A widely cited study about the use of Hydroxychloroquine and azithromycin to treat COVID-19, published in March 2020, has been retracted by its publisher, Elsevier.

The study, published in Elsevier’s International Journal of Antimicrobial Agents, was retracted in the January 2025 edition of the journal (issued last month).

“Concerns have been raised regarding this article, the substance of which relate to the articles’ adherence to Elsevier’s publishing ethics policies and the appropriate conduct of research involving human participants, as well as concerns raised by three of the authors themselves regarding the article’s methodology and conclusions,” the publisher notes.

The study involved 20 French patients, some of whom were given the antimalarial medicine Hydroxychloroquine. Six were also given the anti-bacterial drug, azithromycin.

“Untreated patients from another center and cases refusing the protocol were included as negative controls,” according to the study.

Patients treated with hydroxychloroquine were recruited and managed in the Méditerranée Infection University Hospital Institute in Marseille Marseille centre. Control patients were recruited in Marseille, Nice, Avignon and Briançon centers, all in South France.

Ethical questions

But the patients were recruited to the”open label non-randomised trial” in “early March” – possibly before ethical approval for the trial was given on 5-6th of that month.

In addition, the journal has been unable to establish whether “all patients could have entered into the study in time for the data to have been analysed and included in the manuscript prior to its submission”.

There are also questions about whether informed consent was obtained from the patients, lack of clarity about whether all patients were enrolled in the study upon admission to hospital or if they had been hospitalised for some time and whether there was sufficient “equipoise” between the study patients and the control patients.

None of the control patients are reported to have received azithromycin. At the time of the study, azithromycin was not used as first-line prophylaxis against pneumonia in France “due to the frequency of macrolide resistance amongst bacteria such as pneumococci.”, according to Elsevier. For that reason, informed consent would have been necessary to use it.

Author disputes

Three of the authors, Dr Johan Courjon, Prof Valérie Giordanengo, and Dr Stéphane Honoré, contacted the journal with concerns “regarding the presentation and interpretation of results in this article and have stated they no longer wish to see their names associated with the article”, Elsevier reported.

Giordanengo was concerned with analysis bias, raising that PCR tests administered in Nice were interpreted according to the recommendations of the national reference center,while those carried out in Marseille “were not conducted using the same technique or not interpreted according to the same recommendations”. 

The corresponding author, Didier Raoult, did not respond to the deadline to address concerns.

However, first author Dr. Philippe Gautret, and authors Professors Philippe Parola,  Philippe Brouqui, Philippe Colson, and Bernard La Scola, “disagreed with the retraction and dispute the grounds for it”.

Then US president Donald Trump touted Hydroxychloroquine several times as an effective treatment for COVID-19.

Midwife Neha Mankani attends to a mother and her newborn in a flood affected community in Pakistan.

In 2024, the world reached an alarming milestone: the hottest global temperatures ever recorded. Floods, heat waves, tropical storms, hurricanes, droughts, and wildfires are affecting everyone, everywhere, with devastating consequences. 

But behind the headlines of environmental catastrophe lies a quieter crisis: the health impacts of climate change on women, families and newborns, and the health providers at the forefront of this crisis.

Sexual, reproductive, maternal, newborn, and adolescent health (SRMNAH) needs don’t pause during crises. Babies are still being born, and women and girls can’t wait for care – whether it’s for contraception, treatment for a sexually transmitted infection (STI), or comprehensive abortion care. 

Midwives can provide up to 90% of essential SRMNAH services, even in the most challenging circumstances. Yet their voices are often left out of global climate discussions, and their potential as climate resilience leaders is overlooked.

Minimal infrastructure

“As the world becomes progressively more unstable over time, which it will, having care providers who can operate with minimal infrastructure to deliver care to clients will become increasingly important,” said a Canadian midwife in a new report by the International Confederation of Midwives (ICM). 

“Midwives are ideally positioned to provide flexible sexual and reproductive health and perinatal care to vulnerable populations. We are the face of climate mitigation.”

The report highlights the far-reaching health impacts of climate change and the critical role midwives are already playing in addressing them. It also showcases their vision for building climate-resilient health systems and calls on governments and policymakers to recognise midwives as integral to climate resilience.

A midwife checking a pregnant woman in a rural community clinic in Guatemala.

Impact of extreme heat

Midwives are experiencing first-hand the effect of heatwaves, floods, and other disasters on their patients, with increasing risks of preterm births, stillbirths, and maternal complications like dehydration and postpartum haemorrhage.

“Extreme heat is contributing to increased stillbirth rates, postpartum haemorrhage, and stunting,” shared a midwife from Ethiopia.

Three-quarters of respondents agreed that climate change is harming the communities they serve. These challenges hit marginalised and low-income populations hardest, where access to healthcare is already limited. 

“Low-income communities are more severely affected when there are heat waves. And women are at higher risk of dehydration and preterm labour as a result,” shared one respondent.

Displacement caused by climate disasters adds another layer of inequity. 

A midwife from Ontario, Canada, noted: “Forest fires in my country have displaced Indigenous people from their land. They already face removal from their community to give birth and access care.”

Midwives are already responding

Midwives are not passive observers of the climate crisis; they are active responders. From delivering care during floods and heatwaves to educating families about health risks, midwives are already adapting to the challenges posed by climate change.

“Midwives are vital agents of change in building climate resilience in vulnerable communities. Their multifaceted contributions are critical … they tirelessly educate communities about the health risks of climate change, promote adaptation strategies, provide emergency care during disasters, and integrate sustainable practices within healthcare facilities,” said a midwife from Kenya.

Respondents often reported using their time with clients to discuss environmental health, with 39% doing so regularly. However, 31% expressed a desire to engage in these conversations but felt they lacked the necessary information to do so effectively.

This vital work often comes at a personal cost. The report revealed that 76% of midwives said the climate crisis negatively impacts their work, leading to stress, burnout, and displacement. 

As one Ugandan midwife shared, “I am not able to provide services as I want, and this has affected me psychologically.” 

