and amongst a few key vaccine producers, leaving little space for new omers. That, in turn, left Africa high and dry when the COVID pandemic created a worldwide demand for a new vaccine, which only one or two South African manufacturers had the expertise to produce.

At a two-day meeting this week in Accra, Ghana, the Gavi board also agreed to set up a new $500 million First Response Fund to ensure immediately available financing for the procurement of novel vaccines, in the event of a future pandemic.  The lack of available funds, up front, also pushed the Gavi-backed COVAX vaccine facility to the back of the line of COVID vaccine procurement as rich and middle income countries lined up to stock national supplies in the first months after COVID vaccines became available.

New initiatives launched – but must be sustained

Since COVID, around 30 new vaccine initiatives have been announced on the African continent, involving  various aspects of late stage R&D, active ingredient manufacturing and fill-and-finish.  But sustaining those new efforts requires continued support and investment by national governments, research coommunities, multilateral agencies – and most of all vaccine buyers.

Around 30 investment initiatives for vaccines manufacturing in Africa have been announced since COVID-19.

“Gavi, as one of the largest purchasers of vaccines in the world, is thus sending a powerful signal to global markets that it will support African vaccine manufacturing,” said the agency in its  statement on the board decision.

“AVMA aims to make up to US$ 1 billion available to manufacturers at key moments in the development process as a way of helping offset high start-up costs and provide assurance of demand. By focusing on “priority” antigens, product profiles, and vaccine platforms, as well as constructing clear incentives for both “fill and finish” and drug substance production, AVMA will also support global vaccine markets by targeting clear unmet needs and help establish a thriving, sustainable, end-to-end African vaccine manufacturing ecosystem.”

African public health officials welcomed the move.

“Gavi, the Vaccine Alliance’s AVMA proposal has the potential to be a major step in the right direction and a powerful signal to other donors and investors that African vaccine manufacturing has a bright future,” said the African Vaccine Manufacturing Initiative (AVMI) of the new Gavi platform.

“Lessons from the pandemic have highlighted the need to put vaccine equity at the heart of pandemic preparedness, prevention and response.”

“A strong #AfricanVaccineManufacturing Industry is an opportunity, not a threat,” added Africa Centers for Disease Control in a post on X (Twitter).

https://twitter.com/AfricaCDC/status/1732660651447685226

Image Credits: Dilemma Online/Twitter .

WGIHR starts its sixth meeting on 7 December.

A single oversight and compliance body may be set up to oversee both the new pandemic agreement and the amended International Health Regulations (IHR), according to  Dr Ashley Bloomfield, the co-chair of the Working Group on Amendments to the International Health Regulations (WGIHR).

Bloomfield was responding to a question about whether his group had discussed independent monitoring from Dame Barbara Stocking, chair of the Panel for a Global Public Health Convention, at the start of the WGIHR’s sixth meeting on Thursday.

Several civil society groups have called for independent oversight of the implementation of the pandemic agreement currently being negotiated by the intergovernmental negotiating body (INB) and the amended IHR.

Stocking reiterated the need for “independent assessment in both the IHR and any new treaty” because of a lack of trust between countries, as well as between citizens and governments.

“Having independent assessment is a really important way of actually making sure that there is trust in what is being done, and what is being said to be done,” said Stocking.

“We’re very aware of the importance of this issue of compliance, oversight and monitoring, including what independent monitoring might look like,” responded Bloomfield, who said that the WGIHR and the INB were first considering existing monitoring arrangements such as the independent oversight and advisory committee set up by the WHO Director-General.

Bloomfield added that the issue was featured in a new article in the IHR (Article 53) and well as in Article 54.

“Likewise, there are relevant provisions in the draft INB agreement that were discussed over the last few days,” said Bloomfield, who attended this week’s INB meeting as an observer.

“All these matters are ones that we will be considering within our individual processes, but I can say that there are already informal discussions happening about how a future oversight and compliance arrangement would be constructed that takes into account both processes.” 

He later added that there was considerable overlap between the two groups on financing and there could be a joint process on that too.

Civil society concerns

Meanwhile, other civil society organisations also raised their concerns at the open plenary of the WGIHR. 

The World Trade Organization (WTO) offered its technical expertise and experience to the WGIHR on proposed amendments that “address topics with trade-related elements” such as open supply chains, trade restrictions, unnecessary interference with international traffic and trade, the transfer of technology and know-how and to develop and diversify manufacturing capacity. 

“We have a shared interest in promoting synergies and coherence across our organisations and our legal instruments. To this end, we would welcome the opportunity to collaborate with the WHO on the development and implementation of an international pandemic response as mandated by our ministers last year,” said the WTO.

Jamie Love of Knowledge Ecology International (KEI).

Jamie Love of Knowledge Ecology International reminded the group that the WHO had adopted a resolution at the World Health Assembly in 2019 (WHA78) “on improving the transparency of markets for medicines, vaccines and other health products”. 

“Among the measures we hope can be reflected in future revisions of the IHR are measures to implement the transparency obligations in WHA78, including but not limited to those relating to the transparency of prices and units sold for countermeasures, and the transparency and collection of data on R&D subsidies, patent landscapes, and the outcomes and costs and subsidies relating to relevant clinical trials on countermeasures,” said Love.

