Healthworker administers polio vaccination in Pakistan’s sensitive northwestern region.

ISLAMABAD – As Pakistan heads towards general elections on Thursday, February 08, leaders of its polio programme are hoping that improved political stability and a more stable security situation could help make 2024 the year for final eradication of the crippling disease from the country.

Pakistan and Afghanistan, neighbouring countries sharing a porous border, are struggling to completely eradicate the wild poliovirus from their countries.

Experts predict that wild poliovirus could be eradicated globally within the next three years, if all goes well. What happens in Pakistan and Afghanistan are central, however, is central to making that happen.   

According to the Pakistan Polio Eradication Program, six wild poliovirus cases were reported in the country in 2023 – another six in Afghanistan. While several imported cases of wild poliovirus were also detected in Mozambique and Malawi in 2022, those were deemed to have been imported from Pakistan, and no further cases have been reported over the past 15 months. 

In Pakistan, no wild poliovirus cases have been confirmed so far in 2024 – putting the country on track for ending wild poliovirus soon, if not this year. 

First national anti-polio drive of 2024 was hit by militant attacks

Site of an attack by gunmen who shot and killed a polio programme coordinator in the Bajaur district of northwestern Pakistan, near the border with Afghanistan, on Jan. 19, 2024.

However, Pakistan’s first national anti-polio drive, which kicked off last month to immunize 44.3 million children, suffered a notable setback, with two militant attacks in the country’s turbulent northwestern region bordering Afghanistan within a space of just a few days.

As a result of these attacks, which occurred in the same region of the country, a senior health official coordinating anti-polio efforts and at least seven security personnel were killed.

Pakistan’s current caretaker government, as well as previous governments, have always expressed their resolve to provide security to polio campaigns.

However, the recruitment of police personnel providing teams with security, has remained a challenge in the ultra-conservative tribal region of the country – ever since a fake Hepatitis B vaccination campaign was carried out by the CIA in the Pakistan border region in order to obtain the DNA of Osama bin Laden and identify his location in hiding, finally leading to his assassination in 2011.

The country’s polio eradication program and its global partners, Rotary International, have welcomed Pakistan Law Enforcement Agencies’ (LEAs) role in supporting polio team security.  However, polio vaccinators and local political leaders  say that polio vaccination teams still need more support.  

More security still needed

Door-to-door campaigns, a critical part of Pakistan’s polio eradication strategy, are a challenge in districts rife with insecurity.

Shahzeb Malik, a polio vaccinator in the northwestern region of Khyber Pakhtunkhwa told  Health Policy Watch that security teams accompany the polio workers in anti-polio drives but there must be better operational coordination on both sides.

“Polio workers and police personnel have been targets of the militants in recent  years, so we need an improved version of the security with this polio program,” he said.

There is no doubt about the strong administrative resolve for ending the polio in the country, he asserted, even in remote regions of Pakistan like his own, he asserted. 

But this year’s  first polio campaign also coincided with election campaigns – a time in which health workers, including polio staff, are also supporting the set up of voting stations and other preparations for the big election day. 

Overcoming the ‘trust deficit’ amongst tribal leaders

The CIA’s operation against Bin Ladin left a lasting legacy for Pakistan’s polio program, resulting in an ongoing ‘trust deficit’ with regards to vaccination campaigns, Dr. Humayoun Mohmand, chairman of  Pakistan’s Senate Standing Committee on National Health Services, told Health Policy Watch. 

He expressed hopes, however, that a new government could begin to bridge the gaps, bringing great political stability and focusing on local solutions to a broad range of problems facing rural tribal communities.

“Absence of political stability and lack of coordination between federal and provincial governments does impact the polio program,” said Mohmand.

Hailing from the tribal region of Pakistan, himself, Dr. Humayoun emphasized the need to engage local ‘Jirga’, referring to local tribunals administered by mosques and Imams [religious leaders] in polio vaccination drives.

“We have to incentivize these institutions and provide financial assistance to include them in the fight against polio,” Mohmand stressed.

Rotary International plays a key role in polio eradication 

Administering a polio vaccine in a door-to-door campaign

Religious leaders, including Imams and Islamic scholars, can also play a vital role in reassuring hesitant parents within their communities about the safety and effectiveness of vaccinations, in line with Islamic principles, asserted Aziz Memon, the chair of Rotary’s International’s PolioPlus national Pakistani committee, in comments to Health Policy Watch. 

Rotary International has been a key player in the global campaign to eradicate polio, committing more than $2.7 billion over the decades to the effort through a funding partnership with the Bill & Melinda Gates Foundation,

In Pakistan, Rotary also supports ulema workshops to build community trust and confidence in vaccines, through the Gates-funded Global Polio Eradication Initiative (GPEI). In addition to engaging trusted religious and community leaders, GPEI partners provide communities with desired (complementary) health services alongside polio immunization.

“Challenges to polio eradication in Pakistan include politicization of the polio program and in some cases, vaccine refusals,” Memom observed. 

“The risk of international spread of poliovirus remains a Public Health Emergency of International Concern”, he added, referring to the longstanding WHO declaration of a global polio health emergency for the virus, which was reaffirmed in December 2023. 

“That’s why Pakistan is implementing and deploying tactics to strengthen essential immunization, better target high-risk areas, and integrate basic health services to complement polio immunization activities including leveraging the capacity of female health workers and religious leaders to build community trust and improve vaccine acceptance.

He said the polio programme prioritizes the safety of the healthcare and frontline workers, and works closely with local governments and authorities to protect these individuals.

“Specifically, the government of Pakistan provides security teams to accompany frontline workers during immunization activities,” said Aziz Memon.

GPEI in Pakistan has also been active in working with political leaders at the national, provincial, and district levels, including during this time of political transition, Memon addded.

“When a new government is established, that advocacy will continue to minimize the impact on the programme,” he predicted.

Insecurity leads to rushed campaigns or campaign postponement

Administering a polio vaccination

Pakistans polio programme has the full support of law-enforcement agencies, from the police to the army, that provide security cover to teams in each campaign, agreed Dr. Shehzad Baig national coordinator of Pakistan’s Polio Eradication Programme..

Even so, insecurity still contributes to “rushed campaigns or campaign postponement in security-compromised areas, which means we are unable to reach the children who need the vaccine the most,” he admitted.

Political instability has been a particular problem in the tribal areas of polio endemic southern districts, such as Khyber Pakthunkhwa, as well as in Pakistan’s northwestern region.  

The Programme also has built a “robust communications strategy in place across the country, including digital and on-ground social behavior change strategies, to build trust in communities,” Baig added. 

“In places where we see vaccine hesitancy and refusals for whichever reason, we enlist the help of local influencers, tribal elders, social workers, and religious leaders to engage with communities and increase the threat perception of polio,” he said.

Still, it remains difficult, if not entirely impossible, to conduct quality house-to-house campaigns in conflict-prone areas.

“In areas where some children are inaccessible to our teams, we implement a ring-fencing vaccination strategy to vaccinate people going in and out of the area to prevent the virus from spreading and give the population some protection from the virus,” he observed..

As for the impacts of political rhetoric and administrative re-shuffling during election season, Baig asserted that it had not really hindered vaccination efforts. 

“With the upcoming general elections, we have a full strategy in place for interaction and advocacy with the incoming government to ensure polio remains a priority,” said Baig.

“Even as the elections are near, all District Commissioners and health department staff supported throughout January 2024 the national immunization drive to ensure that we reach over 44 million children with the vaccine.” 

Image Credits: Pakistan Polio Eradication Program , VOA/Google Maps.

Modupe Famodun, 40, and her eight-year-old son, Tiolu, who lives with cerebral palsy.

In resource-restricted countries like Nigeria, parents of children with special needs, particularly mothers, bear the entire burden of care.

In an unexpected turn of events in early 2015, Modupe Famodun’s baby son was diagnosed with cerebral palsy.

