Delegates at a WHO intergovernmental negotiating body meeting.

The latest draft of the World Health Organization’s (WHO) pandemic agreement, which was sent out to member states on Wednesday (15 May), shows just how far the talks still have to go.

Health Policy Watch obtained a copy of the draft agreement, which we are sharing on our paywall-free site:

READ: Latest Pandemic Agreement Draft, reflecting progress up to 10 May

Around a third of the text is still white, indicating either that it has not been agreed on or not even discussed. According to a stakeholder briefing, there were some 300 paragraphs to negotiate on at the last meeting of the Intergovernmental Negotiating Body (INB).

However, some of the most significant articles are awash with yellow and green highlights, indicating progress.

Yellow means the text has been agreed to in a working group. Green means it has been agreed to in the plenary of the Intergovernmental Negotiating Body (INB).

Chapter 1 (Articles 1-3), dealing with aims and definitions, is largely white text but unlikely to take much time to reach agreement on.

Chapter 2 (Articles 4-20) is operation room of the agreement, dealing with equity throughout the chain of pandemic prevention, preparedness and response

One Health (Article 5) is mostly yellow.

Article 11 (technology transfer and know how) is also largely yellow, but there are a number of brackets around phrases such as “voluntary”.

The controversial Article 12 on pathogen access and benefit-sharing (PABS) is a mass of yellow and green.

A new addition to the PABS Article, which is neither yellow or green, is the proposal that, during a “public health emergency of international concern (PHEIC) or pandemic emergency”, manufacturers party to the PABS system “grant to WHO royalty free, non-exclusive manufacturing licences, that can be sub-licensed to manufacturers in developing countries for the production of vaccine therapeutics and/or diagnostics”.

Articles 7, 14, 18, 19 and even 20, on sustainable finance, seem close to agreement.

Chapter 3 (Articles 21-27) on institutional arrangements and final provisions, is largely agreed on.

The INB Bureau has also decided on a timetable for the final talks, with virtual meetings set to be held from 20-24 May, ending two days before the start of the World Health Assembly (WHA) on 27 May:

If there is no agreement by the WHA, the INB will simply present the latest version of the agreement.

When the negotiations ended on 10 May, INB co-chairs Roland Driece and Precious Matsoso said the negotiations had finally started to make progress in the past two weeks.

“The closer you get to the endpoint, the more willingness there is to move. We worked very hard and deep into the night, but there’s just so much so many issues that we need to agree upon and which are sometimes very technical or political,” said Driece.

“I think this is the last mile,” said Matsoso, adding that One Health, PABS, intellectual property and human resources had preoccupied delegates.

But at this stage, it is unclear just how long this “last mile” will be – whether INB delegates will be able to get something together before this World Health Assembly, starting on 27 May, or whether it will need to be stretched to another date months or even a year down the line.

Image Credits: WHO.

Tanzania’s President Samia Suluhu Hassan and Norway’s Prime Minister Jonas Gahr Støre (centre) co-chaired the summit.

In a ground-breaking move, global leaders on Tuesday made an unprecedented financial pledge to tackle the dirty cooking fuels crisis, which silently claims millions of lives across Africa. 

The Summit on Clean Cooking in Africa, chaired jointly by the leaders of Tanzania and Norway, alongside the African Development Bank, secured financial commitments from governments, development institutions and companies. 

The summit was co-hosted in Paris by the Clean Cooking Alliance (CCA) and the International Energy Agency (IEA). 

This was the largest amount of money to be pledged to clean cooking energy at a single gathering, and earmarked for a continent where four in five people still cook on open fires. As such, the summit was billed as a potential turning point for Africa, and particularly African women who shoulder much of the health burden from cookstove pollution.

Lack of access to clean cooking affects over two billion people globally, with over half living in Africa, often reliant on open fires and rudimentary stoves, fuelled by charcoal, wood, agricultural wastes and animal dung. 

In Africa, more than 850 million people still depend on wood and charcoal for cooking, the leading cause of indoor air pollution, with devastating effects on health. 

In fact, toxic indoor smoke is the second biggest cause of premature death in Africa, predominantly affecting women and children. Household air pollution causes nearly half of pneumonia deaths among children under five years of age.

Impact on women

“Successfully advancing the clean cooking agenda would contribute toward protecting the environment, climate, health, and ensuring gender equality,” Tanzanian President Samia Suluhu Hassan told the summit in Paris.

Hassan has called for the generous replenishment of the African Development Fund, which  includes $12 billion for clean cooking with the goal of ensuring clean cooking for all by 2030.

“Insufficient funding and a lack of awareness about the economic opportunities within the clean cooking industry hamper efforts to scale interventions,” she said.

Hassan cited three major challenges facing clean cooking in Africa, including the lack of access to adequate, affordable and sustainable solutions, lack of global attention to the problem and the absence of smart partnerships to ensure clean cooking access for all.

“Amidst these challenges, central to Tanzania’s own commitment is delivering on or recently-launched 10-year Clean Cooking National strategy, which aims to ensure 80% of Tanzanians use clean cooking solutions by 2034,” she said.

Norwegian Prime Minister Jonas Gahr Støre said his country will invest approximately $50 million to support clean cooking energy.

“Improving access to clean cooking is about improving health outcomes, reducing emissions, and creating opportunities for economic growth,” he said.

Respiratory and cardiovascular diseases

The global clean cooking energy campaign received a boost at the United Nations Climate Change Conference in the United Arab Emirates (UAE) in November last year with the launch of the African Women Clean Cooking Support Programme(AWCCSP) which aims to provide clean cooking technologies to women and girls in Africa to reduce the use of firewood and charcoal.   

Dirty cooking causes respiratory and cardiovascular diseases, increases planet-heating emissions, and robs women’s of their time, experts said at the conference.

IEA Executive Director Fatih Birol emphasized the significance of the Summit’s outcome. “This summit had delivered an emphatic commitment to an issue that has been ignored for too long” Biro states, underscoring the potential of the $2.2 billion commitment to support  fundamental rights such as health, gender equality and education, while also mitigating emissions and restoring forests.

Akinwumi Adesina, President of the African Development Bank Group, announced plans to increase financing for clean cooking to $200 million annually over the next decade, while also scaling up the provision of blended finance for clean cooking through Sustainable Energy Fund for Africa(SEFA).

“We are delighted to play a leading role… to definitively tackle lack of access to clean cooking, that affect a billion people in Africa,” he said.