Jane Mpanga, a midwife checks on an expectant mother at her clinic in Kampala.

A sustainable model of care

Continuity of midwife care offers a sustainable model of care that aligns with global climate goals. Unlike resource-heavy obstetric models, midwifery puts women at the centre of care, while relying on fewer interventions, producing less medical waste, and being inherently community-focused.

“As midwives, we are low tech, high touch,” said a midwife from Australia. “We should continue to advance midwifery as climate activists because [midwifery is] good for the environment.”

Midwives are resourceful in their approach. “Midwives are judicious with their use of resources and resilient and resourceful with limited equipment and facilities,” noted a midwife from Australia. 

“Midwife-attended births at home, for example, generate significantly less waste than a similar birth in a hospital setting and are therefore much better from an environmental perspective.” 

Midwife Farhana Jany with Rohingya mothers at Hope Hospital in Cox’s Bazar, Bangladesh.

There is an extensive body of research that shows that in health systems where midwives are enabled and integrated, this type of care gives excellent outcomes.

Midwives also empower women to build their resilience. Through education and support, midwives help women make informed decisions about their health, fostering long-term stability for their families and communities.

An Ethiopian midwife noted, “Midwifery care offers a unique approach to supporting women and families in a climate-changing world. Their focus on community, resilience, and holistic care positions them as key players in ensuring healthy pregnancies and births even amidst growing instability.” 

Call to action

Midwives are key to addressing the health challenges of climate change and building sustainable, climate-resilient health systems. Yet, they remain excluded from most national climate strategies. 

Governments and policymakers must urgently integrate midwives into climate preparedness and response planning processes. This includes ensuring midwives are part of the process, and that when crisis strikes, they have the training, tools, and resources they need to address climate-related health risks and establish referral pathways and transport systems to use when needed.

The climate crisis is a public health emergency that demands immediate, coordinated action. National health strategies, especially those addressing climate resilience, cannot succeed without recognising the vital role of midwives.

The stakes couldn’t be higher. As one Canadian midwife aptly said: “It is hard to remain hopeful in a context where science demonstrates that we have a tiny window to act, but our leaders are not taking the necessary action.”

The time to act is now – for midwives, for the women and families they serve, and for a healthier, more resilient future.

Sandra Oyarzo Torrez is President of the International Confederation of Midwives

Ana Gutierrez is Communications Lead at the International Confederation of Midwives

Image Credits: International Confederation of Midwives.

Sugary drinks have become popular in Africa, driving type 2 diabetes and cardiovascular disease.

Sugary drinks are driving new cases of diabetes and cardiovascular disease, particularly in sub-Saharan Africa, Latin America and the Caribbean, according to a study published in Nature this week.

One in five new type 2 diabetes cases in Sub-Saharan Africa and a quarter of those in Latin America and the Caribbean are attributable to sugary drinks, according to researchers from Tufts University’s School of Nutrition Science and Policy.

They estimate that 2.2 million new cases of type 2 diabetes and 1.2 million new cases of cardiovascular disease occur globally each year due to the consumption of sugary beverages.

Around 11% of new cardiovascular diseases in the Caribbean and over 10% in sub-Saharan Africa are also the result of these drinks. 

The researchers compiled data about 184 countries between 1990 and 2020 using the Global Dietary Database, including 450 surveys with data on sugary drinks totaling 2.9 million individuals from 118 countries.

Biggest increase in sub-Saharan Africa

The biggest increases in diabetes and CVD occurred in sub-Saharan Africa, reflecting changes in the consumption patterns of the region.

Colombia, Mexico, and South Africa have been particularly hard hit.  Almost half (48%) of Colombia’s new diabetes cases, 30% of Mexico’s cases and 27.6% of South Africa’s cases were attributable to sugary drinks.

Meanwhile, sugary drinks were to blame for 23% of Colombia’s CVD cases, 14,6% of those in South Africa and 13,5% of Mexico’s cases. 

“Sugar-sweetened beverages are heavily marketed and sold in low- and middle-income nations. Not only are these communities consuming harmful products, but they are also often less well equipped to deal with the long-term health consequences,” says Professor Dariush Mozaffarian, senior author on the paper and director of Tufts’ Food is Medicine Institute.

‘Clarion call’ to cut consumption

The study describes its findings as “a clarion call that the ‘nutrition transition’ from traditional toward Western diets has already occurred in much of the [sub-Saharan] region”, yet most African nations have not implemented any measures to curb sugary drinks intakes, “perhaps owing to both industry opposition and previous lack of credible country-specific data”.

Those most at risk varied from region to region. In Latin America, the Caribbean, South Asia and sub-Saharan Africa better educated people were most at risk. But in the Middle East and North Africa, lower educated people consumed more sugary drinks. Younger people and men were also more at risk.

There were “modest decreases” in cardio-metabolic burdens related to sugary drinks in Latin America and the Caribbean, which is consistent with slowly decreasing consumption of sugary drinks.

“Nations in this region have implemented several policy efforts targeting sugar-sweetened beverages, including taxes, marketing regulations, front-of-package warnings and education campaigns,” the researchers note.

However, the impact of sugary drinks on health remains high and absolute burdens per million adults continue to rise “owing to continuing increased rates in obesity, type 2 diabetes and CVD” as well as other risks such as high consumption of refined grain and physical inactivity.

Taxes on sugary drinks

South Africans campaign in favour of a tax on sugary drinks in 2017

The authors call for public health campaigns, regulation of sugary drink advertising, and taxes on sugar-sweetened beverages.  

Mexico, which has one of the highest per capita rates of sugary drink consumption in the world, introduced a tax on the beverages in 2014. 

South Africa followed suit with a tax called a Health Promotion Levy in April 2018, taxing all sugary drinks with over 4 grams of sugar per 100 millilitres. 

Colombia’s tax on sugary drinks, which took effect on November 1, 2023, also varies according to the amount of added sugar in the drink:

“Much more needs to be done, especially in countries in Latin America and Africa where consumption is high and the health consequence severe,” says Mozaffarian, who is also Professor of Nutrition. 