A neurologist at the Federal Neuropsychiatry Hospital (FNPH) in Lagos in South-West Nigeria, had been strolling down the hospital corridor when an unusual, shrill cry pierced the air, immediately drawing her attention. Her instinct, sharpened by years of experience, led her to believe something was wrong.

 Upon inquiry, she found out that the crying child was Tiolu, Famodun’s then two-month-old son.

Filled with empathy for the young mother, the neurologist rallied a team within the hospital to conduct a series of laboratory tests for little Tiolu without charge.

 “What is cerebral palsy?” Famodun recalled asking the neurologist after she disclosed the test result. Cerebral palsy is the medical term for a group of disorders that affect balance, movement and muscle tone. And now her son, Tiolu, has been diagnosed with it.

Unable to come to terms with her son’s cerebral palsy diagnosis, Famodun repeated the test at the Lagos University Teaching Hospital (LUTH) two months later.

 She was desperate for a different outcome, but reality soon hit her. The result was no different from the first.

“This was the moment that brought me to tears because I was completely unprepared,” she said, her voice quivering as she fought her emotions.

In resource-restricted countries like Nigeria, parents of children with neurological disorders bear the entire burden of care. The impact is even more profound on mothers, who assume greater caregiving responsibilities.

A study conducted by Andrew Olagunju, a Nigerian psychiatrist and researcher, highlighted that the severity of the child’s disability can have a significant impact on the caregiver’s psychological well-being.

Emotional roller-coaster

In the months following her son’s diagnosis, Famodun would grapple with overwhelming anxiety as she contemplated the chances of her son ever living a normal life.

“I shut myself in and cried endlessly, hoping on God for a miracle,” she shared.

During the initial two months of her self-imposed isolation, she could barely bring herself to touch her son except when she needed to breastfeed him. Her husband took on all the duties.

“I was lost, totally lost,” she admitted, harbouring guilt for Tiolu’s condition and blaming herself for the events surrounding his early days.

Three days after Tiolu’s birth in 2014, Famodun suspected he had jaundice but a senior family member played down her fears. By the fifth day, when she finally sought medical help, it was already too late. In fact, he was presumed dead at the hospital. Eventually, the doctor resuscitated him but hinted at possible brain damage.

The medical confirmation of Tiolu’s cerebral palsy brought back those painful moments from 2014. She wrestled with regrets, guilt, and sorrow all at once, and it felt like her pain had no end. “I felt responsible for his suffering,” she said.

Famodun had initially hoped that her son would reach developmental milestones like walking, sitting, and talking, just like other children. However, she later learned from the doctor at LUTH that his development is unpredictable.

After Famodun’s supervisor at work learned about her situation, she granted her a year’s paid leave. This period allowed her sufficient time to recover from the emotional turmoil and adapt to her new role as a caregiver.

Her husband helped her through this life transition. “My husband offered counsel on several occasions and taught me how to efficiently manage my time, ensuring I could care for Tiolu before leaving for work,” she shared.

However, as she grew stronger in her role, her husband’s support waned. Four years later, he lost his contract job and eventually stopped returning home, choosing instead to live in the church for the next few months.

Feeling abandoned, Famodun slipped back into depression. She was now left alone to cater for the family’s well-being and shoulder Tiolu’s medical expenses.

Cost of care

Stella Igbokwe, a young mother whose only child was diagnosed with hydrocephalus — a condition in which excess cerebrospinal fluid builds up within the fluid-containing cavities of the brain — disclosed that she spends more money on her child’s care than she earns from selling fruit on the street.

“I spend over 50,000 naira ($37) every month on my son, Stanley. Registering him at Flora’s Trust Centre [a formal caregiving home] costs 20,000 naira ($14.7). The rest covers his medications, diapers, special diet and transportation. It is not easy,” she lamented.

In his research, Olagunju noted that in countries with limited resources, caregivers not only play a crucial role in the well-being of these children but often bear the primary responsibility for their treatment.

He attributes this to the unequal distribution of healthcare resources and limited health insurance coverage in these countries, leading to high out-of-pocket expenses for families.

It is estimated that public spending on support for people with disabilities (PWD) in low- and middle-income countries is below 0.3% of GDP. This is in stark contrast to high-income countries, where allocations for such support can exceed 1.4% of GDP.

Weak policies

According to Article 28 of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) and its Optional Protocol, which Nigeria ratified in 2010, effective social protection policies must take into account the additional costs faced by people with disabilities from low-income backgrounds.

In a report by the Office of the High Commissioner for Human Rights (OHCHR), eight Nigerian states were recognized for adopting regional disability laws. However, only five of these states allocated funds in their 2023 annual budget for the implementation of these laws, with Lagos State, the focus of this report, being one of them.

Remarkably, the budget for the Lagos State Disability Fund, aimed at enforcing the 2011 Lagos State Special People’s Law (LSSPL) to safeguard the rights of people with disabilities in the state, was greater than the combined budgets of the other four states.

The LSSPL fails to make provisions for financial assistance for children with disabilities and their families living in poverty, as recommended in the CRPD, but it faces criticism mostly for its poor implementation.

In early 2023, allegations of fund misappropriation were made against the general manager of the Lagos State Office of Disability Affairs (LASODA), the agency charged with implementing the LSSPL and managing its funds.

Following the accusation, the then general manager of LASODA, Dare Dairo, failed to respond to the allegations, simply saying that his office lacked the authority to withhold funds. He also noted that the agency was working with local government officials to enhance healthcare access for PWDs. However, access to free healthcare remains an unfulfilled promise for people with disabilities in the state, as out-of-pocket expenses for treatment remain the norm.

Expressing her discontent with the governing board, Tobiloba Ajayi, a lawyer living with cerebral palsy who contributed to the development of the LSSPL, said, “The law is comprehensive and beautifully written. We put in all the work to get the law passed, and yet, implementation has continued to be lacking.”

Some respite for caregivers – but at a cost

The privately owned Flora’s Trust Centre was established by Chikaodili Ugochukwu, a 55-year-old mother with a teenage son living with cerebral palsy. Her decision was influenced by the challenges she faced in finding a suitable caregiving home for her son close to their place of residence in Lagos.

In Nigeria, the number of formal caregiving homes is limited and unevenly distributed. Quite a number of the well-maintained ones are owned by individuals or non-governmental organisations (NGOs).

 Mothers interviewed for this report have expressed disappointment with government-owned caregiving homes, citing poor living conditions and low staff-to-child ratios, leading them to dismiss these homes as viable options.

Stella Igbokwe, 27, visits her son at Flora’s Trust Centre.

When Ugochukwu began the centre in 2018, it was exclusively dedicated to children living with cerebral palsy, but it was impossible for her to turn her back on mothers raising children with other neurological disorders. “Disability management is a herculean task,” she said.

Ugochukwu felt obligated to take in Igbokwe’s son to ease the burden on the young mother, who does not receive support from her partner.

“Once I drop him off at the centre, I feel a sense of relief, knowing I can focus on my work. My primary concern now is ensuring that I have enough money to pay for another month,” Igbokwe said. 

An unsustainable practice

Although there have been instances where children were admitted to the caregiving home  without paying the enrollment fee, Ugochukwu soon found that this practice was not sustainable.

 “We are non-profit, but in the meantime, we require parents to pay subsidised fees to cover our operational expenses until we can attract more sponsors,” she explained.

Ugochukwu revealed that it costs no less than 800,000 naira ($590) to keep the centre running. This covers their overhead costs and enables them to employ the services of professionals to offer physiotherapy, speech and occupational therapy for the children.

On the centre’s lemon-coloured wall, a whiteboard displayed the names of enrolled children. There were 11 names, although only five children were present at the time of this report.

Drug and food charts for some of the children enrolled at the centre.

Among the absentees was Ifedayo*, a 12-year-old girl living with cerebral palsy. Her mother, Ayomide*, a 49-year-old single parent, had not renewed tuition for that month because Ifedayo’s older brother was on holiday and would be supporting her at home.

