The World Health Organization (WHO) and World Meteorological Organization (WMO) launched the first global knowledge platform dedicated to climate and health on Monday called climahealth.info.

The global open-access platform is envisaged as being the “go-to technical reference point for users of interdisciplinary health, environmental, and climate science”, according to the WHO in a media release. 

“The use of tailored climate and environmental science and tools for public health, such as disease forecasting and heat health early warning systems, have enormous life-saving potential. These tools and resources can enhance our understanding of the connections between climate and health, help us reach at-risk populations, and anticipate and reduce impacts,” according to the media release.

“Climate change is killing people right now,” said Diarmid Campbell-Lendrum, coordinator of WHO’s climate change and health programme. “It is affecting the basics we need to survive – clean air, safe water, food and shelter – with the worst impacts being felt by the most vulnerable. Unmitigated climate change has the potential to undermine decades of progress in global health. Reducing its impacts requires evidence-based policy backed by the best available science and tools.”

Joy Shumake-Guillemot, who leads the WMO-WHO Climate and Health Joint Office, said that public health practitioners who are concerned about the environmental impacts on health “lack access to training and tailored climate information needed to address these growing issues” while  “climate experts (are) sitting on troves of research and resources that could be applied to support public health goals, but just aren’t reaching the right people”.

The initiative is supported by the Wellcome Trust.

“Collaboration between climate, health and technical specialists is crucial for helping us understand and tackle the health effects of climate change,” said Madeleine Thomson, Head of Climate Impacts and Adaptation for the Wellcome Trust. “But right now, experts can’t always partner and share information as effectively as we know they’d like to. We hope this portal will help fulfill the potential of different disciplines to work together on research and gain new insights into how climate change is affecting health around the world.”

Cities’ Malaria Framework launched

On the occasion of World Cities Day 2022 on Monday, the WHO and UN Habitat launched the Global framework for the response to malaria in urban areas, which provides guidance to city government officials, health professionals and urban planners on how to develop a  comprehensive malaria response specifically in urban areas, “where the dynamics of transmission and burden of vector-borne diseases can be different from that of rural areas”.

By 2050, nearly 70% of people globally will live in cities and other urban settings and the WHO predicts that unplanned urbanization is likely to result in a malaria disease burden that is “disproportionately high among the urban poor”.

Speakers at the launch also anticipated that climate change will see malaria in places that were previously too cold for the disease that is carried by mosquitos.

The framework provides guidance for city leaders, health programmes and urban planners to respond to the challenges of rapid urbanization in a targeted way that helps to build resilience against the threat of malaria and other vector-borne diseases.

Omicron
Experts have described the array of subvariants as a “swarm”.

The SARS-CoV2 virus just won’t give up. As the northern hemisphere heads into its third pandemic winter, experts say the continued evolution of Omicron’s sub-variants indicates a fresh wave is coming, but no one knows which variant will fuel it.

Scientists have catalogued 390 Omicron lineages and 48 recombinants of the virus – which occur when at least two variants co-infect the same person, allowing them to ‘exchange notes’ and evolve. The sheer number of Omicron strains circulating makes predictions complicated.

“We’re having trouble isolating which of the omicron sub-variants will have a growth advantage and will take over in dominating the spread,” WHO Senior Emergency Officer Dr Catherine Smallwood explained at a press conference last week. “Some variants like BQ.1 have been noted as potentially accelerated, but we’re not sure yet how this is going to pan out in the longer term.”

The variety of offshoots also creates the possibility of a ‘double wave’ in some places if two successive variants with different immune-dodging characteristics succeed each other.

“Looking at all the data, it seems a sizable new infection wave is certain to come,” Tom Wenseleers, an evolutionary biologist at the Catholic University of Leuven told Nature.

Subvariant surges not causing hospitalization spikes – for now

Omicron
Ranking of the immune evasion for the new variants

There is some good news: early signs show that though the BA.4, BA.5, BQ.1.1 and XBB subvariants are able to break through immune protections and resist certain treatments, they do not appear to be causing increases in hospitalizations.

“An encouraging sign for one of – if not the most – immune evasive new variants XBB: it is dominant in India and Bangladesh without a rise in cases or deaths to date,” said Eric Topol, founder and director of Scripps Research.

Despite the dominance of the highly infectious XBB variant, deaths and cases in India and Bengladesh have remained stable.

Similar findings have come out of South Africa, where the Africa Health Research Institute in Durban conducted studies on the BA.4 and BA.5 sub-lineages. The team, led by virologist Alex Sigal, found that while these Omicron families possess strong enough immune-dodging mechanisms to lead to an infection wave, they are “not likely to cause much more severe disease than the previous waves, especially in vaccinated people.”

The World Health Organization’s (WHO) Technical Advisory Group on SARS-CoV-2 Virus Evolution (TAG-VE), which released a statement singling out BQ.1 and XBB as key variants of concern on Thursday, issued a similar analysis.

“While we are looking at a vast genetic diversity of Omicron sublineages, they currently display similar clinical outcomes, but with differences in immune escape potential,” TAG-VE’s expert panel found. “So far there is no epidemiological evidence that these sublineages will be of substantially greater risk compared to other Omicron sublineages.”

World trending in the right direction – but surprises could be around the corner

WHO
WHO data as of the October 26 SARS-CoV2 weekly situation report.

The question lingering on the mind of many experts is whether the varying properties of subvariants mean infection by one will provide immunity from others – a key determinant of whether double waves will hit.

A team at Peking University in Beijing, led by Yunglong Richard Cao, has been studying the variants’ immune-evading capacities. “I have a feeling that if you’re infected with BQ.1, you might have some protection against XBB,” he told Nature. “We don’t have data yet.”

Experts warn not to rule out more surprises from the virus. With Delta still circulating in the background, the deadlier variant could return to the fore. 

“The virus has surprised us more than once,” said Dr Hans Kluge, WHO Europe Regional Director. “We are much better prepared, and the fall surge has not led to previous ICU admission or severe disease levels, but forecasting remains tricky.” 

Russia’s invasion of Ukraine – denoted by the red line above – caused the country’s ability to report cases and deaths to fall.

Reports emerged this week of yet another subvariant, BA.5.2.6 taking hold in Ukraine. The dire conditions occasioned by Russia’s invasion of the country have made it conducive ground for viral spread, and reporting since the start of the conflict has dropped off a cliff. 