Due to their liquid form, sugary drinks are “rapidly consumed and digested, resulting in lower satiety, higher caloric intake and weight gain”, according to the study.

“High doses of rapidly digested glucose also activate insulin and other regulatory pathways, which can result in visceral fat production, hepatic and skeletal muscle insulin resistance and weight gain.”

Image Credits: Heala_SA/Twitter, Kerry Cullinan.

Chinese doctors perform remote surgeries on patients thousands of kilometres away.

Chinese surgeons have used a surgical robotic system and a high-speed satellite to perform five operations on patients thousands of kilometres away from them, according to China Global Television Network (CGTN), China’s global news  broadcaster.

The surgeons, who were based in the Chinese cities of Lhasa, Dali and Sanya, performed procedures on the Beijing patients’ liver, pancreas and gallbladder.

“The surgeon’s movements would be translated into data, which would be sent up to the satellite, then down to the robotic system working on the patient,” according to CGTN.

“Feedback data would then be sent in the opposite direction. All in all, the data would travel nearly 150,000 kilometers, and yet the surgeons could do their jobs as if they were in the same room as their patients.”

The Apstar-6D broadband communication satellite was the conduit for the surgeons’ movements. Satellites are faster and more stable than ground-based systems.

“This series of remote surgeries spanned China’s mountains and straits, demonstrating the feasibility, safety and effectiveness of performing complex long-distance operations using home-grown satellite technologies and robotic systems,” according to CGTN.

China has raised the possibility that such technology can be used to operate on people in dangerous conflict zones.

“The technology could connect patients with surgeons in ways we’ve never seen before. For example, it’s possible that doctors could treat injured soldiers without going anywhere near the front line,” the CGTN report noted.

However, patients still need to be in a health facility with sophisticated infrastructure including the surgical robotic systems. 

“There may be some way to go, but these operations suggest that one day, a satellite surgeon could save someone’s life.”

Image Credits: China Global Television Network (CGTN).

Evidence of the links between alcohol and cancer is “extensive”.

Alcohol is the third leading cause of cancer in the United States, yet less than half of US citizens polled are aware of its link to cancer, according to the US Surgeon General.

To mitigate this, the warning labels on alcoholic beverages should be updated to include the risk of cancer, advised Surgeon General Dr Vivek Murthy this week.

By 2019, almost 100,000 cancer cases in the country “were related to alcohol consumption including 42,400 in men and 54,330 in women”, according to the Surgeon General’s advisory on alcohol and cancer issued this week. 

Breast cancer accounted for the “largest burden of alcohol-related cancer in the US”, with an estimated 44,180 cases in 2019, according to the advisory. This was 16.4% of the total breast cancer cases for women that year.

Cancer of the colorectum, oesophagus, liver, mouth (oral cavity), throat (pharynx), and voice box (larynx) are also linked to alcohol consumption. 

At least seven cancers are associated with alcohol

There are around 20,000 annual alcohol-related cancer deaths – significantly higher than the approximately 13,500 alcohol-associated traffic crash deaths. Only tobacco consumption and obesity cause more cancer than alcohol.

“The more alcohol consumed, the greater the risk of cancer. For certain cancers, like breast, mouth, and throat cancers, evidence shows that this risk may start to increase around one or fewer drinks per day,” the advisory notes.

Almost three-quarters of US citizens (72%) reported having at least one alcoholic drink a week (2019-2020).

According to the World Health Organization’s (WHO) global status report on alcohol and substance use disorders, based on 2019 data from 154 countries, in the region of the Americas, Canada (21.5) and the USA (20.8) topped the list of alcohol consumption.

Those living in the vast WHO European region, which includes Russia, consumed the most alcohol – 9.2 litres of pure alcohol per person annually. The Region of the Americas, which includes North and South America and the Caribbean, followed with 7.5 litres.

But in a 2019 survey, only 45% of people in the US were aware of the relationship between alcohol consumption and cancer risk.

Only 45% of US citizens were aware of the link between alcohol and cancer

‘Extensive evidence’

There is extensive evidence from biological studies that ethanol (the pure alcohol found in all alcohol-containing beverages) causes cancer in at least four distinct ways, according to the advisory.

First, alcohol breaks down into acetaldehyde in the body. This causes cancer by binding to DNA and damaging it. 

Alcohol also generates “reactive oxygen specie”s, which increase inflammation and can damage DNA, proteins, and lipids in the body through a process called oxidation. 

Third, alcohol alters hormone levels (including estrogen), which can play a role in the development of breast cancer. 

Fourth, carcinogens from other sources, especially particles of tobacco smoke, can dissolve in alcohol, making it easier for them to be absorbed into the body, increasing the risk for mouth and throat cancers. 

The World Health Organization (WHO) has said that there is no safe level of alcohol consumption, calling for global action to combat the consumption of alcohol and and narcotic drugs.

Mitigation of risk

In  order to reduce alcohol-related cancers in the US, the Surgeon General recommends updating the warning labels on alcoholic beverages to include the risk of cancer and making the labels “more visible, prominent, and effective”.

He also suggests reassessing recommended limits for alcohol consumption based on the latest evidence on alcohol consumption and cancer risk.

Other suggestions include stronger and more educational efforts to increase general awareness that alcohol consumption causes cancer, informing patients of their risks and promoting alcohol screening, intervention and treatment referral.

Image Credits: Stanislav Ivanitskiy/ Unsplash, US Surgeon General, US Surgeon-General.

Extreme weather events reached dangerous levels in 2024 due to record-breaking temperatures.

The year 2024 is set to be the warmest year on record, the United Nations’ (UN) weather agency, the World Meteorological Organization (WMO), said in an end-year statement on 30 December. This year caps a decade of unprecedented heat fuelled by human activities, the WMO said.

“In my first year as WMO Secretary-General, I have issued repeated Red Alerts about the state of the climate,” said WMO Secretary-General Celeste Saulo.