Mary Robinson, former president of Ireland, arrives at the summit.

Following the Summit, the IEA announced plans to employ a “double-lock system” to ensure sustained momentum behind clean cooking efforts.

This system entails effective tracking methods to ensure pledges and commitments are fulfilled, alongside continued efforts to engage more partners and generate additional funds to meet the $4 billion annual capital investments required until 2030 to achieve universal access to clean cooking in sub-Saharan Africa.

More than 100 countries, international institutions, companies, and civil society organizations signed The Clean Cooking Declaration, reaffirming their commitment to prioritizing the issue and enhancing efforts toward achieving universal access for all.

Nearly one in three people globally still use open fires or basic stoves for cooking thus causing untold health damage, lower living standards and widening gender inequality, according to IEA report titled, A Vision for Clean Cooking Access for All.

 Women suffer the worst impacts from the lack of clean cooking. The burden of fuel collection and making meals typically falls on women and takes on average 5 hours a day.  

 “Clean cooking is a topic that rarely hits the headlines or makes it onto the political agenda,” said Birol. “And yet, it’s a cornerstone of global efforts to improve energy access, gender equity, economic development and human dignity,”

Former President of Ireland, Mary Robinson, cautioned against unfulfilled promises.

 “We need to know what kind of new money is coming in and how it will be spent. We have to test everything these days, as so many promises are made and not fulfilled,” she said.

“The fact that 900 million women in Africa still cook on dirty stoves should not be tolerated in the 21st century,” Robinson asserted.  “And to hear it only requires $4 billion, with $300 million being allocated each year for the next few years. Isn’t that very doable?”

Test tube rack stocked with electronic cigarettes.

A $3-million “educational” deal between tobacco giant Philip Morris International (PMI) and Medscape, a medical education provider for healthcare professionals, has been abandoned after the BMJ and The Examination exposed it last month.

The deal involved a PMI grant to Medscape to fund continuing medical education (CME) accredited courses on smoking cessation for doctors and other healthcare providers. 

With waning tobacco sales, PMI has moved into selling smokeless tobacco products and e-cigarettes alongside cigarettes.

However, Medscape has “bowed to pressure and agreed to permanently remove a series of accredited medical education courses on smoking cessation funded by the tobacco industry giant Philip Morris International (PMI)”, according to The BMJ.

“Medscape has acknowledged its ‘misjudgment’ in a letter to complainants and says that it will not accept funding from any organisation affiliated with the tobacco industry in the future,” the journal added.

When the exposé was first published, Professor Anna Gilmore, director of the Tobacco Control Research Group at the University of Bath, UK, said that Medscape had “now lost all credibility and has some serious questions to answer. PMI lost all credibility decades ago, despite its ceaseless and highly misleading attempts to rehabilitate its image. It has now sunk to a new low.”

A few years back, PMI established the Foundation for a Smoke-Free World headed by former World Health Organization (WHO) official Derek Yach to promote its tobacco-free products. 

The intention of the Medscape course appears to be to downplay the negative health effects of non-cigarette nicotine products.

“Medscape had planned to deliver 13 programmes under the deal—called the PMI Curriculum, according to the internal document. It had also planned podcasts and a ‘TV-like series’,” The BMJ revealed.

Medscape describes itself as “the leading online global destination for physicians and healthcare professionals worldwide, offering the latest medical news and expert perspectives; essential point-of-care drug and disease information; and relevant professional education and CME”.

The tobacco industry has a long history of sponsoring academics and research aimed at downplaying the negative impact of tobacco and smoking.

In its response to The BMJ, a PMI spokesperson said: “Health agencies around the world have recognised the beneficial role that smoke-free products can play to improve public health.

“We are concerned that known special interest groups are actively blocking medical education that the [US] Food and Drug Administration and medical community have determined are needed. These actions stand to prolong use and possibly increase consumption of combustible cigarettes – the most harmful form of nicotine use.”

But Professor Tim McAfee, former director of the US Centers for Disease Control and Prevention’s Office on Smoking and Health, ctold The BMJ that PMI’s partnership with Medscape “the ultimate example of the fox not only signing up to guard the hen house but offering to sit on the eggs.” 

“It is a perversion of ethics surrounding continuing medical education to allow the very companies that caused and profit from the continuing epidemic of tobacco-related death and disease to be involved in any way,” added McAfee, who is based at the Department of Social and Behavioral Sciences at the University of California in San Francisco.

Image Credits: Unsplash.

NCDs
A nurse vaccinates a baby at a clinic in Accra, Ghana. Investments in nursing can have a ten-fold economic benefit in LMICs.

More than 4.5 billion people lack access to essential health services, while globally 60 million lives are lost due to failures of health care systems, translating into a 15% loss of global GDP.

Yet the consequences in terms of poor health and economies are preventable through increased investments in nurses who deliver upwards of 80% of hands-on care, according to a new report from the International Council of Nurses (ICN). 

Investments in the health workforce in low and middle-income countries (LMICs), and particularly nurses, would result in a massive return on investment at a ratio of 10:1, the report finds.

The economic burden of inadequate health systems is at the forefront of the report, whose release coincides with Sunday’s observance of International Nurses Day. This year’s theme on “the economic power of care” echoes the outsized contributions nurses make to global economic growth, and identifies critical areas for strategic investments in the face of increasing healthcare demands and burnout.

“What governments must recognise is that such investment in nursing is not a cost: investing in health care saves money, and our experts say having a healthy population could boost global GDP by $12 trillion or 8%,” remarked ICN President Pamela Cirpriano. 

The report finds that countries need to increase the size of their nursing workforces so that they have 70 nurse for every 10,000 population, in order to reach key Universal Health Coverage (UHC) benchmarks by 2030. And that means at least 30.6 million more nurses need to be educated and employed around the world. 

In countries where there are more nurses per capita, UHC coverage is also higher.

The report cites WHO data from 2023 to the effect that effective Universal Health Coverage (UHC) could save 60 million lives by 2030, and increase global life expectancy by 3.7 years.

“But achieving it requires a massive increase of investment in the nursing workforce,” Cirpriano stressed, noting that, “nurses are the drivers of Primary Health Care (PHC) which has been recognized by the United Nations as the catalyst for reaching the UHC 2030 goals.”

