Pollution in Delhi peaks in late autumn when drifting emissions from crop burning exacerbate the usual urban household, traffic and industrial sources

A growing body of evidence from India is firmly establishing the country’s toxic levels of air pollution as a leading cause of ill health, particularly non-communicable diseases (NCDs).

The results are significant because the country’s politicians have repeatedly questioned the validity of research that links air pollution with reduced life expectancy and worsening health. 

As many as 80 out of the 100 most polluted cities in the world are in India, as Health Policy Watch reported earlier ithis year, making air pollution a huge health stressor. 

The latest research from India demonstrates how air pollution is worsening anaemia, hypertension, diabetes, cholesterol levels and mental health, as well as other diseases.

Around 74% of all deaths worldwide are attributed to NCDs, according to the World Health Organization (WHO), and while air pollution is already a major risk factor, worsening air quality will worsen the disease burden due to NCDs further. 

Dr Soumya Swaminathan, fomer WHO Chief Scientist.

“The evidence base on the health impacts of air pollution in India is growing. There is a fair amount of data now on the adverse effects of poor air quality on not only respiratory diseases like asthma and COPD [chronic obstructive pulmonary disease], but also cardiovascular and neurological diseases, as well as an increase in metabolic disorders like diabetes mellitus,” former WHO chief scientist Dr Soumya Swaminathan told Health Policy Watch.

“The impact is particularly serious among pregnant women and young children, because it affects the growing organs of the fetus and young child and is likely to have permanent effects on physical and cognitive development,” added Swaminathan, who recently became co-chairperson of Our Common Air (OCA), a new global commission that has been launched by Clean Air Fund (CAF) in London, and the Council on Energy, Environment and Water (CEEW) in New Delhi. 

“[MS Swaminathan Research Foundation] has recently completed a study on the impacts of climate change on women and children in India, where air pollution is one of the major considerations and the evidence has all been collated,” she said of the foundation started by her father that she now chairs.

There are now around 500 studies on the impact of air pollution on health in India, according to Palak Balyan who leads the research team at Climate Trends, a Delhi-based research consultancy. 

She added that some gaps persist as the availability of health data is limited and most of the research comes from clusters around key cities like Delhi and Chennai, but not as much from the country’s rural areas.

Globally there were 8.1 million deaths due to air pollution in 2021.

Shocking and counter-intuitive statistics 

A few statistics that have emerged from recent research have been shocking and some even counter-intuitive, Swaminathan said. 

“The fact that women who stay mostly indoors [in cities] are often exposed to a higher dose of air pollutants than men who work outdoors. This has been documented in a study from Delhi… The fact that life expectancy in parts of north India is reduced by as much as five to seven years because of poor air quality,” she said. 

Indoor air pollution in the developing world is linked to the lack of access to clean cooking fuels, and the health impacts that research has highlighted would have takeaways for other developing countries in similar situation around Asia, Africa and Latin America.   

Swaminathan added that it is also becoming clear that air pollution affects not just the respiratory system but also distant organs like the heart, blood vessels and the brain, which is alarming. 

The State of the Global Air report 2024 listed air pollution as the second largest risk factor of deaths in 2021 after hypertension. However air pollution is also known to worsen hypertension.

Air pollution was the second largest risk factor of deaths in 2021.

 

“Globally, it is established that exposure to air pollution is a major risk factor for hypertension,” said Professor Sagnik Dey from the Centre for Atmospheric Sciences at the Indian Institute of Technology in Delhi. Most of this research is in developed countries but research from India is also emerging on this connection.

All the countries in the top five most polluted in the world are low-and middle-income countries with low resources and high hypertension burden. 

Dey added that initiatives like the India Hypertension Control Initiative focus on screening programmes which have a place but improving air quality will have to go with it. 

“We have strong evidence that additionally if India really works towards clean air, there will be a much accelerated progress and much larger health benefit,” Dey said.

Remaining research gaps

Establishing the health impacts of air pollution requires robust health data, and Balyan said most of the India-based research uses credible health data sourced from the country’s National Family and Health Survey (NFHS) which offers a representative sample. 

But this data is secondary data, and while there are studies that use primary data from communities, getting this data can be challenging. 

Even when the patients come into the health system, often this data is not captured as healthcare professionals are spread thin.
“Doctors are not trained or equipped with this kind of knowledge and also they don’t have this much of time to devote to each patient. When they ask patients’ history they rarely go to the any kind of questions which relates the problem of that patient to environmental stress or occupational stress,” Balyan said. 

Dey also added that a key gap is that often that the health and environment departments work in silos.

Enough evidence to act

Despite the difficulties of gathering primary data, there is enough compelling evidence both globally and on the India level for policy makers to act. 

Currently China, India and Pakistan top the list of the countries with the most number of air pollution deaths, according to the State of the Global Air report 2024. 

India recently re-elected Prime Minister Narendra Modi’s government for the third time. Issues related to health, climate and environment were rarely brought up by his government or the opposition during the election campaign. But India’s air quality has not shown any significant improvement in the past half a decade despite allocation of budgets, and in fact has worsened in some pockets, as Health Policy Watch reported earlier. 

Experts said improvements in air quality will be followed by health gains for the local communities. 

“Many cities around the world have improved air quality in relatively short time-periods and have seen positive impacts on health very quickly. Investing in air quality will have huge pay-offs for health and also for the economy,  and should be a high priority for all governments,” Swaminathan said. 

Image Credits: Flickr, State of Global Air Report 2024.

Satellite technology for telehealth consultations in a rural Guyana community; one of a number of health innovations the small Caribbean nation has spearheaded recently.

While this week’s CARICOM summit in Grenada has been postponed due to Hurricane Beryl, when it does convenes, a key item on the agenda will be the new ‘HeDPAC’ initiative to deepen South-South partnerships to meet shared global health challenges – from pandemic threats to climate change.

In remote communities of Guyana, the introduction of new satellite technology is enabling freshly trained community health workers to get patients an accurate diagnosis and rapid, appropriate treatment in ways unimaginable only a few years ago.  

In Rwanda, meanwhile, the government’s achievement in getting the COVID-19 vaccine innovator, BioNTech, to set up its first mRNA manufacturing facility in Kigali is a success story that small island states in the Caribbean would love to emulate. 

At a high-powered dinner on the sidelines of the recent World Health Assembly, health ministers and high level officials from Africa and the Americas, set out a shared vision for a way forward on closer collaboration between the two regions under the umbrella of a new South-South partnership initiative, known as HeDPAC (Health Development Partnership for Africa and the Caribbean). 

The initiative grew out of an initial set of pandemic-era collaborations between Africa and the Caribbean and was incubated at WHO  until its launch as an independent non-profit in December 2023. 

“HeDPAC offers a model for self-service cooperation. And for sharing knowledge, expertise and resources,” said WHO Director General Dr Tedros Adhanom Ghebreyesus, at the event, noting that the aim is to enhance health infrastructure, improve access to essential medicines, and strengthen health systems.” 

WHO Director General Dr Tedros Adhanom Ghebreyesus

Partnership building self-sufficiency  

The overarching aim, says HeDPAC CEO Haileysus Getahun, is to foster a partnership  between countries in the global south around key objectives critical to handling future pandemics, as well as creating more robust health systems today. 

The peak of the COVID-19 pandemic exposed the flaws in models of North-South cooperation that have come to dominate the global health landscape – when countries in the Global North hoarded the vaccines, medicines and medical products, he observed. The lack of equity and global solidarity were glaringly absent. 

South-south collaboration is one important antidote; a way to foster more self-sufficiency among countries and stakeholders on a more even playing field with a vision of universal health coverage. 

Three concrete priorities   

Jarbas Barbosa, WHO Regional Director of the Americas/PAHO.