When her husband was alive, Ayomide never considered caregiving centres because he effectively supported her at home, even at some point becoming Ifedayo’s primary caregiver.

“After my husband passed away, I was really under pressure,” said Ayomide, who became the sole breadwinner of the family.

 She said that it was impossible to make ends meet while providing round-the-clock care for her daughter. “I was struggling to meet deadlines at work, and not all my clients were understanding.”

 She stumbled upon Flora’s Trust Centre by chance and decided to enrol Ifedayo after learning about the centre’s weekly boarding services. This meant parents could drop off their children on Monday mornings and pick them up at the end of the week.

Even after she found that this would cost her 60,000 naira ($44.2)—significantly higher than the centre’s non-boarding services—she still went ahead with her decision.

“It’s not that I could afford the money, but commuting daily to the centre would cost almost double the amount,” she explained, referring to the mobility challenges she experiences when going out with her daughter, whose condition confines her to a wheelchair.

False hope

At first, Ayomide thought that diligently following her daughter’s treatment plan would help her recover. “But there seems to be no end,” she said.

Like those who came before her, she would realise that caring for children with special needs is a journey, not a sprint. 

“Many of these children will rely on their parents throughout their lives,” said Lillian Akuma, a physiotherapist at the Child and Adolescent Centre of the FNPH. She has been working with children and adolescents living with neurological disorders for 12 years now.

“What I often observe is that many caregivers are unprepared for the transition from childhood to adolescence and eventually adulthood,” she continued. She noted that health professionals who provide care for these children were partly to blame.

Lillian Akuma during a physiotherapy session.

“In a bid to comfort parents, we give them the impression that it’s just a phase the child will outgrow. But that’s not always the case,” she explained.

These parents, clinging to this prognosis, become anxious to witness their children reach important milestones. “They hope to see their children stand, but after two years, if the children haven’t even achieved neck control, the parents become depressed,” she said.

“I have conducted research on caregiver’s burden and discovered that when they are in this mental state, they no longer put in their all to support their children,” Akuma said.

 “When caregivers fail to fulfil their roles effectively, we can’t expect positive treatment outcomes for the children,” she concluded.

A safe place

An empty hallway in the Child and Adolescent Centre. The building has brightly coloured interior walls and adorned with vivid drawings to appeal to the children.

The Child and Adolescent Centre, an annexe of the FNPH, where Famodun’s son was first diagnosed, is one of the few facilities offering medications for children with neurological disorders.

However, it holds significance far beyond being just a healthcare institution for many of these mothers.

“The Child and Adolescent Centre is like a family house for me,” said Wemimo Akinwunmi, a 39-year-old mother of a son living with cerebral palsy. Her son, Ayomikun, had earned the endearing nickname “Ambode” from fellow parents at the centre, which was a nod to a former governor of Lagos State whose first name was also Akinwunmi.

Akinwunmi recounted when she ran out of money for her son’s medication and the other parents rallied to provide the outstanding amount. On days when she had enough, she returned the favour to other parents in need.

The centre has gained immense popularity for two key reasons: first, its specialised treatment for children with neurological disorders, and second, as a safe space where their parents feel genuinely understood.

Wemimo Akinwunmi, 39, and her son, 7, Ayomikun, going out for a walk. She considers the Child and Adolescent Centre, of the Federal Neuropsychiatry Hospital “a family house.”

Famodun disclosed that the centre played an important role in restoring her confidence. ‘In 2016, I was transferred to the pharmacy section of the Children and Adolescent Center, where I met numerous mothers who shared similar experiences. I learned so much from them,” she said. She also benefitted from the return of her husband, whom she described as supportive.

 These days, when parents visit the clinic, the nurses frequently turn to Famodun to address their concerns. “I went from being quiet to becoming an activist for my son,” she said, smiling proudly.

*Chikaodili Ugochukwu lost her teenage son some months after this interview was conducted.

*Some names have been changed to protect their identities.

*Naira exchange rates used were based on the time of report

This story was produced with the support of the Women Radio Centre and the MacArthur Foundation.

Image Credits: Samuel Okoro., Samuel Okoro, Kate Okorie.

Dr Adriana Blanco Macqueso, Head of the Secretariat of the WHO Framework Convention for Tobacco Control

New tobacco and nicotine products and the tobacco industry’s extensive lobbying of governments are likely to be in the spotlight when country representatives meet next week to discuss the implementation of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). 

The 10th Conference of the Parties (COP10) starts in Panama on Monday (5 February) after being postponed from last November because of unrest in the host country.

“Tobacco is, and continues to be, a threat. It is a threat to human life. It is a threat to human health, but also a threat to the health of the planet,” stressed Sabina Timco Lacazzi, WHO’s Legal Officer working on FCTC implementation.

WHO FCTC, signed by 182 parties, entered into force in 2005, and the biennial COP and Meeting of the Parties (MOP) acted as governing bodies working on implementing the treaty.

The Convention is the first international treaty to take into account not only human health but also the impact on animals and the planet, as Lacazzi proudly stated. “It’s really important that parties and the public in general remember this very important reason why we work […] to take stock of tobacco control measures and to continue to push for progress in this regard.”

Tobacco’s health cost

Over a fifth of the world’s population uses tobacco, with four out of five smokers living in low- and middle-income countries, according to the WHO.

Smoking is the cause of over eight million deaths annually, 1.3 million of which are a result of mere exposure to tobacco smoke from other smokers.

Even though the number of tobacco product users is declining, it still amounts to a substantial burden of cancer, stroke, heart and lung disease, says the CDC.

Deadly health effects of cigarettes and similar products are widely known and yet, the tobacco industry is often successful in its lobbying for fewer regulations or discouraging information campaigns.

New products, investment fund to be discussed

The upcoming meetings is also likely to focus on the regulation of emerging nicotine and tobacco products as well as details of a new investment fund covering implementation of the treaty, stated Dr Adriana Blanco Macqueso, head of the WHO tobacco regulation treaty secretariat in a press conference.

But Macqueso could not say what direction the will parties take on heated tobacco products and e-cigarettes. 

“With 162 parties, we may have 162 different positions on this,” she said, but stressed that countries agree that the new commodities “should be regulated,” as traditional ones are.

Lobbying tactics

According to the WHO, “there is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests”.

Despite that fact, many governments fail to resist the persisting lobbying pressure. The industry’s tactics involve many practices, including intimidation, claiming a public health role, influencing scientific research or even undermining existing laws.

A selection of lobbying tactics used by the tobacco industry, as presented by Sabina Timco Lacazzi, WHO Legal Officer working on implementing the tobacco regulation treaty

In Cameroon, for instance, the health authorities had a secret working session with the tobacco industry, according to Vision for Alternative Development (VALD) Ghana, a health-focused NGO.

Even COP meetings have struggled to eliminate the intrusive tobacco industry’s presence. During the last meeting in India, for example, one of the country delegates “actually spoke at the floor, saying tobacco is not addictive,” said Akinbode Oluwafemi, Executive Director of Corporate Accountability and Public Participation Africa based in Nigeria. 

Measuring industry influence

In response to a variety of lobbying practices, the Global Center for Good Governance in Tobacco Control has developed the Tobacco Industry Interference Index which classifies countries based on how independent they are from tobacco companies’ influence.

Tobacco Industry Interference Index scores for a selection of African countries, as presented by Labram Musah from Vision for Alternative Development

Botswana and Ethiopia emerged with the lowest scores (least influence), while Zambia, Tanzania and Cameroon were the most heavily influenced.

Countering industry pressure at COP

Similar to the climate summit in Dubai, where the presence of fossil fuel companies undermined some ambitions for a phase-out, the tobacco regulation COP might face industry pressure, highlighted Oluwafemi.

But the FCTC “represents one of the most effective public debt instruments in the world”, he added.