Costs of underinvestment of nursing
The ICN report identified the numerous costs of underinvestment in nursing

Cost-cutting measures will backfire

Although nurses make up 50% of the healthcare workforce, national investments in nurses education, salary and conditions have been eroded, rather than bolstered, in the post-COVID era.  

“Faced with the global shortage of nurses instead of investing in the current nursing workforce we are seeing too many governments choosing short-term and cost reduction driven policies, such as international recruitment, creating new non-registered nurse roles and looking to reduce the length of nurse education,” said ICN Chief Executive Officer Howard Catton.

“These are the wrong choices, taking us in the wrong direction, and seriously risk putting people off joining the profession and seeing more of our experienced nurses quit or leave earlier than they would have done. 

Even in high income countries such as the United States see “nurses frequently grapple with insufficient staffing levels, heavy workloads, and resource constraints, all of which can detrimentally affect their job satisfaction and retention,” said Lisa Kitko, RN & PhD, dean of the University of Rochester School of Nursing, speaking to Health Policy Watch. 

“It’s essential to recognize the economic value that nurses bring to health care organizations through their expertise, skills, and contributions to patient outcomes,” she said. “As the largest health care profession, and most trusted, nurses are uniquely positioned to improve lives and strengthen communities. They consider the future of health care more systemically, integrating the physical, social, and mental well-being of patients.”

A 1:10 return on investment ratio for nursing

The report notes that every $1 invested in health systems generally brings a return of $2-$4. “Stronger health systems equal better health, and healthier populations bring significant returns on investment.” 

But the economic returns are even greater for lower-and-middle-income countries (LMICs). Investment in the LMIC health workforce, particularly nurses, would result in a massive return on investment at a ratio of 1:10.

“We know investments in nursing will create improvements in health care delivery, be a catalyst for economic development, and will advance peace and social well-being,” said Cipriano. 

“What we do has an impact far beyond the visible care we deliver in hospitals, homes, communities, and crisis settings.”

The report notes the cascading benefits of investments in the nursing workforce include not only better direct job creation but better health overall, leading to productive gains in other sectors.

An opportunity for increased gender equality

Benefits of investments in nursing
The benefits of investments in the nursing sector range from empowering women to fostering peace

Investing in nursing and the broader care economy also “is crucial for closing gender gaps,” the report streses. Improving pay, working conditions, and career advancement opportunities in nursing empowers women and stimulates the rest of the economy, especially in the context where approximately 90% of nurses worldwide are women.

For the same reasons, investing in the nursing workforce also can help alleviate poverty, especially for women and girls.

Such investments also require more economic focus and renumeration for roles that are now unpaid care work. Some 76% of unpaid care work is performed by women, and  when care work is paid, it is characterized by low wages. The report sees the economic opportunity in improving pathways to better paid care work. “Better care systems and recognizing and redistributing unpaid care work can significantly contribute to closing gender gaps in labor markets,” notes the report.

Furthermore, the report highlights how investments in nursing have cascading economic benefits, including globally. One prominent example is the more than $50 billion that nurses educated in the global south and working in the global north send home in remittances each year.  At the same time, LMICs have also suffered a significant nursing “brain drain” as affluent countries rely increasingly on importing nurses from abroad, rather than investing in a stronger domestic healthcare work force.  

“What is important now is to make sure that we reinforce to the world that nurses no longer want to be hidden,” said Cipriano at a recent webinar. ICN CEO Howard Hatton added that “for too long, people have dismissed the economic value of caring as being irrelevant or of having no value, that is plainly wrong.” 

“Social cohesion, peace, and prosperity”

While much of the report identifies the economic implications of nursing, it also makes an argument for the connections between the work nurses do and peace. The report notes that “through their work, nurses address the root causes of ill health and the risk factors that lead to conflict.

As frontline workers and primary care providers, nurses “see the connections to other issues, such as political conflicts, family breakdowns, loss of jobs, poverty and mental health crises,” the report states.

“With their trusted position within communities, nurses can play a critical role in bringing people together, building bridges and the wider partnerships and relationships that are the foundations of peace and community cohesion.”  

Kitko, who is also a vice president of the University of Rochester Medical Center, said that she’s “observed a growing acknowledgement from health care leadership of the need to invest in nursing education, training, and professional development. Today, nurses have unprecedented opportunities to shape policy, conduct research, deliver high-quality care, and spearhead transformative changes aimed at strengthening the well-being and resilience of our nursing workforce.”

At the same time, many societies and governments continue to undervalue nursing, she notes, warning that “people often overlook the advanced education, specialized skills, and leadership roles that many nurses hold.

“We must continue to promote the image of nursing, highlighting nurses’ expertise, compassion, and impact on patient care.”

Image Credits: Kate Holt/USAID, International Council of Nurses , International Council of Nurses.

INB co-chair Precious Matsoso briefs the media on Friday night.

Despite the huge human and economic cost of  COVID-19, over two years of negotiations and substantial diplomatic pressure, the World Health Organization’s (WHO) Intergovernmental Negotiating Body (INB) failed to reach consensus on a pandemic agreement by Friday (10 May), the last scheduled day of negotiations before the upcoming  77th World Health Assembly (WHA).

But the exhausted INB delegates have resolved to solider on with talks right up to the eve of the WHA, which begins on 27 May.

Briefing a handful of media left at the Geneva headquarters on Friday night, co-chairs Roland Driece and Precious Matsoso said the negotiations had finally started to make progress in the past two weeks.

“The closer you get to the endpoint, the more willingness there is to move. We worked very hard and deep into the night, but there’s just so much so many issues that we need to agree upon and which are sometimes very technical or political,” said Driece.

“I think this is the last mile,” said Matsoso, adding that One Health, pathogen access and benefit-sharing (PABS), intellectual property and human resources had preoccupied delegates – although the human resources article was almost entirely “yellowed”, which meant it had been agreed by the working group.

The INB has developed a schedule of work based on significant areas that still lacked convergence, she added.

“Of course PABS is one… But once you get that, the rest is history,” said Matsoso. “You may ask  why we have given PABS so much attention. It’s because they all say it’s the heart, so if it doesn’t go with the instrument, it means there will be no heartbeat.”

She added that there would be one or two days’ work interspersed with breaks in the next two weeks, but that the actual dates still had to be agreed on.

Earlier, some delegates told Health Policy Watch there was simply was not enough time to attend to the outstanding issues. Others, notably Eswatini, remained more hopeful saying that if INB reconvened in the week before the WHA, scheduled to start on 27 May, many of the outstanding gaps could potentially be closed. 