The issues HeDPAC is targeting are not new, but they are perhaps the most critical building blocks to change. They include: 

  • More local R&D, manufacturing of drugs, vaccines and other medical products; 
  • Health workforce strengthening, particularly at primacy health care levels; 
  • Building health system resilience to shocks ranging from climate to supply chain breaks. 

“These are completely aligned with our regional priorities,” declared Jarbas Barbosa, WHO Regional Director of the Americas/PAHO, at the WHA conversation.  

Along with the dependency on outside sources for vital medical supplies laid bare during COVID,  Latin American and Caribbean countries currently are facing a shortage of some 600,000 health care workers, Barbosa observed. 

In Africa, the shortages are even more glaring, according to WHO. A 2023 report showed 37 African nations ranked below the global recommended minimum of 4-5 health workers per 1,000 population.

When the South swings together ….

Alison Drayton, Assistant Secretary-General for Human and Social Development at CARICOM

Registered in Rwanda and Barbados, the initiative aims to work with heads of state and political leaders but without the bureaucratic handcuffs of a formal intergovernmental organization, Getahun said. 

Early champions included the President of Rwanda, Paul Kagame,  Prime Minister of Barbados Mia Mottley and President Irfaan Ali of Guyana. Mottley gained international recognition for her Bridgetown initiative for international debt reform aimed at reducing the crippling burden of low- and middle-income countries to free up more funds for investments in solutions for climate, health and other vital development priorities. 

“My experience has been when the South swings together, we achieve far beyond our wildest dreams,” said Alison Drayton, Assistant Secretary-General for Human and Social Development at CARICOM, the intergovernmental organization of 20 Caribbean states, at the WHA event.

She noted that CARICOM and HeDPAC are currently engaged in the development an MOU to address the three priority areas of: health workforce, health system resilience and local manufacturing of medical products. 

The discussions on collaboration will continue at the 47th CARICOM Conference of Heads of Government. The meeting, planned this week in Grenada, has been postponed because of the effects of Hurricane Beryl.

Moving beyond pandemic poverty 

Barbados received its first shipment of 33,600 doses of COVID-19 vaccines, through the WHO co-sponsored COVAX facility, in April 2021. But after an initial spurt, COVAX deliveries faltered, leaving many low- and middle-income countries scrambling.

On the other side of the ocean, the African Union is a key partner with bonds forged in the early days of the COVID pandemic, when both African and Caribbean countries found themselves struggling desperately to obtain the most basic medical products like protective masks and gloves, and later vaccines.  

“When the world wouldn’t give us vaccines and the world wouldn’t sell us vaccines, and we pulled together an important procurement initiative, to my amazement, it was not just Africa but our brothers and our sisters from the Caribbean who supported this,” declared Dr. Ayoade Alakija, who had, at the time, been asked to lead the Africa Union’s Vaccine Delivery Alliance (AVDA). 

Thanks to those relationships, Caribbean countries like Jamaica, ultimately secured significant  vaccine supplies from African partners at a time when rich nation hoarding and the rise of India’s SARS-CoV2 Delta variant made vaccines almost impossible to secure.  

“And so we have done this before, this South-South collaboration… because we are the same people,” she said.

It was in that period that the initial framework for HeDPAC was laid, recounted Getahun, in an interview with Health Policy Watch. 

HeDPAC CEO Haileysus Getahun

“At the time, Prime Minister Mia Mottley of Barbados was the head of the CARICOM. She reached out to African Union president Uhuru Kenyatta (president of Kenya until 2022). She asked for collaboration between Africa and the Caribbean,” said Getahun.

“After that discussion, the first meeting of the heads of government of CARICOM and the AU was held in September 2021, which laid out clear steps for the two regions to collaborate.”

In November 2022, Mottley, Kagame [then AU champion for Institutional Reform],  and Guyana’s President Irgaan Ali met in Sharm el-Sheikh in November 2022 on the margins of COP27. 

Together with European Commissioner Ursula von der Leyen, Africa CDC and WHO’s DG, the African and Caribbean Heads of State etched the outlines for a new ‘transatlantic alliance for health and vaccine equity.’ 

The initiative quickly won  support in other quarters, including the International Finance Corporation, the World Bank’s investment arm, and several major philanthropies.    

“After observing the inequities and inequalities of COVID, we have to take the valuable lessons  and if a pandemic happens again, the valuable lessons will not be forgotten,” Getahun remarked.

Paul Kagame, Mia Mottley and Ursula von der Leyen at a meeting on the margins of COP27 in Sharm el Sheikh,  November 2022.

“What makes us unique is that we work with heads of government, ministers and political leaders at the highest level to advance a common vision of health development. We utilize political clout but without the handcuffs of a formal intergovernmental organization,” Getahun said. 

HeDPAC’s priorities emerged from a series of consultations of Ministers of Health from the two regions, he said, pointing out that all three pillars – manufacturing, health workforce and resilience – are all critical to greater pandemic preparedness as well as vibrant health systems more broadly. 

“These are the most pressing challenges, on which we will focus. The rationale is not to try to be everywhere.”

And while the first priority is fostering cooperation between like-minded African nations and the Caribbean, that mandate could eventually extend to promoting South-South collaborations more broadly, Getahun suggests.  

“We believe Africa-Caribbean partnership is the starting point, but we are also drawing interest from countries in other regions.’’

Learning from Rwanda’s experience with BioNTech  

International political leaders at the launch of BioNTech’s new facility in Kigali in December 2023.

As just one example of learning from others’ experience, Caribbean nations like Guyana are keen to see how they could duplicate Rwanda’s success in bringing a major pharma experience to their region.

In December 2023, BioNTech launched its first ‘BioNTainer’ in Kigali. The 35,000 m2 modular manufacturing facility is set to produce new mRNA vaccine candidates for malaria, tuberculosis and HIV for use firstly in clinical trials – followed by mass rollout if they are demonstrated to be efficacious.   

“There are many things that are happening in Africa. There are many things that are happening in South America, but very often the good things that happen on one side [of the ocean] are not shared with the other side,” said Guyana’s Minister of Health Frank Anthony at the WHA side event.

 “This will be a platform by which we can share what is happening between the two regions – and HeDPAC can be the bridge that allows us to do that.”

“From the pandemic we could see the needs and the inequities that exist because of lack of medicines or vaccines, and we don’t want that to be repeated. In some cases we had monies available, but we could not get the things that we needed.  

“And therefore, we thought that if we can fix this by locating manufacturing in our regions, so that when these things occur we can easily be able to access it, that this is going to be an important way to prepare for future pandemics.

“What Rwanda has done is major….  Using the mRNA vaccine platform can be a good way to produce other types of vaccines. And I think this is going to be the future. So if we can borrow what they have done, if they can assist us with accelerating [the process], that would be extremely positive. 

Using technology – hybrid courses and satellite health consultations 

At the same time, Caribbean nations also have valuable lessons to share.  

The Guyana Health Minister described how his country, with a widely dispersed population of just 800,000 people, has initiated a new hybrid programme of nurses training to rapidly expand the workforce. 

Guyana’s innovative nurses training initiative grabbed headlines in local media.

The online programme, developed through a collaboration with the University of Sao Paulo’s College of Nursing, enrolled nearly 1200 nurse trainees in 2023 its first year and plans to scale up further over the next several years.  

Simulation centres are being established in core health care facilities along the coast and in more remote regions, to allow students to participate in practicals that are essential for the Registered Nurses (RN) degree.     

“We can easily share that with other countries that are interested in using the courses that we have,” said Anthony. “You don’t have to move from Africa. You don’t have to move from the Caribbean. You will be able to go online and get these courses. That’s how we can share trying to find solutions to the problems that are facing us.”