Noting that cancer treatment was disrupted during pandemics, the European Society of Medical Oncology urged member states to “support amendments to the IHR which would build, develop and maintain health systems capacities at secondary and tertiary care levels to avoid leaving millions of patients with cancer behind in times of health emergencies”. 

Mohga Kamal-Yanni for Oxfam and the People’s Vaccine Alliance

Mohga Kamal-Yanni for Oxfam and the People’s Vaccine Alliance appealed for  “practical measures to operationalize equity of access to pandemic-related products”.

Grega Kumer of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA)  called for three measures to “modernise” the IHR: “One, raising the alarm early by ensuring the rapid sharing of outbreak information and immediate access to pathogens and genetic data. 

“Two, enabling the innovative ecosystem including protection incentives on IP to reinforce the pipeline for needed medical countermeasures, and third, fostering multi-stakeholder partnerships and dialogue, including with private sector, to ensure balanced and implementable approaches.”

WGIHR progress

WGIHR co-chairs Dr Ashley Bloomfield and Dr Abdullah Assiri.

Meanwhile, WGIHR Co-Chair Dr Abdullah Assiri reported that two inter-sessional activities have been held since the group’s last meeting in mid-November. 

“The first was an informal consultation on Article 44 and 44 A, Annex One and 10,” said Assiri. 

“The second was the joint INB-WGIHR briefing on the public health alert system [known as the public health emergency of international concern], the pandemic continuum, including definitions, criteria and the process for determining each.”

The Bureaus of the INB and the WGIHR have also held two joint meetings. The first (25 October), discussed financing mechanisms and preparations for the joint INB-WGIHR briefing. The second (6 December) continued discussions on “key areas of overlap between the two processes, particularly financing, surveillance and prevention, including One Health, capacity building and know-how”, said Assiri.

Bloomfield described Wednesday’s joint meeting with the INB Bureau as “very helpful” in enabling the two bodies to “really think further about how we progress with the work, and where there are overlaps between our two processes”. 

“I’ve certainly found it useful to be in the room during the INB meeting over the last three days and other members of our Bureau were also able to listen into those discussions as well.”

INB update

The INB ended later than anticipated on Wednesday night so its public report-back was perfunctory. 

However, INB co-chair Roland Driece reported on Wednesday that the body had established four drafting subgroups: one on prevention, surveillance, preparedness, readiness, and One Health (Articles 4, 5 and 6 of the negotiation text);  the second on sustainable production and technology transfer (Articles 10 and 11 and possibly 13); the third on access and benefit sharing (Article 12) and the fourth subgroup on financing and capacity building (Articles 19 and 20). 

These drafting subgroups held inter-sessional meetings in November and early December, and the drafting group completed a review of the proposal for negotiation text. The next INB meeting is scheduled for 19 February to 1 March 2024. 

Meanwhile, Bloomfield noted that financing is “an area where there is clearly a lot of overlap and common interest between our two processes”.

“So we will be canvassing [member states’] views on how we might progress that area of financing in a joined-up way to make sure that we coordinate and are coherent across the two processes,” said Bloomfield.

The first-ever Latin American Self-Care Regional Congress took place in São Paulo, Brazil, breaking new ground for self-care initiatives on the continent.

A monumental step for self-care was taken this month at the first Latin American Self-Care Regional Congress. Taking place in November in Sao Paulo, Brazil, the two-day congress brought together stakeholders from across the Latin America region to discuss critical topics, such as public policy and regulation, innovation and sustainability, and empowerment and health literacy, among others.

Together with the Global Self-Care Federation (GSCF), the Brazilian Association of Self-Care Products (ACESSA) and the Latin American Association for Responsible Self-Care (ILAR) brought together government officials, healthcare professionals, industry representatives and experts for an excellent first edition of this event.

The theme of the congress was “making self-care a health movement” and was accompanied by an overall objective to amplify and advance discussions on a future World Health Organization’s Resolution on Self-Care. And we were able to do just that.

The crux of this is the Sao Paulo Declaration on Self-Care for Universal Health Coverage (UHC). The Declaration is a huge step towards advancing global health equity and access to healthcare services.

Discourse and action around self-care have continued to advance this year, with the HRP, WHO, UNDP, UNFPA and the World Bank publishing a joint statement on the importance of self-care at the World Health Summit a few weeks ago.

Using the momentum gained through those advancements, we must continue to grow awareness of the importance of self-care until the adoption of a Resolution on Self-Care for Health at the World Health Assembly (WHA), an initiative driven by the United for Self-Care Coalition partners.

If we are to see sustainable and reliable healthcare systems develop for the future, self-care must be included as a foundational aspect. UHC is a key element to achieving the United Nations Sustainable Development Goals (SDGs). SDG 3 aims to ensure healthy lives and promote well-being for all.

Furthermore, the right to health is fundamentally enshrined in international human rights law. The Declaration endorsed at this congress makes a clear commitment to advocate for policies that advance healthcare and expand access to it.

Self-care: A need for Latin America

Yearly savings through self-care globally, according to the Global Self-Care Federation.

As we look towards a future where health systems are constantly in flux, the need for self-care has never been so apparent. 

The Global Self-Care Federation’s Economic and Social Value of Self-Care report notes that “Latin America has the highest percentage of amenable mortality due to receipt of poor-quality health service.” Amenable mortality is defined as deaths from diseases that are potentially preventable with appropriate treatment.