Little is known about the true state of play on the ground – nor which subvariant will take over next. 

Image Credits: Nature, Stuart Turville.

A Somali boy struggles to find water

The global cholera vaccines shortage relates to the unpredictability of the disease, and the fact that it unattractive to manufacturers as it is a disease of poverty – but if preventive vaccines are part of a routine vaccine package where cholera is endemic, this could stabilise demand and outbreaks

There is no short-term solution to the global cholera vaccine shortage as “the current manufacturers are producing to their maximum capacity, and one is increasing its production capacity but this increase is limited by technical constraints”, according to Dr Philippe Barbosa, the World Health Organization’s (WHO) technical lead on cholera.

Faced with at least 29 global cholera outbreaks – Haiti, Malawi and Syria battling particularly big outbreaks – and a diminishing supply of vaccines in the international stockpile, the WHO recently recommended that affected countries administer only one vaccine dose instead of the usual two. 

 Cholera is an acute diarrhoeal infection caused when people consume food or water contaminated with Vibrio cholera bacteria, and it usually affects those with inadequate access to clean water and proper sanitation.

As the disease primarily affects “the poorest and most vulnerable”, vaccine manufacturers have “no prospect of selling to rich countries”, so production is limited, Barbosa told Health Policy Watch.

“As the demand appears limited, this makes it unappealing for new manufacture to engage in this market,” said Barbosa, adding that the challenge of limited cholera data also made it difficult to forecast of future needs.

But Gavi, the global vaccine alliance, believes that it may be possible to stabilise vaccine production and supply by introducing preventative vaccines in cholera “hot spots”.

“We’re trying to get some preventive vaccination going in regions where cholera is endemic and that will help obviously to prevent outbreaks from a public health perspective,” says Gavi special adviser Aurelia Nguyen.

“It will also help with this ‘peaks and troughs’ view. As you can imagine from a manufacturing perspective, it is difficult to be able to just turn production on and off at very short notice,” added Nguyen, who has over a decade of experience in vaccine supply, most recently as managing director of COVAX, the international COVID-19 vaccine platform.

Gavi advisor Aurelia Nguyen

Only two suppliers

At present, only two suppliers make cholera vaccines available for mass vaccinations. Shanchol is produced by Shanta Biotechnics, a Sanofi subsidiary in India, and Euvichol-Plus, made by EuBiologics in South Korea.

Both companies supply the international cholera vaccine stockpile managed by the International Coordinating Group (ICG), a mechanism that coordinates the provision of emergency vaccines and antibiotics to countries during major outbreaks. The ICG is made up of members from the WHO, UNICEF, Médecins Sans Frontières, and the International Federation of Red Cross and Red Crescent Societies.

All countries that need cholera vaccines apply to the ICG, and those that qualify for Gavi financing get free vaccines while the others need to reimburse the stockpile.

“What we’ve done with Gavi financing is show manufacturers that there is a certainty of regular funding for vaccines, and the minimum stockpile that we want to have at any point in time for outbreak is five million doses,” says Nguyen.

But Shanta Biotechnics announced a while back that it will stop making Shanchol next year, while production at EuBiologics is currently constrained as the company is expanding its facilities. The expansion will ultimately enable it to produce 50 million vaccines a year. 

Nguyen said that “production economics” were behind Shanta Biotechnics’ decision to quit the field, and Gavi has been working “very closely” with EuBiologics “and their volumes are going to keep increasing over the course of next year”.

Neither company responded to questions Health Policy Watch sent to them.

However, Gavi has also “been in very active discussions” with other manufacturers to enter the market in the next two to three year to ensure “resilience in the market”.

“We’ve been discussing with potential new entrants what it would take in terms of their developments, and it also links to another conversation in terms of regional manufacturing on the African continent,” said Nguyen.

Gavi has been in discussions with the African Union, and in the past week with the G7 and G20, about having “a stronger and more sustainable manufacturing base in Africa, and this is one of the vaccines that would be perhaps suitable for a new entrant coming from the continent”, she added.

Unpredictable demand

Typically, the international stockpile has about five to seven million vaccine doses which get replenished as it is used – but the unpredictability of outbreaks has made it hard to ensure regular supply.

“In 2020, we used five million doses for outbreak response. This year, so far we’ve already shipped 18 million doses and we have just seven million doses on hand at the moment and we plan to buy another five million through to the end of the year.”

However, what is more predictable is that climate change will drive more cholera outbreaks. The recent floods in 33 of Nigeria’s 36 states  – the worst in a decade – are expected to increase cholera cases, while Pakistan has been bracing itself for more cases after its recent devastating floods.

“The consequences of a humanitarian crisis – such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps – can increase the risk of cholera transmission, should the bacteria be present or introduced,” the WHO warns.

Meanwhile, earlier this week UNICEF described the cholera outbreaks in Syria and Lebanon as “alarming”.

“The acute epidemic in Syria has left over 20,000 suspected cases with acute watery diarrhoea and 75 cholera-associated deaths since its start. In Lebanon, confirmed cholera cases reached 448 in just two weeks, with 10 associated deaths,”  UNICEF warned in a media release.

“Malnourished children are more vulnerable to developing severe cholera disease, and the cholera outbreak is yet another blow to already overstretched health systems in the region.”

Image Credits: CNN, UNICEF.

ACT-A is going to work more in-country as it transitions out of pandemic mode.

The Access to COVID-19 Tools (ACT) Accelerator is going to focus on vaccinating high-risk populations, introducing new treatments, boosting testing and securing sustained access to COVID-19 tools in the next six months.

ACT-A announced its new transition plan at a meeting on Friday as the world moves to long-term COVID-19 control.  

“Recognizing the evolving nature of the COVID-19 virus and pandemic, the plan outlines changes to ACT-A’s set-up and ways of working, to ensure countries continue to have access to COVID-19 tools in the longer term, while maintaining the coalition’s readiness to help address future disease surges,” according to a media release.

“Through 2023, COVAX will continue to support lower-income countries to protect their populations. In parallel, we will be supporting countries to integrate COVID-19 vaccination into routine national immunization programs, while also preparing for surges and other worst-case scenarios,” said Seth Berkley, CEO of Gavi, the Vaccine Alliance.