Former WHO Chief Scientist Dr Soumya Swaninathan

Dr Soumya Swaminathan is returning to the international stage after leaving the World Health Organization (WHO) in late 2022, just as the world was recovering from the COVID-19 pandemic.

She became the agency’s first Chief Scientist just before the pandemic, a position that propelled her to become a widely-known global voice for WHO, analyzing and communicating the latest information on the pandemic.

Now, the 64-year-old is 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. The other co-chair is Helen Clark, former Prime Minister of New Zealand.

“We bring complementary strengths,” Dr Swaminathan told Health Policy Watch, referring to Clark’s international political connections and her own scientific credibility. She was speaking just ahead of a closed-door meeting in Bellagio, Italy, with leaders of the new initiative, OCA, which aims to raise the political and financial investment in air pollution.

The OCA aims to drive more funding from governments, developmental, and the private sectors to cut down air pollution globally. Air pollution causes 8.3 million deaths a year –  almost 16 deaths a minute – whereas it received only 1% of international development funding, a study by CAF shows.

“We want to raise that profile of air quality as an important determinant of health, as well as bring attention to the actions that individuals, as well as companies, communities, cities, and governments, need to take urgently in order to address this big huge global problem,” said Swaminathan.

Air pollution has short-term and long-term impacts on health, many studies have shown. These range from heart attacks, diabetes, and strokes, and in pregnancy it increases the risk of low birth weight, stillbirth, and miscarriage due to long-term exposure.

Short-term exposure over a few hours or days to high pollution can affect lung function, worsen asthma, and increase hospital admissions related to respiratory and cardiovascular conditions.

A study backed by CAF and the Confederation of Indian Industries (CII) showed pollution is estimated to have cost India $95 billion or about 3% of its GDP. This includes loss of the workforce to deaths, loss of productivity by employees not fully functioning at work because of the effects of pollution, lower attendance at markets on high pollution days, and the stunting of crops among other things.

“What business leaders have to understand is that some of the impacts of climate change – air pollution, heat, food, and nutrition and security – is really going to impact their productivity,” Swaminathan told Health Policy Watch.

Despite spending on air pollution, India’s air quality has continued to deteriorate in the past decade.

Air pollution’s cost-to-company

Despite all the science and data, there is little funding for air pollution control measures. Philanthropic funding between 2015 and 2022 was $330 million. The biggest chunk, about 35%, of philanthropic pie, went to North America, while Europe and India got 15% each and China 15%. Just 2% went to Latin America and 1% to Africa.

Swaminathan admits that OCA has an uphill task. Their targets are not just governments and donor organizations but also businesses.

“There’s enough evidence out there. What will it take, ultimately, to convince I don’t know. When you’re talking about globalization, and companies having employees all over the world, employees will be very much more reluctant to relocate to places where the air quality is poor, they may ask for extra compensation and things like that.

“I’ve seen this happening with some diplomats, for example. They don’t want postings in places with poor air quality. It’s not just a reputational issue, but it becomes a real issue when it comes to getting the work done.”

Pollution is a double whammy for developing countries

Swaminathan describes air pollution as a “double whammy” for developing countries: “It is one of the most important risk factors for non-communicable diseases, which, of course, are on the rise worldwide, as well as in India, and the developing world. So it’s a double whammy because the burden is increasing because of the risk factors. And because care, diagnosis, and treatment are not accessible to everyone, then we’ll also have a higher mortality.”

One of the first major successes she recalls soon after she joined WHO was over air pollution. As Deputy Director General of Programmes, she had a “huge scope.”

This enabled her “to address some very obvious disconnects, which I found, which perhaps had not been addressed in the past because of the siloed nature of WHO.” Air pollution and non-communicable diseases (NCDs) were handled by different teams despite the pollution being a critical risk factor for NCDs like heart disease, strokes, and chronic lung disease.

“By bringing (the two teams) together, we were able to say air pollution is the fifth major risk factor for non-communicable diseases and it goes into the documents. And it then went to the high-level political event in New York in 2018, as one consolidated set of recommendations rather than separately.”

A core focus area for Swaminathan has been tuberculosis. When she was appointed Chief Scientist, it allowed her to make an impact on guidelines. “I was able to put in place improved and more forward-looking and futuristic ways of doing our norms and standards, moving away from individual opinion base to a much more systematic way of synthesizing evidence, including the use of artificial intelligence.”

Proportion of premature deaths from leading NCDs attributable to air pollution according to WHO data.

‘Politically driven’ attacks

Swaminathan is frank about her WHO tenure during COVID-19 when she was targeted by, among others, the US Food and Drug Administration (FDA) during the Trump administration, and the Indian Bar Association. In both cases, she and the WHO were proven right, she points out.

The WHO and Swaminathan were critical of the US FDA’s decision to give emergency approval to Remdesivir as a COVID treatment based on limited evidence, whereas the WHO’s Solidarity Trial found no measurable benefits for the drug’s use.

She dismisses the second attack – over her comments against the use of Ivermectin as a treatment for COVID – as one by a “fringe group” and points out that the WHO was proven right by numerous studies.

“There were extreme views on things during the pandemic, a lot of it was politically driven. But there were also people out there who just wanted to create trouble and wanted to spread misinformation and had some very strange beliefs about things like vaccines and drugs,” Swaminathan said.

“That was very surprising for me – to face that kind of criticism and opposition, but it was also difficult to handle because of the visibility that I had, and the social media presence that I had, and it’s very easy to harass you on social media.”

Former WHO Chief Scientist Soumya Swaminathan

‘Learned to live with criticism, harassment’

“I would not say that I would do anything differently based on that experience because I think, difficult as it was, it was something that I learned to live with. I would say, it did not impact my work and didn’t impact the work of the organization. And in the end, I think we got credit for having stuck to the science.”

Swaminathan says she had the backing of WHO Director General Dr Tedros Adhanom Ghebreyesus, who told her he would back her if she could defend what she said: “To that extent, I had full freedom.”

“It was DG Tedros who was actually facing the most attacks, including from the President of the United States and from various other quarters. So compared to that, I think the attacks on me were minor. But I did have his backing and the backing of the WHO because, before we said anything, we would discuss it internally.”

When she’s away from the international stage, Swaminathan is busy running the MS Swaminathan Research Foundation back home in Chennai. It was set up by her legendary father, Professor MS Swaminathan, in the late 1980s. He and his foundation have made a huge contribution to food security in India through research on plant genetics, agricultural research and development, and the conservation and enhancement of natural resources.

Her new challenge perhaps presents an opportunity to create a similar legacy.

Image Credits: BreatheLife/WHO.

During humanitarian crises millions of people struggle to manage a range of non-communicable diseases (NCDs).

The United Nations estimates that 363 million people are currently impacted by humanitarian crises driven by increasing fragility and conflict, the climate crisis and widening inequality. Around 108.4 million people were forced to flee their homes in 2022, meaning one in every 74 persons globally.

Humanitarian crises, such as those occurring in Ukraine, Gaza, Libya, Somalia and Sudan may vary in nature and scale but they all share population displacement, the destruction of infrastructure and the disruption of supply chains and services.

Health is one of the first casualties. Increasingly, healthcare facilities and supply chains are directly targeted in conflict. Restricted or impeded access to hospitals, health services and staff and life-saving medicines and technologies, as well as food and water shortages, make life precarious.

Much media attention during crises understandably tends to focus on overwhelmed hospitals and what that means for women giving birth, vulnerable newborns and war-wounded people needing life-saving surgery.

Access to medication in crises

Outbreaks of infectious diseases such as measles and cholera also make the headlines. Yet the parallel reality is that during humanitarian crises millions of people struggle to manage a range of non-communicable diseases (NCDs) such as diabetes, hypertension or cardiovascular illness. Access to their essential medications and health professionals may be non-existent.