But this treatment for patients doesn’t only need to come from primary healthcare providers. Pharmacists and overall health literacy can make huge strides for health in low-access regions.

Historically in Latin America, self-care is not simply represented by treatment with over-the-counter medications. Treatment with traditional medicines remains prevalent to this day, and it forms a key pillar of self-care and health literacy for the region.

Individuals need to continue to be empowered in order to seek out optimal healthcare solutions according to their situation, and initiatives such as the São Paulo Declaration will enable health systems to continue to grow holistically.

Speaking at the first Latin American Self-Care Regional Congress, Eva Maria Ruiz de Castilla, Executive Director of the Latin America Patients Academy (LAPA), said: “Individuals should be empowered to be able to manage their own health, and health systems should enable them to do so through making healthcare more accessible.

Self-care is a central component of truly integrated health systems and restores the balance between health professionals and individuals. Additionally, integrating self-care into the health continuum supports the achievement of UHC, preventing overburdening of healthcare systems, and should be further expanded to more systems globally”.

Primary health care: A continuum

The São Paolo Declaration was launched on November 9 at the inaugural Latin American Self-Care Regional Congress in Brazil.

The current barriers to healthcare that populations currently face within our healthcare systems clearly demonstrate that we need to consider Primary Health Care (PHC) as a continuum.

This starts with self-care practices at home, seeking out available resources within a community or online, continues with seeking input from various health professionals such as pharmacists, nutritionists and health promoters, and finishes with taking steps to seek out treatment with a specific healthcare provider. Establishing resources for those seeking care to be able to reach out to in order to practice effective self-care is a needed and critical step.

Dr Alejandra Acuña Navarro, Executive Secretary of COMISCA, (Council of Health Ministers of Central America and the Dominican Republic) was one of the speakers at the congress this week.

In her talk titled “Self-Care in the Health Integration System of Central America,” Acuña highlighted the need for a balanced policy effort to establish the sustainable health systems of the future, noting that we cannot simply focus on expanding primary healthcare providers or hospitals as a sole solution.

“We must continue to work towards international recognition of self-care with a World Health Organization’s Global Self-Care Resolution,” said Acuña “In order to drive real change and ultimately achieve UHC, we need all stakeholders to actively support the Resolution.”

The time is now 

If we are to continue with our goal of creating sustainable health systems for the future, self-care needs to be intentionally recognized and adopted within our systems. We know that self-care can be introduced, scaled up, and established as complementary to existing systems. We saw it worldwide during the COVID-19 pandemic as extraordinary circumstances forced drastic action from Ministries of Health around the world. 

We know that it’s possible – but we shouldn’t wait until the next time circumstances force our hand. Self-care must be integrated into national and international healthcare systems, and we are seeing the first steps with actions such as the Sao Paulo Declaration.

With momentum on our side, and the international healthcare community growing in awareness and knowledge about the importance of self-care this is an opportunity we cannot miss. We must continue our push for a Global Self-Care Resolution at the World Health Assembly.

Being able to participate in an international congress such as this is a true pleasure, and I leave inspired and committed. I look forward to seeing the next steps that my peers from across the world will take as we continue this journey together. 

About the author

Juan Thompson is the Director General of Latin-American Association of Responsible Self-Care (ILAR), a non-governmental organization that leads the promotion of responsible self-care as the best way to be and stay healthy, as well as ensuring proper access and use of self-care products in Latin America. ILAR is an NGO with consultative status with the UN Economic and Social Council (ECOSOC) and members of the GSCF.

Image Credits: GSCF, GSCF.

South Africa’s Economic Freedom Fighters’ party protests against Uganda’s Anti-Homosexuality Act in Pretoria, South Africa.

As violence against LGBTQ people in Uganda continues to rise following the country’s adoption of its harsh Anti-Homosexuality Act (AHA), four legal challenges to the law have been consolidated into a single case.

However, Uganda’s Attorney General has ignored human rights groups’ application for an injunction against the implementation of the law until the appeals have been heard, LGBTQ activist Pepe Onziema told Health Policy Watch.

After a series of meetings between the four groups petitioning against the law and Ugandan Constitutional Court Judge Geoffrey Kiryabwire last week, the petitioners agreed to combine their cases.

Five groups have applied to be amicus (friends of the court) to support the court challenge, including the Joint United Nations Programme on HIV/AIDS (UNAIDS), a group of pharmaceutical companies (VIIV Healthcare, Glaxosmithkline, Gilead and Merck), academics and the two human rights law organisations (the Southern African Litigation Centre and Centre for Applied Legal Studies).

But Uganda’s Attorney General has objected to the amici and their applications will be heard by a panel of five judges.

The hearing date will be set after a final meeting between the parties and Judge Kiryabwire on 11 December.

“These hearings are usually heard by a panel of five judges,” said Onziema, adding that the application for an injunction “has been ignored by the Attorney General” as “they have never given us an opportunity to present it.”

Ugandan LGBTQ activist Pepe Onziema.

Rape, beatings and evictions

The Human Rights Awareness and Promotion Forum (HRAPF), which has a countrywide network of community paralegals and legal aid centres, handled 83 cases in October involving people targeted for their sexual orientation or gender identity. This is up from 68 cases in September.

One of the attacks involved the rape of a transgender woman in Kampala by two men who followed her home one night, then called her neighbours to “wake up and see a homosexual”.