Developed through a consultative process with ACT-A agencies, donors, industry partners, civil society organizations (CSOs) and Facilitation Council members, the plan summarizes priority areas of focus for the partnership’s pillars, coordination mechanisms and other core functions, and highlights the work to be maintained, transitioned, sunset, or kept on standby. The transition plan supports the work of ACT-A agencies as they evolve the financing, implementation and mainstreaming of their COVID-19 efforts.

The next phase of ACT-A partners’ work will centre on three overarching areas:

  • research and development (R&D) and market-shaping activities to ensure a pipeline for new and enhanced COVID-19 tools
  •  institutional arrangements for sustained access for all countries to COVID-19 vaccines, tests and treatments, including oxygen
  •  in-country work on new product introduction (eg new oral antivirals) and protection of priority populations in support of national and international targets

“As the world moves towards managing COVID-19 over the long-term, ACT-A will continue to support countries by providing access to vaccines, tests, and treatments,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “But as this plan lays out, we still have a lot of work to do to achieve equitable access to these life-saving tools, with health workers and at-risk populations as our top priority.”

Other changes outlined in the plan include the transition to a new ACT-A Tracking and Monitoring Taskforce, co-chaired by senior officials of India and the US, with the political-level Facilitation Council going into ‘standby’ mode, with the capacity to reactivate if needed due to a surge in severe disease.

Ebola
Contact tracers and village health teams take on Ebola in Uganda.

Six schoolchildren in the Ugandan capital of Kampala are the latest to be infected with Ebola, according to the country’s health minister on Wednesday – and with 15 cases in the densely populated city, some want the government to impose a lockdown.

So far, there have been 109 confirmed cases, including 30 deaths, of the Sudan strain of Ebola for which there is no vaccine – although two vaccines exist for the Zaire strain.

Ebola is highly infectious and has a mortality rate of up to 90%. The 2014-16 Ebola outbreak in West Africa, the largest on record, killed more than 11,000 people. In 2000, Uganda suffered an outbreak of Ebola that killed over 200 people.

After a slow start, contact tracing kicks into gear

With support from the World Health Organization (WHO) and partners, the Ugandan Ministry of Health has trained and deployed around 300 contact tracers, who play a critical role as the country looks to minimize the spread of the virus.

“When the community cooperates in the response and contacts are identified, it becomes easier to contain the disease,” said Dr Bernard Logouomo, the Ministry of Health Surveillance Lead in Mubende district, the outbreak’s epicenter.

In the first days of the outbreak, only 25% of contacts were properly traced, the WHO said. But by mid-October, nearly 94% of people who had come in contact with the virus were being properly monitored.

Despite dangers of urban Ebola, president resisting Kampala lockdown

Uganda
Kampala is home to 1.5 million people. Doctors worry Ebola could escape containment if it spreads throughout the city.

Ugandan President Yoweri Museveni has so far resisted calls to lock down the capital, although he announced a three-week lockdown in Mubende and Kassandra districts, where the outbreak started, on 15 October. 

However, the Kampala schoolchildren’s infections have been traced to a man who travelled to the city from Mubende.

On Tuesday, the head of the Uganda Medical Association, Dr Samuel Oledo, urged health authorities to impose a lockdown in Kampala. “The earlier we lockdown Kampala, the better,” he told reporters. “People are not even reporting cases right now.”

Uganda’s Ministry of Health acknowledged in a press statement on Thursday that urban Ebola can create “a situation of rapid spread,” but that lockdowns would remain limited to the epicentres of Mubende and Kassanda. 

“The situation in Kampala is still under control,” said Health Minister Jane Ruth Aceng. “There is no reason to restrict people’s movement.”

Trials are working

Without any known treatments available, trials are ongoing amid the outbreak. Uganda’s Ministry of Health said that a number of treatment options are being explored, including monoclonal antibodies, and repurposed drugs like Remdeservir donated by the US government. But doses are scarce.

“Thirteen patients have received these trial drugs with relatively good outcomes,” said health authorities. In total, 34 people have recovered from the virus. Four patients admitted in critical condition died despite treatment, highlighting the importance of early reporting and detection of symptoms.

“The spread of the outbreak relies on reducing the time between the first symptoms of the disease and its management,” said Denis Mbae, outreach project coordinator of Médecins Sans Frontières activities in Uganda. “The earlier patients are treated, the greater their chances of survival and the less risk there is of the disease spreading within the community.”

 

 

 

 

 

 

 

 

 

Image Credits: WHO, Angella Birungi.

Climate
Two deer take refuge in a river during a wild fire in Bitterroot National Forest, Montana, United States.

The existential project to save the planet set out by the 2016 Paris Agreement is in tatters. There is currently “no credible pathway” to limit increases in global temperatures to the 1.5°C degree target detailed in the accords, the UN Environmental Programme (UNEP) said in its global emissions gap report released Thursday.

The chance of temporarily exceeding 1.5°C has risen steadily since 2015, when it was close to zero.  That probability has increased to nearly 50% for the 2022-2026 period. 

The language of the UNEP report stands in stark contrast to the diplomatic assessment by the UN Framework Convention on Climate Change (UNFCCC) Secretariat released on Wednesday.

The UNFCCC report refers to “glimmers of hope,” noting that progress over the last year shows “a strong signal that the world is starting to aim for net-zero emissions.” But the UNEP does not mince words.

“Inadequate progress on climate action means the rapid transformation of societies is the only option,” the report states. “This lack of progress leaves the world hurtling towards a temperature rise far above the Paris Agreement goals.”

Despite a year of devastating climate-driven disasters, updated pledges by the international community since COP26 in Glasgow represent less than a 1% reduction in projected 2030 greenhouse gas emissions. Emissions in 2021 were also likely the highest on record, breaking the ceiling set by 2019 levels, the report found.

UNEP
To get on track to limiting global warming to 1.5°C, the world would need to cut 45 per cent of current greenhouse gas emissions by 2030.

If countries fully implement all present and future plans to reduce emissions, and additional net-zero commitments, the world will be on track for a 1.8°C temperature increase by the end of the century. But even this scenario is “not credible” given the snail’s pace of progress, the UNEP said.

“We are headed towards global catastrophe,” UN Secretary-General António Guterres said at a press conference accompanying the release of the report. “Our world cannot afford any more greenwashing, fake movers or late movers.”

Current policies set the world on pace for global warming of 2.8°C by the end of the century. The two realistic scenarios laid out in the report – in which countries follow through on their “nationally determined commitments” – reduce warming to 2.6°C and 2.4°C.