“This year we saw record-breaking rainfall and flooding events and terrible loss of life in so many countries, causing heartbreak to communities on every continent. Tropical cyclones caused a terrible human and economic toll, most recently in the French overseas department of Mayotte in the Indian Ocean. Intense heat scorched dozens of countries, with temperatures topping 50°C on a number of occasions. Wildfires wreaked devastation,” Saulo said.

Her comments foreshadowed the expected findings of WMO’s formal consolidated global temperatures report for 2024, due to be published in early January.

In a close-up look at just 26 of the 219 major weather events of 2024, climate change-related extremes contributed to the deaths of at least 3,700 people in floods, typhoons, hurricanes, heat waves and wildfires, while leading to the displacement of millions.

This, according to a separate report by World Weather Attribution (WWA), an international consortium of scientists.

“It’s likely the total number of people killed in extreme weather events intensified by climate change this year is in the tens, or hundreds of thousands,” the report stated.

Extreme heat more and more devastating

Climate change also was responsible for an additional 41 days of dangerous heat exposure, per person, on average, in 2024 as compared to pre-industrial exposure levels, the WWA scientists found.

World Weather Attribution studied 26 weather events closely out of the 219 events in 2024.

What is worse is that the countries that experienced the highest number of dangerous heat days are overwhelmingly small islands and developing states that tend to have limited resources to cope.

“Today I can officially report that we have just endured a decade of deadly heat. The top ten hottest years on record have happened in the last ten years, including 2024,” said UN Secretary-General António Guterres in his own New Year message.

“This is climate breakdown – in real time. We must exit this road to ruin – and we have no time to lose. In 2025, countries must put the world on a safer path by dramatically slashing emissions, and supporting the transition to a renewable future,” Guterres said.

Runaway emissions locking in even more heat

Trends are only getting worse, according to the WMO. Currently, the world is at 1.3°C of human-induced warming. In the next five years the annual global temperature is very likely to temporarily breach the 1.5°C target above pre-industrial era that was the target set as a part of the Paris agreement.

And with the most recent UN climate conference COP in Azerbaijan’s capital Baku this November failing to set any new targets for reining in record high fossil fuel burning and emissions, while delivering only $300 billion annually of the $1trillion in climate finance demanded by the poor countries to make a green energy transition, the chances of halting and reversing those trends any time soon looked grim at year’s end.

“Every fraction of a degree of warming matters, and increases climate extremes, impacts and risks,” WMO’s Saulo also said in her a chilling warning. “Temperatures are only part of the picture. Climate change plays out before our eyes on an almost daily basis in the form of increased occurrence and impact of extreme weather events,” she said.

Better monitoring of GHG concentrations 

WMO is in the process of rolling out the Global Greenhouse Gas Watch initiative that will track the GHG concentrations and monthly net fluxes in the atmosphere, for carbon dioxide (CO2), methane (CH4), and nitrous oxide (N2O) at a 1° × 1° geographic latitude-longitude grid resolution (about 100×100 km spatial resolution).

The aim is to “reduce uncertainties and improve the reliability of GHG monitoring,” the organization said, thus helping countries track the atmospheric impacts of greenhouse gas emissions, while addressing data gaps.

Climate change also added 41 days of dangerous heat in 2024, according to a report jointly produced by the team at World Weather Attribution (WWA) and Climate Central.

Push for early warning systems, more data

The UN also is pushing countries to ramp up their own early warning extreme weather systems. Under the Early Warnings for All initiative, WMO plans to support countries in developing their climate services and delivery programmes.

Other multilateral agencies are also doing the same. In Asia, the Asian Development Bank Institute is pushing countries in the Asia and Pacific region to collect more climate data that could  help prioritize vulnerable communities and respond effectively.

Image Credits: WMO, WWA, WMO.

They reached out for a dialogue at the height of the COVID pandemic: Michelle Williams, then dean of Harvard’s School of Public Health, and Margaret Chan, dean of China’s Vanke’s School – face to face in  Geneva in May 2024.

In April 2022, amidst the continuing uproar of the COVID pandemic, four deans of schools of public health from the USA, China, Switzerland and Singapore, first got on a call with each other to see how they could ramp up cooperation – remotely.

Barred by lockdowns from the usual academic meetings and conferences, the urge to link up was stronger than ever.

Co-founders of the high-powered group were Michelle Williams, then dean of Harvard’s School of Public Health, and former WHO Director General  Margaret Chan, now dean of Beijing’s brand-new Vanke School of Public Health.

“At the height of the pandemic, my good friend here, Margaret and several others amongst us, decided that we needed to come together with deans of schools of public health, to promote solidarity, and to continue to be assertive about what global health diplomacy means for all of us,” said Williams at the first face-to-face Coalition meeting in May 2024.

“We were surprised at the lack of dialogue, the lack of cooperation and collaboration worldwide,” said Chan, of that difficult pandemic period. So, she was delighted when Williams reached out about a conferring virtually. “We felt that change is necessary, and we can make a contribution as universities – which represent the creation and translation of knowledge, through science, to policymaking.”

Other founding members included Antoine Flahault, director of the Zurich-based Swiss School of Public Health and long-time actor in Geneva, the world’s “global health hub”. And the deans of public health schools at the University of Cape Town; Mahidol University, Thailand. Heads of public health institutes in Huazhong, China, Mexico, Sydney, Chile and Singapore.

Online hosted by China

Vanke School of Public Health, Tsinghua University, China.

 That first encounter, organized online by Chan at the Vanke School, was naturally focused on health issues related to the COVID crisis – but with an eye beyond the immediate issues of vaccines, travel restrictions and lockdowns to the long-term challenges that everyone knew lay ahead.

Challenges like the need for countries to come together on the all-important task of building more resilient health systems, better prepared for the next pandemic.

“Working with Dr. Margaret Chan to co-create the Coalition was one of the few bright spots during the early part of the pandemic,” Williams, who recently stepped down as dean, told Health Policy Watch by email from California, where she is currently on sabbatical.

“I was delighted that Margaret, and I joined forces and then had other deans join us. I felt it was important that we academic leaders needed to redouble our efforts to break down real and perceived barriers to global health collaboration, cooperation and diplomacy.