“If we can work intelligently and with dedication, I think we can deliver a stronger outcome at the World Health Assembly,” the delegate said.

INB’s mandate

“Our mandate is to report to the WHA on the outcome of the process, and that is what we will do,” said Driece. “And the outcome will be where we will be a day before the WHA. We do hope if we put all the efforts in that it’s going to be with the final agreements. But if not, we just report on where we are at that moment.”

If no agreement is reached in the next two weeks, other options include an extended WHA running into June, a WHA Special Session in November or December or – the least popular option – postponing the deadline until the next WHA in May 2025.

Whatever happens in the next two weeks, the INB is obliged to report an outcome at the WHA, including sharing the latest draft of the agreement so far, including all of the bracketed, green and yellow text, WHO’s legal department has reportedly told delegates on Friday.  The INB will also recommend a way forward on final negotiations, with the WHA making the final decision.  

WHO chief legal officer Steven Solomon told the media briefing that “the INB wants to provide the assembly with a basis to consider their two and a half years of work. They want to meet their mandate to give the assembly a basis to consider their work.”

Solomon added that there is confusion about what adoption by the WHA means.

“Adoption doesn’t mean the treaty applies to any country. It’s the start of a process by which countries go back and consider whether this instrument makes sense for them. They would consider, at the domestic level, whether they should ratify the agreement.

“What I’ve seen in the press, and in, particularly social media, is the view that if it’s adopted, then it applies. You all know that’s not the case, but it’s not necessarily clear.

“And I guess the other thing I’d say is that every negotiation of every international agreement, begins as a marathon and finishes with a sprint. Member states have been running this marathon for two and a half years, and they’re in the sprint phase now. That shows their commitment to to achieving a result that delivers both global health equity and global health security, and is effective at preventing future pandemics and responding to them.”

Important progress

However, WHO officials, INB members and stakeholders stressed that the agreements, even in principle, on key points regarding equity, benefit sharing and technology transfer that have been reached so far are important for advancing equitable access to medicines and vaccines.

Provided there is no backsliding in subsequent rounds of negotiations, these would represent important, albeit imperfect, advances in preparing for and responding to the next pandemic. 

Draft text from late Thursday reflected the still large areas of disagreement with a number of critical articles still to be discussed. 

The text is still a mess of green (agreed on in plenary), yellow (agreed on by working group) and brackets

Friday morning’s session did not return to disputed articles but discussed various definitions. This is important for amendments to the International Health Regulations (IHR), due to be finalised in the coming week, which are supposed to use common definitions.

Knowledge Ecology International’s James Love told Health Policy Watch that, while the current text did not go far enough in many aspects to ensure equitable access to pandemic medicines and vaccines, there were important advances.

In Article 12, which deals with pathogen access and benefit sharing (PABS), “every version has some amount of vaccines that will be available to the WHO for free and affordable prices”, said Love. 

“Some people would like, more some people would like less, but no one is arguing it would be zero. So if that succeeds, it will definitely expand access.”

The current draft has two versions – either “up to” or “at least” 20% of health-related pandemic health products being allocated to the WHO for distribution. 

Love also said that a number of the articles also established new norms – such as on public money invested in research and development (R&D), technology transfer and global supply chains.

Putting an obligation on countries that fund R&D of pandemic products to “look after the access conditions” of whatever medicines and vaccines are produced as a result of their investment, not only in their own countries but worldwide, particularly in developing countries, is “something brand new”, said Love. 

While much of the language on technology transfer (Article 7) is not binding, the text does mandate countries and the WHO to move ahead on this, ditto with the establishment of global supply chains.

The progress achieved by those who believe in a multilateral approach to pandemic prevention could, however, be viewed as a setback by ultra-nationalists that would rather go it alone even in a pandemic, sources here warned.

For instance, parts of the media in the United Kingdom have been claiming, somewhat hysterically, that an agreement on benefit sharing would mean the UK would have to give up 25% of its vaccines in future pandemics.  But this is a distortion of the agreement, WHO officials have pointed out. 

Like any international instrument, the proposed agreement would be subject to ratification and countries’ sovereign laws – even though pathogens know no boundaries.

Families flee Rafah to seek safe shelter in central Gaza, 7 May 2024.

With Gaza’s Rafah crossing into Egypt closed by an advancing Israeli incursion, and Israel’s Kerem Shalom crossing shut since last Sunday’s Hamas missile attack, Gaza hospitals have only about three days left of fuel and medical supplies, said WHO Director General Dr Tedros Adhanom Ghebreyesus Wednesday.    

The global health agency is making contingency plans for a full-scale Israeli invasion of Gaza in the wake of an impasse in Israel-Hamas talks over a cease-fire, including release of Israeli hostages. But such preparations would only be a “drop in the ocean” of human need that would follow the death and injuries incurred in such an operation, added Dr. Rick Peeperkorn, head of WHO’s office in the Occupied Palestinian Territories at the press briefing. 

“WHO has pre-positioned some supplies in warehouses and hospitals, but without more aid flowing into Gaza, we cannot sustain our lifesaving support to hospitals,” Tedros said.

Meanwhile, one third of Sudan’s population is facing acute hunger and  70% of hospitals in conflict affected areas are not functioning, Tedros noted – calling for a cease-fire in the African country wracked by a year-long civil war as well as in the war between Israel and Hamas.    

Rafah’s population fleeing and hospitals shutting down

Dr Rick Peeperkorn, head of WHO’s Jerusalem-based office of the Occupied Palestinian Territories (OPT) speaking at a WHO press briefing Wednesday

In war-torn Gaza, tens of thousands of people left Rafah’s eastern outskirts, as Israeli tanks moved in Tuesday and Wednesday through a narrow wedge of land between the city and its crossing into Egypt, taking full control of the strategic entry point for the first time since Israel’s withdrawal from Gaza in 2005.

More people were packing up and leaving by the hour, local media reported, showing scenes of advancing Israeli tanks, artillery explosions, and families pulling up tents and loading belongings onto tractors and donkeys.   

Despite the evacuations, some 1.4 million Gaza Palestinians remain in the densely populated Rafah area and “at risk”, including about 600,000 children, said Tedros. Areas designated by the Israeli military as safe zones, such as the Muwasi district westwards, near the Mediterranean Sea, are already packed with displaced Palesitnians, and lack infrastructure to accommodate tens of thousands more people, added Peeperkorn. 