“We had our chance to make incremental changes, but that time is over,” said Inger Andersen, executive director of the UNEP. “Only a root-and-branch transformation of our economies and societies can save us from accelerating the climate disaster.”

A decimal can make all the difference

 

Temperatures during the last ice age, known as the Last Glacial Maximum, were an average of just 6 degrees cooler than today.

These temperature discrepancies can appear insignificant, but even minute shifts in the earth’s temperature have drastic impacts. At the peak of the last ice age, when glaciers covered about half of North America, Europe, South America and many parts of Asia, average temperatures were only 6°C degrees colder than today.

“In your own personal experience that might not sound like a big difference, but it’s a huge change,” said Jessica Tierney, primary author of the report on ice age temperatures.

Warming to 2°C, compared with 1.5°C, is estimated to increase the number of people exposed to climate-related risks and poverty by up to several hundred million by 2050. As the most affected regions are among the poorest in the world, possessing little ability to adapt on their own, the impacts will be devastating.

“Nature has been telling us all year, through deadly floods, storms and raging fires: we have to stop filling our atmosphere with greenhouse gasses, and stop doing it fast,” Andersen said. “Every fraction of a degree matters.”

For millions, the climate crisis is already here

Expansion of extremely hot regions in a business-as-usual climate scenario. Black and hashed areas represent unlivable hot zones. Absent migration, that area would be home to 3.5 billion people in 2070

Climate change discourse often unfolds in future-oriented language, but the consequences of the present 1.1°C degree increase in global temperatures are already hitting millions, and many are being forced to flee.

Amid unpredictable monsoon rainfall and increasingly strong droughts, more than eight million people in Southeast Asia have moved toward the Middle East, Europe, and North America, the World Bank found. Droughts and crop failures have impacted millions of rural people in the African Sahel, too, creating streams of internal displacement towards the coasts and cities.

And this is just the beginning. A groundbreaking study in the journal Proceedings of the National Academy of Sciences (PNAS), found that by 2070, up to 19% of land currently inhabited by people could become unlivable hot zones, akin to the Sahara, placing billions – one of every three people alive – in climate situations that will force them to leave. 

Should the flight away from hot climates reach the scale that current research suggests, it will amount to a vast remapping of the world’s populations, a joint investigation by the New York Times and ProPublica reports.

And the visible impacts of climate shifts are already staggering. Bangladesh, a country of 168 million people, now has over 10 million climate refugees – and an estimated 2,000 people move to its capital, Dhaka, every day, according to the Mayor’s Migration Council.

People who have lived in the coastal areas of Bangladesh for generations are migrating to escape flooding, and the government predicts that by 2050, one in every seven Bangladeshi citizens will be displaced by climate change. 

Financial hurdles present big challenges

June floods in Pakistan killed 1,717 people and the health impacts of the devastation are still unfolding.

In neighboring Pakistan, historic floods in June devastated millions, killed 1,717, and placed the country at the center of a developing international dialogue set to define the upcoming COP27 climate conference about who should foot the bill for the consequences of our shifting climate.

Cycles triggered by natural disasters and their rebuilding efforts trapped many countries in inescapable debt before the question of infrastructure investment for a clean transition even entered the conversation.

According to the IMF, 60% of low-income countries are in or at risk of debt distress due to climate change-induced events. A study by the World Weather Attribution group showed that climate change contributed to up to 50% of the rains that made this August the wettest on record in Sindh, the region of Pakistan where the floods struck.

“It is imperative to reform financial systems so that indebtedness is not a barrier for access to finance when countries are in need,” Andersen said. “These institutions were created in the shadow of the Second World War, but we are in a different time now. There is homework to be done in the halls of 193 capitals.”

As disasters hit populations in vulnerable regions, they also take a significant toll on the development journey of the countries they call home. All progress towards larger development goals can be wiped out overnight, and countries seeking funds to develop are forced to take out loans to pay for the cost of recovery – trapping them in an interminable cycle.

Pakistan is preparing to issue a request for new loans to rebuild infrastructure that would survive the extreme weather patterns, an effort it estimates will cost $30bn.  

“If you look at the numbers, it is the climate event of the century, not just for Pakistan but for the whole world,” Sherry Rehman, Pakistan’s climate change minister told the Financial Times. “It surpassed all numbers for climate events, and it is now creating a catastrophic health crisis.”

For governments grappling with the human, health, and economic impacts of increasingly frequent natural disasters, green energy is just one piece of a bigger puzzle.

COP27: slim hopes for urgent action amid divisions over funding responsibilities

COp27
COP27 will be held from 6 to 18 November 2022 in Sharm El Sheikh, Egypt.

As alarm sirens sound across the world, hopes for a watershed moment in the international community’s approach to combating the climate crisis at next week’s COP27 in Egypt remain slim.

The event will unfold against the backdrop of compounding energy, food and cost of living crises exacerbated by the war in Ukraine, coupled with the deep divisions around who should be responsible for funding the energy transition.

In addition to money for adapting to a shifting climate, low- and middle-income countries require technical assistance and investment to facilitate the envisioned transition directly to sustainable energy sources. The UNEP coordinates a technology sharing mechanism, but getting financing on the table is difficult.

“Climate finance structure today is biased against climate-vulnerable countries. The more vulnerable you are, the less climate finance you receive,” Kevin Chika Urama, chief economist at the African Development Bank, told Reuters.

Leaders of impacted countries are keenly aware of the threats posed by climate change, but the question of how to balance emissions targets with lifting people out of poverty has no easy solution. For them, energy is not a simple question of emissions: it is one of poverty, health, and survival. 

A disproportionate burden

CFR

“For Africa, the problem of energy poverty is as important as our climate ambitions,” Nigerian Vice-President Yemi Osinbajo said in a video address announcing his country’s aim to raise an initial US$10 billion in funding to implement its energy transition plan ahead of the conference. “Energy use is crucial for almost every conceivable aspect of development — wealth, health, nutrition, water, infrastructure, education and life expectancy.”

The perceived hypocrisy displayed in recent months by countries that have fashioned themselves as leaders of the green energy transition have made this conversation even more difficult.

Since the onset of Russia’s invasion, Europe has raced to import as much natural gas from Africa as possible to shore up its domestic supplies. It has provided no additional funding for projects that would allow the world’s poorest continent to burn more gas at home.

Meanwhile, in South Sudan, only 6% of people have access to modern energy. “Energy poverty and injustice is real, but we need to make sure that energy expansion is done sustainably,” Andersen said.