“All around us, in political and public health practice spaces, I observed decision makers looking inward and sometimes missing the important imperatives and values of global public health,” Williams said.

“Vaccine nationalism, unthoughtful border closings and some other policies ran counter to public health, global health diplomacy and practice.  This was disheartening especially as pandemic threats, threats from climate change and other threats like antimicrobial resistance are global threats that require global cooperation.”

Linking academia’s public health leadership

‘Our aim is not to duplicate’, Antoine Flahault, dean of the Swiss School of Public Health (on left), with Geneva University’s Alexandra Calmy at a meeting of the Coalition in May, 2024

Indeed, while there are other established coalitions of Public Health Schools, mostly US-based, such as the American Association of Schools of Public Health, the World Federation of Schools of Public Health, and the Consortium of Universities for Global Health, one unique aspect of the GHF-based Coalition of Deans has been the way it links public health leaders, and not only the institutions, says Flahault.

“Our aim is not to duplicate, but to be complementary to all of these groups, with which we coordinate,” he said.

The loosely-knit group now includes about a dozen institutions, as well as the leading European and American associations or federations of Public Health universities and schools.

“Our vision is that this Global Coalition will allow us to learn more from each other, sharing our experiences, facilitating exchanges of students and faculty among schools and fostering joint research programs,” Flahault observed.

Adds Michel Kazatchkine, a physician, academic and former French diplomat, who also spoke at the group’s last meeting on the margins of the World Health Assembly:

‘Increasing interest in health diplomacy’: Michel Kazatchkine, physician and former diplomat.

“We’re now seeing an increasing interest in health diplomacy. But in this context, academia is particularly important because science is essential in evaluating the impact of policies and providing feedback analysis to politicians so that they can correct trajectories if needed.

“And academia provides the freedom to do research on any topic, even the most sensitive – to collect, analyze and speak about the findings of your data. So, we should not underestimate the role of academia as a fundamental pillar of knowledge-based, democratic societies.”

Focusing on planetary health and other neglected topics

The Sydney School of Public Health’s Flagship planetary health initiative in Fiji was one example featured at the Geneva Health Forum. A study of watershed interventions, it aims to reduce incidence of typhoid, dengue and other deadly diseases in Pacific Island countries.

This year, after two years of remote meetings organized by the Vanke School and Harvard in succession, members of the coalition convened face-to-face, for the first time in Geneva, on the margins of the World Health Assembly, hosted by the Geneva Health Forum and the University of Geneva.

The group focused on planetary health as their principal topic.

“We shared experiences from Australia, China, and the USA about academic programmes dedicated to this issue – and asked the question: how do schools of public health integrate planetary health into their curriculum?” Flahault said. Doctoral and masters’ students from selected schools were also invited to speak along with faculty about lessons learned, he noted.

The discussions continued a thread from the 2023 remote meeting, which examined climate-driven food insecurity in the global health context – another cutting- edge issue that rarely gets much attention in classic public health school textbooks or classrooms.

“The Coalition of Deans have already been instrumental insofar as bringing attention to the importance of creating multi-national and interdisciplinary collaboration to bring multiple perspectives into designing curriculum,” reflected Williams.

“We’ve also provided a platform (as seen in the meeting hosted by Prof Flahault last spring) for showcasing junior faculty members and graduate students working in the fields of global planetary health and environmental justice,” Williams pointed out.

The effort is all the more topical insofar as Harvard’s Chan School of Public Health just launched a concentration in climate and planetary health in 2024.

In China, the Vanke School is also planning to pilot a planetary health course in 2025. That course will bring together students of public health with those in students from economics, urban design, environmental health sciences and engineering to examine multi-sectoral challenges and design solutions, said Chan, speaking with Health Policy Watch.

Chan: Vanke’s new planetary health course will bring together students of diverse disciplines.

“Everyone knows about how John Snow stopped the cholera epidemic [by breaking the pump on a contaminated water cistern], but what about the sanitary engineer who helps to renovate and overhaul the London sewage system,” Chan said.

Tsinghua University, where the Vanke School is located, is world famous for its engineering school, she observes.  “So. this will train future decision-makers to bridge between disciplines such as engineering and health.”

Indoor air pollution and wastewater epidemiology

Along with partners in the WHO, the GHF and European Universities, Coalition members have also supported the development of a series of events on other interdisciplinary health topics over the past year.

These included a conference on Indoor Air Pollution, in September 2023 in Berne, as well as a recent Conference in Paris on Wastewater-based Epidemiology. See related story:

Post Pandemic: Wastewater-based Surveillance of Diseases Comes of Age 

 

“Of course we have moved on from the pandemic to other topics,” noted Chan, speaking with Health Policy Watch recently in a phone interview. “The change in the conversation is a reflection of the changes in the current trends in Public Health. And it’s going to be more diverse as we move along.

One topic she’d like to see the Coalition tackle at some point would be the challenges of harnessing AI for good in the broad context of public health research and policymaking.

“There is a lot of talk about AI in clinical work, but what about AI in public health?” she asks. “Patient confidentiality is important. But we also need policies in place to enable the use of AI in research and outreach, but also to protect people’s privacy.”

Whatever the theme may be, the approach is the same, says Williams, who was instrumental in establishing a student exchange programme between Harvard and the Vanke School in 2021.

“Sharing of teaching materials and experiences related to launching new courses and concentrations are ways we can facilitate the spread of ideas across other universities.

“Developing and supporting annual workshops, and supporting student and faculty exchanges, are another. It is hoped that the Deans can secure resources to help operationalize these collaborative initiatives.”

Looking forward to 2025

Cabo Verde's Minister of Health, Filomena Mendes Gonçalves.
Geneva Health Forum 2024 session on malaria elimination with Cabo Verde’s Minister of Health, Filomena Mendes Gonçalves.

Looking forward, Flahault says the group aims to maintain its informal modus operandi, to facilitate exchange across borders – and keep the focus on meaningful meetings and liaisons.

