Bombed out ruins of Tel Al Zaatar neighborhood in northern Gaza City, near the Indonesian Hospital.

Fierce gun battles between Israeli and Hamas forces raged in the vicinity of several strategically located hospitals in northern Gaza over the weekend and into Monday – leaving the fate of the remaining patients hanging in the balance. 

At Al Shifa hospital, hospital staff were reportedly trying to keep some 37 premature babies warm by wrapping them in foil in an operating room – after electricity in the nursery housing their incubators failed due to a lack of fuel.  Three babies had already died, the hospital director Mohammed Abu Salmiya told Al Jazeera in a phone interview early Monday, and others were at risk as oxygen supplies dwindled.

“Premature and new-born babies on life support are reportedly dying due to power, oxygen, and water cuts at Al-Shifa Hospital, while others are at risk. Staff across a number of hospitals are reporting lack of fuel, water and basic medical supplies, putting the lives of all patients at immediate risk,” the regional directors of WHO, UNICEF and the UNFPA reported in a joint statement Sunday

“We have no electricity except in the emergency section. The nursery section is out of service, maternity hospital is out of service,” Salmiya said, “The oxygen generator is not working. Water, we don’t have a single drop,” he said, describing the situation as “catastrophic.” 

“The world cannot stand silent while hospitals, which should be safe havens, are transformed into scenes of death, devastation and despair,” said WHO chief Tedros Adhanom Ghebreyesus, reiterating calls for an immediate stop to the fighting.

The appeals were echoed by US President Joe Biden who said Monday that Gaza’s hospitals “must be protected”

Partial evacuation of Al Shifa  

Al Shifa Hospital – 15 October. Emergency Medical Teams (EMTs) deployed in tents outside of the compound alongside displaced people sheltering in the area.

Thousands of people sheltering at the hospital left the compound over the weekend. But many still remain on the hospital grounds, aerial photos published Monday by the New York Times suggested.

“An unconfirmed number of IDPs, along with several staff and patients have reportedly fled the Shifa hospital over the past few days, amid the intensified attacks and Israeli calls to evacuate it,” OCHA reported in its  latest newsflash, noting that the Israeli military had opened a “corridor” for people to leave.

“However, reports cited by the WHO indicated that some of those fleeing have come under fire, resulting in casualties. Humanitarian agencies have received desperate calls from staff and patients’ relatives willing to leave but fearing reported snipers around the hospital. Others, particularly people with disabilities, are physically unable to leave by themselves,” OCHA added.

Israel has said that Hamas forces are trying to discourage people from fleeing Shifa and other hospitals in the area – where it says Hamas maintains key command and control centers underground. Hamas has denied the claims.

Israeli military spokesman Daniel Harari told a Sunday evening media briefing that it had offered help to the Shifa hospital director in the evacuation of the remaining patients, but Hamas was preventing them from leaving. Troops also brought some 300 litres of fuel to the hospital entrance Sunday night, but Hamas intercepted the delivery, he said. 

OCHA said in response,“Shifa’s director has stated to the media that the amount delivered would have been sufficient for 15-30 minutes only.” It added that “the hospital would have accepted if it was delivered through the International Committee of the Red Cross (ICRC).”  

Fighting interrupts Al Kuds Hospital evacuation – Israel says weapons found at Rantisi Hospital

View of Rantisi Hospital from the entry point to a nearby tunnel, as displayed by Israel’s military spokesman in a video tour of the now vacant hospital grounds.

There were also fire exchanges with Hamas at the entrance to Gaza City’s Al Kuds Hospital, according to Palestinian and Israeli reports;, the latter displayed aerial video footage of Hamas gunmen by the hospital walls facing off against an Israeli tank. 

The Palestinian Red Crescent later said that Al Kuds Hospital was no longer operational – but it could not reach the installation to evacuate it either due to the fighting in the area. 

At Al Rantisi Children’s Hospital, evacuated by patients and staff over the weekend following an earlier standoff between Hamas and Israel, a video of the now-emptied grounds, released by Israel’s military, revealed an array of weapons in a room decked with childrens posters in what appeared to be the hospital basement. Mounted on the wall was an electronic device bearing a World Health Organization logo.  In other videos and photo footage, a deep, steel-reinforced tunnel was displayed, some 200 meters from the hospital walls. 

Recent Palestinian casualties now unclear

Due to a collapse in communications, the Hamas-controlled Ministry of Health in Gaza did not update casualty figures over the weekend, OCHA also added. 

“The latest updated, provided on Friday, showed showed that 11,078 people had been killed in the Strip since 7 October. According to Israeli official sources, 47 soldiers have been killed since the start of [Gaza] ground operations,” OCHA said.  

Around 1300 Israelis have been killed since the original Hamas incursion into Israel on 7 October, including about 300 soldiers and police.  Over the weekend, Israel revised its estimate of Israeli casualties from the 7 October raids downward from 1400 to 1200, saying that extensive forensic investigations had been required to identify the precise number of victims, some of whom had been so badly burned that even DNA samples were difficult to extract.     

Humanitarian aid deliveries in south – inferno in north  

UN water truck at Khan Younis refugee camp, in southern Gaza where hundreds of thousands of displaced people are sheltering. UNRWA has said a fuel shortage will force it to cease operations in 48 hours.

While Israeli forces tightened its chokehold on northern Gaza, the pace of humanitarian aid deliveries increased slightly in the south, with some 140 trucks entering Gaza from Egypts Rafah crossing with fuel, medicines and water supplies. But that is still a fraction of the aid that arrived daily before the war began. 

UNRWA said that its humanitarian operations in Gaza would grind to a halt within 48 hours without fuel resupplies. 

Israel has imposed a total ban on fuel deliveries to Gaza, although there were unconfirmed reports that fuel had recently been delivered to the city’s desalination plant, which forms a vital part of the region’s fresh water supplies.  

Two other water pipelines from Israel to the southern Gaza strip were also restored last week, Israel has said. But supplies to the enclave, which suffers from water scarcity in the best of times, remained desperate, particularly in the northern part of the enclave where battles continue to rage.   

Jebalya refugee in the northern strip was the scene of an inferno Monday evening as an Israeli anti-bunker munitions collapsed buildings and triggered multiple fires.  

Not too far away, the once posh Rimal neighborhood, home to a number of Palestinian government insitutions, malls and a UN Beach club, along with Al Shifa Hospital, was also a scene of devastation, with fires burning in some bombed out buildings. 

Sexual violence on 7 October  – Israeli women publish evidence of assaults

Report on gender-based violence in connection with the 7 October Hamas attacks, presented in Tel Aviv, attended by WHO Representative to Israel Michel Tieran (center right).

Meanwhile, in twin events in Tel Aviv and Boston, reports by victims and their famlies of the 7 October incursions into Israelis communities around Gaza provided grisly testimonies of alleged gender-based violence faced at the hands of Hamas gunmen that entered villages and homes early that morning.   

“Women were violently tortured… murdered and raped. Mothers were separated from their young children who were kidnapped to Gaza, Others were abducted from their homes in front of their children,” said the Israeli civil society group “Bring them Home Now,” in a report of their findings, launched in the presence of Michel Tieran, WHO Representative to Israel.

“There is a wide variety of evidence of sexual violence and horrific gender-based crimes among them videos of survivors, eyewitness, first responders… and forensic evidence,” said Dr Cochav Elkayam-Levy, an expert in international human rights law, at another event sponsored by an association of Harvard University medical students. She said videos released by Hamas and eyewitness accounts by responders described how some women were stripped, bound, and bloodied by acts of sexual violence before being killed or taken captive. 

Later in the day, Hamas’ armed wing, the Al Qassam Brigades, published a statement and video footage claiming that one Israeli female hostage, 19-year-old soldier Noa Marciano, had been killed in an Israeli airstrike, while another captive soldier was wounded.    

There are still no clues as to the whereabouts or condition of the hostages still presumed to be alive.  But some of the women are elderly and require medicines for chronic diseases; others are under treatment for breast cancer, the families noted in the event in Tel Aviv. They called upon UN Women, the International Committee of the Red Cross, and other UN organizations to review the evidence of sexual violence against victims and to demand access to the hostages in captivity, including not only women but some 30 children.   

Image Credits: @GazaReport, WHO/EMRO, @idfonline.

Alcohol has had a fairly easy pass from public health authorities – although the World Health Organization (WHO) recently asserted that there is no safe level of drinking, upending many people’s cherished illusion that a glass of alcohol at the end of the day is harmless.

RESET Alcohol, a new public health initiative led by Vital Strategies, aims to tackle alcohol’s ubiquitous influence primarily by working with governments to increase taxes.

The $15 million initiative will focus initially on Brazil, Colombia, Mexico, Kenya, the Philippines and Sri Lanka.

“We were looking for governments that are committed to doing alcohol policy work and could demonstrate that they were willing to go forward and, particularly, raise taxes,” said RESET director Jacqui Drope of the choice of countries. 

Population size and alcohol abuse burden were also factors, she added in an interview with Health Policy Watch.

Most of these countries already have alcohol taxes. In the Philippines, for example, alcohol taxes already help to pay for universal health care, while in Kenya, civil society advocates are fighting to make sure alcohol tax rates keep pace with inflation.

Following the tobacco control example

“The primary focus has always been on increasing alcohol taxation as it’s one of the most effective things you can do,” added Drope, who has a long history in tobacco control.

Cigarette taxes have been shown to curb smoking, particularly in young people. For example, in New York state cigarette taxes are the highest in the US and the state has seen youth smoking rates drop by more than 90% since 2000 as a result. 

RESET Alcohol will work mainly by supporting governments, civil society and research groups to build their capacity to implement and strengthen alcohol policy. 

It will do so in part by mentoring people in policy and regulation development, taxation research, strategic communication and advocacy, and alcohol data and monitoring systems.

RESET Alcohol Director Jacqui Drope

Not prohibition

The initiative isn’t about prohibition, Drope stressed: “We’re coming at this from a harm-reduction standpoint. That is why it is about policy and what we can do at the population level. We aren’t working at the individual level and prescribing what individuals do.