Policymakers are now being forced to take an ‘all hazards approach’ to emergency planning and response, together with an inclusive health and humanitarian response that leaves no one behind.

There are plenty of factors to consider: increasing fragility, widening inequality, uneven economic growth, a fragmented geopolitical landscape, inadequate financing, the potential for new pandemics, and climate crisis encroaching on and shifting the way societies produce, eat and live.

Of course, the degree to which countries are able to respond to health emergencies will depend on the scale of the crisis they face at any given time, the financial situation, preparedness, and how resilient the health system is.

Many low- and middle-income countries have fragile health infrastructures to begin with, and when faced with crises, they are much more vulnerable. But the success of an emergency response is more likely if established models of care and strong partnerships between government and civil society are already in place.

The International Committee of the Red Cross headquarters in Geneva, Switzerland.

Collaboration to deliver better NCD care

Partnering for Change – a collaboration between humanitarian organisations, the International Committee of the Red Cross (ICRC) and the Danish Red Cross (DRC), and the private sector company, Novo Nordisk – was launched to identify best practice to support people living with diabetes and hypertension in humanitarian crises. They have partnered with academia, the London School of Hygiene and Tropical Medicine (LSHTM) in research initiatives to design, evaluate and improve models of care.

Since 2020, the ICRC has supported a primary health care service run by the local NGO Chabab Al Ataa Al Jazeel Association (CAJA) in Bireh in Northern Lebanon. Initial research from P4C with patients, caregivers and service providers highlighted patients’ multiple care needs and the huge burden families faced in navigating a fragmented care system.

Improving the patient-centeredness of care by integrating cardio-metabolic disease management with mental health and physical rehabilitation services with defined referral pathways, and a joint patient management system was seen as a potential solution. An adapted integrated model was developed and is currently being implemented. In parallel, an evaluation is being conducted for a better understanding on how to implement, sustain and scale up this type of integrated model for NCD care in humanitarian settings.

Outside of Partnering for Change, the Danish Red Cross is supporting the Somali Red Crescent Society, one of the biggest health care providers in Somalia, in its efforts to integrate screening and management of diabetes, hypertension and asthma as well as mental health and psycho-social support into already existing health programmes.

They have until now mostly focused on maternal and child care but decided to include NCD care and prevention based on needs assessments. As well, Somali Red Crescent Society are seeking to include focus on health-promoting behaviour, NCD prevention and awareness of risk factors through community engagement and community health committees.

Trucks carrying humanitarian aid wait to cross into Gaza from Egypt through the Rafah border point.

Integrate care in humanitarian settings

A recent report on the financing of NCD care in humanitarian settings has pointed to the essential role of community-engagement in reaching people early, before conditions become serious and require costly hospital-level care.

These kinds of interventions are hopefully a window into the future, further building on what already exists. The idea of integrated care across the non-communicable and infectious disease spectrum has slowly been gaining traction: both the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund now include NCDs in their HIV and tuberculosis financing portfolios.

Yet more evidence is still needed to adequately demonstrate that integration is cost-effective. To address this gap, a recent report has looked into how integrated NCD care can save resources for both patients and health systems. Patients benefit the most – about 85 per cent of the total savings. From a health-system perspective, the extra cost to integrate these programmes are relatively small compared to the positive health outcomes they generate.

While delivering these integrated care services in humanitarian settings logistically still remains a leap into the unknown, the rationale for financing them is clear – if we are to achieve Universal Health Coverage, NCD services must be integrated into community services and primary healthcare facilities to ensure that people living with these chronic diseases have access to quality services across the continuum of care and during disruptions in care from disasters or conflict.

We’ve heard the growing calls for health services to be protected during conflicts. We’ve seen first-hand the growing alignment of climate change and health agendas at the recent COP 28 meeting. Now, we need to see political will that better responds to an uncertain future for the growing number of people living with NCDs and that guarantees their right to health.

Micaela Serafini is head of the health unit at the International Committee of the Red Cross.

Katie Dain is CEO of the NCD Alliance.

Nicolai Haugaard is Vice President and Global Head of Health Equity, Novo Nordisk

Image Credits: Unsplash, Flickr – US Mission Geneva, © UN Photo/Eskinder Debebe.

Patients undergoing chemotherapy for cancer.

New cancer cases are projected to increase by a massive 77% between 2022 and 2050 – mainly as a result of tobacco, alcohol, obesity and air pollution.

Ageing and population growth are also factors pushing new cases from 20 million in 2022 to an expected 35 million in 2050, according to the Global Cancer Observatory  released by the International Agency for Research on Cancer (IARC) on Thursday.

The IARC research, published every two years, covers 185 countries and 36 cancers with data drawn from countries themselves.

Lung cancer was both the most common cancer and the leading cause of cancer deaths in 2022 – likely because of “persistent tobacco use in Asia”, according to the IARC, which is the World Health Organization (WHO)’s cancer agency .

There were 2.5 million new lung cancer cases (12.4% of total cases) and 1.8 million deaths (18.7% of total) in 2022 – with men being more likely to succumb than women.

Breast cancer ranked second (2.3 million cases, 11.6%), followed by colorectal cancer (1.9 million cases, 9.6%), prostate cancer (1.5 million cases, 7.3%), and stomach cancer (970 000 cases, 4.9%).

However, colorectal cancer was the second biggest killer (900 000 deaths, 9.3%), followed by liver cancer (760 000 deaths, 7.8%). Breast cancer, which is the biggest killer of women, was the third highest cause of cancer mortality with 670 000 deaths (6.9%), closely followed by stomach cancer (660 000 deaths, 6.8%). 

Absolute numbers of cancers per continent in 2022

Low-income countries face doubling of deaths

In terms of the absolute burden, wealthier countries with a high human development index (HDI) – a measure of life expectancy, education rates and income – are expected to experience the greatest absolute increase in incidence, with an additional 4.8 million new cases by 2050 compared. 

Yet the increase in incidence is most striking in low HDI countries, which face a projected 142% increase, and in medium HDI countries (99%). Cancer deaths are projected to almost double in 2050.

“Those who have the fewest resources to manage their cancer burdens will bear the brunt of the global cancer burden,” says Dr Freddie Bray, IARC’s head of the cancer surveillance told a media briefing this week. 

Bray also called for better cancer data, as a number of countries do not have cancer registries.

Global cancer burden 2022

 

The Global Cancer Observatory was released alongside a WHO survey on cancer care on the eve of World Cancer Day on 4 February.

Only 39% of 115 countries surveyed covered the basics of cancer management as part of their financed core health services for all – ‘health benefit packages’ (HBP) – according to the WHO survey.

People living in poorer countries had much worse outcomes thanks to later diagnosis and often unaffordable treatment

In countries with a very high HDI, one in 12 women will be diagnosed with breast cancer in their lifetime and one in 71 women die of it.  But in countries with a low HDI, only one in 27 women will be diagnosed and one in 48 women will die from it.

“Women in lower HDI countries are 50% less likely to be diagnosed with breast cancer than women in high HDI countries, yet they are at a much higher risk of dying of the disease due to late diagnosis and inadequate access to quality treatment,” explains Dr Isabelle Soerjomataram, IARC’s deputy head of cancer surveillance.

Meanwhile, cervical cancer was the eighth most commonly occurring cancer globally and the ninth leading cause of cancer death. It is the most common cancer in African women with significant mortality although it can be eliminated as a public health problem through the scale-up of the WHO Cervical Cancer Elimination Initiative.

Female cancer mortality: Africa compared to Europe

“Despite the progress that has been made in the early detection of cancers and the treatment and care of cancer patients, significant disparities in cancer treatment outcomes exist not only between high and low-income regions of the world, but also within countries,” says Dr Cary Adams, head of the Union for International Cancer Control.

“Where someone lives should not determine whether they live. Tools exist to enable governments to prioritise cancer care, and to ensure that everyone has access to affordable, quality services. This is not just a resource issue but a matter of political will.”