“We are a lean organization without any budget and staff and not competing with any other organizations,” Flahault said.

At the same time, he envisions the Coalition playing an advisory role in a soon-to-be-formed Think Tank that aims to continue dialogue and problem-solving around the themes of the Geneva Health Forum throughout the year. “One major fruit or byproduct of this will be the GHF Think Tank, which we are launching this spring, and will tap the academic network the Global Coalition assembles,” he said.

That, in addition to their annual meetings, on the margins of the Geneva Health Forum’s annual conference during the World Health Assembly – with the next event organized by Teo Yik-Ying, dean of the Saw Swee Hock School of Public Health at the National University of Singapore.

Now that face-to-face meetings are once more feasible, working from the Geneva axis offers a unique vantage point that can transcend some of the sharp geopolitical divides that academic leaders face in dialogues at other venues, Flahault also points out.

Says Chan, who served as WHO Director General from 2006-2017, “I’m very biased – to me, Geneva is the capital of public health. And all countries come to the World Health Assembly. So, it’s natural that all of us in the Coalition would meet here, to make our voices heard.”

Returning to basics of infectious disease elimination

A child paralyzed by polio breathes in an iron lung – the best available intervention before the polio vaccine’s discovery in 1955.

Along with emerging global health issues around climate and planetary health – Flahault sees a future role for the group in reviving interest around some of the world’s longstanding, and unsolved public health challenges – such as elimination of polio, cholera and other preventable infectious diseases.

“Personally, I would love to see a WHA resolution against the three major diseases, polio malaria and cholera – with the same sense of determination we displaced against smallpox in the 1950s and 60s, with the same sharp formulation, we want to eradicate these diseases as soon as possible,” he said in a recent interview.

 “All of the major actors would push and row together to make this successful. For polio it’s already done but we have to say we have to end the job.

“We need to be modest and realistic,” Flahault admitted. “Surely, eradicating cholera from the planet, which has already been the subject of one WHA resolution, needs a huge political commitment. This is not in the portfolio of the Global Coalition or schools of public health.

“But we could still play a role. With players in the media ..we could try to mobilize political leadership which is lacking today. We don’t have many political leaders embracing global health issues, as happened during the pandemic, but today global health issues remain a source of power for promoting multilateral commitments.

“And in the coalition, we have a great opportunity for liaison between China, the USA and Europe and all of the other constituencies that are in the room, which give us an opportunity to push public health as a form of ‘soft power’ to move forward agendas.

After all, we succeeded in the 20th century to eliminate smallpox at the height of the cold war between the USSR and the USA.  It was not easy, but we succeeded thanks to a shared commitment to health.”

–Written as part of a Health Policy Watch collaboration with the Geneva Health Forum.

Image Credits: Vanke School of Public Health , Aaron Jenkins, Sydney School of Public Health, Geneva Health Forum, Paul Palmer/ WHO.

Sugary drinks now face additional taxes in Brazil.

Brazil’s National Congress approved a selective tax on tobacco, soft drinks, and alcohol this week as part of wide-ranging fiscal reform that also saw a reduction in taxes on healthy foods.

The trio of unhealthy consumables is now located in the same tax category as harmful goods and products including coal, vehicles and betting.

The specific tax rates for tobacco, alcohol, and soft drinks will be determined in 2025, but they will need to be high enough to deter consumers from buying these products to have an impact on health. 

The Congressional vote is a victory for advocacy groups as the Brazilian Senate had removed sugary drinks from the selective tax a week earlier, causing a public outcry.

The tax reform also establishes a National Basic Food Basket (CBNA) that will be tax-exempt. Meat, poultry and fish are included in this basket.

In addition, taxes have been slashed by 60% on horticultural and minimally processed goods including crustaceans, dairy products, honey, flour, cereals, pasta, juices, bread, nuts and fruit.

Lowering the price of healthy food

Brazilian legislators and civil society advocates aim to ensure that the prices of healthy foods are not higher than those of ultra-processed and unhealthy products.

 “This is a landmark moment for Brazil and a historic victory for global public health,” said Pedro de Paula, regional country director for the global public health organisation Vital Strategies in Brazil.

“By implementing a tax on these products, Brazil is not only saving lives by curbing the consumption of harmful products but also championing equitable access to healthier, more sustainable alternatives.  We commend Brazil’s National Congress for their leadership in this critical effort.”

De Paul said fiscal reform was necessary as Brazil had a “very complex, clunky system for production and consumer taxes”.

The new selective tax is an excise tax “for a handful of products which had clear negative externalities in terms of health and environment’, he added.

“This is landmark change, since it establishes a system that has clear taxes on top of the general VAT-like taxing structure with a clear narrative and purpose of reducing consumption and internalising the costs of the mentioned negative externalities,” he added.

While the tax will not be ring-fenced for health, De Paulo said that as the health system in Brazil is based on universal and free access, “any additional revenue implies additional minimum investments on health.”

However, Vital Strategies raised concerns about some of the provisions, such as “the inclusion of infant formula in the basic food basket and reduced tax rates for small alcohol producers.”

It will “collaborate closely with partners to advocate for tax rates that prioritise public health”, as “setting these rates at levels that significantly reduce consumption of harmful products will protect communities from preventable diseases.”

Sweetened beverages including soft drinks, artificial juices, and teas are “among the most consumed food groups in Brazil, with an average consumption of 65 litres per year per individual,” according to a recent article in the journal, Nature.

“Excess sugar is considered one of the main causes of excess weight and, consequently, its associated diseases (type 2 diabetes, hypertension). Therefore, the consumption of sugar-sweetened beverages is associated with an increased risk of developing obesity.”

Image Credits: Heala_SA/Twitter.

An Afghan woman amongst ruins caused by ongoing conflict in the country.

Medical institutions were the last hope for Afghan girls and women seeking higher education since the Taliban banned schools and universities for women

“Why do you torture us every day? Just give us poison and end it all,” a heartbroken Afghan medical student told Taliban forces, expressing the despair of thousands of girls whose dreams of becoming healthcare professionals were shattered by the Taliban’s latest decree.