Courses for community health workers also are being revamped, with health workers taught to use telecom and satellite technology to diagnose serious diseases in remote locations with the support of experts elsewhere. 

Satellite technology in rural Guyana enables high-quality telehealth consultations

“We call it ‘’tele-pathology’,” said Anthony, describing how high-resolution slides of suspect tissue can be quickly relayed to a partner hospital, Mount Sinai in New York City, to diagnose dangerous malignancies. 

Some two dozen clinics in remote regions of the country have been equipped with satellite technologies that allow doctors to “examine” patients remotely together with a local health worker to obtain a fast diagnosis in an emergency. .  

He shared the recent story of one patient whose life was saved through the quick action of a community health worker whose remote consultation led to the rapid diagnosis of life-threatening sepsis. 

“They called a medivac and he was airlifted to a hospital and operated on right away. Otherwise, he probably would have died by the time they figured out what’s wrong and got him to the hospital.”  

Elevating the status of community health workers  

Translating such stories of success into more systematic approaches is one of the big challenges that HeDPAC wants to facilitate, said Getahun. 

He notes that while community health workers are the foundations of primary health care, many  countries still treat them as quasi-volunteers, working for stipends and funded by donor grants – rather than as civil servants in the public health system. 

Catalyzing government moves to advance their status as regular civil servants is one important  HeDPAC target, he says. “This creates employment opportunities for women with far-reaching societal impacts’’.     

Mapping of Community Health Worker accreditation and salary status in Africa, Latin America and the Caribbean.

Throughout much of central and southern Africa, CHWs lack either regular salaries or accreditation.

In Rwanda, a PHC success story, CHWs are accredited but not salaried. But a major 4×4 reform of the health workforce launched in 2023 by the national government could lead to changes for that workforce as well. The 4×4 initiative is part of a broader Rwandan aspiration to quadruple the healthcare workforce and meet the WHO recommended goal of at least 4 health care professionals per 1000 people. 

And as an outgrowth of the new Africa-Caribbean links, doctors and nurses from Cuba are supporting Rwanda with training for its health workforce, said Rwanda’s Minister of Health, Dr. Sabin Nsanzimana.

“As we speak, a group of Cuban doctors has landed in Rwanda to support our 4×4 initiative,” he said. 

It takes guts…   

Ethiopian Minister of Health, Dr Mekdes Daba.

Regional collaborations in manufacturing and procurement will become all the more critical as countries seek to realize the promise and potential of the new African Vaccine Manufacturing Alliance (AVMA), experts also note. 

Only last week, AVMA secured commitments of more than $1 billion in finance at the kickoff at  the Gavi, the vaccine alliance replenishment drive co-hosted by France and the African Centres for Disease Control. The new initiative aims to facilitate the production of 60% of the continents’ vaccine needs with local supplies by 2040.  

Collective manufacturing and procurement arrangements are just as vital to small Caribbean nations that can’t possibly compete alone in global markets.  

“It’s so important to take a regional and cross regional approach, with south south solutions because it offers the possibility of creating economies of scale, and more sustainable production, and building thus a diversified production capacity,” said Johanna Hill, World Trade Organization Deputy Director. 

“Initiatives like this take guts and that’s where HeDPAC has been born – from that guts of taking into consideration South- South collaboration,” added Ethiopia’s Minister of Health, Dr Mekdes Daba.  

“I lost my grandma from COVID, a very dear, very dear person to me,” she added.  “We’ve [all] lost parents, family members, and it was very late for us to get the vaccine. So when things like a pandemic happen, we see how interconnected we are. 

“Now, it’s time to use this connectedness to realize our potential for South-South Collaboration.” 

This story was updated to note the postponement of the CARICOM meeting.

Image Credits: @DPA, HeDPAC, Caricom.org, PMO Barbados, Guyana Standard , Community Health Impact Coalition @Mapbox @OpenStreetMap.

Women carrying grain in Sudan

Fourteen months into its devastating civil war, one-half of Sudan’s 25.6 million population faces levels of food security ranked as “crisis,” emergency, or “catastrophic,” according to the latest Integrated Food Security Phase Classification (IPC) analysis. 

The IPC analysis of Gaza also found that a “high and sustained risk” of famine persists across the entire occupied territory as conflict between Israel and Hamas rages on – although increased food aid deliveries since have so far averted earlier predictions of widespread famine, made in March. Even so, some 96% of the population of 2.15 million people face emergency levels of food insecurity, the latest IPC report stated. Nearly 343,000 Gazans, or 15% of the population are currently experiencing “catastrophic” levels of food insecurity (IPC 5), according to the IPC assessment. 

Sudan’s food insecurity, meanwhile, has reached the worst recorded levels the country has ever seen. The humanitarian emergency has left 755,000 people at catastrophic levels of food insecurity (IPC Phase 5) in 10 states, with the widening spectre of famine. At current levels over 1,000 people per day are at risk of death, the report stated.

Map of Sudan food insecurity
The IPC’s latest projections show intense levels of food insecurity concentrated in the western portion of the country.

Some 8.5 million Sudanese – 18% of the population – are likely to experience catastrophic emergency-level levels of food insecurity (IPC Phase 4) within the coming months, warned  the IPC, which ranks food insecurity and hunger on a 1-5 scale.

The latest survey, conducted between late April and early June, marks a dire and rapid deterioration in the food security situation since IPC’s December 2023 report. Nearly 8 million more Sudanese have faced  high levels of acute food insecurity, ranked as IPC 3 or greater – an increase from 17.7 million to 25.6 million in just six months. 

Violence disrupts aid, fuels famine

Grain shipment in Sudan
The prolonged conflict in Sudan is hindering key humanitarian aid, inlcuding the World Food Programme’s work.

Intense fighting between the Sudanese Armed Forces (SAF) and the paramilitary rebel group, Rapid Support Forces (RSF), has led to the most brutal civil war seen in decades, with snowballing effects on health, hunger and displacement. 

Since violence erupted on 15 April 2023 between the Sudanese Armed Forces (SAF) and the RSF, the country has experienced the highest levels of food insecurity in its history. 

Armed fighting between the two factions that began in Khartoum quickly spread from the capital region to engulf Greater Darfur, Greater Kordofan, Khartoum and Al Jazirah states in the western regions of the country near the border with Chad. These regions are also now the epicentre of the hunger crisis. 

“There is a risk of Famine in 14 areas – affecting residents, internally displaced persons (IDPs) and refugees – in Greater Darfur, Greater Kordofan, Al Jazirah states and some hotspots in Khartoum if the conflict escalates further, including through increased mobilization of local militias,” warned the June IPC report. 

Systematic obstruction of aid

Despite the tremendous needs, the warring parties have  systematically obstructed aid workers and deliberately denied access, said the Inter-Agency Standing Committee (IASC) on Sudan in a statement last month. 

“Movements across conflict lines to parts of Khartoum, Darfur, Aj Jazirah and Kordofan have been all but cut off since mid-December. The closure of the Adre border crossing in February – our main route into western Sudan from Chad – means that limited assistance is trickling into Darfur. Aid workers are being killed, injured and harassed, and humanitarian supplies are being looted,” the IASC said.

Earlier this year, nearly 860,000 people were denied humanitarian aid in Kordofan, Darfur and Khartoum states. The Committee warns that these represent “deliberate hindrances to humanitarian assistance that leave the civilian population without the essentials to survive [and] violate international humanitarian law.”

“This is the worst hunger crisis that has ever been recorded in Sudan. The biggest challenge aid agencies are facing is humanitarian access. We need unhindered access to reach the people most in need with life-saving assistance. Any further delays can be catastrophic and will result in deaths. It is evident the most vulnerable children and their families are bearing the brunt of the conflict,” said John Makoni, Interim National Director for World Vision Sudan.