Recent IEA findings estimated the exploitation of all proven natural gas reserves in Africa would amount to an increase of just 0.5% in Africa’s global emissions burden, to 3.5% up from 3.0%. In July, the EU voted to classify natural gas as ‘green’, freeing up public subsidies and greenlighting new infrastructure projects set to extend the bloc’s reliance on fossil fuels.

Together, G20 countries contribute 75% of greenhouse gas emissions annually, and any consensus will likely depend on new commitments from rich countries to invest in the climate transition beyond their own borders.

“The worst impacts of fossil fuel-driven climate change are being felt by developing countries – those least responsible for having caused it,” said Dr Jeni Miller, Executive Director of the Global Climate and Health Alliance. “High-income countries must provide developing countries with the necessary financial and technical support for the equitable access to the clean energy their people need.”

Total systemic change is a big ask

UNEP
The window to reach climate change goals is closing fast: inadequate progress on climate action makes rapid transformation of societies the only option, the UN said.

Though the future of the planet is at stake, success at COP27 appears unlikely. Multilateral negotiations – in the best of circumstances – are exceedingly complicated affairs. The EU and Canada spent over seven years negotiating a mutually beneficial trade deal, and it nearly collapsed at the last hurdle.

That a total transformation of global financial, food, electricity and financial systems is the requirement set out by the UNEP makes the stakes of COP27 as daunting as they appear unfeasible, the report acknowledges.

“The task facing the world is immense: not just to set more ambitious targets, but also to deliver on all commitments made,” it states. “This will require not just incremental sector-by-sector change, but wide-ranging, large-scale, rapid and systemic transformation. This will not be easy, given the many other pressures on policymakers at all levels.”

In this context, any progress will be welcomed.

“Even if we don’t meet our 2030 goals, we must strive to get as close as possible to 1.5°C,” said Andersen. “This means setting up the foundations of a net-zero future: one that will allow us to bring down temperature overshoots and deliver many other social and environmental benefits, like clean air, green jobs and universal energy access.”

The clock is ticking, but there’s a roadmap: energy, finance, building and food practices must change

UNEP roadmap for a sustainable transition outlined in the report.

If the UNEP report’s findings are dire, they are also constructive. The report is formatted as a roadmap for achieving net-zero greenhouse gas emissions in electricity supply, industry, transportation and buildings, providing a groundwork for launching towards a carbon-neutral future.

“The recommendations in today’s report are clear,” Secretary-General Guterres said. “End our reliance on fossil fuels. Avoid a lock-in of new fossil fuel infrastructure. Invest massively in renewables.”

And significant progress has already been made. The falling prices of renewable power sources like solar and wind make energy the closest sector to attaining the necessary transition outlined in the report. But while market prices have caught up and requisite technologies exist, the world is not transitioning to them fast enough.

On the other extreme, food systems are in critical need of an overhaul. The sector already accounts for one-third of all emissions, and if current practices remain in place, this is on track to double by 2050.

Global systemic change is a tall order, but “we have to try”

Inger Andersen, executive director of the UNEP, speaking to reporters on Thursday.

Without a systemic reform of the global financial system, the targets set out by the UNEP are unatainable: change requires capital.

The report estimates that an international transformation to a low-carbon future will require at least $4-6 trillion per year. For scale, the World Economic Forum estimates India’s transition to net-zero emissions will require $10 trillion in investment. Financial systems must play a crucial role in enabling the energy transition, Andersen said, and massive reform is required.

“There is a conversation that needs to take place in capitals across the world between the governors of central banks, ministers of finance, and their environmental or meteorology counterparts,” she said. “Unless these talks happen, and a broader understanding of how climate shifts hurt our chances of reaching the Sustainable Development Goals is understood, we will be stuck.”

Hopes for increased climate investment hinge on the successful communication of the win-win opportunity renewables present. Researchers at Stanford University found that while a global transition to 100% renewable energy sources would cost countries $73 trillion upfront, it would pay for itself in less than seven years and create 28.6 million more jobs. 

Decisions made today can define emissions trajectories for decades to come. If the international community does not act decisively, the window of opportunity will close by 2030.

“I don’t want to waste your time talking about the impacts of climate change, we all know they are going to get worse,” an impassioned Andersen told reporters. “Is it a tall order to transform our systems in just eight years? Yes. Can we reduce greenhouse gas emissions by so much in that timeframe? Perhaps not. But we must try.”

Image Credits: PNAS, OXFAM.

Shelves stand empty in a Wuhan supermarket in an earlier lockdown.

China administered the world’s first oral aerosol COVID-19 vaccine boosters in Shanghai on Wednesday, as new lockdown measures were imposed on Wuhan, the supposed birthplace of the pandemic.

Chinese vaccine manufacturer CanSino Biologics said in a media statement that the inclusion of its vaccine in Shanghai’s booster vaccination program marked “the start of the rollout of the world’s first inhaled COVID-19 vaccine, Convidecia Air”.

The inhaler, approved as a booster for adults last month by the National Medical Products Administration of China, “provides a non-invasive option that uses a nebulizer to change liquid into an aerosol for inhalation through the mouth”, according to the company.

“Convidecia Air is needle-free and can effectively induce comprehensive immune protection in response to SARS-CoV-2 after just one breath,” it added. The aerosol vaccine is based on Sinovac (marketed as CoronaVac).

The Chinese-developed Sinovac uses a modified version of an adenovirus to deliver inactive parts of SARS CoV2 to a person’s immune system to prime it recognise and attack the virus when it becomes infected. This is followed by a second vaccine to boost the immune system a few weeks later.

Results from a clinical trial that compared the oral aerosol vaccine to an injectable version of Sinovac, published in The Lancet in August, found that the aerosol elicited 6.7 to 10.7 more neutralising antibodies than the injection after two to four weeks.

However, Sinovac is less efficacious against COVID-19 than mRNA vaccines, and there are some early indications that it offers very little protection against the latest variants.

Nasal sprays

Meanwhile, there are other clinical trials of SARS-CoV-2 vaccines delivered through the mucosa, but these are all nasal sprays.

Researchers at Yale University in the US recently published a pre-print paper reporting early success in mice using a vaccine booster strategy, “prime and spike”.