Unaffordable treatment

WHO’s global survey of health benefit packages also revealed significant global inequities in cancer services. 

Lung cancer-related services were four to seven times more likely to be included in standard health benefits in high-income than lower-income countries. On average, there was a four-fold greater likelihood of radiation services being covered in a HBP of a high-income than a lower-income country. The widest disparity for any service was stem-cell transplantation, which was 12 times more likely to be included in a HBP of a high-income than a lower-income country.

“WHO’s new global survey sheds light on major inequalities and lack of financial protection for cancer around the world, with populations, especially in lower income countries, unable to access the basics of cancer care,” said Dr Bente Mikkelsen, WHO’s Director of Noncommunicable Diseases (NCDs). 

“WHO, including through its cancer initiatives, is working intensively with more than 75 governments to develop, finance and implement policies to promote cancer care for all. To expand on this work, major investments are urgently needed to address global inequities in cancer outcomes.”

Image Credits: Roche.

Gaza man walks across a pile of rubble.

The World Health Organization (WHO) was able to get medical supplies to Nasser Hospital in southern Gaza on Monday but trucks attempting to deliver food were delayed near the checkpoint then were raided “by crowds who are also desperate for food”, said Dr Tedros Adhanom Ghebreyesus, the global body’s Director-General.

Despite challenges including heavy fighting in the vicinity, Nasser Hospital – the main hospital serving the south – continues to offer health services but at a “reduced capacity”, he added.

“The hospital is operating with a single ambulance. Donkey carts are being used for transporting patients,” Tedros told the WHO’s weekly press conference on Wednesday.

“WHO continues to face extreme challenges in supporting the health system and health workers. As of today, over 100,000 Gazans are either dead, injured, or missing and presumed dead,” he added.

Tedros warned that the risk of famine in Gaza is “high and increasing each day with persistent hostilities and restricted humanitarian access”.

Dr Tedros Adhanom Ghebreyesus

He also described the decision by various countries to freeze aid to the United Nations Relief and Works Agency for Palestinian refugees (UNRWA) as “catastrophic”.

“No other entity has the capacity to deliver the scale and breadth of assistance that 2.2 million people in Gaza urgently need,” added Tedros, echoing a statement released earlier in the day from the Inter-Agency Standing Committee that coordinates humanitarian aid amongst the United Nations agencies, including the WHO. 

Israel has claimed that UNRWA staff members were involved in, or assisted, the Hamas attack on Israel on 7 October. The UN has launched an  investigation and some staff members have already been fired.

However, the WHO’s executive director of health emergencies, Dr Mike Ryan, dismissed a claim by an Israeli diplomat that the WHO was “colluding” with Hamas.

“We cooperate with NGOs but collude with no one,” Ryan told the press conference, adding that such a claim endangers WHO staff in the field.

Ryan described the environment for health workers as “frantic” and “terrorising”, as they tried to  do more and more with less and less, while Tedros said that both health workers and patients were surviving on one meal a day.

“The humanitarian space is is very constrained,” said Ryan. “Every aspect of what the agencies and NGOs are trying to do is constrained. We are constrained in bringing assistance in across the border. We’re constrained in how we store it. We’re constrained in  how we can distribute it, with so many distribution plans being denied or being impeded.

We’re constrained in the number of health facilities that are operational.”

Towards Zero Leprosy

Yohei Sasakawa, WHO Goodwill Ambassador for Leprosy

Meanwhile, Tedros also addressed leprosy, one of the world’s neglected tropical diseases (NTDs), a day after global NTD Day and three days after international Leprosy Day.

“One of the oldest and most misunderstood diseases in the world is leprosy,” said Tedros.

“The world has made great progress against leprosy. 

“The number of reported cases has dropped from an estimated five million a year in the mid-1980s to about 200,000 cases a year now. Although it has now been curable for more than 40 years, it still has the power to stigmatise. Stigma contributes to hesitancy to seek treatment, putting people at risk of disabilities and contributing ongoing transmission,” said Tedros.

Yohei Sasakawa, the WHO Goodwill Ambassador for Leprosy, appealed for assistance to spread the message globally about leprosy’s symptoms and treatment in order to achieve “zero leprosy”.

Massive stigma

Sasakawa said that the disease still existed in 100 countries.

“Over the past 50 years, I have visited leprosy endemic areas in over 120 countries,” said Sasakawa. “Everywhere, I met with countless numbers of people who have been abandoned, not only by society, but even by their own families and are living in despair and in solitude.”

He said that many people ignored initial signs of the disease – discoloured patches on their skin – because it was initially painless.

“We need to carry out extensive work to do our [Zero Leprosy] campaign to find the hidden cases, now that the drugs are available free of charge worldwide,” he stressed.

“I believe it is an opportune time to give another strong push to achieve zero leprosy by strengthening active case detection and prompt treatment.”

Image Credits: Care International .

 

 

 

Amina, an 18-year-old noma patient from Yobe state, has been disfigured since early childhood, and has a habit, like many noma survivors, of hiding her scars behind a veil.

A milestone World Health Organization (WHO) decision to recognise noma (cancrum oris or gangrenous stomatitis) as a neglected tropical disease (NTD) is the result of a longstanding campaign waged for over a decade by global health researchers and advocates in Geneva and beyond. Proponents believe that inclusion can offer noma’s victims the hope of new investments and eventually treatments for one of the world’s least understood diseases.

The WHO decision in December 2023, came shortly ahead of the fifth annual World NTD Day, observed on Tuesday (30 January).

Noma is a severe gangrene disease in the oral and facial regions that predominantly afflicts undernourished young children, typically between the ages of two and six, usually residing in areas marked by extreme poverty. It starts as inflammation of the gums but progresses rapidly, damaging facial tissues and bones if not promptly addressed.

Some 140,000 people – most in sub-Saharan Africa – are diagnosed with the disease a year, according to Dr Maria Guevara, International Medical Secretary for Médecins Sans Frontières (MSF), speaking at a May 2022 event on the margins of the World Health Assembly. The disease currently has a 90% fatality rate, she said. It is most prevalent in West Africa, parts of Central Africa and Sudan, although there are also cases in Asia and South America.

What explicitly causes noma is still unknown, but doctors believe it is the result of a bacterial infection that attacks children who have weakened immune systems as the result of a previous illness, such as measles or tuberculosis.

“Noma’s inclusion on the NTD list is the result of a campaign that has lasted over 10 years,” according to Dr Eric Comte, director of the Geneva Health Forum, which has been active in promoting awareness around the disease over the past months and years. “Several organisations and personalities were involved in this campaign.”

International Society for Neglected Tropical Diseases (ISNTD) and MSF hosted a Geneva Press Club event in May 2023, coinciding with the 76th World Health Assembly, to advocate for its inclusion and helped facilitate networking amongst noma stakeholders.

Noma recognition: impact

The WHO decision was lauded by these stakeholders, who now have very high expectations that the move could lead to several benefits and significant changes in visibility and awareness.

The inclusion on the NTD list “can stimulate research on the disease, particularly on its causes, treatment, and prevention, as researchers may be more inclined to focus on disease recognised by the WHO,” explained Marlyse Morard, director of Sentinelles, a Lausanne-based NGO fighting noma in the field. “The allocation of financial resources is likely to increase.”

Morard said they also expected improvement in prevention and control, mainly through training healthcare staff and epidemiological surveillance.

“Large-scale public awareness campaigns remain essential, as early detection of the disease reduces its impact and saves lives,” she said.

“The creation of awareness programs requires meticulous planning to ensure that they are effective. Improved coordination between public and private stakeholders is crucial, especially when it comes to fighting diseases like noma, which can lead to the stigmatisation of affected people.

“Awareness-raising is a powerful tool to promote a better understanding of the disease,” she continued. “Also, a disease recognised by WHO as a neglected tropical disease can benefit from increased political commitment and the creation of national disease control programs for countries that do not have them.”