OCHA: Gaza aid deliveries still being hindered  

Food insecurity Gaza
The entire Gaza Strip faces ICP Phase 4 Emergency food insecurity. A child receives nutritional supplements from the WFP.

While increased food deliveries to Gaza have led to “a marked improvement in the food consumption outcome indicators” in all areas of Gaza, according to the IPC, the UN Office for the Coordination of Humanitarian Affairs (OCHA) warned that access constraints continue to hamper aid operations, including efforts to scale up nutrition support. 

Some 8,000 children under five years old have been diagnosed and treated for acute malnutrition in Gaza since the war began, according to the World Health Organization.

But limited access in the north is preventing the establishment of new nutrition services there, OCHA noted. Escalations in fighting in southern and central Gaza, following Israel’s invasion of the Rafah border area, have severely limited the World Food Programme’s (WFP) ability to deliver food supplies. 

“Due to insecurity and lack of access, only two stabilization centers for severely malnourished patients can operate,” said WHO’s Director General Dr Tedros Adhanom Ghebreyesus in a June X post.

IPC mapping of Gaza hunger risks present and future.

Despite these challenges, WFP reached more than 766,000 people in Gaza with food in June, “though these rations have been reduced due to limited aid and dwindling food stocks,” said the WFP in a statement, noting that it had provided some 9.4 million hot meals through a network of more than 90 community kitchens. 

Sanitation and hygiene challenges

Gazans struggle to obtain basic supplies of food and water amidst mounting piles of garbage and debris

WHO and other agencies also warned of the severe hygiene and sanitation situation brought about by the conflict, the closure of borders and the demise of services for waste and sanitation. 

“Further concentration of displaced populations into areas with significantly reduced water, sanitation, hygiene (WASH), health and other essential infrastructure increases the risk of disease outbreaks, which would have catastrophic effects on the nutritional and health status of the population,” warned WHO in a statement June 25, as fighting across the enclave continued to displace civilian populations over and again.

People in Gaza are living surrounded by piles of waste and sewage, said the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) in a post on X. 

Efforts to collect and transfer solid waste to temporary sites continued this month, but at a lower rate due to the lack of fuel. Fuel shortages could also hinder ongoing maintenance work on the electricity feeder line for the Southern Gaza Seawater Desalination Plant.  And due to a lack of cooking fuel, Gazans are burning toxic plastic waste and other trash, UNRWA stated. 

Pleas for more aid

More than two months have passed since the International Humanitarian Conference for Sudan met in Paris, the IASC has received just 16% of the $2.7 billion needed to avert the looming famine. The limited support from donors follows a worrying lack of international attention towards the conflict.

The IASC writes that “donors must urgently disburse pledges made in Paris and fast-track additional funding for the humanitarian appeal. With a famine on the horizon, we must deliver much more life-saving aid now, including seeds for farmers before the planting season ends.”

In Gaza, the OCHA has issued a flash appeal, calling for $2.82 billion for UN agencies and NGO partners to address the needs of the more than three million people in the Gaza Strip and the West Bank. The WHO adds that given the unpredictability of the ongoing conflict “and humanitarian access challenges, any significant change may lead to a very rapid deterioration into Famine.”

Image Credits: WFP/Abubakar Garelnabei, IPC , WFP/Ali Jadallah​​​​, IPC , UNRWA .

The spread of bird flu in US cattle prompts concerns about the safety of commercially sold milk products.

Amid the growing avian influenza epidemic in American cattle, the US Food and Drug Administration (FDA) launched new research Tuesday to ensure dairy products available in the market do not contain the virus in its active form.

The research will involve a series of studies to test pasteurised milk samples collected from store shelves. The study aims to determine if, and to what extent, virus contamination may occur in individual as well as pooled milk product samples, as well as in other diary products like cream and cheese.  

The retail survey aims to cover geographic and product gaps in the sampling of 297 products in late April and early May, which found all products tested were H5N1-free.

“As outlined in the FDA’s research agenda released today, the FDA is working on multiple efforts to understand the effectiveness of pasteurization and other inactivation methods,” the FDA advisory stated. So far, pasteurisation proves effective but more research is needed to ensure the virus does not present risk to the food supply.

Farmers reluctant to agree to cattle surveillance

Since March, the highly pathogenic avian flu strain, H5N1, has infected 131 US dairy cow herds in 12 states, according to a separate update from the US Centers for Disease Control and Prevention (CDC). Three human cases of infection following exposure to infected dairy cows have also been reported.

WHO has assessed avian flu risks to public health as low for the general population and low-to-moderate for people working with animals. Yet, as the virus gains ground infecting more species, the risk of human-to-human transmission rises. In the US case, for instance, some 21 cats also have been infected since March. CDC has warned that dogs could become another virus reservoir, increasing risks of transmission to humans, although this scenario remains unlikely for the moment.

H5N1 strain infects a still growing number of species, including many mammals

“CDC monitors disease outbreaks, looking at […] surveillance in wild animals. […] Risk assessments are performed,” said Christine Oshansky of the Biomedical Advanced Research and Development Authority (BARDA) during a National Vaccine Advisory Committee meeting June 13.

Despite the CDC’s and other agencies’ efforts, the US epidemic response has been regarded by many experts as woefully insufficient to date. 

Farmers are reluctant to have themselves or their herds tested – practices that remain voluntary. Farmers also have expressed resistance to using personal protective equipment during milking, when, most likely, infections occur. 

Abiding with CDC and FDA guidelines has perceived downsides, while the positives are not as evident: goggles or respirators, recommended by the CDC, can be cumbersome in the humid and hot milking parlors and reporting just one infected cow marks the whole herd as potentially sick, meaning financial loss for the farm.

The net result has been that only 45 people, so far, have been tested for avian flu symptoms, despite the estimated  million tests distributed across the country. Lack of testing means the real epidemic situation is largely unknown. “We’re flying blind,” assessed Dr. Jennifer Nuzzo, the Director of the Pandemic Center at the Brown University School of Public Health, told KFFHealth News last week.

Stockpiling for emergency

Dedicated vaccines, another element of the epidemic response, are also not yet ready. The FDA has so far approved three H5N1 vaccines: made by Sanofi, a GSK subsidiary, ID Biomedical Corporation of Quebec (IDB), and CSL Seqirus –  all of which take several months to produce.

Other countries, for instance the United Kingdom, are also preparing  stockpiles, while Finland is starting a vaccination programme designated for risk groups, using a vaccine against the H5N8 strain.

Finnish fur animal farming is a potential source of avian flu infections

Seasonal flu vaccines, though only moderately effective in preventing avian influenza infections, can still be helpful, Dr Aspen Hammond, a technical officer at the WHO, said during an Epidemic Information Network seminar on June 6. 

“It has been recommended to use seasonal vaccines, especially in […] healthcare workers, obviously, but also in people that are exposed to potentially infected birds, just to try to minimise them developing symptoms,” he said.

Vaccinating animals also has an important role to play, emphasized Ian Brown, Chairman of the joint World Organisation for Animal Health/Food and Agriculture Organisation network of expertise on animal influenzas, during the seminar:

 “It’s a simple equation: you reduce the infections in domestic birds, you reduce the risk of spillover to wild birds, you reduce the risk of spillover to humans.”

Image Credits: Ashoka Jegroo, USDA, Oikeutta eläimille.

UNAIDS has welcomed the recent ruling by Namibia’s High Court that its laws prohibiting same-sex acts between men are unconstitutional as they unfairly discriminate against gay men.

Namibian citizen Friedel Dausab, supported by the Human Dignity Trust, sought to have laws prohibiting sodomy and “unnatural sex acts” and sections of the Immigration Control Act and the Defence Act that criminalised homosexuality declared invalid.