A woman in the Isingiro district, who provided counselling services to HIV-positive lesbian women, was attacked after being accused of “recruiting women into lesbianism”, and her leg was broken. She was also attacked at her home by the same group and was forced to flee.

HRAPF says 28 of the cases involved violence while 37 people were evicted. The law makes it illegal for landlords to rent property to LGBTQ people.

Meanwhile, this week US Secretary of State Antony Blinken announced visa restrictions on “current or former Ugandan officials or others” who are believed to be responsible for, or complicit in, undermining the democratic process in Uganda or for policies or actions aimed at repressing members of marginalised or vulnerable populations” including “environmental activists, human rights defenders, journalists, LGBTQI+ persons, and civil society organisers”. 

Previously, the US excluded Uganda from its African Growth and Opportunity Act (AGOA) trade programme, which gives preferential treatment to certain trading partners.

However, Ugandan Parliamentary Speaker Anitah Among, a staunch promoter of the AHA, told Parliament this week that she did not regret backing the law despite having her visa application rejected. Meanwhile, MP Jonathan Ebwalu (Soroti West) told Ugandans opposed to the Act to relocate to nations like US and UK , saying he is ready to shed blood “to fight against homosexuality “.

Solidarity as activists ‘walk through fire’

Onziema says that both international, regional and local solidarity have helped the LGBTQ community after the enactment of one of the world’s harshest laws against sexual orientation.

Within Uganda, LGBTQ activists and allies in academia, the medical sector and the hospitality industry have come together to form the Convening for Equality to oppose the law and offer support and often shelter to people.

“Some landlords and hotels have told us that we deserve shelter and have offered us safe places,” said Onziema.

He added that lobbying of politicians, the World Bank and other stakeholders at an international level had opened the door to dialogue between the Ugandan government and the LGBTQ leaders. 

“Much as they say we are Western agents, it seems that they are only interested in engaging with us when Western governments engage them,” said Onziema.

In August, the World Bank suspended new public loans to Uganda after the country passed the Act. The US President’s Emergency Plan for AIDS Relife (Pepfar) has also paused new funding to Uganda.

Onziema appealed to donors to provide unrestricted funds to assist LGBTQ activists “as we are literally walking through fire. There are attacks, kidnappings, and extortion. We have to change tactics all the time as something that works today might not work tomorrow.”

Helping vulnerable populations get access to energy options that reduce air pollution during cooking is an easy way to cut carbon emissions while also improving health and gender equity

Improving access to clean cooking will not only help the world get closer to net-zero carbon emissions by 2050, but it will not be possible to reach the 2030 Sustainable Development Goals (SDGs) without doing so, said experts speaking on the sidelines of COP28. 

“We don’t want people to be breathing polluted air as a result of the fact that they are preparing food,” said Maria Neira, the World Health Organization’s (WHO) Director of Environment, Climate Change and Health.

Globally around 2.3 billion people rely on polluting traditional fuels like wood and biomass for cooking, according to the latest report by WHO. It estimates that the cooking sector contributes 3% to the annual global carbon emissions.

It also causes tremendous indoor air pollution. In 2022 alone, indoor air pollution was estimated to be responsible for 3.2 million deaths, according to WHO. 

Women and children are particularly vulnerable as in many cultures they are responsible for cooking and related chores like gathering firewood. Air pollution is also linked to a rise in miscarriages and worsens pregnancy outcomes. 

The lack of clean cooking is a human rights issue, especially for women and children, said Bhushan Tuladhar, Chief of Party of USAID Clean Air in Nepal.

 “There are so many co-benefits associated with it that it’s almost a no-brainer. And it’s a low-hanging fruit,” he told a COP28 side event on a just and inclusive cooking transition.

The impact of indoor air pollution on women’s health has only in recent years garnered some attention, despite clear evidence of it.

 

Bhushan Tuladhar, an air pollution expert from Nepal.

In addition, cooking with biomass leads to the release of a sooty black material called black carbon. In fragile ecosystems like the Himalayan country of Nepal, this black carbon settles on the glacier ice and increases the rate of melting.

“It’s not just about climate benefit, but when you are reducing black carbon emissions, you’re also not altering your monsoon seasons. There’s energy and agricultural security, and food security is being impacted by this emission,” Michael Johnson, Technical Director of Berkeley Air Monitoring Group, told the event.

The $2.3 trillion cost of inaction

WHO estimates that 1.9 billion people will not have access to clean cooking by 2030 if the pace of improving access is not accelerated. 

In its report titled, “Achieving universal access and net-zero emissions by 2050,” WHO estimates that the annual cost of the impacts of lack of clean cooking on health, gender, and the global climate is US$2.4 trillion.

“Lifting the world’s 2.3 billion people still living in cooking poverty, as we call it, is an urgent issue. And it has enormous potential for societal benefits, particularly for public health, women’s productivity, empowerment, climate and environment. The important thing is the cost of inaction is a staggering US$2.4 trillion given all the damages this can cause,” said Chandrasekhar Govindarajalu, an energy specialist at the World Bank. 

 

Chandrasekhar Govindarajalu of the World Bank said the bank is working to improve access to clean cooking in 33 countries, and its support has reached 43 million people.