Israeli evacuation order Sunday to Gazans – telling them to leave neighborhoods on the edge of Rafah (marked in red) for Khan Younis and Muwasi, skirting the Mediterranean sea, marked in yellow and beige.

One Rafah hospital, An-Najjar, has already been forced shut down since the Israeli incursion into the southernmost area of the Gaza strip overnight Tuesday – and the city’s other two hospitals are threatened with closure should the military advance further into the city core, said Peeperkorn, speaking by video from Jerusalem. 

Efforts are now being made to shift critical supplies and operations to hospitals further north, such as Nasser Medical Complex in Khan Younis and other hospitals in Gaza’s ‘Middle region’, Peeperkorn and Tedros said. Nasser hospital has recently been reopened after undergoing extensive repairs following damage in earlier phases of the seven months of war, and even just opened a dialysis center. 

Only three days of fuel left 

WHO Director General Dr Tedros Adhanom Ghebreyesus

However, if the Israeli advance continues, and key entry points remain cut off, then hospitals will have no more fuel or supplies with which to operate, Tedros warned. 

“Fuel that we expected to be allowed in today has not been allowed in, meaning we only have enough fuel to run health services in the south for three more days,” he said.

Already, WHO has had to suspend a number of medical missions to northern Gaza due to a lack of fuel to move EMTs, added Peeperkorn.  Israel has promised the United States that the Kerem Shalom entry from Israel would reopen Wednesday, but as of late afternoon that hadn’t happened, Peeperkorn said.

“There were discussions that fuel will come in through Kerem Shalom, but the current state is that just that there’s no fuel coming in today. So anyone with influence, it’s the biggest item that is needed. I’m not only talking about food distribution, I’m talking about fuel for bakeries, fuel for hospitals, fuel for any operations.

The WHO remarks were echoed by the UN Office for the Coordination of Humanitarian Affairs (OCHA) in a statement Wednesday: “An average of 48 trucks and more than 160,000 litres of fuel entered Gaza via the Rafah crossing between 1 and 5 May. We need that fuel to sustain our humanitarian operations.

“We are engaging with all involved on the resumption of the entry of goods, including fuel, and so that we can again begin managing incoming supplies. However, the situation remains extremely fluid, and we continue to confront a range of challenges, amid active hostilities.

“We count on cooperation and facilitation to get these crossings operational again, since stocks of critical supplies – including fuel – are being depleted by the hour.” 

‘WHO has no intention of withdrawing’

Tedros said that WHO is coordinating the work of some 20 Emergency Medical Teams in Gaza, comprising 179 internationals and 800 local staff based in 10 hospitals and five field hospitals. 

“WHO has no intention of withdrawing from Rafah and will stay and deliver alongside our partners,” Tedros asserted. 

Sudan faces humanitarian disaster after year of fighting

WHO team member providing nutrition support to internally displaced children in Gedaref state, Sudan, in August 2023 during the ongoing civil war.

As for Sudan, some 15 million people – nearly one-third of the population –  are in urgent need of humanitarian assistance and almost nine million people are displaced, Tedros said.  And even in areas where there is no active combat going on, one-half of the hospitals are not functioning.

“Those that are functioning are overwhelmed by people seeking care, many of whom are internally displaced,” he said. “Health facilities, ambulances, health workers and patients continue to be attacked, depriving entire communities of essential health services. Just last week, two of our colleagues from the International Committee of the Red Cross were killed in South Darfur.”

“The conflict has led to a devastating deterioration in food security. More than one-third of the population is facing acute hunger, and there is a risk of famine in Darfur and Khartoum. Humanitarian partners have released a famine prevention plan,” he added.

“WHO’s priority is to ensure continuity of health services to prevent and respond to outbreaks, and to provide care for those most in need, including pregnant and breastfeeding women and children under five,” he said.

Late last year, WHO launched a $US 178 million appeal for an emergency health response in Sudan.  But the agency has said little recently about efforts underway to support hospital capacity in the war-torn country. Although it does have a major nutrition stabilization effort underway, the last detailed report to Geneva media was in late February.

And Tedros didn’t provide any added details at Wednesday’s briefing, saying only: “It is imperative that all sides to the conflict provide unhindered humanitarian access to those in need, including through cross-border routes.

“Most of all, we call for a ceasefire and a comprehensive peace process for Sudan. It is time to silence the guns and raise the volume for peace. The best medicine is peace.”

Image Credits: OCHA/Olga Cherevko. , Twitter/@IDF, WHO.

Insulin supplementation is the daily reality for diabetes patients. Lower prices for insulin pens could make their everyday reality easier.

Insulin pens are more affordable and preferred by diabetics but they are available almost exclusively in high-income countries due to gross overpricing, according to a report by Médecins Sans Frontières (MSF) and T1International, a British NGO fighting for equal treatment access for people with diabetes type 1.

The research was presented on Wednesday, ahead of the fourth Symposium on Diabetes in Humanitarian Crises happening in Athens late this week, which is hosted by the International Alliance for Diabetes Action (IADA).

“In Lebanon, offering pens to people with diabetes in our care has had a significant and positive impact on their quality of life, especially for children who are more likely to stick to their treatment schedule with the easier-to-use and less painful pens,” said Dr Sawsan Yaacoub, Paediatrician for MSF in Lebanon, where insulin pens were implemented instead of the traditional treatment administering with syringes and vials of insulin.

Numerous benefits of using insulin pens instead of the traditional syringe and vial make it a preferred choice for a vast majority of patients

The pens offered many advantages, especially to young patients, MSF evaluated. They make it easier to inject insulin, calculate doses and they induce less pain during the procedure, they are also more practical in terms of transport and stocking. Thanks to their advantages, children and adolescents participating in MSF’s programme in Lebanon were more likely to stick to the prescribed injection schedule.

Growing burden

Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin produced. 

Type 1 diabetes (insulin-dependent) is a deficient insulin production of the organism and requires daily administration of insulin.

There were 529 million people living with diabetes worldwide in 2021, as a Lancet study found. According to WHO, the number increased five-fold, from 108 million, in the four last decades.

The disease and accompanying conditions are a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation. Diabetes and kidney disease alone accounted for two million deaths in 2019.