He brought the case against the Ministers of Justice, Home Affairs and Defence, the Prosecutor General and the Attorney General. 

Judges Nate Ndauendapo, Shafimana Ueitele and Claudia Claasen ruled in Dausab’s favour, noting that these laws discriminated as they treated gay men differently from women who have sex with men, and heterosexual men who have sex with women.

Dausab told Reuters after the ruling that he was “just happy” after the court’s decision as “it won’t be a crime to love any more.”

“The enforcement of private moral views of a section of the community (even if they form the majority of this community), which are based to a large extent on nothing more than prejudice, cannot qualify as such as a legitimate government purpose,” noted the judgement.

Anne Githuku-Shongwe, UNAIDS regional director for East and Southern Africa, described the court’s decision as ” a powerful step towards a more inclusive Namibia”.

“The colonial-era common law that criminalised same-sex sexual relations perpetuated an environment of discrimination and fear, often hindering access to essential healthcare services for LGBTQ+ individuals. To protect everyone’s health, we need to protect everyone’s human rights,” she said.

 In sub-Saharan Africa, men who have sex with men in countries where they are criminalised are five times more likely to be living with HIV than in countries that do not criminalise this, according to UNAIDS.

Globally, in 2022, men who have sex with men were 23 times more likely to acquire HIV, and transgender women 20 times more likely to acquire HIV than other adults aged 15–49.

Project HOPE, which also works to combat HIV in Africa, said that “dismantling discriminatory laws is a crucial step toward ensuring everyone can safely access health care, including HIV testing and treatment”.

“While much progress has been made toward mitigating HIV and AIDS, we cannot hope to end the epidemic in Africa unless we fully embrace human rights and provide stigma-free services for all, including LGBTQIA+ communities. Access to evidence-based HIV services are quite literally a matter of life and death,” said Steven Neri, Project HOPE’s Africa director.

Iraq outlaws ‘effeminacy’

Namibia’s ruling is similar to that of Botswana’s High Court in 2019, which declared that Section 164 of Botswana’s Penal Code was unconstitutional as it discriminated against LGBTQ people’s right to liberty and privacy.

While over half of Africa’s 54 countries prohibit consensual same-sex relations, since 2019, Botswana, Gabon, Angola, and Mauritius have repealed laws that criminalised LGBTQ+ people.

Further afield decriminalisation has also happened in Bhutan, Antigua and Barbuda, Barbados, Singapore, Saint Kitts and Nevis, Cook Islands, and Dominica.

Namibia’s High Court decision also bucks the trend set by Uganda and Ghana, which have made their colonial anti-LGBTQ laws even more harsh in the past 18 months.

Earlier this year, Iraq introduced anti-LGBTQ legislation that imposes a prison sentence of up to 15 years for same-sex sexual relations. Transgender people face up to three years in prison for receiving gender affirmation care, while the “intentional practice of effeminacy” is outlawed, and people who “promote homosexuality” face up to seven years in prison. 

UNAIDS urged all countries to follow Namibia’s lead, remove punitive laws, and tackle prejudices against LGBTQI people.

“Criminalising consensual same-sex relationships and gender expression not only violates fundamental human rights but also undermines efforts to end AIDS by driving marginalised populations underground and away from essential health services, including life-saving HIV prevention, treatment and care services,” according to UNAIDS.

“Stigma, discrimination and criminalisation can be lethal,” said Winnie Byanyima, executive director of UNAIDS.

“In the response to HIV, we have learnt that a human rights-based approach is critical in responding to a health crisis and leaving no one behind. Countries must remove these discriminatory criminal laws and introduce legislation which protects rights if we are to end AIDS as a public health threat for everyone.”

Image Credits: UNAIDS.

People running
The World Health Organization sees physical activity as a “missed opportunity” in combatting noncommunicable diseases.

Physical inactivity levels have jumped to 31%, meaning that around 1.8 billion people did not meet the recommended levels of physical activity in 2022 , according to a new report from the World Health Organization (WHO). 

This is an increase of 10% since 2000, mostly driven by data from lower-middle income countries. Lack of physical activity increases the risk of a host of non-communicable diseases (NCDs)  like heart disease and diabetes, poor physical and cognitive function, weight gain, and mental ill-health. 

Map of global physical inactivity
Global physical inactivity has risen by 10% in the past two decades. Much of the world’s inactivity is concentrated in lower-middle income countries.

The WHO recommends at least 150 minutes of moderate-intensity activity, 75 minutes of vigorous-intensity activity, or an equivalent combination per week. Yet much of the global adult population fails to meet the recommendation.

The study, published in The Lancet Global Health Journal, is the first global estimate since 2016, and uses data from over 500 population-based surveys covering 5.7 million participants in 197 countries and territories. 

The WHO’s physical activity global target aims to reduce the prevalence of insufficient physical activity by 15% from 2018 to 2030. However global trends indicate physical inactivity will instead rise to 35% by 2030.

This poses a “silent threat” to global health and drives the burden of chronic diseases, as Dr Rüdiger Krech, WHO director of Health Promotion, noted in a press release. 

“We need to find innovative ways to motivate people to be more active, considering factors like age, environment, and cultural background. By making physical activity accessible, affordable, and enjoyable for all, we can significantly reduce the risk of noncommunicable diseases and create a population that is healthier and more productive,” said Krech.

High levels of inactivity in Asia Pacific and South Asia

Japan, the Republic of Korea, and Singapore, considered high-income Asia Pacific countries, had the highest prevalence of insufficient physical activity at 48% in 2022. 

Second to this region is South Asia, with a 2022 prevalence of 45%. These numbers are especially worrying as those who are physically inactive have 20-30% increased risk of death compared with those who are physically active. Physical inactivity is linked specifically to heart disease, diabetes, stroke, colon and rectal cancer, and breast cancer. 

However, lower-middle income countries face the highest levels of physical inactivity at 38% in 2022 compared to low (17%), upper-middle (27%), and high income (33%) countries. 

Gender disparities persist 

Map of physical inactivity for women
Prevalence of insufficient physical activity among women.

Beyond geographic variations, the study warns of widening gender disparities. Globally, 34% of women are physically inactive, compared to 29% of men. In some countries, this difference is as much as 20 percentage points, according to a press release. 

The gender physical activity gap stems from many complex barriers limiting women’s physical activity: less leisure time, stereotypes, body image insecurities, and the constraints of cultural acceptability. Women and girls’ sports also receive less investment, according to a recent Lancet editorial on the issue.

Map of physical activity in men
Prevalence of insufficient physical activity in men.

These disparities widen as women age, with women over 60 having the highest relative levels of physical inactivity across all regions.

Physical inactivity increases as women age across all regions.

“These new findings highlight a lost opportunity to reduce cancer, heart disease and improve mental well-being through increased physical activity,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General in a press statement. “We must renew our commitments to increasing levels of physical activity and prioritize bold action, including strengthened policies and increased funding, to reverse this worrying trend.” 

Hopes for a more active world

The authors note that, although their physical inactivity estimates exceed the WHO targets for many countries, several countries are on track to increase physical activity by 2030. For example, at least six countries in Oceania have seen marked reductions in physical inactivity since 2000, from 23% to 14% in 2022. 

The WHO recommends at least 150 minutes of moderate-intensity activity, 75 minutes of vigorous-intensity activity, or an equivalent combination per week.

An additional 16 countries are on track to reach the global target of reducing inactivity by 15% by 2030 if their trend continues at the same pace.

The WHO has called on countries to strengthen their policy implementation to promote and enable physical activity. Listing community sports, active recreation, and better active transport as ways to promote physical activity, the WHO aims to promote its 2030 targets through country-level policies. 