“We know this is an unhealthy product, and there’s good evidence from the WHO to show that there is no safe level [of consumption]. What we’re trying to do is reduce the harms through policy, rather than saying that people should never drink again. This isn’t what we’re trying to accomplish.”

‘War of perception’

For adults aged between 25 and 49, alcohol is the leading cause of death and disability globally based on the Global Burden of Disease analysis. 

“Often the underlying connection of alcohol consumption between these deaths – from liver disease, heart disease, cancer, violence, vehicle crashes, falls, tuberculosis, HIV/ AIDS, and other conditions – is overlooked,” according to Vital Strategies.

People calling for more alcohol oversight is “cast as a buzzkill”, according to the global health organisation.

“It’s a war of perception that claims millions of lives each year. Alcohol use remains stubbornly rooted as a cultural norm in most of the world, and few recognise it as a public health threat.”

Drope acknowledged that alcohol is so deeply entrenched that even the health sector has been complicit in perpetuating the notion that moderate alcohol consumption is healthy: “We have a lot of work to do and think about to change norms, and change how we talk about alcohol.”

At risk ‘from the first drop’

Recent data that shows half of all alcohol-attributable cancers in the WHO European Region are caused by “light” and “moderate” alcohol consumption – less than 1.5 litres of wine or less than 3.5 litres of beer or less than 450 millilitres of spirits per week. 

“This drinking pattern is responsible for the majority of alcohol-attributable breast cancers in women, with the highest burden observed in countries of the European Union (EU),” according to the WHO European Region.

“We cannot talk about a so-called safe level of alcohol use. It doesn’t matter how much you drink – the risk to the drinker’s health starts from the first drop of any alcoholic beverage. The only thing that we can say for sure is that the more you drink, the more harmful it is,” explained Dr Carina Ferreira-Borges, WHO regional advisor for alcohol and illicit drugs. 

Alcohol consumption and related deaths in different regions of the world

Globally, the WHO European Region – which includes heavy-drinking countries such as Czechia, Latvia, Lithuania, Russia and Germany – has the highest alcohol consumption level and the highest proportion of drinkers in the population. Over 200 million people in the region are at risk of developing alcohol-attributable cancer.

“Although it is well established that alcohol can cause cancer, this fact is still not widely known to the public in most countries. We need cancer-related health information messages on labels of alcoholic beverages, following the example of tobacco products; we need empowered and trained health professionals who would feel comfortable informing their patients about alcohol and cancer risk; and we need overall wide awareness of this topic in countries and communities,” added Ferreira-Borges.

In early November, WHO Europe Regional Director Dr Hans Kluge and the Director of the International Agency for Research on Cancer (IARC), Dr Elisabete Weiderpass, issued a joint statement to the European Parliament calling for more awareness about the link between alcohol and cancer.

“The contribution of alcohol consumption to cancer incidence and mortality should be clearly recognized without the use of any qualifiers or misleading adjectives such as ‘harmful’ or ‘heavy’ consumption of alcohol or ‘responsible drinking’,” they noted.

“Measures should be taken to clearly inform the public of this risk, which is not well known among the general population,” they added, pointing out that two WHO health plans “recommend the use of health warning labels on alcoholic beverage containers to inform the public about the health consequences of alcohol use”.

Image Credits: Unsplash, WHO .

Lab technicians at work in Cape Town’s Afrigen Vaccines & Biologics, one of the core partners in the WHO co-sponsored mRNA vaccine technology transfer hub, founded by WHO in 2021.  Much more needs to be done to foster local manufacturing of vaccines and health products, said participants at the Second World Forum.

A new Health Technology Access Pool (H-TAP), which aims to broaden the scope of IP and patent-sharing with low- and middle-income countries and a new African Union co-sponsored ‘manufacturing support platform’ were among the initiatives announced this week at the Second World Local Production forum in The Hague.

The global forum, the second ever to be convened, brought together industry, governments, civil society and multilateral organizations, including WHO, in a quest to bolster the local production of medicines and vaccines in underserved regions, particularly Africa, which was last in line to get COVID treatments during the pandemic.

The new H-TAP aims to overcome the shortcomings of the COVID-19 Technology Access Pool, C-TAP, which failed to gain significant buy-in from the industry. It also will include medicines and vaccines beyond COVID products, said Dr Yukiko Nakatani, Assistant Director-General for Access to Medicines and Health Products, at the Forum.  However, whether the new mechanism can really overcome the shortfalls seen in C-TAP, which drew little industry support, remains to be seen.

“Six license agreements for 15 health products have been agreed upon with Covid-19 technology holders – including from one private sector manufacturer. A serological test license from the Spanish National Research Center (CSIC) led to a sub-license to Biotech Africa to develop their diagnostic technology,” said Nakatani at the Local Production Forum, in his review of the slim achievements of the C-TAP pool.

“A review of C-TAP has been undertaken and a new technology access pool operating model is being developed and will be launched end of 2023. Stakeholders consultations will be held to help in the refinement and implementation of the model,” Nakatani said.

H-TAP and the WHO Pandemic Accord – interface unclear

As for further details on the H-TAP initiative, WHO did not comment.  However Ellen ‘t Hoen, head of the non-profit Medicines Law and Policy,  said that she expected the ongoing WHO member state negotiations on a new pandemic accord would also have to “address the need for the expansion of such a mechanism to enable the sharing of IP, including know-how and trade secrets.”

Meanwhile, in an open letter published at the start of the three-day Forum, a coalition of 30 prominent medicines access organizations, including Oxfam, the People’s Vaccine Alliance, Unitaid, and Public Citizen, warned that efforts to strengthen local medicines production in LMICs without addressing IP to “building a bridge to nowhere”.

“Plans and seed resources for building a bridge to local manufacturing abound, but they all have one feature in common – they systematically refuse to address the intellectual property barriers,” the open letter states.

At the World Health Summit in Berlin last month, German Health Minister Karl Lauterbach stated that any agreement without strong IP protections would “not fly” for Germany and its fellow EU countries, comparing IP to part of the EU’s “DNA.”

That stance was further reinforced at the start of the seventh round of INB negotiations on Monday when European countries asserted that any changes to IP rights should be thrashed out at the World Trade Organization (WTO) – not the WHO.

Tedros acknowledges the shortcomings of C-TAP model

WHO Director-General Dr Tedros Adhanom Ghebreyesus and Dutch Minister of Health Ernst Kuipers at the second World Local Production Forum in The Hague, Netherlands.

It took a staggering three years for a vaccine license to be shared with C-TAP, long after its potential to save lives had diminished. Aside from one Taiwanese firm, noit’s some private pharmaceutical company shared vaccines or therapeutics with the platform.

In his opening remarks, WHO Director General Dr Tedros Adhanom Ghebreyesus acknowledged the shortcomings of the C-TAP, the WHO’s ambitious platform aimed at facilitating patent-sharing for COVID-19 vaccines, treatments and medical technologies during the pandemic.

“The COVID-19 pandemic demonstrated the incredible power of vaccines, tests, treatments, and other medical technologies to save lives, but it also exposed the vast inequalities in our world,” Dr. Tedros stated. “Of course, this is not the first time.

“When HIV emerged over 40 years ago, life-saving medicines were developed, but more than a decade passed before the world’s poor got access to them,” he lamented. “When the H1N1 influenza pandemic struck 14 years ago, vaccines were developed, but by the time the world’s poor got access, the pandemic was over.”

However, the wakeup call provided by the pandemic also marked a turning point, Tedros and other speakers noted. That led to the creation of WHO’s mRNA vaccine technology transfer hub, launched in 2021 in South Africa.  Another global training hub in biomanufacturing capacity was also launched by WHO in collaboration with The Republic of Korea.

Local manufacturing has become more prominent on agenda now

Mapping of existing and planned manufacturing initiatives in Africa, as of December 2022.

The issue of local manufacturing was ignored for decades when UN-backed initiatives like The Global Fund to Fight TB, HIV/AIDS and Malaria, and Gavi, The Vaccine Alliance, channeled most contracts to a handful of large, well-established manufacturers in China, India, Europe or North America – ostensibly to reduce costs.  The concentration of their procurement, however, also tended to disadvantage local startups in other low- and middle-income countries, which could not compete with pharma giants in economies of scale, or pricing.   

Technology transfer and local production of medicines was first included on the agenda of the World Health Assembly (WHA) in 2018. During the WHA that year, Medecins Sans Frontières representative Elena Villanueva-Olivo condemned the failure of global research and development efforts and unequal access to affordable health technologies as “crises of international concern.”

Belatedly the pandemic cast a sharp light on the dearth of local manufacturing, particularly in Africa. It highlighted the long-term damage of concentrating procurement amongst only a handful of manufacturers, and highlighted how over time, more local manufacturing of essential medicines and vaccines could offer greater affordability and improved access to life-saving treatments, as compared to reliance on imports.

Since then, a flurry of new initiatives have been announced by WHO, the African Union and pharma companies themselves, including giants like Pfizer.  Big questions remain, however, regarding the durability and sustainability of the new projects in planning or already underway. 

New platform launched to support African manufacturers

The new Health Products Manufacturing Support Platform, launched at the Forum by Unitaid, the African Union Development Agency, and WHO aims to address some of those sustainability issues.

The platform will provide technical assitance to African manufacturers along the entire “health products manufacturing value chain,” its promoters said.

The support could range from technical assistance in “business management, sales and operations”, to support for the acquisition and development of active pharmaceutical products, and preparation of drug dossiers to ensure compliance with regulatory standards, the project initiators said.

The initiative calls upon African manufacturers, R&D centers and centers of excellence, as well as “market actors” including industry associations to collaborate in the initiative.

Over 79% of African pharma products are imported, while Africa supplies only 3% of global production of medicines and vaccines, it’s developers note.

Sidestepping IP issues? 

Filling vials for vaccine R&D at South African’s vaccine manufacturer Afrigen.