Inaccessible

The diabetes burden is increasing for low- and middle-income countries, but, as MSF pointed out, the treatment options offered there are limited and old-fashioned.

MSF and T1International’s survey found that 82% of over 400 respondents in 38 countries preferred insulin pens when compared with injecting insulin with a syringe.

The pens could also be a more affordable option. “We have shown that it could be more affordable to use insulin pens instead of the old-fashioned vials and syringes,” said Dr Helen Bygrave, a Non-communicable Diseases Advisor for MSF.

MSF’s research into the cost of production shows that analogue insulin pens, offering more durable insulin without having to keep it refrigerated, could be sold at a profit for $111 per patient per year, including insulin cartridge and the pen itself. 

This technology is widely used in high-income countries, contrary to the human insulin administered with syringes, which is the standard in low-income settings as it is sold for a lower price.

MSF argues that the production of analogue insulin and insulin pens is 30% cheaper than the alternative. It is the selling prices that make insulin pens inaccessible. Each long-acting analogue insulin pen costs $2.98 in South Africa, $7.88 in India and $28.40 in the US, compared to the cost-based price of $1.30.

“No matter where a person lives in the world, they should be able to have equal access to their preferred diabetes care option,” Bygrave added.

The situation is similar to that of new diabetes drugs, GLP-1 agonists, which increase the feeling of satiety, helping patients to curb obesity. 

Semaglutide, a commonly used diabetes drug, could be sold at a profit for just $0.89 per month – a daunting difference from its cost in a pharmacy: $115 per month in South Africa, $230 in Latvia, and $353 or more in the US, which is 400,000% higher than the estimated generic price.

Near-monopoly dictates prices

The main manufacturer of GLP-1 drugs, Novo Nordisk, has recently faced a hearing in the US Senate about the gigantic markup it imposes on the market.

Due to intellectual property rights restraints, only three firms are currently providing insulin: Sanofi, Novo Nordisk and Elly Lily. The two latter ones are the only producers of GLP-1 medicine.

Price comparison and the difference between the sales prices and the ones based on production costs, according to MSF’s estimates.

Numerous benefits of using insulin pens instead of the traditional syringe and vial make it a preferred choice for a vast majority of patients

Despite their limited capacity making it difficult for them to meet the demand worldwide, the firms is still blocking generic manufacturers from entering the market.

“Pharmaceutical corporations Eli Lilly, Novo Nordisk and Sanofi must drop their insulin pen prices now, and at the same time, humanitarian agencies need to start procuring insulin pens and more systematically integrating them into the diabetes care they provide,” said Bygrave. 

As gross overpricing stands on the way to improved diabetic care, the new report shows clearly the production costs are not the reason behind it.

 “There is really no excuse for today’s double standard in diabetes care to continue,” Bygrave added.

“We firmly believe that every person with diabetes should have affordable access to the insulin and delivery device that is best for their body,” Elizabeth Pfiester, T1International’s Founder said.

Image Credits: WHO, MSF.

Philanthropists gather to commit $300 million for global health research
Leading global health philanthropists gather near Copenhagen to commit $300 million for global health. From left: Mads Krogsgaard Thomsen (Novo Nordisk), Bill Gates (Gates Foundation), Catherine Kyobutungi (African Population and Health), Ismahane Elouafi (CGIAR) and John-Arne Røttingen (Wellcome).

The Novo Nordisk Foundation, Bill & Melinda Gates Foundation, and Wellcome Trust have announced a new partnership, committing $300 million over three years to stimulate innovative research in developing countries into three of the world’s most critical global health challenges and their interlinkages – including climate change, infectious diseases and antimicrobial resistance (AMR).

An additional funding stream would aim to support research for greater understanding of the interplay between nutrition, immunity, infectious and non-communicable (NCDs), and developmental outcomes. 

All of the challenges disproportionately affect people in low-and-middle income countries (LMICs).  Consequently, funding will be directed mainly to LMIC countries and communities to strengthen research and development capacities and scale “equitable access to existing tools and technologies,” the partners said. 

The announcement by the world’s biggest health philanthropy heavyweights also aims to signal the urgency of making bigger global health investments more broadly to face new and emerging threats. 

“We face huge challenges to protecting and improving physical and mental health, compounded by vast inequities globally,” said John-Arne Røttingen, CEO of Wellcome, speaking at a two-day “Global Science Summit” in Helsingør, Denmark, where the initiative was announced. 

The most effective solutions to pressing challenges often emerge from the very communities they affect,” said Dr. Catherine Kyobutungi, executive director of the African Population and Health Research Center, one of the scientific research institutions that will collaborate in the new effort. “I’m encouraged that this new partnership seeks to unlock novel ideas and support the scientists working directly with the communities that stand to benefit the most.”

Climate change, infectious disease, and nutrition-disease interactions

Girl receives oral polio vaccine, funded by Gates Foundation philanthropy
The philanthropic partnership will fund additional scientific research and vaccine development into emerging and persistent health threats.

The initiative will support interdisciplinary initiatives that advance, for instance, better collection and use of climate data, innovation in more sustainable agriculture and resilient food systems, and other measures protecting  people from climate change, according to a press release by the Bill and Melinda Gates Foundation. 

“We’re on the cusp of so many scientific breakthroughs in agriculture, health, and nutrition, and with the right support these innovations will save and improve lives around the world,” said Mark Suzman, Gates CEO. “Every sector has a critical role to play, and we hope this collaboration opens the door for other funders and partners to contribute to scaling up existing innovations and developing the tools of tomorrow.”

“Many of these challenges are overlapping and intersecting, with profound impacts on human health,” said Dr Tedros Adhanom Ghebreyesus in remarks at the two-day summit, hosted by Novo Nordisk Foundation, which ended Tuesday.  

Since the late 1990s, NCDs have overtaken infectious diseases as the world’s leading cause of premature mortality on every continent, except Africa, Tedros noted, while big gains against HIV, malaria and TB have plateaued recently. 

“NCDs can weaken the immune system, making people more vulnerable to infectious diseases. In turn, infectious diseases can exacerbate the progression of NCDs and cause complications. And the climate crisis exacerbates both of them.”

More equitable use of available tools also are needed

WHO Director General Dr Tedros Adhanom Ghebreyesus – innovation is an engine of global health improvements, but available health tools and strategies also are not being used well enough.

But while research and innovation have always been the “engine of improvements in public health”, Tedros also reminded his audience of donors and philanthropists that available solutions to NCDs, infectious disease and climate change also are not being harnessed. 