“Promoting physical activity goes beyond promoting individual lifestyle choice – it will require a whole-of-society approach and creating environments that make it easier and safer for everyone to be more active in ways they enjoy to reap the many health benefits of regular physical activity,” said Dr Fiona Bull, Head of the WHO Unit for Physical Activity in a press statement.

 

Image Credits: Gabin Vallet, The Lancet Global Health, WHO.

The MSF’s leadership wants its medicine advocacy to focus on products its field offices need for humanitarian efforts.

The leadership of Médecins sans Frontières (MSF) is under significant global pressure to reverse its decision to close its Access Campaign, with indications that the issue may be raised at the organisation’s general assembly that begins in Geneva on Thursday (27th).

The decision has been described as a triumph for technocrats within MSF, who want the organisation to be more narrowly focused on humanitarian efforts and less on the wider political issues hampering patients’ access to medicines.

Over 100 civil society organisations and 250 individuals have signed a letter addressed to MSF’s leadership and board, urging them to reverse the decision to close the iconic unit, which they say will “cause catastrophic and irreparable damage to access to health technologies for communities served by MSF projects and beyond”.

Signatories include past MSF leaders Dr Unni Karunakara (former international president), Kris Torgeson (former international secretary general), Gorik Ooms (former general director) and Dr Tido von Schoen-Angerer (former executive director of the Access Campaign).

Dr Mariângela Simão, former World Health Organization (WHO) Assistant Director-General for Access to Medicines and former New Zealand Prime Minister Helen Clark also joined civil society organisations and health experts in their appeal to MSF.

“The planned dismantling of the Access Campaign’s core structure, capacities, expertise, and networks will reverberate across the access to medicines movement and beyond,” they write.

“It will be yet another setback to the already-shrinking patient activist and civil society space critical to holding pharmaceutical companies and governments accountable so that medicines are never a luxury.”

‘Longstanding power struggle’

Von Schoen-Angerer, who headed the Access Campaign from 2006 to 2012, told Health Policy Watch that the closure was the outcome of “a longstanding power struggle” between MSF’s international office and its five powerful operational centres – Paris, Amsterdam, Brussels, Geneva and Barcelona – and the strong global and somewhat independent Access Campaign.

“It’s also a clear move from some people in MSF who want to depoliticise [the organisation], with a stronger focus on a technocratic approach; on products alone, shying away from some of the underlying political issues that determine access,” he added. 

“They are no longer willing to take up the political battle to really fight these access battles for better prices, more research and development, greater equity. 

“We’re looking at a more inward, more technocratic MSF that wants to get health products for their patients alone, and is no longer wanting to fight the bigger political battles that need to be fought.”

However, an MSF spokesperson told Health Policy Watch that the letter’s concerns were based on “the misleading notion that MSF is halting or reducing its work on access to products for healthcare. 

“This is 100% wrong. MSF is redoubling its efforts to deliver tangible improvements in access to products for healthcare driven by our new collective vision to expand our efforts to improve access to products for healthcare.”

Access Campaign victories

MSF’s ‘Europe! Hands Off Our Medicine’ campaign demands removal of harmful provisions from the EU-India trade agreement, which threatens the supply of affordable medicines made in India.

The Access Campaign has advocated for lower prices and better access to a range of medicines for over 25 years and won some major victories – particularly for HIV and TB patients. 

It was launched in 1999, first campaigning for Thai drug companies to be able to produce affordable generic versions of Pfizer’s costly fluconazole, used to treat infections in people with HIV. Its latest triumph was earlier this year when it helped to secure affordable access to bedaquiline for people with multi-drug-resistant TB.

In 2003, it helped to launch the Drugs for Neglected Diseases initiative (DNDi), an independent, non-profit drug development organisation focused on developing new treatments for some of the world’s most neglected diseases.

The Access Campaign is unique as it has both a global view of issues blocking access to medicines –  such as Free Trade Agreements that prevent generic competition – and local knowledge of communities’ needs from MSF’s field offices. 

But the unit is the victim of a costly two-year restructuring exercise aimed at redirecting resources from global issues to MSF’s work on the ground, according to sources.

These sources told Health Policy Watch that around 50 staff are to be cut to 19 and housed in a new unit called “Access to Products for Healthcare”. Current staff will have to compete with one another for the posts. The new unit will advocate for access to specific products needed by MSF’s humanitarian efforts.

At present, there is no strategic plan for the new unit, and staff are to be dispersed between five regional offices – Kuala Lumpur in Malaysia; Nairobi, Kenya; Dakar, Senegal; Rio de Janeiro, Brazil; and Brussels, Belgium.

Von Schoen-Angerer described as “arrogant” the restructuring process which cost “hundreds of thousands (of Euros)” yet involved “MSF talking entirely to itself, completely ignoring the hundreds of allies in terms of organisations in the Global South, but also the North – the academics, the governments that the Access Campaign has worked with.”

“That’s why they have come out with this letter because they’ve never been consulted,” he added.

In 2015, MSF’s “A Fair Shot” campaign called on Pfizer and GSK to reduce the price of the pneumonia vaccine – the most expensive standard childhood vaccine – to $5 per child. In 2016, a price of $9 per child is offered to humanitarian organisations like MSF, but only for use in emergencies.

MSF International stands its ground

An MSF spokesperson told Health Policy Watch on Wednesday that they were not aware of the issue being on the agenda of the general assembly, MSF’s highest decision-making body, or when it would be discussed by the MSF board.

Asked what the motivation was for closing the Access Campaign, the spokesperson said that “the new structure will be closer to our medical humanitarian operations, to better support the needs of the communities we assist. Five regional offices will work together with our operational teams and patients as well as with our partners and networks.”  

They added that populations’ access to healthcare were being affected by new developments including “technological breakthroughs, new political players, and new legal and commercial realities and regulations”. 

“For our patients and also our networks, we have a duty to ensure that we remain optimally organised to leverage our unique positions for improving access to products for healthcare for those deprived of them.”

MSF’s International Office said in statement  this week that the organsation’s “focus is on directly addressing the problems our patients and our operational teams face.

“We will also continue to work globally to address systemic barriers causing or amplifying these problems. This includes advocating for changes to policies and practices that determine who can or cannot access lifesaving health care products in many of the more than 70 countries around the world where we work.” 

MSF’s Alexandre Michel boarding a UN Air Service helicopter bound for Les Cayes in southern Haiti following an earthquake.

Loss of global advocacy?

Many access activists fears that MSF will no longer advocate around HIV, neglected tropical diseases, intellectual property, research and development, trade agreements, transparency, and other cross-cutting access issues

However, when asked directly whether MSF would cease its global work on issues such as the pandemic agreement negotiations and global trade agreements, the spokesperson simply responded: “In 2025, MSF’s new structure dedicated to our work with improving access to products for healthcare will continue the work of the Access Campaign that aligns with our new collective access to products for healthcare priorities, including dossiers on vaccines, diabetes, [anti-microbial resistance], TB, and diagnostic tools. Next year will also be dedicated to dedicated to finalising the new structure’s longer-term strategic plan.”

The spokesperson added that “around 35 staff are contracted to the Access Campaign” as well as “a number of others with temporary contracts”.  

“At least 19 of them have the immediate opportunity to work for the new structure. Others may also be absorbed (due to their expertise) by other MSF sections, operational directorates or projects.”

But Von Schoen-Angerer expressed concern that there is no strategy in place for the new unit “beyond vague priorities” and  it will take at least a year to develop a strategic plan.

Loss of unique skills

“They are firing all the fantastic staff or humiliating them by making them reapply if they want to be part of the new structure. Allies will be lost, battles will be lost and it will take years before this will become effective.” he added.

Fatima Hassan, director of the South African Health Justice Initiative (HJI), described the skills of Access Campaign staff as “unique, unprecedented, and multi-disciplinary.”