While developed countries and the private sector have emphasized the need to create a broad “ecosystem” to foster local manufacturing of health products, including investments in training, knowledge transfer and procurement preferences of global agencies and countries, civil society have long contended that IP restrictions constitute the key barriers:

“All of these hopes for local and regional production hinge on whether low- and middle-income countries (LMICs) have access to IP-protected research tools, technology platforms, product and process inventions, trade secrets, regulatory data, biologic resources (such as cell lines), and other knowledge essential to product development,” said the CSO  signatories to Monday’s letter. 

“We cannot be complacent – or resigned – to the siren song of purely voluntary measures and continued private hegemony over tools and knowledge by which the right to health is realized,” the letter states.

“We learned the painful costs of knowledge privatisation during the COVID-19 pandemic when major vaccine producers, including leading participants in the World Local Production Forum, refused to license their IP and share their breakthrough technologies and manufacturing know-how with capable producers in LMIC regions,” the coalition of civil society groups wrote in their letter to the forum.

“Instead of building bridges to nowhere, international and multilateral institutions … must finally commit to supporting countries in their collaborative efforts to overcome IP barriers that will otherwise stifle local manufacturing,” the signatories added.

A draft set of recommendations from the Forum, seen by Health Policy Watch recommends “four interrelated elements to an ecosystem that need to be present,” to stimulate local manufacturing, including:

  • The essential components of supplies, infrastructure, skills and technologies for manufacturing capacity.
  • Financial investments for procurement, the scaling up of production and the equitable distribution of health products.
  • Skilled and trained policy makers and regulatory authorities for product quality, safety and predictability.
  • Information on, for example, actual production capacity and market demand.

It also recommends the “establishment of a network for synchronizing training resources and facilities for building private and public sector capacity in manufacturing, technology transfer, R&D, policy, regulation and implementation. For the moment, access to IP and other know-how needed for R&D and manufacturing is not on the map.

Stefan Anderson contributed reporting for this story. 

Image Credits: Rodger Bosch for MPP/WHO, Netherlands MoH, Clinton Health Access Intiative , Health Products Manufacturing Support PlatformMSP , Rodger Bosch/ MPP & WHO.

Palestinian civil defence responders search the rubble of a building  for survivors in the aftermath of an Israeli air strike in the Gaza Strip.

There has been a massive rise in diarrhoea, respiratory infections and skin conditions and in Gaza since Israel’s siege and bombing of the territory began in early October, disrupting supplies of clean water, sanitation, food, fuel and leaving thousands homeless.

Since mid-October, over 33,551 cases of diarrhoea have been reported in the area, over half affecting children under age five, according to the World Health Organization’s (WHO) Eastern Mediterranean Region (EMRO). During 2021-2022, the average number of diarrhoea cases in children under five was around 2,000 a month.

Almost 55,000 people have been diagnosed with upper respiratory tract infections, over 12,600 with rashes, almost 9,000 with scabies and over 1000 with chicken pox.

United Nations (UN) aid agencies have also warned of cholera, typhoid and measles outbreaks as many people lack access to clean water, food and shelter.

No water in Gaza

In northern Gaza, the two main sources of drinking water, a desalination plant and a water connection from Israel, have been shut down for “several weeks”, while on 4 and 5 November, seven water facilities across the Gaza Strip were directly hit and sustained major damage, including three sewage pipelines in Gaza city, two water reservoirs (in Rafah and Jabalia refugee camp) and two water wells in Rafah, according to the UN’s Office for the Coordination of Human Affairs (OCHA).

OCHA said that by Thursday, all of the Gaza Strip’s 120 municipal water wells were expected to shut down as fuel to pump water is depleted. Israel said last week that it had restored supplies from two pipes into southern and central Gaza, one of which was damaged in the fighting. It is unlikely those supplies can reach the embattled north. 

Israel has blamed Hamas’s monopolization of scarce resources such as food, fuel and water for its own military purposes for the escalating humanitarian crisis in Gaza. But the daily volume of drinking water Israel has allowed to cross the Gazan border with Egypt is enough to serve just 4% of Gaza’s population, OCHA said in its daily update on Wednesday.

WHO EMRO reports that “lack of fuel has led to the shutting down of desalination plants, significantly increasing the risk of bacterial infections like diarrhoea spreading as people consume contaminated water” and has “also disrupted all solid waste collection, creating an environment conducive to the rapid and widespread proliferation of insects and rodents that can carry and transmit diseases”.

It added that “damaged water and sanitation systems, and dwindling cleaning supplies” have made it almost impossible for health facilities to maintain basic infection prevention and control measures. 

“These developments substantially increase the risk of infections arising from trauma, surgery, wound care and childbirth,” it added. An estimated 50,000 women are pregnant in Gaza.

Emergency Medical Teams (EMTs) have been deployed to support Shifa, Aqsa, and Abu Yousuf Al Najjar hospitals in expanding their emergency departments’ capacity.

‘Disastrous conditions’ at biggest hospital

Meanwhile, the medical conditions at Al-Shifa, the largest hospital in the Gaza Strip and one of the oldest Palestinian health institutions, are “disastrous”, according to a joint statement by the United Nations Relief and Works Agency for Palestine Refugees (UNRWA) and WHO. 

Fierce fighting between Israel and Hamas has reportedly been raging for the past several days in the vicinity of the hospital, an area Israel has described as a major Hamas command and control centre.

“There are currently almost two patients for every bed available. The emergency department and wards are overflowing, requiring doctors and medical workers to treat wounded and sick patients in the corridors, on the floor, and outdoors.”

“The number of wounded increases by the hour while patients are undergoing immense and unnecessary pain as medicines and anaesthetics are running out,” they added.

Dr Marwan Abusada, the hospital’s head of surgery, told The Guardian that they have “zero capacity”. 

“We have 153 patients at the ER. All the beds are occupied. We have no space for patients to go after they undergo surgery. We have a type of worms [in] the wounds after the surgery. Most injuries and surgeries have no follow-ups as the medical teams cannot cope with the influx of injuries every hour,” said Abusada.

On Wednesday, the UNRWA facilitated the delivery of WHO’s emergency medical supplies and medicines to Al-Shifa Hospital in Gaza City,” only the second delivery of lifesaving supplies to the hospital since the escalation of hostilities and the total siege of Gaza began”.

Out of almost 1.5 million displaced people, nearly 725,000 are in 149 UNRWA facilities, while 122,000 are sheltering in hospitals, churches, and other public buildings, and about 131,134 in 94 non-UNRWA schools, while others are living on the streets near hospitals.

Shelters run by UNRWA are so overcrowded that an average of 160 people are sharing a toilet and there is one shower for every 700 people, according to the agency.

France hosts Gaza conference

Delegations from over 80 countries and organisations met on Thursday at the International Humanitarian Conference for the Civilian Population in Gaza hosted by France on the eve of its annual Paris Peace Conference.

United Nations (UN) Under-Secretary-General for Humanitarian Affairs Martin Griffiths told the conference that the UN “cannot be part of a unilateral proposal to push hundreds of thousands of desperate civilians in Gaza into so-called safe zones”  if there is no agreement between all the parties on the establishment of these zones.

Calling for an immediate humanitarian ceasefire, he also expressed concern that “satisfactory conditions do not exist anywhere in Gaza to ensure adequate shelter, food, water, sanitation and health”.

Meanwhile, International Rescue Committee President David Miliband told CNN on Wednesday that a humanitarian ceasefire in Gaza needed to last for an “absolute minimum” of five days to allow aid agencies to do their work. Israel gave people in northern Gaza four hours to leave the territory on Wednesday before it intensified its attacks again.

“There needs to be a massive scale-up of the aid flows – that’s medicines, that’s non-food items, that is food, that is water, the basics of life and the fuel to get those goods around the Gaza Strip,” said Miliband.

“Second, you can’t deliver aid without aid workers,” he added, but it was unsafe for them to operate. 

“Thirdly — essential — we’ve got to be able to have safety for civilians who come to receive aid when they bring their kids when they bring their wounded, they’ve got to be able to be safe in a health centre,” added Miliband, warning of the threat of cholera, measles and typhoid.

On Thursday, the US White House announced that Israel had agreed to daily four-hour military pauses in northern Gaza, which would be announced three hours beforehand. They are intended to encourage people to flee to the south via two humanitarian corridors that have also been agreed upon.

No end in sight as war enters second month 

A Palestinian Civil Defense vehicle was struck by an Israeli air strike on 21 October. The strike killed between 6 and 10 civilians, according to Airwars.

As the brutal war between Israel and Hamas presses on into its second month, over 10,569 people – one in every 190 Palestinians living in Gaza – are dead, according to the Gaza Health Ministry. The Ministry does not distinguish between combatants and civilians.

Nearly 1,400 Israelis and foreign nationals have been killed in Israel, the vast majority on 7 October, according to Israeli authorities. Some 240 men, women and children kidnapped by Hamas and other militias on the day of the attack continue to be held hostage. Their locations within Gaza and the number still alive are unknown.

UN Secretary-General Antonio Guterres strongly condemned both Hamas’s brutal and deadly assault on thousands of Israeli civilians on 7 October, as well as its war tactics of embedding military facilities into critical civilian infrastructure and using civilians as “human shields,” in an interview with Reuters on Wednesday.

Hamas has fired over 9,500 missiles into Israeli cities since its 7 October incursion into 22 Israeli communities where civilians  were shot and burnt to death in their homes. Hamas-aligned militias in southern Lebanon have also stepped up their missile attacks into northern Israeli cities, reaching as far as the outskirts of Haifa.

Guterres also emphasised the deadly toll the massive Israeli airstrike campaign is inflicting on civilians in Gaza: “When one looks at the number of civilians that were killed with the military operations, there is something that is clearly wrong.”

The first 19 days of the war saw Israel conduct over 7,000 airstrikes on Gaza, killing an estimated 6,500 people. The 7,000 bombs dropped on Gaza – a territory half the size of New York City – in under three weeks outpaced even the most intense month of the bombing campaign by the US-led coalition against the Islamic State in Iraq and Syria (ISIS), according to Airwars.

The rate at which Israeli airstrikes are hitting Gaza ranks as one of the most intense campaigns of the 21st century. The deadly toll on humanitarian, medical and media workers has been unprecedented.