She said the expectation included facilitated access to healthcare and reconstructive surgery, as well.

An individual with Noma
An individual with Noma

Noma challenges ahead

However, Morard noted that it was unlikely that these expectations would be met too quickly, as they would depend on each country’s legislation and their commitment to international guidelines.

“It is important to note that the fight against noma is complex and requires the long-term commitment of multiple stakeholders, including affected communities, governments, non-governmental organisations, political and religious leaders and international health agencies,” she said.

Comte expressed similar sentiments, noting that including noma on the NTD “is good news, but it is only a first step. We must now mobilise to establish an action plan and a roadmap against noma through collaborations between WHO Geneva, WHO Afro, the ministries of health of the countries concerned and civil society, which implements actions on the ground.”

WHO has said that there are multiple risk factors associated with this disease, including:

  • poor oral hygiene;
  • malnutrition;
  • weakened immune systems;
  • infections;
  • and extreme poverty.

Although the disease is not contagious, it tends to strike people when their body’s defences are down.

To help halt noma, countries need to run early detection programs for gingivitis, facilitate access to vaccinations, strengthen their clean drinking water systems, improve sanitary facilities, and enhance food support programs, Morard said.

Treatment generally involves antibiotics, improving oral hygiene with disinfectant mouthwash and nutritional supplements.

“If diagnosed during the early stages of the disease, treatment can lead to proper wound healing without long-term consequences,” Morard said.

Survivors face severe social impact

“In severe cases, though, surgery may be necessary. Children who survive the gangrenous stage of the disease are likely to suffer severe facial disfigurement, have difficulty eating and speaking, face social stigma and isolation, and need reconstructive surgery.”

Noma survivor Mulikat Okanlawon, an advocate and hygiene officer at the Noma Hospital in Sokoto, Nigeria, described the effects of noma on her life as follows: “I recovered from the disease, but it left a deadly mark on my face, which stopped me from interacting with people and being a part of the community. I could not go out. I could not go anywhere. I could not even look at myself in the mirror like other children.”

“I always cried… I often wished that I had not survived,” she added, speaking at one recent global health event.

Morard said, “It is truly tragic that noma continues to exist because it is a preventable and treatable disease. Those most severely affected will bear the burden for their entire lives due to late diagnoses or inadequate treatments. The persistence of noma serves as a poignant reminder of health inequalities around the world and underscores the importance of collective action to combat diseases linked, among other factors, to poverty.”

Eradicating noma, she continued, “represents a true challenge and requires strong willpower.”

Mulikat, a 33-year-old former patient originally from the south of Nigeria, moved to Sokoto 17 years ago to undergo facial reconstructive surgery. 

Recent NTD achievements

There have been successes. For example, Sentinelles, Morard’s organisation, has been operating in Niger for the past 30 years, including running awareness-raising activities in coordination with the National Noma Control Program and health authorities. Working with local hospitals has helped ensure noma patients to access reconstructive surgery. Sentinelles also provides support and training for residents and medical staff, which has helped prevent the disease.

Some 1.34% of children aged 1-6 in Niger developed noma – some seven to 14 cases for every 10,000 children aged 0-6, according to an article published in the peer-reviewed journal Health in April 2023. The scientists said this was higher than the incidence of the whole sub-Saharan region.

Last week, at the WHO Executive Board meeting, a representative of the WHO Africa region shared some NTD successes in general, noting that between 2021 and 2023, 10 countries were certified to have eliminated at least one NTD: Lymphatic filariasis (elephantiasis) was eliminated Moreover, some 42 countries have been certified free of guinea worm disease.

WHO’s Dr Jérôme Salomon (center) provides an update on NTDs, including noma’s inclusion in the WHO list, at the WHO Executive Board meeting 22-28 January.

Noma was the first disease to be added to the WHO NTD list in over five years. Scabies and snakebite envenoming were added in 2017. There are currently 21 diseases or groups on the WHO NTD list.

At the Executive Board meeting, WHO Director-General Tedros Adhanom Ghebreyesus updated the delegates on the progress since the WHA73(33) road map for neglected tropical diseases was adopted at the World Health Assembly in November 2020. He shared the following statistics:

  • There was a 25% reduction in people requiring interventions against neglected tropical diseases between 2010 and 2021.
  • The Southeast Asian region had the highest proportion of people requiring intervention against NTDs in 2021 at 52%, followed by the African region (35%). All other areas made up less than 5%.
  • Some 14.5 million disability-adjusted life years were lost to NTDs in 2019, compared to 16.3 million in 2015.

However, the report showed that NTD programs were “severely impacted” by the COVID-19 pandemic and have not yet recovered.

“Much remains to be done to overcome the devastating impact caused by a restriction of movement, disrupted supplies of medicines and other health products, and repurposing of health staff in response to the pandemic,” the report said. “Today, financial support is still far less than before the pandemic and remains limited at all levels, thus jeopardising activities in countries, hampering meaningful planning, and preventing effective coordination at global and regional levels.”

A Global Health Council NGO representative responded to the report by highlighting the inextricable ties between poverty and inequality and NTDs. The representative also noted significant gaps in research and development tools needed to control and eliminate these diseases.

“We call on member states to sustain and expand investments to accelerate R&D of safe and affordable treatments for NTDs and improved diagnostics, particularly for NTDs with specific unmet needs for use in primary health care settings,” the representative said. “We urge WHO member states to collaborate to explore regulatory and manufacturing pathways to facilitate simultaneous or aligned pre-qualification and regulatory approval processes of in vitro diagnostics to accelerate market access.”

Germany, too, emphasized R&D, while Russia focused on the need for increased surveillance.

Others, such as the United States, urged WHO “to undertake the necessary internal reforms to strengthen the functions and operations of the program to support member states in reaching NTD goals, including by reinforcing WHO leadership through accountability, transparency, predictability and equity; filling normative gaps; and ensuring strong data systems enabling reliable surveillance, monitoring and evaluation.

“We also call for well-aligned leadership within the WHO neglected tropical diseases department with the ability to work effectively across sectors,” the US representative said.

Image Credits: Claire Jeantet – Fabrice Catérini / Inediz’, Wikimedia Commons.

Pandemic
A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic.lder

World leaders have a duty to deliver “an effective, legally-binding pandemic accord” by May to prevent the devastation wrought by COVID-19, according to a group of influential leaders and organisations.

The call came in an open letter issued on Tuesday, the fourth anniversary of COVID-19 being declared a global emergency, and was signed by The Elders, The Global Preparedness Monitoring Board, The Independent Panel for Pandemic Preparedness and Response, Pandemic Action Network, The Panel for a Global Public Health Convention, and Spark Street Advisors.

Signatories include former presidents, prime ministers, health ministers and academics.

The accord needs to ensure that “all countries have the capacity to detect, alert, and contain pandemic threats, and the tools and means required to protect people’s health and economic and social well being”, according to the letter.

To succeed, the accord needs three key ingredients, they assert.

The first is equity, ensuring that “every region must have the capacities to research, develop, manufacture, and distribute lifesaving tools like vaccines, tests, and treatments”. 

Second, the accord needs to map out a “pathway to sustained financing for pandemic preparedness and response”, including “the additional $10.5 billion per annum needed for the Pandemic Fund to fill basic gaps in low and middle-income countries’ pandemic preparedness funding”. 

Thirdly, countries need to be “held accountable for the commitments they make via the accord”, including via independent monitoring and a regular Conference of Parties. 

The World Health Organization (WHO) is hosting the pandemic accord negotiations, with the deadline the World Health Assembly (WHA) in May. However, there are still a multitude of disagreements between countries.

Delay proposed

Last Thursday, during the WHO’s executive board meeting, Poland suggested that it might be better to delay the pandemic accord to ensure an “ambitious, clear and consistent” agreement.  