Need for clean cooking in sub-Saharan Africa

Access to clean cooking fuels has improved around the world. In Asia, governments have been pushing policies to improve access to LPG cylinders and electric stoves. 

In Nepal for instance, now 54% of the households rely on biomass compared to 75% 10 years back, due to the government initiative to improve LPG access, Tuladhar said. In India, the world’s most populous country, government push improved LPG access from 43.8% in 2016 to 58.6% in 2021. While the numbers are higher for urban households, rural areas continue to lag. 

But in sub-Saharan Africa, the number of people without access to clean cooking has increased. “Population growth has outpaced these improvements, particularly in Sub-Saharan Africa where the number of people without access reached 0.9 billion in 2021,” according to WHO’s report. 

 

The number of people without access to clean cooking is the highest in sub-Saharan Africa, as the growth of population has outpaced rate of the growth of access.


Govindarajalu added that to meet the climate and energy access targets, the rate at which access to clean cooking is currently improving has to be double or triple.

Alternate options: LPG and electric stoves

The two options for clean cooking to replace traditional fuel are electric stoves and LPG cylinders. Both have their challenges, especially in rural areas. While for electric stoves one needs steady and reliable electricity, it is hard to lug LPG cylinders across rural and mountainous terrain. 

Tuladhar said electric stoves are proving to be cheaper in Nepal’s rural areas but electricity access is not yet 100% and the intensity of electricity is not adequate in all areas. 

WHO too estimates that while LPG access will improve in the near term, in the long term it will be the electric stoves that will have to be employed to reduce emissions.  

WHO’s roadmap to help the cooking sector get to net-zero carbon emissions.

Tuladhar told Health Policy Watch that while soon the focus will have to be to increase LPG access, in the long-term it is electric stoves that will bring the maximum reduction in air pollution and carbon emissions. They can only be pushed once electricity access improves.  

Countries are also including clean cooking as a part of their national climate targets, said Johnson which is a good move but its impact is hard to measure, and each country is currently using their own frameworks to do so.

Experts reiterated that the issue of clean cooking is closely linked to the development of the country. “When it comes to energy transition there is no silver bullet, and clean cooking has to be part of the solution, especially as an issue that is so anchored to the development of the country,” said Duccio Tenti, UNDP’s energy team leader

Image Credits: Aalok Atreya/ Unsplash.

Despite strong evidence that taxing alcohol is one of the “most effective measures to reduce consumption and address alcohol-related harms”, countries are not using this effectively, according to Ruediger Krech, the World Health Organization’s (WHO) director of health promotion.

Krech was speaking on Tuesday at the launch of a WHO manual on alcohol tax policy and administration and a report on sugar-sweetened beverage (SSB) taxes. 

“Alcohol is one of the few toxic and psychoactive substances that many governments permit to be sold widely in the market. However, with this permission comes responsibility and governments have a duty to regulate the market to minimise harm,” said Krech.

“Alcohol is one of the leading risk factors for non-communicable diseases, including cancers and cardiovascular diseases. It is also associated with communicable diseases, prenatal conditions, injuries, drowning, mental health conditions and violence. Given the extensive list of harmful effects, addressing the harmful use of alcohol is a priority for the World Health Organization.”

At least 148 countries have applied excise taxes to alcoholic drinks, but wine is exempted in at least 22 countries, mostly in Europe. 

Meanwhile, around 108 countries are taxing some sort of sugar-sweetened beverages but the global average is a low 6.6%. In addition, half of all countries taxing SSBs are also taxing water, which is not recommended by WHO. 

The alcohol manual provides data from the tax systems of different countries as well as advice on the different tax options and their administration. It is the third in a series of WHO manuals on harmful products, with previous manuals addressing tobacco and SSB taxes.

Underwhelming

Devora Kestel, WHO’s director of Mental Health and Substance Abuse, said that while alcohol was linked to over 200 health conditions and had “far-reaching and often devastating effects”, progress to curb consumption at a country level has been “underwhelming”. 

“The global average of alcohol consumed per person has only seen a marginal decline, highlighting the need for more impactful action,” said Kestel.

Furthermore, the World Bank’s Ceren Ozer pointed out, “in high and low and middle-income countries, alcohol has become more affordable over the last three decades”. 

Moreover, the industry is expecting serious growth in the consumption of alcoholic beverages across the board, she added.

Yet alcohol taxes contributed only about 0.3% of GDP in tax revenue globally, which is about half that of tobacco taxes. However, a few countries have shown progress, said Ozer. 

“For instance, in the Philippines between 2012 and 2020, alcohol excise revenue has increased by 140% in real inflation-adjusted terms following significant increases in beer and spirits excise taxes,” said Ozer.

“South Africa is another country where we have detailed data-driven research that shows improvement not only to revenue but also the health impact due to improvements to after alcohol tax design and increasing in rates leading to significant gains from the late 1990s to recent years,” said Ozer.

South African Treasury official Mpho Legote told the launch that as his country taxed the alcohol content of beverages (as opposed to the size as in some countries), this had “incentivized the industry to introduce lower alcohol beers”, for example.

South African Treasury official Mpho Legote.

Improvements in Kosovo and Lithuania

Kosovo has had a “dramatic increase in revenue” almost entirely due to improvements in tax administration, and tax compliance, with an increase of almost a 25% in alcohol tax revenue between 2019 and 2022, Ozer said.