The war in Gaza is already the deadliest conflict for journalists since the Committee to Protect Journalists (CPJ) began gathering data in 1992. As of 9 November, 39 journalists – 34 Palestinian, four Israeli and one Lebanese – were confirmed dead, according to the CPJ. This accounts for 70% of journalists who have lost their lives reporting since the start of 2023.

The situation for humanitarian workers is even more dire. UNRWA announced on Wednesday that two members of its staff had been killed in the preceding 24 hours. Seven more UNRWA staffers were confirmed dead by the time the agency’s Commissioner General, Philippe Lazzarini, spoke at the international conference on Gaza in Paris on Thursday.

The 99 UNRWA staffers killed since the onset of the war is “the highest number of United Nations aid workers killed in a conflict in the history of the United Nations,” the agency said.

Civilian lives buried beneath a war of numbers 

The deaths in Gaza include at least 2,550 women and 4,237 children, with another 25,956 people injured, Gaza’s Health Ministry has said. A further 2,260 people are reported missing, many presumed to be buried beneath the rubble left behind by Israeli air strikes, including 1,270 children. The Gaza Health Ministry is controlled by Hamas. 

More than 1.5 million Palestinians – three-quarters of the population of Gaza – have been displaced since the start of Israel’s military operations in the enclave. The flow of aid on which Gazans depend has slowed to a trickle. In peacetime, around 500 trucks transporting humanitarian aid and commercial goods entered Gaza every day. But a month after the Hamas attack on Israel, just 650 trucks had been allowed to enter the enclave. 

One out of every 19 people in Gaza are either injured, missing, or dead, according to Gaza Health Ministry figures. Hamas is estimated to have a fighting force of between 20,000 and 30,000 combatants – 1.5% of the population of Gaza. Children, meanwhile, make up around 47% of Gaza’s population, according to UNICEF. 

“We need to distinguish – Hamas is one thing, the Palestinian people (are) another,” said Guterres. “If we don’t make that distinction, I think it’s humanity itself that will lose its meaning.”

Gilad Erdan, Israel’s Ambassador to the United Nations, shot back at the UN chief, stating that Israel is working to limit civilian casualties and has opened an evacuation corridor to South Gaza, while Hamas targets Israeli civilians. 

“Would the Secretary-General dare say that since the number of German civilian casualties during World War II was higher than American or British civilian casualties, it meant that something was ‘wrong’ with the US and UK military operations when fighting a genocidal regime?” Erdan told Reuters, adding that the death toll provided by the Gaza Health Ministry should not be trusted. 

Israeli officials have repeatedly disputed the casualty figures provided by the Gaza Health Ministry, citing its lack of distinction between civilian and military casualties and influence exerted by Hamas over death tolls. US President Joe Biden has voiced similar scepticism, stating on October 27 that he had “no confidence in the number that the Palestinians are using”. 

However, the Gaza Health Ministry’s death tolls from previous wars with Israel have proven reliable. The numbers provided by the Ministry during clashes with Israel in 2008, 2014 and 2021 all matched – with small discrepancies – the post-war tallies reached by UN, independent, and even Israeli investigations. 

“The numbers may not be perfectly accurate on a minute-to-minute basis,” Michael Ryan, head of the WHO’s Health Emergencies Program said of the Gaza Health Ministry figures. “But they largely reflect the level of death and injury.”

Children dying at an unprecedented rate 

The estimated 4,237 children killed in Gaza account for 40% of all deaths since the war began, a staggering rate with few precedents. 

Three weeks into the war, Save the Children revealed the number of children killed in Gaza was greater than the total number of children who lost their lives in all global conflicts since 2019. A further 980 children in Gaza have been confirmed dead since that report. 

“An average of about 160 children are killed every day based on the figures of the [Gaza] Ministry of Health,” WHO spokesperson Christian Lindmeier said at a media briefing on Tuesday.

Seven years into the ongoing Yemeni civil war, a conflict in which both sides have employed child soldiers and notorious for its high rate of child casualties, 3,773 children – fewer than in just one month of the war in Gaza – have died, according to the UN. The deadliest conflict for children in recent decades is the Syrian civil war, in which 27,126 children were killed in over 10 years of fighting. 

If child deaths continue to proceed at the current rate, the number of children killed in Gaza would match that of more than 10 years of Syria’s civil war in around seven months.

The historic rate at which children are losing their lives in Gaza is transforming the enclave into “a graveyard for children”, Guterres said on Monday. 

“Every year, the highest number of killings of children by any of the actors in all the conflicts that we witness is the maximum in the hundreds,” said Guterres in an interview with Reuters on Wednesday. 

“We have in a few days in Gaza thousands and thousands of children killed, which means there is also something clearly wrong in the way military operations are being done,” he stated.

Hamas’s bloody calculation

Flames and smoke billow during Israeli strikes in Gaza, which have caused an unprecedented level of destruction since the 7 October Hamas incursion into Israel.

To Hamas leadership, the deaths and displacement of Palestinian civilians are not a surprising or unwanted outcome, but a pivotal part of a bloody calculation, according to new reporting based on interviews with its senior leadership in Doha, Qatar. 

“We succeeded in putting the Palestinian issue back on the table, and no one in the region is experiencing calm,” Khalil al-Hayya, a high-ranking member of Hamas’s leadership, told the New York Times of the largest massacre of Jews since the Holocaust.

“What could change the equation was a great act, and without a doubt, it was known that the reaction to this great act would be big,” al-Hayya added when asked about the scale of civilian deaths in Gaza.

The terror group’s leaders have repeatedly declined to express any remorse for the brutal actions of its fighters in the raid on Israel and its citizens that left 1,400 dead and more than 200 taken hostage.

“We had to tell people that the Palestinian cause would not die,” al-Hayya concluded, regarding the thousands of Palestinian and Israeli lives lost since the Hamas attack on 7 October.  

On Thursday, Palestinian terror group Islamic Jihad released a video of two hostages, offering their release. The captives include a 77-year-old woman and a 13-year-old boy, abducted with his brother, father and partner, from Kibbutz Nir Oz.

Negotiations are reportedly underway in Doha between Israel, the United States and Qatari mediators over the possibility of the release of 10 to 15 hostages in exchange for a one-two-day humanitarian pause, Reuters reported.  

“Israel is a country that has no place on our land,” declared Hamas official Gazi Hamad in a Lebanese TV interview last week. “The existence of Israel is illogical….7 October, 10 October, 1 million October, it is justified.”

Elaine Ruth Fletcher contributed to this report. 

Image Credits: Airwars, WHO EMRO.

Pandemic agreement negotiations are underway again this week

An effective pandemic agreement will need to include “accountability mechanisms” to ensure that countries implement the terms – and these will need to be independently monitored, according to new research published in BMJ.

“Accountability mechanisms are used through a variety of methods across global treaties and governance mechanisms to varying degrees of effectiveness,” argue the researchers, based on their evaluation of other global treaties and interviews with experts. 

“The pandemic agreement should have accountability mechanisms built into it from the start to increase the likelihood of countries complying with the obligations they sign up for.”

 

‘Soft incentives’ for compliance

While finding consensus is the current imperative for the INB, there is a risk that countries will simply fail to implement the terms of a pandemic agreement.  During the COVID-19 pandemic, for example, many countries did not comply with the  International Health Regulations (IHR), despite the fact that they are legally binding.

To enhance compliance with a pandemic agreement, the researchers – mostly from Spark Street Advisors – argue for the provision of “soft incentives” such as “technical and material resources” to help countries.

“Reputational incentives” could also assist with compliance, they add, arguing against “the harms of sanctions and benefits-based incentives”.

But compliance with the terms of the agreement should not simply rely on countries’ self-reporting, as is the case with many international agreements.

“The pandemic agreement should establish, as part of its institutional arrangements, an independent monitoring committee, tasked with producing regular assessments of state parties’ compliance with the pandemic agreement and the timeliness, completeness and accuracy of self-reporting,” they argue.

This monitoring committee “should be politically, financially, technically and operationally independent of the WHO and donors”, and able to” triangulate” information from a diverse range of sources including civil society about countries’ compliance.

It would report to a high-level political body to promote compliance with the pandemic agreement.

‘Find common ground between public health and profit’

Meanwhile, Dr Tedros Adhanom Ghebreyessus, the Director-General of the World Health Organization (WHO), appealed to member states negotiating a pandemic agreement to find “common ground”  between equitable access and innovation; protecting public health and making a fair profit; global health security and national or regional interests. 

Addressing a closed session of the seventh meeting of the intergovernmental negotiating body (INB) in Geneva on Wednesday, Tedros warned that “a pandemic agreement that fails to ensure collective security and equity in all its forms, fails”. 

Referring to “numerous meetings” in the almost two years since a special session of the World Health Assembly decided to establish the INB, Tedros said “I believe strongly that this [negotiating] text may help you come closer together on the path towards consensus.

“No one is pretending your work is easy. I know it is not. It is not surprising that, with 194 member states, reaching consensus is not straightforward. But that does not mean it is unachievable,” said Tedros, whose INB speech was released by WHO.

Sovereignty ‘nonsense’

Tedros also appealed to member states to counter the “torrent of fake news, lies, conspiracy theories and mis- and disinformation”. 

“There are those who say – whether they believe it themselves or not – that the accord will cede sovereignty to WHO; that it will give the WHO Secretariat power to impose lockdowns or vaccine mandates on countries, and other nonsense. 

“You know and we know that the agreement will give WHO no such powers.  We need your support to put this nonsense to rest.  We need your support to counter these lies, by speaking up at home and telling your citizens that this agreement will not, and cannot, cede sovereignty to WHO. Period.”

The seventh INB meeting started on Monday, will break on Friday, and then resume on 4-6 December.

As the world teeters on the brink of climate catastrophe, major fossil fuel-producing nations plan to expand production.

Amidst a global chorus calling for urgent action on climate change, major fossil fuel producers are doubling down on their plans to expand production, defying climate science and “throwing humanity’s future into question”, a UN report revealed on Wednesday.

The report, compiled by the United Nations Environment Programme (UNEP) in collaboration with academic partners, scrutinized the plans of the 20 largest fossil fuel-producing countries, responsible for a staggering 84% of global carbon emissions and roughly three-quarters of the world’s fossil fuel consumption in 2021. 