Noting that protection offered by mRNA vaccines weakens fairly fast, particularly in the nasal mucosa and respiratory tract, in those already vaccinated (“primed”), they tested an intranasal “spike” to “elicit mucosal immune memory within the respiratory tract”. 

Their trial found that “prime and spike” induced a robust immune response in animals that protected against SARS-CoV-2 infection. 

Indian company Bharat has also developed an intranasal vaccine for Covaxin, which it says has been successful in animal studies although it has not yet submitted results for peer review.

Wuhan locks down

Meanwhile, China has locked down Wuhan’s central Hanyang district after COVID cases were found, as China persists with a zero-tolerance approach almost three years after the virus was first reported in the city, and about 900,000 residents were told to stay at home, according to Bloomberg.

This follows the re-election of Chinese President Xi Jinping – the architect of the “zero-COVID” strategy – for a third five-year term as leader of the country’s ruling communist party.

China’s zero-COVID strategy has resulted in lockdowns of entire cities. People living in districts where COVID-19 cases are detected are obliged to stay indoors for seven days and take a daily test.

The lockdowns have had a negative effect on the country’s economy, with a 1.7% contraction in sales last month largely as a result of quarantines in various parts of the country.

Meanwhile, a 14-year-old girl teenager, Guo Jingjing, died in a quarantine facility earlier this month, according to the BBC.

She apparently developed a fever two days after being taken to a facility in Ruzhou, and her family posted videos on social media of her shaking and convulsing on a bed. Her father, Guo Lele, said in a video on Douyin (Chinese TikTok) that the facility had not provided her with any help.

However, the videos and most references to the incident have since been removed.

Image Credits: Studio Incendo.

Testing for antimicrobial resistance at the Liverpool School of Tropical Science.

The World Health Organization (WHO) has raised the alarm over drug-resistant fungi as it released its first-ever priority list of fungal pathogens at risk from antimicrobial resistance (AMR). Nineteen species of fungi have been identified by the global health agency as representing “the greatest threat to public health” due to their growing drug resistance.  

Meanwhile,  a new report by a civil society coalition warned that unmitigated use of anti-fungal and antibacterial drugs on crop and animal production is fueling the fires of AMR – with too little action by countries and the UN system.

Speaking to media Tuesday, Dr Haileyesus Getahun, the director of AMR Global Coordination at WHO, said that WHO had compiled a list of piority fungal pathogens to put the issue on the public agenda and identify the areas for further research and development on fungal diseases.

Underlining the need for more documentation and surveillance on the fungal infections and diseases, Dr Getahun said, “ “We want the documentation of what’s happening currently … to dictate or to guide, while waiting for the evidence to be complete, what public health actions can be taken, particularly in raising awareness around these fungal infections.” 

Of the 19 species of fungi identified as priority pathogens, four pathogens were labelled as having “critical priority”. Those include Aspergillus fumigates, which causes respiratory infections in humans.  Others are Cryptococcus neoformans, Candida auris, which can cause bloodstream infections, wound infections and ear infections, and Candida albicans (thrush).  

Dr Haileyesus Getahun, the director of AMR Global Coordination at WHO, explaining the risk posed by drug-resistant fungi
Dr Haileyesus Getahun, the director of AMR Global Coordination at WHO, at the virtual press briefing on Tuesday.

The WHO report highlights how common fungal infections are becoming increasingly resistant to available treatments, raising risks particularly for people with low immunity. “Populations at greatest risk of invasive fungal infections include those with cancer, HIV/AIDS, organ transplants, chronic respiratory disease, and post-primary tuberculosis infection,” the report stated. During the Covid-19 pandemic, many health agencies also reported spikes in drug-resistant bacteria in samples collected from patients. 

While bacterial antimicrobial resistance (bacterial AMR) has received increasing attention from researchers and health ministries, information and data on fungal AMR is nowhere close. This is reflected in the fact that currently there are only four classes of antifungal medicines available to treat pathogenic fungal diseases. With few more treatment candidates in the clinical pipeline, WHO has warned that drug-resistant fungal pathogens are spreading far and wide across the globe due to many factors including unchecked use of antifungal agents in agriculture and aquaculture and climate change. 

All-age rate of deaths attributable to and associated with bacterial antimicrobial resistance by GBD
region, 2019

Role of azoles in fungal AMR

Rice fields are one type of agriculture where azoles are widely used.

Meanwhile, the new report on AMR released Monday by a civil society coalition carried an even stiffer warning abou the role of agrobusiness in spurring AMR – through rampant use of antifungal, antiboitic and antiviral agents on livestock and crops.

The report was co-authored by Nicoletta Dentico of the Society for International Development and the Geneva-based AMR Think-Do Tank.

The report, Untangling Antimicrobial Resistance, highlights, in particular, the role played by the widespread use of fungicides belonging to the azole family on agricultural crops – in the process fostering more drug resistant strains of Aspergillus fumigates, one of the pathogens on WHO’s priority list as a hazard for human health.

While antifungals may be regarded as key to food security, wanton use is increasing drug resistant mutations of fungi, and thus “selective pressure on human pathogens”, especially in regions where regulations against the on the use of fungicides are weak, the SID report added. 

Aspergillus fumigates causes an “environmentally acquired respiratory illness,” with Europe reporting the highest number of cases from the fungus. A 2021-study described how Aspergillus fumigatus has been spreading in all continents across the world, except Antarctica. 

Uncontrolled release of drug-laced effluents by industry, agriculture, households and the health sector is another pathway by which AMR resistance is growing silently, but steadily – particularly in parts of the world lacking good sewage treatment systems, the report states.

Not enough data on drug-resistant fungi

Deaths from drug resistant bacteria such as S. pneumonia and K. pneumonia have been mapped recently – but similar work is lacking for fungal agents.

Another issue faced in coming to grips with the surge of fungal AMR, is the lack of data, WHO officials said at their briefing. There are no systematic requirements for countries’ reporting on the use of antimicrobial or antifungal agents in human health or agriculture – or for reporting on AMR hotspots that emerge from overuse.  Whatever data may be collected by WHO, it is not harmonised with data collected by FAO or OIE.  Without data, it is tough to know where fungal drug resistance is growing, and what is the global burden of diseases from related deaths.

“But it doesn’t mean that it’s not a problem,” Dr Getahun pointed out. “That is why we have identified the priority pathogen list. And that is why we are actually encouraging more research, more surveillance, to understand the actual extent. Then we will be able to have appropriate estimates about global [burden].”

