Dharriwaa Elders Group staff and Elders protesting the need to buy bottled water given the poor quality of Walgett’s tap water.

A project born from community advocacy and Indigenous leadership has catalysed a unique partnership between a small, rural Australian community and global health experts, shining a light on the link between climate, health and the power of community-driven change.   

Systematic water mismanagement combined with droughts and floods exacerbated by climate change has led to unreliable town water supplies for residents of Walgett in New South Wales.

Early this year, a survey led by local Aboriginal community-controlled organisations conducted in the Aboriginal community found that 43% of people were experiencing moderate to severe water insecurity. The drinking water supplied to the town from bores was found to be so high in sodium that it posed a threat to the many community members living with high blood pressure, heart disease, kidney disease and diabetes.

The survey showed the levels of water insecurity in Walgett were even worse than those recorded in Bangladesh’s capital, Dhaka; a city of 23 million people struggling to cope with the impacts of extreme heat. A rise in the salinity of drinking water in Bangladesh has been linked to increases in hypertension and chronic kidney disease and elevated rates of pre-eclampsia and gestational hypertension in pregnant women.

The George Institute partners with communities in both these contexts, and we are keenly aware that for the people most impacted by the interlinked threats of environmental change and chronic disease, the climate crisis is a health crisis and vice versa.

Indeed, to separate the two is incompatible with Indigenous peoples’ holistic understanding of health, which encompasses not only the physical, social, emotional and spiritual well-being of the whole community, but also its connection to Land and Country, including the earth, waterways and skies.

As we prepare for the first-ever ‘Health Day’ at this year’s UN Climate Change Conference (COP28) in the United Arab Emirates, we argue that progress in breaking down siloes between climate and health is welcome, but far too slow. To accelerate urgently needed inter-sectoral action, we need to put affected communities at the heart of decision-making processes.

Integrating climate in health priorities

WHA76
World Health Assembly 76 in progress.

At the World Health Assembly in May, the climate crisis made an appearance in several official agenda items, as well as multiple side events.

The links between environmental change and health were at least nodded to in resolutions to address the health challenges faced by Indigenous peoples; the burden of drowning; and actions for the prevention and control of non-communicable diseases. In addition, the first-ever resolution on the impacts of chemicals, waste, and pollution on human health was approved at the Assembly – ironically, without naming fossil fuels. 

The integration of environmental considerations across multiple health priorities was a positive step, as is progress towards the adoption of a resolution on climate change and health in 2024, supported by the Global Climate and Health Alliance and partners. Nevertheless, the visibility of the climate crisis at the World Health Assembly was by no means congruent with its status as one of the greatest threats to health this century. 

Integrating health in climate priorities

World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus delivered his first speech at COP28 on the eve of ‘Health Day’, which will take place on December 3.

The inclusion of a ‘Health Day’ on this year’s COP agenda aims to signal a shift in focus, highlighting the recognition of health as a central pillar in climate discussions at the highest level.

Last year’s conference laid some foundations to build on. For example, with the launch of the Sharm El-Sheikh Adaptation Agenda, which aims to enhance resilience for four billion people living in the most climate-vulnerable communities by 2030.

This year, a set of new ‘Health Outcomes’ will be integrated into the Agenda, comprising a plan to address the increasing impacts of climate change on human health and health systems. COP28 will also feature a Health Pavilion for the third time.

In addition, COP28 will see the inaugural Health and Climate Ministerial meeting, at which governments will be asked to endorse a Declaration on Climate and Health. The Declaration has been developed with the WHO, and is ‘intended as a clear signal of ambition and unity on health’, according to the COP28 Presidency.

However, the Declaration is a voluntary call to action which sits outside the formal conference negotiations, raising concerns that it may become just another commitment for which governments can’t be held to account. It also overlooks the importance of reducing emissions to limit health hazards and alleviate pressure on strained health systems.

Communities as catalysts for integrated approaches

Yuwaya Ngarra-li is a community-led partnership between the Dharriwaa Elders Group, an Aboriginal Community Controlled Organisation working for cultural management and community development in Walgett for more than 23 years, and partners at the University of New South Wales.

There will likely be many more health-focused civil society organisations at COP28 than there were climate-focused groups at the World Health Assembly. However, there is still much room for greater intersectorality in advocacy, as well as policymaking. For example, those seeking tighter regulation of fossil fuels may have something to learn from advocates with decades of experience in battling tobacco and other health-harming industries. 

However, to really shift the dial on intersectoral action, we need to centre the voices of people who are experiencing every day the dire health consequences of environmental degradation; from increased heatwaves to the spread of vector-borne diseases, from failed food systems to rising drinking water salinity.

Moreover, it is imperative that we hear from and listen to Indigenous voices, which are often relegated to the margins yet hold sophisticated knowledge in climate mitigation and adaptation strategies that are land-informed, community-driven and holistic.

Through the Yuwaya Ngarra-li partnership between the Walgett Dharriwaa Elders Group and UNSW researchers, advocacy around ongoing water crises and the important cultural connection to Country (lands and waters) has led to significant media coverage and a ministerial commitment to a long-term water solution.