The findings paint a grim picture: governments’ plans show they intend to produce, in total, 110% more fossil fuels in 2030 than are compatible with the 1.5°C limit set out in the Paris Agreement, and 69% more than is consistent with 2°C of warming.

The analysis found national fossil fuel plans would result in 460% more coal, 83% more gas, and 29% more oil production in 2030 than the world can afford to burn on its increasingly miniscule 1.5 C carbon budget.

The findings underscore the persistent gap between national climate pledges and fossil fuel production, a worrisome trend that has remained largely unchanged since the UN first quantified it in 2019.

“The addiction to fossil fuels remains deeply entrenched in many nations,” said Inger Andersen, Executive Director of UNEP. “Governments must stop saying one thing and doing another … [these] plans to expand fossil fuel production are undermining the energy transition needed to achieve net-zero emissions, throwing humanity’s future into question.” 

“The fossil fuel production gap, the difference between governments’ plans and projections and levels consistent with limiting warming to 1.5°C and 2°C, remains large and expands over time,” the report found.

None of the top 20 fossil fuel-producing countries have committed to aligning their output of oil, coal and gas to limit warming to 1.5°C, despite 17 committing to net-zero emissions pledges, the report found. All continue to subsidise, support and plan expanded fossil fuel production. 

The combined levels of coal, oil, and gas production planned by 10 high-income countries alone would already exceed 1.5°C-consistent pathways for each fuel by 2040, the report found.

The lack of progress by major polluters in realigning their production of fossil fuels with global climate targets comes against a backdrop of new records for global greenhouse gas emissions, sea levels, and fossil fuel subsidies set in 2022. In 2023, one-third of days have seen average global temperatures exceeding 1.5°C over pre-industrial levels.

“The whole world is clinging to the handrails on a boat that is lurching through increasingly turbulent seas,” said Andersen. “Nations must unite behind a managed and equitable phase-out of coal, oil and gas — to ease the turbulence ahead and benefit every person on this planet.”

UN Secretary-General Antonio Guterres, a vocal critic of fossil fuel interests, expressed dismay at the report’s findings. “Governments are literally doubling down on fossil fuel production,” he said, emphasizing the need for credible commitments to ramp up renewables, phase out fossil fuels, and boost energy efficiency while ensuring a just, equitable transition.

India, Saudi Arabia, and Russia lead fossil fuel expansion surge

Government plans and projections would lead to an increase in global coal production until 2030, and in global oil and gas production until at least 2050, the end of the time frame covered by the report. These findings contrast with those of the IEA, which forecast a peak in demand for all three fossil fuels by 2030.

India, Saudi Arabia, and Russia are spearheading the global surge in fossil fuel production, with their expansion plans accounting for the largest share of carbon emissions for coal, oil and gas, respectively, according to the report. 

India’s coal production plans dwarf any other nation, with its Ministry of Coal projecting domestic coal production to more than double to 1.5 billion tonnes by 2030. In March 2022, the Indian government set a goal of increasing production by state-owned Coal India Limited (CIL) alone to one billion tonnes by 2024.

Saudi Arabia, which relies on oil and gas production for half of its GDP, is planning the largest single-country increase in oil extraction. Documents from state-owned Saudi Aramco, which controls nearly a fifth of global oil output, suggest a 47% increase in production by 2050. Aramco also plans to ramp up natural gas production to meet future demand.

Russia, the world’s largest gas exporter, also has ambitious expansion plans. The most recent government figures project coal production increases of between 11% and 53%, and between 6% and 31% for gas by 2035. 

Russia’s energy exports have become a lifeline for the country’s foreign reserves and economy, which have been severely strained by international sanctions and wartime expenditure stemming from its invasion of Ukraine in February 2022.

The United States, Canada, Australia, Norway, and the United Kingdom also play a significant role in fossil fuel expansion plans. According to a recent analysis by Oil Change International, these five countries account for 51% of planned new oil and gas extraction by 2050. 

The United Arab Emirates, hosts of the upcoming UN climate summit starting on November 30, plans to boost its oil production by one million barrels per day by 2027 and increase its natural gas production by 259% by 2028 as part of a $150 billion investment plan in its national oil company, ADNOC. Sultan al Jaber, president of the UN climate summit, serves as the president of ADNOC.

“Governments offer a variety of rationales for increasing production: reducing import dependency, generating government revenue … and winning out as one of the last producers in a shrinking market,” Michael Lazarus, a lead author of the report, said at a closed-door media briefing on Monday.

“But when you take all these reasons together, that’s what leads to the production gap itself – the desire for each country to maximize their own production,” Lazarus added.

Money, money, money

The top 10 countries in extraction-based greenhouse gas emissions account for 75% of the global total, while the top 35 countries account for 96% (data represents 2021 levels).

The report’s findings underscore the crux of the fossil fuel crisis: governments and private companies continue to reap massive profits from fossil fuel production, creating a disincentive for any party to exit the lucrative market. 

Amidst an energy crisis triggered by Russia’s invasion of Ukraine, which caused oil and gas prices to skyrocket, major oil companies more than doubled their annual profits to a record $219 billion in 2022. Buoyed by record profits, major petroleum companies have quietly retreated from their already modest climate commitments.

In October, American fossil fuel giants ExxonMobil and Chevron reaffirmed their expansion plans, both announcing acquisitions of smaller shale producers in the United States for a combined total of over $100 billion. The United States is the largest producer of oil and gas in the world. 

In India, low monsoon rainfall over the summer months led to a surge in electricity consumption. Adani, the country’s second-largest power producer, responded by amplifying coal generation, from which it raked in $792 million, compared to $84 million the year prior, Semafor reported this week.

The Organization of the Petroleum Exporting Countries (OPEC), the global oil cartel that supplies 51% of the world’s oil and controls 81% of proven oil reserves, forecast in its annual report released last month that it expects oil demand to increase by 17% by 2045.

In the foreword of the report, OPEC Secretary General and Kuwaiti oil executive Haitham Al Ghais cautioned against calls to halt investments in new oil projects, asserting that such measures could lead to “energy and economic chaos.”

Scientific consensus and expert bodies agree that new oil and gas field development is incompatible with all pathways for limiting global warming to 1.5 degrees Celsius.

“This is the heart of the problem,” said Ploy Achakulwisut, a lead author of the report. “Major producers are not willing to transition from fossil fuel production.” 

Expanding fossil fuels: Economic ‘insanity’ 

Despite plans by leading fossil fuel producers to expand output, the IEA projects fossil fuel demand will peak by 2030 due to the accelerating economic momentum of renewables.

The International Energy Agency’s (IEA) latest annual report, released in October, projects a significant shift towards renewable energy sources in the coming decade. By 2030, renewables, including solar, wind, and hydropower, are expected to account for nearly half of the global electricity mix, up from around 30% today.

IEA Executive Director Fatih Birol emphasized the irreversible nature of this transition, declaring it “unstoppable.”

“It’s not a question of ‘if’, it’s just a matter of ‘how soon’ – and the sooner the better for all of us,” said Birol. “Taking into account the ongoing strains and volatility in traditional energy markets today claims that oil and gas represent safe or secure choices for the world’s energy and climate future look weaker than ever.”

This rapid transition towards clean energy renders planned expansions in fossil fuel production economically questionable, according to experts.

“Government production plans and targets, help to influence legitimise and justify continued fossil fuel dependence,” said Achakulwisut. “At the same time, many of these investments and infrastructure are at risk of becoming stranded assets as the world decarbonises.” 

Despite the growing adoption of green technologies, the allure of fossil fuel profits continues to hold sway, preventing countries from decisively stepping away from these energy sources. This reluctance stems, in part, from fears of losing out on market share in a shrinking market. 

“Despite their climate promises, governments plan on ploughing yet more money into a dirty, dying industry, while opportunities abound in a flourishing clean energy sector,” said Neil Grant, an environment analyst at Climate Analytics and a co-author of the report. “On top of economic insanity, it is a climate disaster of our own making.”

Major fossil fuel producers resist loss and damage fund

The US, the largest producer of oil and gas in the world, threatened earlier this week to exit loss and damage fund negotiations altogether.

As the largest fossil fuel-producing nations refuse to halt their expansion of coal, oil, and gas production, they are also resisting calls to compensate vulnerable countries for the climate-related damages they are causing and help them prepare for the escalating dangers of a warming climate.

Tensions are escalating ahead of the crucial UN climate summit, COP28, over the establishment of a loss and damage fund, a cornerstone of the global climate response and the crowning achievement of last year’s UN climate summit in Egypt.

The fund, aimed at compensating developing nations for the impacts of climate change, was nearly derailed at a recent preparatory meeting in Abu Dhabi due to financing disagreements led by the United States, which signalled that it is unwilling to provide any funding beyond voluntary contributions.

Developing countries, bearing the brunt of climate change impacts, have staunchly opposed the US proposal to house the fund at the World Bank, citing the institution’s outdated structure and excessive US influence.

China is also playing a pivotal in discussions surrounding the fund, urging the United States to make substantial contributions while remaining careful to sidestep any financial obligations of its own.

Outi Honkatukia, co-chair of the Abu Dhabi negotiations, called reaching an agreement on the fund “mission impossible”. A shaky agreement was reached, but it fell short of consensus, leaving the fund’s future uncertain. For now, the fund will be housed at the World Bank, a key U.S. demand, but developing countries hope this is a temporary step toward an independent fund. The battle will continue at COP 28 in Dubai.

“The US’s inability to agree on even a watered-down text highlights their lack of commitment to establishing an effective fund,” Lien Vandamme, a senior campaigner at the Center for International Environmental Law, told Politico.

The fate of the loss and damage fund hangs in the balance, casting a shadow over the upcoming COP28 climate summit. Its failure to materialize could jeopardize the overall progress of climate negotiations.

Image Credits: UNEP, UNEP .

A tobacco crop in northern Malawi

BLANTYRE, Malawi – Boyden Ndlovu of Mzimba district, one of Malawi’s tobacco growing districts located in the northern region says that his lifetime has been synonymous with tobacco farming.