“There are no other groups right now in the world that can replicate its work or fill its large shoes,” said Hassan, urging MSF not to “dilute” it.

Ellen ‘t Hoen, director of Medicines Law & Policy and former policy and research director of the  Access Campaign, has also expressed her alarm at the move, describing the campaign as “a pillar of global access to medicines work”.

“Access issues have never been more front and centre in global health, as the recent lack of progress in the negotiations of the WHO pandemic accord – and the desperate scramble to access COVID-19 countermeasures that preceded the launching of the accord process – have underlined,” noted ‘t Hoen’s Medicines Law & Policy this week.

“If MSF proceeds with this decision, it will leave a significant void in the access movement. Particularly, groups in low and middle-income countries will bear the brunt of this loss. There are no apparent players who can take over the role of the MSF Campaign because most lack the multidisciplinary expertise and resources MSF has.”

This week, Unitaid’s executive director, Philippe Duneton, also added his voice to appeals for MSF to continue its access work in an open letter to MSF’s president, Dr Christos Christou.

“MSF’s voice and work in access remains more needed than ever, addressing the grassroots causes of inequities whether in HIV or global health emergencies, neglected diseases, and neglected populations that the market keeps failing,” noted Duneton, whose organisation works to ensure low- and middle-income countries have access to treatment and tools to combat major health challenges.

Image Credits: MSF, MSF Access Campaign.

Delegates during the launch of a WHO visceral leishmaniasis elimination framework

WHO framework to eliminate visceral leishmaniasis (VL), a deadly disease most prominent in East Africa, was launched Thursday.

It can play an important role in eliminating VL as a public health problem by 2030: a goal key countries of the East African region committed to in last year’s Nairobi Declaration.

“The VL elimination framework will offer important direction to countries in the region and provide momentum to reach the finish line of elimination,” said Dr Dereje Duguma, the Health Minister of Ethiopia, a co-host of the launch.

“The Government of Ethiopia remains committed to working with partners to develop programs at all levels, from national to community, to expand access to healthcare and achieve the targets of elimination by 2030.”

Visceral leishmaniasis, or kala-azar, is a deadly parasitic disease causing fever, weight loss, spleen and liver enlargement, transmitted by the bite of infected female sandflies. Lethal if left untreated, the disease is endemic in 80 countries worldwide, with 73% of the estimated 50,000 to 90,000 cases annually occurring in the Eastern African region in 2022, according to the WHO. Children under 15 account for half of the infections.

Malnutrition, but also poor sanitary and housing conditions increase the risk of leishmaniasis infection. Sandflies, which transmit the disease, often live next to crowded buildings or spaces with open sewages or bad waste management. VL outbreaks are also frequent when many people without immunity to the parasite migrate to areas where it is endemic or with environmental changes, such as deforestation, building of dams, but also climate change.

Successful elimination thanks to framework

A good implementation of a regional Strategic Framework for VL led to a total elimination of the disease in Bangladesh in 2023 – becoming the first country worldwide to achieve the status – and a significant reduction of cases in the region. Eastern Africa wants to follow a similar path.

 

A 2014 plan to eliminating VL in Bangladesh, India and Nepal brought a massive decline in case numbers

Between 2004 and 2008, Bangladesh, India and Nepal accounted for 70% of global visceral leishmaniasis cases. The regional framework adopted in 2005, paired with sustained stakeholder support and a political will for an accelerated program implementation contributed to a successful case reduction.

The combined number of cases for the three countries decreased almost forty times, from 39,809 in 2005 to only 1,074 in 2022, according to WHO data.

Nairobi Declaration commitments

Representatives of eight East African countries pledged to follow the path to VL elimination, signing the Nairobi Declaration in 2023. The ministries of health of Chad, Eritrea, Ethiopia, Kenya, Somalia, South Sudan, Sudan, and Uganda, along with key stakeholders in the region set the goal of significantly curbing VL cases by 2030. Djibouti has also signed the declaration and co-hosted the WHO elimination framework launch last Thursday.

The framework, developed in partnership with the Drugs for Neglected Diseases initiative (DNDi) and Ministries of Health across the region, outlines five main strategies for VL elimination: early diagnosis and treatment, vector management, surveillance, social mobilisation, and operational research.

It also features a step-by-step guide through elimination phases as well as sets regional and country targets, such as a 90% reduction in VL burden in Eastern Africa by 2030, decreasing the number of cases to 1,500 annually.

“By providing countries with tailored tools and strategies, we are laying a strong foundation for sustained progress in the fight against this neglected tropical disease,” said Dr Saurabh Jain, WHO’s Focal Point for VL.

Image Credits: WHO.

The WHO stresses that there is no safe level of alcohol consumption.

Romania, Georgia and Czechia have the highest alcohol consumption rates in the world while, in the best-case scenario, only 14% of those who abuse alcohol have access to treatment.

These are some of the insights from the World Health Organization’s (WHO) global status report on alcohol and substance use disorders, based on 2019 data from 154 countries. 


Around 400 million people lived with alcohol and drug use disorders, with 209 million of these being people with alcohol dependence.

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.

In Romania, the average daily pure alcohol consumption per capita was a staggering 36.9 grammes, the highest in the world. Georgia (31.1g), Czechia (28.8) and Latvia (28.4) – all in the European region – were not far behind.

Despite Australia’s hard-drinking image, its drinkers averaged 21.9 g per capita per day, the third highest in the West Pacific region after Laos (25) and the Cook Islands (22.9). 

In the region of the Americas, Canada (21.5) and the USA (20.8) topped the list. In Africa, South Africa (19) had the highest alcohol consumption, while Thailand (17) was the highest in the South East Asia region. Alcohol consumption was low in the Muslim-dominated Eastern Mediterranean region, topped by the United Arab Emirates (5).

Severe harms; ‘No safe level’

“Substance use severely harms individual health, increasing the risk of chronic diseases, mental health conditions, and tragically resulting in millions of preventable deaths every year. It places a heavy burden on families and communities, increasing exposure to accidents, injuries, and violence,” wrote WHO Director-General Dr Tedros Adhanom Ghebreyesus in the report’s foreword. 

Dr Vladimir Pozniak, WHO’s head of alcohol, drugs and addictive behaviours

“The level of alcohol consumption per capita among drinkers amounts to an average of 27 grammes of pure alcohol per day, which is roughly equivalent to two glasses of wine, two bottles of beer or two servings of spirits,” Dr Vladimir Pozniak, WHO’s head of alcohol, drugs and addictive behaviours, told a media briefing this week.

Of all deaths attributable to alcohol in 2019, an estimated 1.6 million deaths were from non-communicable diseases (NCDs), including 474,000 deaths from cardiovascular diseases and 401,000 from cancer.

Some 724 000 deaths were due to injuries, such as those from traffic crashes, self-harm and interpersonal violence. 

Another 284 000 deaths were linked to communicable diseases. For example, alcohol consumption has been shown to increase the risk of HIV/AIDS as people are more likely to have unprotected sex, and increase tuberculosis and lower respiratory infections by suppressing a wide range of immune responses.

The highest proportion (13%) of alcohol-attributable deaths in 2019 were young people aged 20-39 years.

Globally, almost a quarter (23.5%) of all 15 to 19 year olds were current drinkers, with the highest rates in the European region (45.9%) followed by the Americas (43.9%).

Pozniak stressed that “there is no risk free levels of alcohol consumption”.

“The WHO has not produced guidelines [on safe alcohol consumption] because the diversity of countries, the diversity of populations, their exposure to alcohol, are so different, that to come up with universal levels of risks would be an unmanageable task,” said Pozniak.