“The health challenges we face globally are not fundamentally scientific challenges; they are largely political, economic and social challenges,” the WHO DG asserted. “Of course, we need more technologies, but using the existing ones to the maximum is important.

“Many NCDs can be prevented through healthier diets, physical activity or by stopping smoking. Premature deaths from NCDs can be prevented with the right diagnosis and treatment.

“Most cases and deaths from infectious diseases can be prevented with vaccines, prophylaxis, bed nets or other tools to prevent exposure.

“And climate change can be reversed, and its impacts mitigated, by weaning ourselves off our addiction to fossil fuels.

“The problem is not that we don’t have the tools or the knowledge to address these threats; the problem is that those tools are not equally available, for multiple reasons.”

Emphasis on AMR

The partnership will also channel funding to infectious disease research, with an emphasis on addressing AMR, advancing disease surveillance, and developing vaccines for respiratory infections. 

Supporting new advances in detection and the development of vaccines and other tools should  help “reduce the burden of disease in LMICs and prevent outbreaks from turning into global crises,” the partners said. 

An overarching aim of the initiative is to “break down barriers between often isolated areas of work—between cardiometabolic and infectious diseases, or between scientific discovery and delivery of solutions, for example,” said Mads Krogsgaard Thomsen, CEO of the Danish-based Novo Nordisk Foundation.

Both over and under-nutrition continue to burden countries in both the global North and South. In that context, the partnership aims to support advances in nutritional science and the microbiome – the trillions of micro-organisms that co-exist in our bodies – as an avenue to tackle nutrition-related diseases. 

“It’s kind of mind-blowing how little research was going into understanding malnourishment,” remarked Bill Gates. “In some cases, for things like the microbiome, we had to fund scientific research because it was just an ignored area.” 

Faltering global health investments

Wellcome Trust CEO speaks at Copenhagen global health forum
John-Arne Røttingen, Wellcome Trust CEO, speaks the Novo Nordisk Foundation Global Science Summit in Denmark

The new initiative aims to signal that renewed global health investments are all the more important in the current post-pandemic context. 

“We have a challenging macroeconomic situation,” said John-Arne Røttingen, Chief Executive Officer at Wellcome. “We also see that the major part of global health financing is really not for science and innovation.”

After the surge in funding during the COVID-19 pandemic, national investments in health have since faltered. Governments face competing budgetary priorities in the wake of inflation and debt crises.

A recent World Health Organization (WHO) analysis of global health expenditures found that most governments fail to meet the global targets for spending of 5% of GDP and 15% of national budgets on health care. Meeting those two benchmarks indicates if a country is on track to achieve universal health coverage. Many low-and-middle income countries spend even less on health today than they did  in 2000. 

“Funding and attention for global health and development is faltering, putting progress at risk. Debt crises are forcing governments to cut funding for essential health programs; climate change and conflict are shattering communities; and progress to protect lives from diseases known and unknown is under threat. Across all of these challenges, it is the world’s poorest who are most affected,” said the Gates Foundation announcement.

New obesity drugs filling Novo Nordisk philanthropy’s coffers  

The Novo Nordisk Foundation contributed $100 million for a new global health partnership along with Gates Foundation and the Wellcome Trust

Ironically, the Novo Nordisk Foundation’s participation in the new partnership comes on the heels of the recent landslide success of the pharmaceutical firm Novo Nordisk A/S – which  Novo Nordisk Foundation controls – with the sale of two new drugs Ozempic® and Wegovy® to control obesity..

“The booming market for weight-loss drugs has pushed the assets of the Novo foundation to more than double those of the Gates foundation,” noted Bloomberg Law in a recent article.  

“In turn, the Danish organization is broadening its giving and its footprint outside its home market. The Novo foundation already backs 27% of Danish medical research, awarding a record $1.3 billion to projects related to innovation and science last year.

The partnership may be extended beyond the initial three years if successful, Novo Nordisk Foundation CEO Thomsen was quoted as saying. “To be honest, three years is a short time for making a change on global climate, agri-food systems, human health.” 

If early results are positive, he said, “the most natural thing is to continue such a relationship, of course.” 

Image Credits: CDC.

Some of the areas covered by the WHO Results Report

“The world is off track to reach most of the Triple Billion targets and the health-related Sustainable Development Goals,” said World Health Organization (WHO) Director General  Dr Tedros Adhanom Ghebreyesus. 

His comments were part of the WHO Results Report 2023 released on Tuesday.

The triple billion targets involve one billion more people benefitting from universal health coverage, one billion more people better protected from health emergencies, and one billion more people enjoying better health and well-being by 2025. 

Using data from 174 countries, the report shows some progress towards the 46 targets, however.

One billion enjoying better health? Yes

The current trajectory indicates that the target of 1 billion more people enjoying better health and well-being will likely be met by 2025, driven primarily by improvements in air quality and access to water, sanitation and hygiene measures, according to the summary.  

But the progress will be insufficient to reach all the health-related targets of the Sustainable Development Goals (SDGs) by 2030, with only one target on tobacco use likely to be met.

Tobacco use is declining in 150 countries, 56 of which are on track to achieve the global target of reducing tobacco use by 2025. There are 19 million fewer current tobacco users globally than there were two years ago.

Forty-five countries also reduced their road traffic deaths by 30% or more.

But adult obesity continues to rise in all WHO regions, with no immediate sign of reversal. Ambient air pollution continues to be a challenge in many areas of the world. 

One billion access to universal health coverage? No

The world is off track to meet the target of one billion more people benefiting from universal health coverage by 2025. However, 30% of countries have made progress on both the coverage of essential health services and the provision of financial protection. 

But “the overall measures of progress are largely driven by increased HIV service coverage”, according to the WHO. 

Over three-quarters of people living with HIV globally are receiving antiretroviral therapy and almost all of those who are receiving treatment are achieving viral suppression, which means that they cannot infect others. 

Global HIV services are the beneficiary of the US President’s Emergency Plan for AIDS Relief (PEPFAR), which has strengthened health systems in many countries, particularly in Africa.

However, the COVID-19 pandemic disrupted progress on childhood vaccination and tuberculosis and service coverage for malaria, non-communicable diseases and preventive services continue to lag.  