Tobacco has been a mainstay of Malawi’s economy, historically generating about 70% of export revenue and now accounting for over half – yet the country finally ratified the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) in August this year.

The FCTC, adopted by the World Health Assembly in 2003, is designed to protect present and future generations from the devastating impact of tobacco consumption and exposure to tobacco smoke by reducing both demand and supply of tobacco. 

Article 17 of the Convention requires signatories to promote economically viable alternatives to tobacco.

But Ndlovu, although knowledgeable about crop diversification, swears he will never quit tobacco farming because it’s the only “lucrative crop” in Malawi. 

“My parents educated us with proceeds from tobacco farming. I have never had a white-collar job in my life, I’m content being a farmer,” says Ndlovu, who has been a tobacco farmer for 35 years.

He believes tobacco farming has always been very profitable because the prices are in dollars, boasting that the 2022/23 farming year had better prices with an average selling price of $2.35 per kilogram. 

At first, Ndlovu explains, he farmed tobacco on all of his 35 hectares, but this has changed over the years due to fluctuating tobacco prices. He now farms tobacco on only eight hectares, growing food crops such as maize, legumes, fruits and vegetables on the rest.

“Many tobacco farmers have moved away from growing tobacco to legumes and other presumably cash crops. Most farmers were discouraged by the global anti-smoking lobbies and erratic profits threatening the industry,” Ndlovu tells Health Policy Watch.

There were a few farmers in the last tobacco growing season, he adds. “I believe this contributed to the few to make more profits. Many farmers who moved away didn’t make much money from legumes. I’m foreseeing an increase in tobacco growers this year.”

Tobacco farmer Boyden Ndlovu of Mzimba district in Malawi

Industry manipulation

But Ndlovu’s tobacco “lucrative” farming is partly supported by the tobacco industry’s contract farming system. Farmers are granted loans by commercial banks that enable them to buy what they need to produce quality tobacco, backed by the tobacco companies’ guarantee that they will buy their tobacco. The loan amounts are deducted at source and farmers are given the remaining amount as their profit.

Dr Lonjezo Masikini-Phiri, a social science lecturer at the University of Bath and an expert on tobacco production in Malawi, observes that Malawi’s tobacco production is heavily influenced by the industry’s multinational companies. 

These companies prefer to buy African tobacco as it is cheaper, thus enabling higher profits. In addition, tobacco growing has decreased in the United States and United Kingdom.

Masikini also observes tobacco multinational companies have supported tobacco farmers to grow legumes alongside tobacco – largely to enrich the soil for tobacco, and possibly also to counter the anti-tobacco lobby’s argument that tobacco farming is undermining food production.

“Malawi should look ahead on what the ratification of the FCTC means. The country should use this opportunity to lobby for tobacco-shifting diversity projects or funding so that the farmers are attracted to food crop farming. This however requires a political will to be implemented,” he says.

Production decline

Malawi is one of the top five producers of tobacco in the world. Malawian tobacco is found in blends of nearly every cigarette smoked in industrialised nations including Camel and Marlboro brands, according to the Malawi Investment and Trade Centre. 

The main tobacco-growing countries in Africa are Zimbabwe (25.9% of total output), Zambia (16.4%), Tanzania (14.4%), Malawi (13.3%) and Mozambique (12.9%). n.

But Malawi’s Minister of Agriculture, Sam Kawale, told Health Policy Watch that the FCTC is not a threat to the country and that his ministry and the health ministry are working together to find ways to protect the population from tobacco harm and ,at the same time, stimulate the economy.

 “We have been encouraging farmers to diversify their crop production. This is important, even now that we have climate change. We are encouraging them to grow drought-, pest-, and disease-resistant crops, as well as invest in irrigation,” he said.

Dr Rosemary Hiscock, a research associate at University of Bath’s Department of Heath,  says the amount of land used to grow tobacco in Africa appears to be declining.

Exports by tobacco leaf volume have been in decline since 2018 and export value has mostly been in decline since 2016.

The UN estimates that in 2019, 616 527 tonnes of tobacco leaf was exported from Africa. 

But in 2021, 519 121 hectares of land were used to grow tobacco and 564,960 tonnes were grown in Africa. Of this, 550 916 tonnes (98%) were estimated to be exported. 

The UN estimates that tobacco production took up less than 1% of land used for crop production in Africa.

Hiscock says Africa’s proportion of global leaf production is estimated to have increased slightly between 2012 and 2021 from 7% to 10%. 

“However the increase is related to a decline in the production of tobacco in the rest of the world rather than an increase in production in Africa,” she explains.

Clinging to ‘green gold’

Interestingly, farmers do not fear that the FCTC ratification could be Malawi’s economic suicide.  

Nixon Lita, CEO of the Tobacco Growers Association of Malawi (TAMA)

Nixon Lita, CEO of the Tobacco Growers Association of Malawi (TAMA), says farmers believe that Malawi being part of the discussions relating to tobacco through FCTC could offer alternative economic opportunities.

“We encourage farmers to diversify alongside tobacco but unfortunately tobacco production makes a lot of economic sense to farmers unlike most of the alternatives. Ratification does not demand a stop to growing,” he told Health Policy Watch.

Lita says that TAMA does not have data on tobacco farmers growing food, but notes that farmers usually reduce their tobacco production after a year of unsatisfying prices. 

“For example, 2023 good prices are likely to influence an increased production for the 2024 market. Previously, 2011 poor prices led to a slump in the production for the 2012 market,” he says.

“Farmers are attracted to tobacco upon being convinced of getting good profit after production and sales. Other alternative crops have failed to convince them of economic benefits, profitability and market access. There is a global demand for tobacco which Malawian farmers are failing to meet,” Lita stresses.

Malawian Agricultural expert Tamani-Nkhono Mvula says Malawi’s argument remains that if the amount of tobacco is reduced or halted, the livelihood of millions of people and national economy will be affected.

He notes that, although FCTC has led to a decrease in tobacco consumption in Europe and North America, it is increasing in countries like China.

“It’s the Chinese who are also buying a lot of Malawi’s burley tobacco.”

Nkhono-Mvula states that although farmers are encouraged to grow legumes, they are unlikely to be convinced of the same in the next farming season considering losses made in the last farming year.

He observes that tobacco’s biggest advantage is a well-organised value chain where farmers are guaranteed a market and a good price.

“If someone is growing soya, they are not sure of the market or profit. In such situations, it will be difficult for Malawi to stop growing tobacco as long as the tobacco market is going to be profitable and well structured,” Nkhono-Mvula said.

Vincent Kimosop, a Kenyan-based policy and governance expert, urges the Malawi government to progressively introduce measures to support farmers to adopt viable economic alternatives.

“This has been done in many countries including Brazil and there are lessons that can be borrowed by Malawi,” he observes. 

He cites the Kenyan example, where the government has taken steps to enlighten farmers that there is no future in tobacco farming although it is still struggling to find ready market alternatives.

Food crops quest

Nkhono-Mvula says that although tobacco is Malawi’s economic backbone, its agricultural land is geared towards maize, the staple crop, followed by cassava and sweet potatoes.

“It’s the estates that may have larger land for tobacco growing and not the small holder farmers. A tobacco crop in itself doesn’t deplete the soil, but it’s the chemicals used that do. They, in the long run, may have an effect on the soil. 

“The use of trees to dry the tobacco also leads to environmental degradation,” Nkhono-Mvula says.  

Hiscock suggests improving the supply chain for alternative crops, including building up extension services so farmers can grow other crops efficiently and ensuring there are guaranteed buyers for other crops.

She also suggests “educating farmers to understand that they rarely make long-term profits from tobacco”.

She also recommends tobacco control measures to reduce internal demand for tobacco, such as “tobacco taxes, ‘smoke free’ buildings, graphic picture warnings on packaging, plain packaging and banning flavoured tobacco products”.

Preparing to plant tobacco at Ndhlovu’s farmer. Tobacco farmers and workers are exposed to toxins from the fertiliser and nicotin.

Meanwhile, Malawi’s Ministry of Health (MoH) says the country ratified the FCTC to protect citizens  from the harmful effects of direct or indirect exposure to tobacco and its products, which is aimed at reducing lung cancer, cardiovascular and respiratory diseases.

“Malawi ratified to show high-level political commitment to reducing public health effects and from tobacco products. With that high level political commitment, Malawi can negotiate with investors on its diversity plans,” says MoH spokesperson Adrian Chikumbe.

Tobacco is also unhealthy for farmers, labourers and their families as well as factory workers who process it.

Dr William Maina from the WHO’s Africa Regional Office, points out that farmers have prolonged exposure to toxins in the chemicals used, and exposure to nicotine when picking the tobacco leaf.

“A tobacco farmer who plants, cultivates and harvests tobacco may absorb nicotine equivalent to 50 cigarettes per day,” said Maina.

Tobacco growing and manufacturing also threatens biodiversity, negatively impacts soil health by causing nutrient depletion and soil erosion which results in global deforestation and produces environmental harm such as toxic emissions, greenhouse gases and air pollution.

“Most of the tobacco-growing countries in Africa are suffering from food and nutritional deficiencies. However, most of the fertile and arable land has been put on tobacco growing instead of food production. Diverting prime land away from food production is contributing to world hunger.”

He suggests that countries whose economy relies on tobacco should assist their farmers to switch to alternative crops and other livelihoods that provide them with equivalent or higher returns compared to tobacco with reduced labour and exposure to health and environmental risks.

“Governments should stop providing direct tobacco subsidies to tobacco farming and reallocate these to tobacco control programmes including, where applicable, support to alternative livelihoods to tobacco programmes and agriculture extension services,” he advised.

Image Credits: Josephine Chinele.

In Pakistan, a healthcare worker listens to a child’s lungs for signs of pulmonary tuberculosis.

A massive 7.5 million people were diagnosed with tuberculosis in 2022, the highest number ever – but this is positive as it indicates that countries’ ability to detect the disease is recovering after the COVID-19 pandemic, according to the World Health Organization (WHO) 2023 Global tuberculosis (TB) report.