“It’s very important, especially in reference to a future pandemic treaty, to have an ambitious, clear and consistent document, which will really contribute to the prevention of future crises,” said the Polish delegate.  

“And here I would like to share with you our concern that it would not be beneficial if time pressure leads to a weakening of our ambition, and the quality of the final document.  It is time to ask if we will be ready to present an agreement on a draft pandemic treaty by May 2024?” 

However, Norway, the UK and others  rejected Poland’s suggestion. 

But WHO Director General Dr Tedros Adhanom Ghebreyesus also expressed his concern at the start of the executive board about the gulf between countries on a range of issues at the intergovernmental negotiating body (INB).

Tedros also condemned the global misinformation campaign that is pushing the “lie” that a pandemic agreement will “cede sovereignty to WHO and give the WHO Secretariat the power to impose lockdowns or vaccine mandates on countries”.

“We cannot allow this milestone in global health to be sabotaged by those who spread lies, either deliberately or unknowingly. We need your support to counter these lies by speaking up at home and telling your citizens that this agreement and an amended IHR [International Health Regulations] will not, and cannot, cede sovereignty to WHO and that it belongs to the member states,” said Tedros.

Image Credits: Photo by Maksym Kaharlytskyi on Unsplash.

Qatar’s Dr Hanan Al Kuwari, chair of the WHO executive board.

The African region is accelerating the implementation of the global roadmap for neglected tropical diseases (NTDs), and 10 countries have eliminated at least one NTD since 2021, Dr Matshidiso Moeti, World Health Organization (WHO) regional director for Africa told the body’s executive board last week.

Togo eliminated four NTD, while Egypt eliminated lymphatic filariasis and trachoma has ceased to be a public health problem in Morocco. Moreover, 42 countries in the region will also be certified free of guinea worm disease before 2025, said Moeti.

The countries were guided both by the WHO global framework and using the Africa region’s Framework for the Integrated Control, Elimination and Eradication of Tropical and Vector-borne Diseases in the African Region  for 2022 to 2030.

“The strides made by the WHO African region and other WHO regions result from strong country leadership and effective partnerships,” said Moeti. 

She emphasised the role of the expanded special project for the elimination of neglected tropical diseases (ESPEN), which enabled countries to pool resources and work closely with the global NTDs community. She urged the board to sustain ESPEN’s funding in order to expand its successes as the region moves to the last miles of NTD elimination. 

“We must maintain and accelerate our progress by sustaining political commitment, enhancing multisectoral actions through effective partnerships and mobilising additional domestic and international funding to achieve the NTD roadmap goals,” Moeti concluded.

The roadmap sets global targets and milestones to prevent, control, eliminate or eradicate 20 diseases and disease groups as well as cross-cutting targets aligned with the Sustainable Development Goals. It is based on three foundational pillars: accelerated programmatic action, intensified cross-cutting approaches, and changing operating models and culture to facilitate country ownership.

Appeal for flexible funds

Senegal expressed its commitment to align with the roadmap “to speed up efforts in prevention, control, and elimination of NTDs”, and urged the WHO to increase flexible funding for NTDs within Universal Health Coverage (UHC) efforts, emphasising the need for collaboration and domestic funding.

Cameroon, aligning with previous statements, praised the WHO’s roadmap and emphasised its commitment to national plans for NTDs. The country outlined specific goals for 2024-2028, including the interruption of Guinea worm disease and leprosy transmission. Cameroon highlighted the need for cross-sectoral collaboration, calling for mobilisation of human resources and domestic financing.

Meanwhile, Germany reiterated its dedication to the fight against NTDs, emphasising the Kigali Declaration on NTDs. Germany dwelt on improving access to quality health services, expanding water, sanitation, and hygiene initiatives, and investing in social security. 

The United States called for internal reforms within WHO to strengthen NTD programs and ensure accountability, transparency, and equity.

Non-state actor the Global Health Council (GHC) called for improved access to new drugs for NTD and better diagnosis ,as central to accelerating progress and meeting the goals of the roadmap.

“We call on member states to sustain and expand investments to accelerate R&D of safe and affordable treatments for NTDs and improved diagnostics, particularly for NTDs with specific unmet needs for use in primary healthcare settings,” the GHC said.

To accelerate market access for diagnostics, it recommended the exploration of regulatory and manufacturing pathways by the WHO and member states, to facilitate simultaneous or aligned prequalification and regulatory approval processes.

While highlighting the inextricable link of NTDs to poverty and inequality, it noted that the increased attention in recent years has brought new resources to the fight against NTDs and fuelled research breakthroughs.

“Yet very significant gaps remain in the arsenal of tools needed to control and eliminate these diseases, underscoring the need for research and development (R&D) of new tools,” it noted. 

Injecting new urgency into the fight against AMR

Member States also discussed antimicrobial resistance (AMR), which they framed as a growing and existential threat that hasn’t seen the sustained political attention it demands. 

The need for new actions is further supported by the WHO’s global action plan on antimicrobial resistance which is coming to an end in 2025.

Germany expressed its support for the WHO’s global AMR initiative and emphasised collaboration with academia, the private sector, and civil society. They asked that attention be on increasing investment and innovation in quality-assured, priority,  new and improved antimicrobials, novel compounds, diagnostics, vaccines, and other health technologies to fight AMR.

Morocco, speaking on behalf of the Eastern Mediterranean region, emphasised the diverse challenges faced by countries in the region. The representative stressed the importance of adapting responses to the varied contexts, emphasising the need for a coordinated, cross-cutting approach. They advocated for strengthening health systems, particularly in vulnerable and conflict-affected areas, and urged action beyond hospitals to include primary care, emergency, and public health programs.

“We believe that in our region, we have a very diverse picture. Therefore, in our response to AMR, we have to ensure that it is adapted to these different contexts if it is to be effective,” said the Moroccan representative.

Second UN high-level meeting on AMR

The US supported the continuation of AMR as a priority for the WHO, especially as the world prepares for the second UN General Assembly high-level meeting on AMR in September.

“We urge WHO to be fully inclusive of all partners, including Taiwan, and support Taiwan’s participation as an observer to the World Health Assembly, truly embodying the meaning of health for all,” said the U.S. representative.

Japan emphasised the importance of political momentum in addressing AMR and called for strategic allocation of resources at the national level. The Japanese representative highlighted the need for international collaboration, citing the example of Taiwan’s significant public health achievements. Japan pledged support for the implementation of National Action Plans on AMR in collaboration with the WHO and member states.

“In the September second UN high-level meeting on AMR, we have a good opportunity to increase the political momentum for countermeasures. The Government of Japan would like to contribute to promoting the implementation of the National Action Plan on AMR,” stated the Japanese representative.

Rwanda, speaking on behalf of the WHO Africa region, emphasised the urgent need to accelerate the implementation of national action plans on AMR and acknowledged progress made by member states in developing these plans.

“We take note of the report and call for effective implementation of all strategic and operational priorities by all members and stakeholders,” said the African region representative.

Problems with national AMR plans

According to the WHO DG’s report on AMR, while 178 countries had developed multi-sectoral national action plans on AMR as at November 2023, only 27% of countries reported implementing their national action plans effectively and only 11% had allocated national budgets to do so. He also fragmented implementation of national action plans in the human health sector, which he observed is often limited to hospitals, despite the vast majority of antibiotic use being outside hospitals. 

“Capacity to prevent, diagnose and treat bacterial infections and drug resistance, and the evidence base for policy development, are very limited in low- and middle-income countries. The integration of antimicrobial resistance interventions in health systems, and inter-dependencies with other health systems capacities and priorities, are often not recognized in strategies for universal health coverage or health emergencies,” the DG reported.

He proposed three urgent strategic priorities for a comprehensive public health response to antimicrobial resistance in the human health sector, notably surveillance of both antimicrobial resistance and antimicrobial consumption; the development of new vaccines, diagnostics and antimicrobial agents; and measures to make these accessible and affordable.