“Currently, fungal infections receive less than 1.5% of all infectious disease research funding. Consequently, the evidence base is weak, and most treatment guidelines are informed by limited evidence and expert opinion. Tackling the problems posed by invasive fungal disease will require increased research funding, targeted at the key priorities, new antifungal medicines and improved diagnostics,” the report added. 

While a recent Lancet study estimated that drug-resistant bacterial infections directly cause around 1.3 million deaths every year, and are associated with the deaths of some five million people every year, no such numbers are available for drug-resistant fungi. “We do need surveillance to identify the real burden and direct the public health as it is.”

Coordination between WHO, FAO, OIE and UNEP – hope or smokescreen?

Stefano Prato, top left, describes the economic model that has locked in farmers to overuse of drugs critical to human health. Nicoletta Dentico, lower left, moderates.

Recognizing the growing AMR threats from animal production and crop cultivation, WHO in April 2022 signed a Memorandum of Understanding (MoU) with Food and Agriculture Organization of the United Nations (FAO), World Organization for Animal Health (OIE) and United Nations Environment Programme (UNEP) to collaborate on so-called One Health, approaches encouraging more judicious use of available drugs and chemical agents. 

Getahun, who is also director of the Quadripartite joint secretariat, told Health Policy Watch that under the MoU, the agencies – dubbed the Quadripartite – are working more closely together to identify those antibiotics that are critical to human and veterinary health. “[This was done] in order to ensure that these antimicrobials are not prescribed without the necessary veterinary or physiotherapy, you know, indications for plants.”

However, Getahun acknowledged that this work is in its early stages.

Speaking at the launch of the civil society report on AMR at Geneva’s South Centre, SID managing director Stefano Prato criticized the Quadripartite’s work as largely “theatrical” lacking normative teeth.  Meanwhile, veterinarians and farm extension advisors often receive huge financial incentives from encouraging farmers’ over-use of antibiotics, antivirals, antifungal agents and other drugs, driving uncontrolled use of such products.

“In many countries vets are really the ones who prescribe, earn and enjoy income and profits from the prescription of antiviral or antibiotics at the farm level,” observed Prato, who is both a veterinarian and an economist by training.”

In addition, developing countries have become locked into monoculture systems of industrial crop production, which typically require large drug and chemical applications – in order to generate cash crops for export.  Shifting out of that model to more sustainable agriculture systems that can supply more nutritious foods locally, is now extremely difficult because of their foreign debt burden, Prato said.

“Many countries that are locked into that export-driven model are also exposed to significan foreign debt… That means that they need the income and the currencies that are related to their export of commodities, because they need to repay those currencies”

“And so the conflicts of interest are so entrenched, not only at the global level but also at the national and micro level,” he said.

As for the new collaborations between WHO, FAO OIE and UNEP, Prato observed: “Without a proper governance structure, there will be no solution… it will end up being some kind of policy entertainment..theatrical red carpet solutions.”

-Updated 26 October with correction to the names of the report co-authors.

Image Credits: Flickr – UK Department for International Development, WHO, The Lancet, Creative Commons Zero, E. Fletcher/Health Policy Watch.

Exercise is an essential part of health.

Most countries are failing dismally to promote physical exercise despite inactivity playing a major role in heart disease, obesity and diabetes, according to the World Health Organization (WHO).

The WHO’s newly released Global status report on physical activity 2022 measures the extent to which governments are implementing recommendations to increase physical activity across all ages and abilities. 

Data from 194 countries shows that less than half the countries have a national physical activity policy, and only 30% have physical activity guidelines for all age groups. Just over 40% of countries have roads designed to enable safer walking and cycling.  

“We need more countries to scale up implementation of policies to support people to be more active through walking, cycling, sport, and other physical activity. The benefits are huge, not only for the physical and mental health of individuals, but also for societies, environments, and economies,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, “We hope countries and partners will use this report to build more active, healthier, and fairer societies for all.”  

The economic burden of physical inactivity is significant and the cost of treating new cases of preventable non-communicable diseases (NCDs) will reach nearly $300 billion by 2030, according to the WHO. 

To help countries increase physical activity, WHO’s Global action plan on physical activity 2018-2030 offers 20 policy recommendations, including policies to create safer roads to encourage more active transport, provide more programmes and opportunities for physical activity in key settings, such as childcare, schools, primary health care and the workplace. 

The report calls for countries to prioritize physical activity as key to improving health and tackling NCDs, integrate physical activity into all relevant policies, and develop tools, guidance and training to improve implementation. 

“It is good for public health and makes economic sense to promote more physical activity for everyone,” said Dr Ruediger Krech, Director Department of Health

Exercise and COVID-19 vaccine

Meanwhile, a South African observational study of over 190,000 people suggests that regular physical activity may have boosted the efficacy of the Johnson & Johnson (J&J) COVID-19 vaccine. 

The study, published in the British Journal of Sports Medicine on Wednesday, was conducted by the health insurance company, Discovery Health, and its wellness programme, Vitality, in collaboration with Witwatersrand Sport and Health Research Group and the South African Medical Research Council (SAMRC).

It drew on the anonymised medical records, and recordable activity tracker data for 196,444 healthcare workers vaccinated with the J&J vaccine, who were clients of both a Discovery Health Administered Scheme and a Vitality wellness programme.

Those who were fully vaccinated and had high weekly levels of physical activity were nearly three times less likely to be admitted to hospital than those who were vaccinated but in the low physical activity category. 

“We set out to test the hypothesis that regular physical activity enhances the immune-boosting effect of COVID-19 vaccines, reducing severe outcomes in vaccinated people (measured by hospital admission),” explains Discovery Health’s analytics actuary, Shirley Collie. 

“The risk of hospital admission among fully vaccinated healthcare workers was reduced by 60% in the group who engaged in low levels of physical activity, and by 72% and 86% in the medium and high physical activity groups, respectively.” 

However, Professor Glenda Gray, President of the South African Medical Research Council, cautions that more research is needed to understand why exercise enhances the vaccine’s effects.

“For now, we suggest this may be a combination of enhanced antibody levels, improved T-cell immunosurveillance and psychosocial factors,” said Gray.

Image Credits: WHO/A. Loke.

Polio
Representatives from Rotary International and the government of the Philippines sign the agreement that starts Rotary International’s first polio project, 1979.