The hardline group has banned all female medical students from pursuing education, marking the closure of nursing and midwifery programs across Afghanistan, the last lifeline for girls seeking higher education in a country where women’s rights have been systematically eroded since the Taliban’s return to power in 2021.

The Taliban’s recent decree, issued directly by the group’s supreme leader, Hebatullah Akhundzada, has caused immediate devastation. 

For the past three years, nursing and midwifery were the only remaining fields of study open to women after the Taliban banned girls from attending secondary schools and universities. The abrupt closure of these institutions has ignited widespread despair across Afghan society.

The ban comes a few months after the Taliban banned women’s voices and faces in public under so-called new vice and virtue laws. 

‘Are we not human?’

The abrupt ban came just days before completion of the last 2024 semester for many aspiring students like Zohra*, a nursing and midwifery student at the Abu Ali Sina Institute in the country’s northern Balkh province.

She told the Health Policy Watch: “These institutes were our last chance to continue our education after schools and universities were closed. I had set a new goal and worked hard, receiving good grades. I was on my way to becoming a midwifery graduate, to help my family, my country, and other women. Now, I’ve truly lost all hope for life.”

Kabul-based Maryam* echoed the despair. “We are Muslims, we observe Islamic hijab, and we just want access to education. Why do they not open the doors of the medical institutes for us? Since the closure of the institutes, I’ve lost track of day and night. I can’t sleep. My parents took me to a psychologist a few times, but nothing is helping. Are we not human?”

‘I have turned homeless’

“I have turned homeless, wandering aimlessly,” one student said in a viral video. Her words, along with others like it, have echoed through Kabul and beyond as girls wearing full-body black veils, many in tears, left their classrooms for the final time, uncertain if they would ever return.

Fariba*, a mother from Kabul, received devastating news when her daughter, Parwana, called early one morning, sobbing uncontrollably. 

“She never calls at this time,” Fariba, who once taught elementary education to girls, told Health Policy Watch. “It’s when she’s in class.” 

Her daughter Sara* had been studying nursing after her dream of attending university to study computer science was dashed by the Taliban’s closure of higher education for girls.

“Now, we are left without hope,” Sara, 20, lamented. “Our dreams are shattered. We are being pushed into the darkness.”

Conservative estimates suggest that around 35,000 girls were enrolled in over 150 private and 10 public medical institutions offering diplomas in fields such as nursing, midwifery, dentistry, and laboratory sciences before the Taliban’s ban. 

These programs were the last available option for young Afghan women who sought to contribute to their communities, particularly in healthcare.

The abrupt suspension has left students in shock. The administrator of one of the nursing institutes sent a message to all female students: “With a heavy heart, I must inform you that until further notice from the Islamic Emirate, you must not come to the institute for studies.”

Deepening health crisis

Training to be a nurse or midwife was the sole remaining career option for Afghan women after the Taliban takeover in 2021.

This move not only marks the end of the academic ambitions of girls and women, but also deepens the country’s already precarious healthcare crisis.

Afghanistan’s healthcare system was already under strain before the Taliban’s return to power, with one of the highest maternal mortality rates in the world. 

In 2020, the country saw 620 women die for every 100,000 live births – a stark contrast to just 10 deaths in the UK, according to the World Health Organization (WHO). 

Less than 60% of births were overseen by trained health personnel in 2019, according to the  United Nations Population Fund (UNFPA), which estimates that Afghanistan requires an additional 18,000 skilled midwives to meet the needs of its women.

Despite the overwhelming need for female healthcare workers, the Taliban’s decision to block access to medical education for women will exacerbate the crisis. 

Médecins Sans Frontières (MSF) warned that the country’s lack of female healthcare professionals would directly impact the provision of essential health services, especially maternal care.

“There is no healthcare system without educated female health practitioners,” said Mickael Le Paih, MSF’s Country Representative in Afghanistan. 

“In MSF, more than 41% of our medical staff are women. The decision to bar women from studying at medical institutes will further exclude them from both education and healthcare.”

The healthcare sector’s reliance on female professionals is especially critical in Afghanistan, where cultural norms often prevent women from being treated by male doctors. 

Dr Ahmed Rashed, a Kabul-based health policy expert, warned that the Taliban’s latest decree would create numerous social challenges, especially for Afghan women who prefer to be treated by female healthcare workers.

“If girls cannot attend secondary school, and women cannot study at universities or medical institutes, where will the future generation of female doctors come from?” Rashed asked. “Who will provide healthcare to Afghan women when they need it most? For essential services to be available to all genders, they must be delivered by all genders.”

International outcry

Last week, the United Nations (UN) Security Council criticized the medical education ban and the “vice and virtue” law issued in August in a unanimous resolution voicing concern about “the increasing erosion” of human rights in the country.

“If implemented, the reported new ban will be yet another inexplicable, totally unjustifiable blow to the health, dignity, and futures of Afghan women and girls. It will constitute yet another direct assault on the rights of women and girls in Afghanistan,” according to UN Special Rapporteurs working on women’s rights, human rights and health. 

“It will undoubtedly lead to unnecessary suffering, illness, and possibly deaths of Afghan women and children, now and in future generations, which could amount to femicide.”

The Norwegian Afghanistan Committee (NAC), which trains female healthcare workers in collaboration with the Ministry of Health, reported that it had been verbally informed that classes for women would be “temporarily suspended.” 

As the Taliban’s gender-based restrictions continue to devastate the lives of millions of Afghan women and girls, the question remains: What is the future of Afghanistan’s healthcare system? Without access to education, Afghan women will be barred from becoming the doctors, nurses, and midwives their country so desperately needs.

This decision, experts warn, will not only create immediate social and healthcare challenges but will have long-term consequences for generations to come.

* Names changed to protect their identities. Updated 22.12.2024.

Manija Mirzaie is an Afghan journalist now based abroad.

 

Image Credits: WHO EMRO, Ifrah Akhter/ Unsplash.