But the world’s first malaria vaccine, RTS,S/AS01, was administered to more than two million children in Ghana, Kenya, and Malawi during the biennium, reducing mortality by 13% among children eligible for vaccination. WHO’s prequalification of a second vaccine, R21/Matrix-M, is expected to further boost malaria control efforts. 

Indicators for financial hardship has worsened with 13.5% of households spending 10% or more of their income on health services (vs 13% in 2017).

Management of diabetes has also worsened. 

One billion better protected from health emergencies? No

Although the coverage of vaccinations for high-priority pathogens shows improvement since the pandemic-related disruptions in 2020–2021, it has not yet returned to pre-pandemic levels. 

But there has been a 62% increase (from 103 to 167) in the proportion of member states with genomic sequencing capability for SARS-CoV-2 between February 2021 and December 2023. Angola, Bahamas, Central African Republic, Dominican Republic, Honduras, Maldives and Sudan are among the countries that have gained a sequencing capacity.

The Pandemic Fund made its first round of $338 million disbursements to 37 countries in 2023 to assist them to bolster systems to prevent and respond to pandemics and outbreaks.

However, the Intergovernmental Negotiating Body (INB) still has not come up with a pandemic agreement, while the Working Group on Amendments to the International Health Regulations (2005) seems close to agreement on amendments to present to the Seventy-seventh World Health Assembly which starts on 27 May.

“With concrete and concerted action to accelerate progress, we could still achieve a substantial subset of [the targets]. Our goal is to invest even more resources where they matter most—at the country level—while ensuring sustainable and flexible financing to support our mission,” said Tedros.

Mechanical milking machines may be facilitating the fast spread of H5N1 avian flu in dairy cows in the US.

Although cows have been infected with avian influenza subtype H5N1 for the first time and viral remnants have been found in milk, the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) characterise its current risk to humans as “low”.

The risk for people exposed to infected birds and other animals is low to moderate, they add.

So far, there have been no cases of avian flu being transmitted from person to person in the current outbreak – only from infected birds and animals to humans.

The last human-to-human transmission of avian flu was detected in 2017 and involved infections between a small group of health workers.

Only one person has been infected in the current outbreak in US dairy herds, a man working on a Texas dairy farm who developed conjunctivitis. Swabs of the man’s throat and eye tested positive for H5N1, but he had mild symptoms and did not infect anyone in his household.

Meanwhile, some 220 workers who work at the 36 US dairies affected by the H5N1 outbreak have been screened, but none has been infected with the virus, according to the US CDC’s Dr Todd Davis, speaking at a WHO Information Network for Epidemics (EPI-WIN) briefing on Monday.

“After sequencing several hundred viruses from cattle, we don’t see any molecular changes that would indicate increased possibilities of infection or transmission from person to person,” said Davis. 

“So we still consider this public health risks to be quite low. I think some of the exceptions may be prolonged unprotected exposure to infected dairy cattle, so there are some likely risk associated with occupational exposure.”

US CDC’s Todd Davis

Milk and meat risks

About 20% of milk samples collected by the US Food and Drug Administration (FDA) tested positive for H5N1 viral RNA, said Dr Richard Webby, director of the WHO’s Collaborating Centre for studies on the ecology of influenza in animals and birds.

Meanwhile, a smaller sample set targeted at the states where outbreaks had occurred found  40% of the milk products contained viral remnants,  added Webby, who is based at St Jude Children’s Research Hospital in Memphis in the US.

“There has been a relatively large number of samples tested, but so far from a safety perspective, it does look like the pasteurisation process is removing viable virus from those samples,” added Webby.

Dr Moez Sanaa, head of the WHO’s Standard and Scientific Advice on Food Nutrition, confirmed that while viral RNA has been found in pasteurised milk, none of this was live virus “suggesting that the pasteurisation process effectively inactivates H5N1,” said 

“Preliminary results [of ongoing studies] indicate that virus is inactivated by heat treatment similar to pasteurisation,” said Sanaa, but added that more studies of milk with higher viral loads was still needed. He warned people to avoid raw milk.

Meanwhile, last week the USDA’s Food Safety and Inspection Service (FSIS) announced that all 30 samples of ground beef from retail outlets in the states with infected dairy cattle herds tested negative for H5N1. These results reaffirm that the meat supply is safe.

Webby’s group has also tested eggs and found them to be free of H5N1.

Richard Webby, Director of the WHO’s Collaborating Centre for studies on the ecology of influenza in animals and birds

Cow transmission: mechanical?

From the genomic analysis, it appears that the outbreak in the dairy farms stemmed from “a single introduction” but that “the moving of dairy cattle has spread that to multiple farms and different locations”, according to Dr David Swayne, a US influenza veterinarian.

Swayne added that as transmission seemed to occur “in the unique environment of a dairy parlour”, there were two leading hypotheses about how the rapid transmission was taking place.

One was that there was “mechanical transmission” with infections being spread via milking machines, for example.

The other was that transmission occurred during the “continual cleaning” in dairies that enabled viral spread through “large droplets produced from that washing down process”. 

Meanwhile, Dr Aspen Hammond from WHO’s Global Immunization Programme (GIP) said that H5N1 had been found in other animals near the affected dairy cattle herd, including cats, raccoons and wild and domestic birds nearby.

‘One Health in action’

Dr Maria van Kerkhove, the WHO’s acting head of Epidemic and Pandemic Prevention and Preparedness (EPP), described the outbreak as “one Health in action”.

“You cannot look at human health risk without looking at the risk in animals,” said Van Kerkhove, stressing that partnerships with bodies in the animal health field were essential.

“Right now, there’s a lot of focus on the US but we are seeing a global epizootic of avian influenza, and we’ve seen H5N1 infection in wild birds and poultry and marine mammals and land mammals,” she said.

“But what is concerning is that we are seeing new species that are being infected… We need much stronger surveillance in animals globally, not just in the US, looking at the species that we know can be infected with H5N1, but also in humans at the animal-human interface. “

She urged those doing surveillance to continue to sequence and share those sequences to enable regular assessments of the viruses as well as “what any changes in these viruses mean, in terms of transmissibility in terms of severity.”

Van Kerkhove also stressed that occupationally exposed people needed to be protected from infection, including by using personal protective equipment and washing hands frequently, “because prevention is key”. 

She also said that, while it was not yet necessary, the current H5N1 flu was covered by the candidate vaccines in the influenza prevention pipeline.

Image Credits: pxfuel, Charyse Reinfelder.