The two countries that contributed most to the global rebound in new diagnoses were India and Indonesia, together accounting for 56% of the increase between 2021 and 2022. They were followed by Philippines (11% of the global increase) and Pakistan (8.4%).

Meanwhile, an estimated 10.6 million people fell ill with TB in 2022 – 300,000 more than the previous year, with WHO’s South-East Asia Region (46%), Africa (23%) and the Western Pacific (18%) worst affected.

But the good news for those with TB is that treatment coverage has recovered to the pre-pandemic level of 70%, up from 62% in 2021.

Slight decrease in deaths

Dr Tereza Kasaeva, WHO’s Global TB Programme director,

TB was the second leading cause of death in 2022, beaten only by COVID-19 – despite being “completely preventable and curable”, said Dr Tereza Kasaeva, WHO’s Global TB Programme director, at the report’s launch on Tuesday.

“What is missing? Prioritisation and enough investment, as we have much better tools for successful treatment, even for the most severe forms of drug-resistant TB,” she added.

However, TB deaths were down to an estimated 1.3 million, in comparison to an estimated 1.4 million for 2020 and 2021, according to the report.

But the net reduction in deaths between 2015 to 2022 is only 19% – far from the WHO End TB Strategy milestone of a 75% reduction by 2025.

The WHO African and European regions have made the best progress in cutting deaths since 2015, while 47 countries have achieved reductions of at least 35%

Drug-resistant TB is a ‘public health crisis’

“Multidrug-resistant TB remains a public health crisis,” said Kasaeva, adding that only two out of five people with multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB) received treatment last year.

With around 410,000 people developing drug-resistant TB in 2022, Kasaeva described drug-resistant TB as “stable” with “no  clear progress toward the decrease of the burden”.

“The cumulative reduction in the TB incidence rate from 2015 to 2022 was only 8.7%, far from the WHO TB strategy milestone of over 50% reduction by 2025.”

Some 42% of the global burden of people with drug-resistant TB comes from just three countries – India (27%), the Philippines (7.5%) and Russia (7.5%). 

“The uptake of the latest recommendations of the WHO for the shorter treatment option is not fast enough,” said Kasaeva. “That’s why we can’t celebrate any progress. It’s stable, it’s concerning and should be improved significantly.

On the positive side, almost three-quarters (73%) of people diagnosed with pulmonary TB were tested for rifampicin resistance, up from 69% in 2021. Some 4.4% were diagnosed with MDR/RR-TB.

The cumulative number of people with MDR/RR-TB on treatment from 2018 to 2022 was 825 000 – 55% of the 5-year target of 1.5 million. For children, the cumulative number was 21 600 – a dismal 19% of the five-year target of 115 000.

But the report notes that there have been “steady improvements in the treatment success rate for people diagnosed with MDR/ RR-TB”, although its latest figures are from 2020, when the treatment success rate was 63%.

“By the end of 2022, 40 countries had started to use the new six-month BPaLM/BPaL regimen to treat people with MDR/RR-TB or pre-XDR-TB. A total of 92 countries were using the shorter nine-month oral regimens for the treatment of MDR/RR-TB,” the report notes.

Price reductions

However, Medecins sans Frontieres (MSF) notes that price reductions for the TB test GeneXpert MTB/RIF Ultra, key to diagnose TB, and the drug bedaquiline, an essential part of the new shorter and safer DR-TB treatment regimens,  has made the scale-up of these medical tools “significantly more achievable”.  

In September, US corporation Cepheid reduced the price of the GeneXpert MTB/RIF Ultra test in high-TB-burden countries by 20% (from US$9.98 to $7.97). 

Meanwhile, Johnson & Johnson decided not to enforce its secondary patents for bedaquiline in 134 low-and middle-income  countries. J&J also granted Stop TB Partnership´s Global Drug Facility`s (GDF) a licence that enabled it to tender, procure, and supply generic versions of bedaquiline to most LMICs. 

The WHO first recommended the GeneXpert MTB/RIF as the initial test to diagnose TB in December 2010, and the shorter, safer and more effective all-oral six-month DR-TB treatment regimens BPaLM and BPaL in December 2022. 

“Although today’s TB statistics once again highlight how TB, a neglected but curable disease, keeps killing millions of people year after year, there may be light on the horizon,” said Dr Gabriella Ferlazzo, TB Medical Adviser of MSF’s Access Campaign.

“Over the last three months, we’ve witnessed a striking string of good news for TB, with long-fought price reductions finally coming through for better tests and drugs, and governments meeting at the UN [at the high-level meeting on TB in September] to promise to ramp up TB testing, treatment and prevention for their people, including children.”

The UN High-Level Meeting on TB set new targets for 2023-2027, including reaching 90% of people in need with TB prevention and care services, using a WHO-recommended rapid test as the first method of diagnosing TB, providing a health and social benefit package to all people with TB, ensuring the availability of at least one new TB vaccine and closing funding gaps for TB implementation and research by 2027.

Ferlazzo called on governments to “use the WHO-recommended tools and strategies we now have to diagnose and treat everyone who needs it, and to increase funding for TB research and care.” 

Stop TB Partnership Executive Director, Lucica Ditiu, paid tribute to all those who had managed to diagnose and treat the 7.5 million people with TB.

“Now that we have shown what can be done – can we get the financial resources and the political commitment so that we are done once and for all with this disease? It is a matter of choice for the governments, donors, and all of us,” she added.

‘Catastrophic’ out-of-pocket costs

Handaa Enkh-Amgalan, a TB survivor from Mongolia.

The report also notes that more than half of TB patients and their households face “catastrophic health costs”  – medical expenses as well as indirect costs, such as travel expenses to pick up their daily medicines, income loss, food supplements and the cost of carers. 

“These costs amount to greater than 20% of total household income,” said Handaa Enkh-Amgalan, a TB survivor from Mongolia.

“Twelve years ago, I was one of those statistics where my family and I were affected by the same level of financial burden of TB that we are seeing in this report. My mom and I faced a tough choice to make. It was down to either affording bread for me and my siblings or going to a TB clinic to have an X-ray done for diagnosis,” said Enkh-Amgalan.

“My mom was able to make the decision to head to a clinic. But there are many more people who are simply unable to make that decision. TB patients are often labelled and stigmatised as irresponsible or non-compliant. These catastrophic costs and stigma are two of the many barriers that are driving millions of patients away from seeking diagnosis and treatment.”

Lack of funds

It’s not only TB patients that are short of cash, however. The entire sector is under-funded despite the impact of the disease.

“Less than half of the $13 billion needed for TB prevention, diagnosis, treatment and care to achieve the global targets was mobilised,” said Kasaeva.

Around  80% of spending on TB services in 2022 came from domestic sources, yet “for low and middle income countries, international donor funding remains crucial”, she added.

The US contributes about 51% of international donor funding for TB and Cheri Vincent, TB Division Chief at the US Agency for International Development (USAID), stressed her government’s “deepest commitment” to move forward on the UN targets.

Image Credits: Stop TB Partnership.

Saima Wazed (in black), along with her mother Bangladesh Prime Minister Sheikh Hasina, during an official visit to the United States to meet US President Joe Biden and First Lady Jill Biden. Wazed’s election as WHO-SEARO’s regional director has been dogged by allegations of nepotism, and her mother’s government is said to have relentlessly lobbied for her win.

Amidst a flurry of allegations of nepotism and political corruption, Saima Wazed, daughter of Bangladesh Prime Minister Sheikh Hasina, has emerged victorious in the race for the World Health Organization’s South-East Asia (WHO-SEARO) regional director.

Wazed’s limited international public health experience and expertise, confined to the narrow field of autism, have raised concerns among experts about her ability to effectively lead the region’s health agenda.

“It is a bit of an experiment to see if a non-public health qualified person with zero public health experience can actually provide the degree of inspiration that is needed to bring about significant shifts or strengthening public health policy,” Mukesh Kapila, a public health expert with experience working in 120 countries, told Health Policy Watch.

While acknowledging the possibility of improvements in the management and internal workings of WHO regional and country offices under Wazed’s leadership, Kapila remains sceptical.

“Can she improve the relevance, effectiveness and efficiency of the WHO in the region? Time will tell,” said Kapila.

Wazed’s dual Canadian citizenship has also drawn scrutiny, raising questions about potential conflicts of interest and her commitment to public health in Bangladesh and the wider South-East Asia region.

Politics wins over experience in WHO-SEARO backrooms 

Wazed’s victory is being attributed to a relentless campaign by her mother’s government, which mobilized its diplomatic network to secure her election. She will now be responsible for providing independent and impartial advice to Bangladesh from WHO.

“The fact [is] that professionals and staff, from my own conversations with them in SEARO, have no confidence in her,” said Kapila. “She’ll be trying her very best not to ruffle [them] too much as she will be trying to win them over. And that means she is unlikely to be much of a change agent.”

Her election opponent Shambhu Prasad Acharya is a veteran WHO official with three decades of experience with the UN health body. Acharya, who received immense support from Nepal’s civil society, was seen as a more qualified candidate but lacked support from other countries in the region.

Kapila attributed Acharya’s loss to Nepal’s position as a poor country that was unable to strike backroom deals to push its candidate, emphasizing that such tactics should not be necessary in the selection of WHO officials.

Of the 11 countries in the region, 10 were eligible to vote in a secret ballot, with Myanmar being disenfranchised because of the sanctions imposed on it. The Bangladesh High Commission shared that Wazed had received 8 out of the 10 votes.

Wazed will take charge in February next year and will be succeeding India’s Poonam Khetrapal Singh who has held the post for a decade now.

Outgoing WHO-SEARO Regional Director Dr Poonam Khetrapal Singh announced earlier this month that Bangladesh has become the world’s first country to eliminate visceral leishmaniasis.

The selection process of WHO’s regional offices has been in the news for a while now. In September, the medical journal The Lancet carried an editorial about the concerns about the candidate selection, and opacity of the election process. Wazed’s candidacy was also questioned on similar grounds.

Earlier this year WHO fired the regional director for the Western Pacific region on an enquiry into allegations of misconduct, as HPW reported in March this year.