Meanwhile, Lithuania increased alcohol tax revenue from €234 million in 2016 to €323 million in 2018 and saw alcohol-related deaths drop from 23.4 per 100 000 people in 2016 to 18.1 per 100 000 people in 2018, according to WHO.

“About 0.5% to almost 2% of the country’s GDP is lost every year due to alcohol consumption or alcohol use,” pointed out Odd Hanssen, a health economist with the United Nations Development Program (UNDEP,

“This comes from a couple of ways, mainly in what health systems have to spend in order to treat people who have alcohol-caused diseases, but more significantly, the indirect costs of people with these diseases who are unable to work as productively,” said Hanssen.

No ‘one size fits all’

Explaining the manual’s key messages, the WHO’s Jeremias Paul said that “there is really no one size fits all given the heterogeneity of alcohol beverages and tax structures.

Each country’s context was different, and governments had to “consider several factors, such as the patterns of consumption, the administrative capacity, the different kinds of alcohol, beverages available, the policy goals of a country and the political economy and industry structure”, said Paul.

The bottom line, however, was that “the taxes should be high enough to impact affordability”, said Paul.

“One thing for sure is that you can expect industry pushback to reform and in the manual you can essentially find tips. What are the typical industry arguments against tax increases, and how to counter them.”

Image Credits: Taylor Brandon/ Unsplash.

pandemic
Health workers donning personal protective equipment during the COVID-19 pandemic.

This is a bumper week for pandemic negotiations – the last formal set for the year – with meetings of both the World Health Organization’s (WHO) intergovernmental negotiating body (INB) and the Working Group on Amendments to the International Health Regulations (WGIHR).

The INB, which is negotiating a pandemic agreement, meets until Wednesday, while the WGIHR meets on Thursday and Friday.

The proximity of the meetings is intentional, as it enables negotiating teams to attend one another’s meetings to ensure synergy between the two processes.

The International Health Regulations (IHR) define the processes leading to the declaration by the WHO Director General of a public health emergency of international concern and member states’ responsibilities. They are the only global internally binding obligations related to health emergencies.

The pandemic agreement is due to map out pandemic prevention, preparedness and response based on equity, and establish the institutional requirements to achieve this.

INB focus

INB co-chairs Roland Driece and Precious Matsoso

Unlike previous INB meetings, this week’s session did not start with an open plenary as the meeting is considered to be a continuation of the seventh meeting, which started a month ago. In the intervening period, member states have been meeting to discuss various issues related to the negotiating text for the pandemic agreement.

This week’s INB started with several sub-groups looking at key issues on Monday, including pandemic prevention and surveillance, One Health and preparedness, readiness and resilience (Articles 4-6); sustainable production and tech transfer (10-11),  access and benefit sharing (12), global supply chains (13)  Implementation capacity and financing (19-20).

Plenary sessions on Tuesday and Wednesday will consider member states’ text submissions on several of the articles that have been discussed since the previously discussed, including the contentious research and development article, as well as terminology and institutional arrangements needed to implement the agreement.

The INB will conclude with an open plenary to report back to stakeholders who are not part of the INB on Wednesday afternoon.

Meanwhile, Geneva Health Files reported recently that Namibia’s representative at the INB – an articulate champion of equity – had been sent home at short notice and that sources had speculated that wealthier countries may have applied pressure on the small African country to do so.

However, the US and the European Union denied this. Interestingly, Namibia’s response to GHF did not deny that they had come under pressure to recall their diplomat but simply indicated that his term had ended and that Namibia was a sovereign country.

The INB has to conclude its work in time to present the draft pandemic agreement to the next World Health Assembly in May 2024.

WGIHR agenda

WGIHR co-chairs Dr Ashley Bloomfield and Dr Abdullah M Assiri.

According to the WGIHR draft programme of work, the closed-door meeting will begin on Thursday with the co-chairs proposing a way forward to address the amendments received. It will then proceed to discuss text proposals received for several articles, including the proposal by Bangladesh and the Africa Goup for Article 13A on “equitable access to health products, technologies and know-how for public health response” the establishment pf an implementation committee (also proposed by the Africa Group) and the compliance committee (US proposal).

The co-chairs will also introduce the Bureau’s text proposals for a number of articles  and annexes and facilitate discussion on these proposals. This includes the heart of the IHR – the “assessment and notification of events that may constitute a public health emergency of international concern”.

The WGIHR is due to report to the WHO’s executive board on 22 January 2024.

Image Credits: Tehran Heart Centre .

Bhavreen Kandhari of Warrior Moms at a meeting during the UN General Assembly in New York, September, 2023.

Two mothers battled air pollution in Delhi and its suburbs well before it became a thing. Motivated by how their children have suffered,  Ruchika Sethi Takkar and Bhavreen Kandhari speak with Health Policy Watch about why they don’t give up and what other parents can learn from their work. 

DELHI, India – On a gently rolling field of garbage next to swanky high-rises, Ruchika Sethi Takkar bends to look closely at a piece of wrapping. “Sometimes you can trace where a load of garbage came from,” the 51-year-old says, sounding like a veteran detective. She’s standing by the side of a major road in the Delhi suburb of Gurugram. 

Takkar’s no detective nor did she ever imagine that she would often stand ankle-deep in rubbish. She’s the driving force behind Citizens For Clean Air Bharat, a small loose grouping of Gurugram residents.   