Particles of air pollution settle on the leaves in a south Delhi neighbourhood where the PM 2.5 is  approximately 400 micrograms/cubic metre.

New evidence shows that one in four deaths between 2009 and 2019 is linked to PM 2.5, one of the most dangerous pollutants commonly monitored. 

NEW DELHI – In November Delhi recorded its worst day of air pollution since 2019. As concerned citizens expressed outrage, authorities scrambled for answers – and it seems that the dirty air crisis may be worse than previously reported.

A new study published in The Lancet this week analyses the link between air pollution and deaths in districts (an administrative jurisdiction of a state or province) in India over 11 years from 2009. 

It shows pollution is not just a Delhi problem nor is it a recent problem, estimating that during the time period, 16.6 million deaths are attributable to PM 2.5 pollution. This is the particulate matter pollutant that is much finer than human hair that penetrates deep into the human body. 

The report is timely as the Supreme Court is now expanding the scope of its air pollution hearing from Delhi to cover all of India. 

A south Delhi neighbourhood with PM 2.5 at approximately 400 micrograms/cubic metre.

The study calls for a fundamental rethink of India’s battle against air pollution. Firstly, it shows 24.9% of deaths – almost one in four – are attributable to air pollution, more specifically PM 2.5. 

Secondly, it calls for India’s regulatory standards for air quality to be tightened. The Indian National Ambient Air Quality Standards for annual mean PM2.5 is 40 micrograms per cubic metre (µg/m³) whereas WHO’s guideline is 5 (µg/m³). 

Thirdly, the authors say this report is more relevant to policymakers than previous reports as it is based on data from India. In the past senior Indian government officials have questioned or rejected data linking deaths to air pollution, particularly from global agencies. 

More deaths than previously estimated

The Lancet report found an average of 1.5 million deaths from air pollution between 2009 and 2019, almost a quarter of all deaths.

This is a higher estimate of mortality than earlier studies. For instance, a WHO study reported an average of 830,000 deaths annually in the decade ending 2019, a conservative estimate based on secondary data sources. 

A study for 2019 by the Indian Council of Medical Reseach (ICMA), a government agency, and others estimated 1.7 million deaths. The new study tops that with 1.8 million attributable deaths for that year.

Applying the more relaxed guideline of 40 µg/m³ for PM 2.5 set by the Indian government, the number of deaths is estimated by the Lancet report to be 3.8 million over 11 years, or 300,000 every year. 

The entire population of India breathes air of a quality worse than the WHO’s guideline for an annual average.

New data is ‘more credible’ 

While there have been several large-scale studies globally on the link between PM 2.5 air pollution and deaths, this is the first such one in India which in recent years has the most polluted places. 

One of the authors, Dr Siddhartha Mandal, told Health Policy Watch that studies usually make associations between exposure to PM 2.5 and mortality. However, this report “lends more credibility” to the numbers because it uses a difference-in-difference approach to reach causal estimates. This methodology compares the changes in outcomes over time between a treatment group and a control group.

(A) Annual mean concentrations of PM2·5 in 2009. (B) Differences in annual concentrations in 2014 compared with 2009. (C) Differences in annual concentrations in 2019 compared with 2009.

“We believe that our study provides the most accurate exposure-response function and health impact assessment in India to date based on causal estimations from a state-of-the-art comprehensive exposure assessment and nationwide mortality data collected in India,” according to the authors.

It covers air pollution across 655 districts of India. The authors collected and analysed national counts of annual mortality for the 11 years, and also factored in the population and GDP per capita for each district. 

The authors say they observed stronger associations between annual PM2.5 averages and mortality in poorer districts (in terms of GDP).

Risk of death rises with pollution

In a country racked by an air pollution health crisis, there is one pressing figure for policymakers. Every 10 microgram/cubic meter increase in PM 2.5 leads to an increase in all-cause mortality rates by 8.6%, the study estimated. 

PM2·5 concentration is shown up to the 99th percentile.

While the AQI at 500 or 1,000 grab headlines, what the research points out in terms of health risks at lower levels is an eye-opener. 

“As the exposure levels increase, a plateauing effect is seen where, if you keep increasing the levels, additional increments in health are likely to be small,” says Mandal, who is affiliated with the Centre for Chronic Disease Control, New Delhi, and the Centre for Health Analytics and Trends, Ashoka University.

Simply put, that means that the risks rise from much lower levels of PM 2.5, when many thought the air quality was fine, but as the levels become extremely high, the risk may plateau or taper. 

How PM 2.5 harms humans

“Due to its size, PM 2.5 can enter the bloodstream and hence gets transported to multiple organs,” Mandal explains.

“Thereafter several common mechanisms such as inflammation and oxidative stress are triggered or exacerbated in the tissues.

“One of the major ways by which PM2.5 affects cardiovascular health is by inducing an imbalance in the autonomic nervous system, which controls several involuntary functions in humans such as cardiac rhythm. So PM2.5 contributes in multiple ways leading to exacerbation or acceleration of these conditions and subsequently death.”

A few days before this report was published, the Indian government reiterated in Parliament that “there are no conclusive data available in the country to establish direct correlation of death/disease exclusively due to air pollution.

“Health effects of air pollution are synergistic manifestation of factors which include food habits, occupational habits, socioeconomic status, medical history, immunity and heredity etc. of the individuals.” 

However, the authors say that policymakers could first take stock of all the recent work done relating air pollution and health (including mortality) using Indian data.

Experts from multiple domains, including public health, clinicians and engineering disciplines can deliberate on how to incorporate health-related evidence into designing interventions, mitigation strategies as well as revision of air quality standards. 

In parallel, there should be targeted actions backed by scientific evidence in the short and long-term, rather than reactive actions. For example, one could design and test out a public transport based intervention in certain areas within Delhi to assess how it affects pollutant levels across time. 

But they say, “most importantly, we should not wait for a perfect study to emerge and rather utilise available national as well as international evidence to take steps to improve the quality of air in the context of health.”

Image Credits: Chetan Bhattacharji, The Lancet.