Despite a quarter of the world’s population living in the SEARO region and the high number of COVID-19 deaths recorded during the pandemic, the SEARO office was hesitant to hold press conferences or provide regular updates on the situation. This contrasted with other WHO regional offices that were more proactive in communicating with the public.

Indian journalists faced difficulties in accessing accurate information about the country’s COVID-19 death toll at the height of the pandemic. The Indian government reportedly lobbied the WHO against releasing its excess deaths report, which would have revealed the country’s true death toll. The SEARO office remained largely silent on this matter, despite the significant public health implications.

Shenanigans in WHO South-East Asia as Politician’s Daughter Contests Regional Director Election

The region also has exceedingly high air pollution levels, an issue that WHO could get involved with more actively. Severe air pollution has once again engulfed Delhi, affecting health in the region. This year, cities like Mumbai with relatively clean air have also been hit hard.

While Singh was hesitant to take a stronger stand on the issue with the respective governments, Wazed is likely to follow suit, given how instrumental the Indian government’s support has been for her victory, experts HPW spoke to said.

“It was a victory not for global health or professionalism,” said Kapila. “It was a victory for state politics, and interstate politics and money and basically Bangladesh’s clout to get votes. But then I suppose that is politics for you.”

Experts also said that given Hasina’s government is in trouble in Bangladesh and Wazed is aware of her unpopularity within the WHO, she might not want to ruffle any feathers and is unlikely to take any strong policy stand.

Image Credits: X, WHO.

Al-Quds Hospital on 29 October.  WHO denounced weekend attacks around the hospital; Israel says Al Kuds and other facilities are being used by Hamas.

Gaza’s struggling health facilities were again caught in the crosshairs of the Israeli-Hamas conflict over the weekend, as Israel acknowledged it had attacked an ambulance that it claimed was ferrying Hamas gunmen out of Gaza City’s Shifa Hospital, and a dozen UN leaders called for an urgent cease fire. 

Israel pounded Gaza by air and on the ground over the weekend in what was reportedly amongst the heaviest days ever of bombardment. Hamas continued to fire missiles at Tel Aviv and other major Israeli cities in the center and south. Monday evening, news reports had fighting intensifying around Shifa Hospital, the largest hospital in Gaza, which has been identified by Israel as a major Hamas underground command and control center.

Meanwhile, Iranian-aligned Hezbollah forces in Lebanon claimed responsibility for a barrage of rocket attacks on northern Israeli cities, as far south as Haifa. 

”We need an immediate humanitarian ceasefire.  It’s been over 30 days,” said the heads of over a dozen UN agencies along with six NGOs in a joint appeal published on Monday. “Enough is enough. This must stop now.

In Israel, some 1,400 people have been killed and thousands have been injured, according to the Israeli authorities. More than 240 people, including children, have been taken hostage. Rockets continue to traumatise families. More than 200,000 people have been displaced.

“This is horrific,” stated the letter, signed by WHO’s Director General, Dr Tedros Adhanom Ghebreyesus, as well as the heads of UNICEF, UN Women and Care International. “However, the horrific killings of even more civilians in Gaza is an outrage, as is cutting off 2.2 million Palestinians from food, water, medicine, electricity and fuel.”

In Gaza, according to the Ministry of Health, nearly 9,500 people have been killed, including 3,900 children and over 2,400 women. More than 23,000 injured people require immediate treatment within overstretched hospitals.

Extensive destruction caused by the unprecedented level of Israeli airstrikes on Gaza since the 7 October Hamas incursion into Israel.

“An entire population is besieged and under attack, denied access to the essentials for survival, bombed in their homes, shelters, hospitals and places of worship,” stated the UN appeal. “This is unacceptable. More than 100 attacks against health care have been reported,” stated the letter, which also called for “the immediate and unconditional release of all civilians held hostage.”

Israeli ground troops have now encircled Gaza city on all sides – and are slowly advancing toward the city center, in a complex operation that they say is focused on rooting out and destroying from the air and the ground, the extensive underground tunnel network developed by Hamas over the past decade.  

On Monday, Israel’s military again urged the estimated 300,000 Palestinians still trapped in northern Gaza to flee south via Gaza’s Salahuddin Highway,  between 10-2 p.m. But the Gaza-based Health Ministry warned Palestinians against fleeing via the route, calling it a “death corridor.”

WHO protests attacks in the area of Gaza hospitals

On Sunday, WHO also condemned Israel’s attack on two ambulances as they tried to leave Shifa hospital, as well as attacks in the vicinity of two other major Gaza hospitals in the north of the enclave, Al-Quds and the Indonesian hospital. 

“According to reports, at Shifa Hospital, ambulances were evacuating critically injured and sick patients to hospitals in the south of the Gaza Strip,” said the WHO statement, “when there was an attack at the entrance of the hospital.

“According to early reports, at least 13 people were killed and more than 60 injured. The hospital infrastructure and one ambulance sustained damage. This was in addition to an earlier incident that had resulted in damage to another ambulance in the same convoy,” said the WHO statement. 

WHO also reported that “two further attacks were reported on the same day at Al-Quds hospital, resulting in 21 injuries, as well as near the Indonesian hospital,” noting that “attacks on health care.. may amount to a violation of international law.

Israel: Hamas systematically using hospitals and ambulances   

Aerial view of the Gaza’s Indonesian Hospital, with the outlines of what Israel says are military tunnels.

In a foreign press briefing Sunday, Israel’s military spokesperson Dan Hagari charged that the ambulances attacked by Israel were being used to transport Hamas gunmen. His briefing followed comments by senior US administration officials earlier in the week that Hamas had tried to sneak its fighters out of Gaza in ambulances taking seriously wounded to Egypt. 

“It’s a war crime,” he said, “that Hamas is using hospitals for military purposes.”

As for the hospitals, Hagari displayed aerial and satellite photographs of alleged Hamas’ operations in and around the Indonesian Hospital and Gaza’s Qatari-funded Sheikh Hamad bin Khalifa al-Thani Hospital. 

They included pictures of what Hagari said were tunnel entry points by the Qatari hospital, exposed by Israel’s forces in recent ground operations, as well a video of alleged Hamas shooting from the hospital grounds.  Parts of the hospital were also damaged in aerial raids, earlier in the month. 

At the Indonesian Hospital, Hagari displayed time series photos showing stacks of cement arches on the hospital grounds when the facility was being built in 2010, which he said laid the foundations for the tunnel network now buried under the facility. 

Israeli military spokesman Daniel Hagari points to cement arches that he says Hamas used to expand its tunnel network during the hospital’s 2010 construction.

“How Hamas uses hospitals to disguise the war machine is systematic,” he said.  “Cement arches are not needed when building hospitals. They are used to build an underground city of terror and underground metro tunnels. We have watched Hamas use these arches to build tunnels for many years.

“Instead of building homes for Gazans, Hamas built this metro over hundreds of kilometers underneath Gaza and underneath places like hospitals and mosques. 

Israel continues to rebuff reports of fuel shortages

Israel has also continued to rebuff humanitarian appeals for fuel to replenish what WHO says are severely depleted hospital supplies.  

“There is no shortage of fuel in Gaza,” Hagari declared at the briefing, playing what he said was a covertly recorded conversation between a Hamas operative and a Shifa Hospital administrator, about the movement of fuel supplies. 

“Hamas stores this fuel underneath hospitals in Gaza – the very hospitals that Hamas tells the world is running out of fuel,” he said.

On Sunday, Israel’s Ambassador to the UN in New York City shared a video of Shifa’s windows illuminated at night, along with outdoor spotlights, for what he said was a public screening by Hamas of a military video on the hospital grounds.   

“Hamas has plenty of fuel for whatever they choose to prioritize,” Erdan said. “If only ICU incubators were as important to Hamas ….” 

Hostages largely forgotten in the bitter conflict 

Sharon Cunio and her husband with their twin daughters, prior to being kidnapped by Hamas.

As the claims on both sides rage along with the bitter military conflict, the families of the estimated 241 hostages held by Hamas since 7 October  expressed growing desperation over the fate of their families, and the lack of attention the captives are receiving. 

“All around me I have witnessed a silence so enormous, it feels cacophonous;” wrote Alana Zeitchik, a New York City-based media professional of Yemenite-Israeli origins in the Sunday New York Times. 

Her cousin Sharon Cunio, husband David and their three-year old twins are being held captive along with Sharon’s sister and five-year-old daughter, since being snatched by Hamas gunmen from their bomb shelter on Kibbutz Nir Oz. Their plight, she said, is an issue which few in the humanitarian community have cared to address.  

“Again and again I hear that Israel is a country of white colonizers and oppressors,” she wrote in the Times. “Some of my bewilderment is in my very skin. My maternal grandparents, Avraham and Sara, grew up in a tiny rural village in central Yemen. Like other Jews in the Arabian Peninsula, Yemenite Jews were persecuted as second-class citizens… In 1949, after pogroms against Jews in Yemen, my grandparents set out by foot and donkey on an arduous journey to the capital, Sana. From there, they were airlifted during Operation Magic Carpet to the newly formed state of Israel. As refugees fleeing oppression in their birth country, they began their lives in Israel in poverty. Slowly they built a humble but comfortable life and raised five children, amongst them my mother.

So maybe you can imagine my surprise the first time I heard my Israeli family called “white colonizers.” When did we become white? And how could a family fleeing persecution be perceived as colonizers?

“It would appear they believe my suffering to be collateral damage in service of some universal truth they hold higher. Is it really impossible to hold these two truths at the same time — that both Israeli and Palestinian civilians are suffering at great cost?” she asked. 

Within Israel there is widespread sentiment that any cease-fire needs to be conditioned upon release of the hostages – who are being held in unknown locations, and without any access to the International Red Cross.

“Israel allowed humanitarian aid into Gaza, why aren’t our children getting the same?” asked Moran Alony, brother of Sharon, speaking on the sidelines of the UN Security Council in New York City late last month.

Image Credits: https://www.emro.who.int/media/news/hospitals-in-the-gaza-strip-at-a-breaking-point-warns-who.html  , WHO/EMRO , Times of Israel .