Ruchika Sethi Takkar standing on a garbage dump, where she looks for addresses to trace the source. For several years she’s been pushing authorities to prevent open dumping and burning of rubbish in Gurugram.

Bhavreen Kandhari is a more familiar face in India, often seen on national television and quoted in reports about air pollution. Based in Delhi, Kandhari, also 51 years old, began Warrior Moms with a few others. 

Both women aim to improve the quality of air in India, something that more and more people across the country are increasingly concerned about. In the most recent global rankings, 39 out of 50 of India’s major 50 cities were listed as the most polluted in the world.

But Takkar and Kandhari’s journeys began over 20 years ago, at least a decade before the air pollution crisis hit the headlines in 2014 when the World Health Organization (WHO) ranked Delhi as the most polluted city in the world – worse than Beijing, which until then had held the top pollution spot. 

There are striking commonalities in their paths, and Takkar and Kandhari’s learnings may be seen as useful case studies at a time when citizen activism is rising. Be it their organisational approach, their strategies, their negotiations with authorities or even the harsh pushback they’ve faced at times because of their, self-admittedly, privileged background.  

‘My world collapsed months after my daughter was born’

In 2001, Takkar was pregnant and heading an export team doing over $10 million in business annually. Her daughter was born on her 30th birthday. Within a couple of weeks, the new parents realised there were “issues” with their baby. Their doctor advised tests and, when she turned three months, he broke the news to Takkar. She recounts, “He said: ‘Your daughter has mental retardation’. And at that point, my world just collapsed.” =

Apart from the many things Takkar had to deal with, including giving up her job to care full-time for her infant, she wanted to understand what happened. Her doctor said it could be a neurodevelopmental disorder and the foetus had microcephaly, described as a birth defect where the baby has a small head.

Genetic profiling tests gave no indication of what caused it. During her pregnancy, Takkar had been diagnosed with intrauterine growth retardation (IUGR), and doctors noted that the foetus wasn’t growing that well. But the ultrasound didn’t flag anything, she recalls.

Looking back, she wonders whether the fumes from a diesel generator she was exposed to in the early months of her pregnancy could have been the cause. There were power outages at her office and fumes used to “flood in” though she accepts it’s hard to pin blame on this alone. Studies have linked IUGR, developmental disorders and other conditions to air pollution.

Soon, Takkar’s baby developed frequent respiratory ailments and had to use a nebuliser. It made Takkar aware of their surroundings. At the time they lived a short drive from a massive landfill in east Delhi. 

“I was aware that there is something in the environment also which is not helping. It was known that Noida [a suburb in east Delhi] has much more industrial pollution even next to the residential area. But still, I had no idea about municipal laws and environmental laws. All I knew was that the children were now being diagnosed a lot with asthmatic conditions.”

November 2023 saw average PM 2.5 levels in four cities including Delhi hit a five-year high.

By 2011, Takkar’s family had shifted to Gurugram, bordering south Delhi, to an up-market residential complex. But she frequently noticed a burning smell and was in for a rude surprise. It was waste being burnt next to their complex from their complex that had been dumped there by the builders. The rude surprise wasn’t just this but the apathy of some of her neighbours. One of them told her: ‘Why bother, you can just pop a medicine’. 

The following year Takkar started a group called Malba Hatao Movement (‘Remove Garbage Movement’.) It drew her into a maze of red tape and direct contact with three major government departments – the district administration, city municipality and building regulator. 

Three long years later, she had her first success when two departments banned the burning of waste, Takkar proudly recollects. All she had done was read the rules. “There came this realisation that the law is there, but for it to work you need more voices.”

Takkar’s biggest breakthrough came when she managed to get the top bureaucrats of the three departments into the same meeting in November 2015. They had one agenda: to stop waste burning in Gurugram, and they agreed to start pilot projects. 

Before setting up this meeting, Takkar made progress with two other stakeholders. First, more residents began to see waste burning as a health risk not as a solution to waste. She conducted over a dozen roadshows which meant taking residents to garbage dumps to drive home both the problem and solution. 

Her second success was using the simpler and more sidely understood word, pollution:  “The press kept focusing on the seasonal factors but not the persistent local factors which I had started coining as pollution because nobody else was picking up the word ‘civic deficiencies’.” 

However, eight years later, waste burning remains rampant in Gurugram. Takkar and other citizens frequently complain either directly to officers or on social media, tagging top ministers and the press. If there are any gains from those years of activism then it is that the administration is more responsive – although whether their responses are sufficient is another matter. 

In 2016, Takkar started a new group, Citizens for Clean Air Bharat. A loosely organised collective with no funding or organisation structure, the group frequently reports open burning to officials and politicians in charge. 

‘Something not right’

Bhavreen Kandhari in front of Delhi’s iconic Jawharlal Nehru Stadium.

Bhavreen Kandhari’s advocacy for air quality began earlier, after 1995 when frequent trips between Delhi and New York, enabled her to compare the air quality.

“I started kind of feeling that there is something not right in the air. And when I go from here to there [New York], you feel more energetic, and (it’s better for) your skin, and your hair,” said Kandhari, who had begun reading up on the Great Smog of London and California’s battle with air pollution, but could not get data about Delhi’s air. 