A historic window of opportunity to eradicate polio could be slipping away, World Health Organization (WHO) Europe leaders warned at a press conference marking World Polio Day on Monday. 

Since the 1980s, global polio cases have fallen by 99.9% and if polio were to be eradicated, it would join smallpox as only the second disease to be consigned to history.

“Polio is on the verge of becoming a story of the past,” said Dr Hans Kluge, WHO Europe Regional Director. “We stand on the cusp of eradicating the virus, but progress and the European region’s polio free status remain vulnerable.” 

The European region has been free from wild polio for two decades. But over the past year, circulation of vaccine-derived polio virus – a strain mutated from the weakened virus contained in the oral polio vaccine – has been confirmed in Israel, Ukraine, and the United Kingdom. This weakened variant can only spread in pockets of under-immunized communities, highlighting the need to reinforce vaccination efforts.

“The fight against polio has demonstrated the wonders of immunization, but this is not something we can take for granted,” Kluge said. “We are so close to the prospect of a polio free world. Choosing to leave the fight now would be a tragedy for future generations.”

Journey to eradication: from dream to reality

Polio
The 1979 agreement between Rotary International and the Philippine Ministry of Health for a joint multi-year effort to immunize children against polio

In 1979, a member of Rotary International issued a challenge to their peers in the Philippines chapter to eliminate polio from the island nation. It would take years of work, but the initiative was successful. The last case of wild polio in the Philippines was recorded in 1993. 

The challenge was then put to Rotary’s 1.4 million members globally. With representatives in over 200 countries, the goal became global eradication of the disease. Since the start of the 1979 vaccination campaign in the Philippines, Rotary International has invested $2.6 billion in the fight against polio.

“The thought was ‘if we can do it here, can we do it everywhere?‘” explained Rotary international president Jennifer Jones in her opening statement at the Monday press conference. “We started to speak with health professionals and organizations around the world, but it wasn’t seen as being a possibility at all.”

In 1988, the WHO, UNICEF and the Centers for Disease Control and Prevention, came together to form the Global Polio Eradication Initiative (GPEI). Later, the Bill and the Melinda Gates Foundation joined and GPEI became the largest international public health initiative in history.

Just last week, GPEI secured $2.6 billion in commitments at the World Health Summit, which is over half of its funding target of $4.8 billion set out in its 2022-2026 Strategy. This money is needed to provide vaccinations and essential healthcare services to over 370 million children worldwide. In total, over $19 billion has been invested into the programme since its launch.

The global effort has led to a reduction in polio cases by 99.9%.  “We are closer than we’ve ever been,” Jones said.

Endemic regions making progress

The mountains of North Waziristan, Pakistan.

Two years ago, wild polio was eradicated from endemic reservoirs in India and the African continent, and efforts in the last two endemic countries – Pakistan and Afghanistan – are trending in the right direction. But with the finish line in sight, the last mile is proving difficult.

“Pakistan has made incredible progress against polio, but recent challenges have allowed the virus to persist,” said Dr Zulfi Bhutta, professor at Aga Khan University in Pakistan. “Polio, like any virus, knows no borders; its continued transmission threatens children everywhere.”

Waziristan, a mountainous region of Pakistan on its Afghan border, faces high levels of vaccine hesitancy that have led to it becoming polios’ most resilient reservoir. The surrounding mountains – once strongholds of the Taliban – are a fitting backdrop for the disease to take its final stand.

The return of the Taliban from these very mountains to the levers of power in Afghanistan have complicated progress in reaching its unvaccinated communities. But negotiations to allow vaccinators better access to the country are underway.

Children pay the price of low-vaccination

Vaccine-derived polio strains are only a threat to the under-immunized. Too often, this means the heaviest burden falls on children.

“The occurrence of vaccine-derived polio around the globe clearly indicates one thing: we have left our children behind by not getting them vaccinated,” said Dr Siddhartha Datta, WHO Europe’s Regional Immunization Advisor. “It is extremely important that every child gets the vaccine doses which are part of the national vaccination schedule.”

Hundreds of children have already been paralyzed this year due to the spread of a vaccine derived strain amongst non-immune people in parts of Africa, Asia and Europe.

“Children deserve to live in a polio-free world, but as we have seen this year with painful clarity, until we reach every community and vaccinate every child, the threat of polio will persist,” said UNICEF Executive Director Catherine Russell. 

Polio anywhere is a threat everywhere

The re-emergence of polio in non-endemic regions highlights the difficulties of eradicating diseases in an increasingly interconnected world.  

“Polio is still a plane ride away,” Carol Pandak, the Chicago-based director of Rotary’s PolioPlus program told Bloomberg. “We’re sticking with the fight until we finish the job and keep our promise to the children of the world.”

But while cases in non-endemic countries are cause for anxiety, there is no need to panic, Jones explained.

“Seeing cases outside of the endemic areas is concerning, but we don’t need to fear-monger,” she said. “We should utilize the opportunity to raise awareness of what polio is and why it’s important to eradicate.”

COVID-19 has also taken a toll on polio immunization programmes. Across the WHO’s European region, coverage of the third dose of polio vaccine fell by 1% between 2019 and 2020. In 2021, only 25 out of 53 of the region’s countries had reached the 95% polio vaccination coverage rate recommended by the WHO.

“It is paramount that we ensure high vaccination coverage in all population groups,” said Kluge. “Until polio is eradicated, every country will remain at risk.”

COVID remains a threat, and forecasting is shaky

WHO Europe Director Hans Kluge at a press conference marking World Polio Day.

Last week marked 1000 days since the first cases of COVID-19 arrived in Europe. Entering the third pandemic winter, the continued evolution of the virus driven by a range of sub-lineages of the Omicron variant remains a concern.

An autumn surge has led to a tripling of cases in the European region since early September. In the second week of October, the region accounted for nearly 60% of new global cases and 42% of deaths.

“We are much better prepared, and the surge has not led to previous ICU admission or severe disease levels,” Kluge noted. “But the virus has surprised us more than once, and forecasting is tricky.”

WHO Senior Emergency Officer Dr Catherine Smallwood echoed the difficulty of projecting how the disease will develop through the winter.

“We’re having trouble isolating which of the omicron sub-variants will have a growth advantage and will take over in dominating the spread,” she explained. “Some variants like BQ.1 have been noted as potentially accelerated, but we’re not sure yet how this is going to pan out in the longer term.”

Image Credits: Rotary International, Rizwan Ullah Wazir.