“It’s advisable to consult with a health professionals on the risks associated with level or pattern of consumption, taking into consideration the individual characteristics of a person [such as] pre-existing disorders or current health conditions because the risks varies substantially, depending on all these factors.”

Lack of treatment options

The total alcohol per capita consumption decreased slightly from 5.7 litres in 2010 to 5.5 litres in 2019. But the world is far from reaching the Sustainable Development Goal (SDG) target 3.5 by 2030 of reducing alcohol and drug consumption and improving access to quality treatment for substance use disorders.

Although effective treatment options for substance use disorders exists, treatment coverage is incredibly low. 

The proportion of people in contact with substance use treatment services ranged from less than 1% to a maximum of 35% in 2019. This was even lower for alcohol-related treatment, with up to 14% of people who needed it, accessing treatment.

 “Most of the 145 countries that reported data did not have a specific budget line or data on governmental expenditures for treatment of substance use disorders. Although mutual help and peer support groups are useful resources for people with substance use disorders, almost half of responding countries reported that they do not offer such support groups for substance use disorders,” according to the WHO.

“Stigma, discrimination and misconceptions about the efficacy of treatment contribute to these critical gaps in treatment provision, as well as the continued low prioritisation of substance use disorders by health and development agencies.”

A significant number of countries reported interference from the alcohol industry in their efforts to develop effective alcohol policies, according to the report. Industry interference was highest in countries that were effectively increasing the price of alcohol.

“Industry interference was most frequently reported in the African Region (62.1%). However, across all income groups, between 42% and 50% of countries pointed to this interference as a barrier to move forward,” it notes.

Actions for progress

To accelerate progress towards achievement of SDG target 3.5 and reduce the health and social burden attributable to substance use, the WHO recommends action in eight areas.

These include increased awareness through a coordinated global advocacy campaign, and the re-commitment to implement the Global Alcohol Action Plan 2022-2030 with a focus on the SAFER package.

It also calls for increased capacity of health and social care systems to deal with substance abuse, more training of health professionals, better monitoring and research and more engagement with civil society organisations, professional associations and people with lived experience.

Image Credits: Stanislav Ivanitskiy/ Unsplash.

Breast cancer screening in Nigeria
Breast cancer is among the many non-communicable diseases growing in lower-and-middle-income countries, where funding for prevention is often diverted to other health concerns.

When Felicia Knaul met Tonya Rosa, a Mexican woman undergoing chemotherapy for breast cancer, “she was there with a big smile on her face…even though her cancer had recurred.” 

But Rosa told Knaul that her first round of treatment had impoverished her family, “they had to sell their business, their home, their assets to be able to pay for her care.”

But now, she had a card that gives her access to Mexico’s public insurance to cover her treatments.

Rosa’s story was one of many shared at a two-day international financing dialogue for NCDs and mental health hosted by the World Health Organization (WHO) and the World Bank in Washington, DC. The meeting convened as part of the preparation for the United Nations High-Level on these issues in 2025.  

For Knaul, a global health economist, cancer researcher and advocate, providing care for NCDs and mental health patients requires “a health system that could deal with the whole gamut of issues that go through, from primary prevention all the way through to end-of-life care.”

Representatives from over 30 countries reiterated this call for strengthened, affordable health coverage as the means to address NCDs and bolster mental health. 

Adriana Alfonso, Director of Health Surveillance with Uruguay’s Ministry of Health, credits the country’s recent mental health successes to its decree in making psychiatric care obligatory in an affordable and universal manner at health centers. These interventions were only possible through concerted government cooperation and willpower. 

Primary care financing as a sustainable solution

Graphic on NCD financing
Health and finance leaders from over 30 countries met to discuss a path forward to sustainable NCDs and mental health financing.

“In the past, when we prepared annual budgets, we didn’t really take into account the mental health issues. In the case of Uruguay, we have a yearly budget that is discussed at the parliament level, and we needed to make sure that we had a mental health budget that was sustainable,” Alfonso noted. 

Providing dedicated funds for mental health has translated into co-payment reductions and increases in beds in mental health facilities and halfway homes. 

Lester Tan, director of Health Policy, Development, and Planning at the Department of Health in the Philippines, echoed this sentiment in describing the economics of mental health in the Philippines. 

In 2021, mental health conditions cost the Philippine economy an estimated $1.37 billion dollars, equivalent to 0.4% of GDP.  Yet, investing in more treatment of epilepsy and depression would have an incredibly high return on investment – 6.6 and 5.3 times respectively. 

“This evidence, together with the implementation of a mental health law passed in 2018 have contributed to the scaling up of mental health services in the country. There are now 362 mental health access sites nationwide, which have served 124,000 users in 2022,” said Tan.

These mental health successes hinge on expanded financing of primary health care, the “how” of NCDs and mental health care, as a panelist noted.

Tan notes that the Philippines benefitted from expanding the number of health professionals trained in mental health at the primary care level. “This capacity building prioritized depression, epilepsy, self harm and psychosis.”

A multi-sectoral approach to overcome ‘fragmentation’

School girls with caption on primary health care and mental health
Increased primary health care investment has the potential to reduce the global burden of NCDs through prevention, treatment, and care.

Other panelists noted the urgency for multisectoral approaches to financing NCDs and mental health care – working across government institutions and ministries. An NCD expert from the Tunisia Ministry of Health, noted that her ministry recruited the help of the Ministry of Youth, Sport, and Heritage to organize a national day of exercise. 

“During this National Day, everybody was invited to exercise, and we talked about the importance of physical activity. The Ministry of Health decided to do screenings for hypertension and diabetes on this day, and we, of course, had a very large media campaign and awareness raising campaign in the entirety of the country,” she said. 

Beyond the more straightforward partnerships between adjacent ministries, the health sector must work more closely with ministries of finance, noted Aleksandra Altievska, head of fund budgets at North Macedonia’s Ministry of Finance. “I recommend that every Ministry of Health always keep in mind that the Minister of Finance has other priorities.”

Working with ministries of finance to fund NCDs and mental health interventions is critical because, as Joanna Ralston of the World Obesity Federation explained, NCDs are challenges that “can’t be targeted by one sector.”

“We have a global health system that really was built around single vector diseases, just to oversimplify, and yet, now we’re coming in with something that has these commercial elements, [environmental] elements, all these factors, this great level of complexity that that has to be respected,” Ralston said. 

Obesity, as just one example, continues to impact nations across all age levels, because of the fragmentation of the response, said Ralston. “The increase of obesity is around 100% in the past couple of years, when the goal was a 0% increase.” Fragmented, under-resourced responses undermine progress on NCDs and mental health – something that advocates hope can be overcome by renewed multi-sectorial frameworks and partnerships. 

Leveraging patient experiences 

NCD finance conference in Washington, DC June 2024
Several panelists shared their own experiences living with an NCD at the Washington, D.C conference.

Knaul, who founded the Mexico-based breast cancer advocacy organization Cancer de mama: Tomatelo a Pecho, notes that the numbers alone won’t sway policymakers – bringing in patient narratives is paramount to the future of non-communicable disease prevention, treatment, and care. “Health systems repeatedly fail patients with cancer and other NCDs,” she said.

Engaging people with lived experiences of NCDs or mental health challenges bolsters local and international support, argued Charity Muturi, an NCDs and mental health policy advocate in Kenya. 

“When a national task force on mental health was formed, we felt that, as patients, our voices needed to be on the table,” said Muturi, who discussed her own challenges navigating mental health care in Kenya. 

Ralston summed up the struggle with communicating the burden of NCDs and mental health. “Evidence and narrative are what are needed to be successful. We need to be rooted in evidence, but we need to have a way of communicating that story to decision makers, policy makers, and the wider public. And that has been a challenge with NCDs.”

Image Credits: Roche, WHO.