After 2002, things changed for Kandhari. Her twin girls were born prematurely at just six months and weighed 600 grams each and spent several weeks in hospital. From their first year, they began getting coughs and colds. 

“After three to four years, I realised that their colds and coughs don’t go away easily. They start around the same time year after year,” she said.

But when the children were taken to New York, from “the moment you land there, (their coughs and colds) would go away magically. The elders would always blame allergies. But now I was sure. This is something really about the air.” 

Around 2007-08, she participated in small protests outside India’s Ministry of the Environment demanding policy action for clean air – but there was little resonance amongst the public or the press, which she blamed on the absence of data. 

That information gap began to be addressed around 2011 when a Delhi-based think-tank started advising Kandhari. The tipping point for her clean air advocacy came after the WHO’s 2014 shock listing of Delhi as the world’s most polluted city.

‘Elite’ protest

Kandhari and a few other organisers decided to protest in the heart of Delhi, at a designated protest spot near Parliament in November 2016. While a couple of hundred people showed up, some of them arrived in diesel SUVs which are notorious for spewing pollution. “Many of our cars were photographed, and the media said that they are the elite mothers coming for this thing.”

The elite tag is something both Takkar and Kandhari have faced from several stakeholders. Both are self-funded, and both their fathers were in government service – one in the top bureaucracy and the other in the air force. Both belong to the ‘cream’ of civil society, and are urbane and well-off. And both could see that their approach needed to change. 

Kandhari admits the protest with SUVs “was my game changer. I thought that yes, this movement cannot be elite, it has to have masses with us. The biggest mistake I think I was making those days was not writing much in Hindi.”

Takkar says she was already working a lot with Hindi newspapers. She positioned the air problem and her campaign simply, as a “dhool aur dhooyen ki kahaani” – a story of dust and smoke – something that’s tangible. 

Providing a template for complaints

Widening the social net took their work to a new level. “What I could sense is that if government officials think that only a few people are bothered about it, then they don’t think it’s a problem. Then they think it’s your fetish, it’s your pastime,” says Takkar.

The outreach led her to adopt a new approach for those approaching her with pollution complaints. “That’s where my time goes, just talking to people and then telling them how to go about it. What bothered me was they would expect me to solve their problems. I said: ‘It can’t be done this way. I will give you a template. This is the number, this is the email’.” 

Kandhari says that, as she has been campaigning for clean air for a long time, she can help others. “Air pollution is a problem in different cities. But I can’t manage that. I have no resources. I can just connect people.” 

It led her and a few others to set up Warrior Moms in 2020, ironically because of blue skies instead of haze. The COVID-19 lockdowns showed how removing cars and several other sources of pollution could lead to blue skies. 

“It was the world’s biggest experiment, you know, a natural experiment showing us that it’s the emissions and it was so easy for us to prove. But we couldn’t go out.” 

Warrior Moms was born out of this need. It grew from a core of about five groups to almost 20 today with a membership of over 1,700, especially when pollution is high. ‘

But it is all voluntary work. There’s no structured membership and people can join or leave depending on their requirements. It’s essentially now a knowledge and support network as more people, including top personalities, voice their concerns about air pollution. 

Cricket stars troubled by air pollution

During the recent Cricket World Cup hosted by India, air pollution levels started to peak. India’s cricker captain, Rohit Sharma, expressed concern about air pollution in Mumbai when he landed for a match: “Looking at our future generations, your kids, my kid, obviously it is important that they get to live without any fear. Every time I get to speak outside of cricket, or not discussing cricket, I always talk about this. We have to look after our future generations.” 

England’s Joe Root, said following his team’s defeat to South Africa in Mumbai. “I’ve not played in anything like that before,” Root had said. “It just felt like you couldn’t get your breath. It was like you were eating the air. It was unique.” 

The teams playing in Delhi were worse off. The comments forced the organisers to acknowledge the poor air quality in Delhi and Mumbai. 

After 20 years with little progress, why not give up? 

Since Takkar and Kandhari began their advocacy work,  air quality has barely improved especially between October to March. The waste burning continues, and they have little or no financial or logistical support. Why don’t they just give up? 

For the first time in an hour-long interview, Takkar pauses. Her eyes well up. “You know, you just need to live with my daughter for a day. She’s getting nothing back from this society. Nothing. Yet, I think you have to make do with what you have.” 

After another pause, she continues: “There is always somebody out there who is weaker, who is getting affected. So we need to recognize, I think just by virtue of the fact that we are alive and we have some abilities, we have to do better for our lot.”

The Gurugram mom wants fellow residents to ask questions about their welfare. “We have data which is coming in about the non-communicable diseases (NCDs) growing, your own loved ones… you don’t have answers, where did (that) cancer come from?

“I don’t think anybody should give up. But yes, I do feel exhausted now, especially with the courts and all that,” Bhavreen Kandhari says, referring to her work petitioning courts to protect trees in the Capital. 

Kandhari speaks of tense times at home when her husband’s business hit a rough patch. They came through that but she’s determined to continue accepting that she’s not indispensable. 

“Everyone’s looking towards each other. I’ve always looked up to so many people. That’s how people are looking up to me. And how can we do this? How can we allow… I mean, if I’m angry, I am angry that, yeah, what you said, 20 years. And my girls are turning 20 and I have not been able to give them clean air and only damaged lungs.” 

Image Credits: Chetan Bhattacharji, Respirer Reports.