The partnership has also led to innovative, community-driven actions, including the employment of a local food and water coordinator, the installation of a safe drinking water kiosk by the Dharriwaa Elders Group, and a drought-proof micro-farm at the Walgett Aboriginal Medical Service.

In Bangladesh, as part of our work on non-communicable diseases and environmental change, we are in the process of setting up a Public Advisory Board, as we have in India and Indonesia. Comprised of members with diverse backgrounds and lived experiences, the Board is a platform for community members to provide input and participate in decision-making processes. ensuring that their voices are prioritised in shaping interventions to reduce water salinity.  

Further examples of putting community voices at the heart of discussions to set policy agendas and allocate resources can be found in ongoing efforts to establish mechanisms for social participation in health, and the critical role played by communities in progress towards ending AIDS. 

Success will be rewarded with intersectoral policies and services that build on the Traditional Knowledges of Indigenous peoples and respond to community needs; particularly those of women, girls, young people and other groups who experience the impacts of the climate crisis disproportionately.

By mobilising local communities as communicators, advocates and agents of change – from Australia to Bangladesh and beyond – we can prioritise action that directly improves health outcomes for both people and planet, ensuring a more equitable and resilient future for us all.

About the authors

Chhavi Bhandari is the head of Impact and Engagement for India and Multilaterals at The George Institute for Global Health, working from India on a programme of multilateral, regional and national advocacy and engagement. She is the Community Engagement and Involvement (CEI) lead for the National Institute for Health and Care Research (NIHR) Global Health Research Centre for Non-Communicable Diseases (NCDs) and Environmental Change and a member of the WHO-Civil Society Working Group to Advance Action on Climate & Health.

Keziah Bennett-Brook is a Torres Strait Islander woman and Program Head of Guunu-maana (Heal) Aboriginal and Torres Strait Islander Health Program at The George Institute for Global Health, Executive Member of the Australasian Injury Prevention Network, and Indigenous Committee lead. Keziah has chaired the Research Committee for Aboriginal and Torres Strait Islander Health since 2017 and leads the development and implementation of Aboriginal and Torres Strait Islander health research strategy, policy, stakeholder partnerships and Indigenous research coordination within a global research institute. 

Emma Feeney is the Director of Impact & Engagement at The George Institute for Global Health, where she leads a global programme of activities including advocacy, policy engagement and thought leadership to help increase the impact of the institute’s health and medical research. Emma co-chairs the WHO’s NCD Lab on Women and Girls and the NCD Alliance Supporters’ Group.

Full house at the opening of CPHIA2023

LUSAKA, Zambia – The silver lining to Africa being denied access to COVID-19 vaccines during the pandemic is how it has galvanised continental leaders to focus on self-reliance – instead of depending on wealthy countries for assistance.

The determination to build the continent’s health systems capacity was abundantly evident at this week’s Conference on Public Health in Africa (CPHIA) hosted by the Africa Centres for Disease Control and Prevention (Africa CDC).

“Having a major conference like CPHIA on the continent here in Africa means that we can change the narrative. It means that we can lead the conversation. We can change it by centring what matters most to African communities and spotlighting extraordinary science from African researchers that would normally go unnoticed,” said Shingai Machingaidze, Africa CDC’s acting chief scientist and a rising star in global health.

Shingai Machingaidze, Africa CDC’s acting chief scientist

“There have been concerns raised about access and representation at global health conferences and meetings, and many of our African leaders have raised these concerns, including visa challenges,” Machingaidze added in an address to the conference’s closing plenary on Thursday.

It is often extraordinarily difficult for African scientists to get visas for North America and Europe, even when their papers have been accepted at international conferences.

The Africa CDC – which was only launched in 2017 – won the respect of member states for how hard it fought for the continent during the pandemic.

This support was reflected in the fact that conference attendance surpassed the body’s expectations by over 1000 delegates – attracting 5,100 delegates in-person and 30,000 online – double that of the first in-person CPHIA in Rwanda last year.

CPHIA2023 summary

Multiple disease outbreaks

The obstacles are huge. Africa has already experienced 158 health emergencies this year alone, of which 90% were infectious diseases and three-quarters were zoonotic diseases (passed on from animals), according to Dr Merawi Aragaw Tegegne, Africa CDC’s head of surveillance and disease intelligence.

One new pathogen a year has emerged on the continent for the past 30 years – again, three-quarters from animals – adding to the already daunting stack of threats, Merawi told the conference.

African countries are ill-prepared for pandemics, scoring an average of 29.1 out of 100 in the Global Health Security (GHS) Index.

None of the continent’s 55 states scored over 20% for biosecurity, and only two countries – Kenya and South Africa – scored over 50% for biosafety capacity, revealed Dr Talkmore Maruta, director of programmes at the African Society for Laboratory Medicine.

Many countries simply lack the capacity to comply with international agreements, including the World Health Organization’s (WHO) International Health Regulations (IHR) and the United Nations Biological Weapons Convention.

The biggest obstacles are the shortage of appropriately trained staff, lack of resources, and inadequate or unclear regulations.

There are also tussles between government departments – primarily defence, health, environment and agriculture – about who should take control of biosecurity when the legal framework should ensure shared responsibility, according to Maruta.

Preparing for climate crises

A submerged house in Nsanje in Malawi after Cyclone Freddy.

But the continent is not only threatened by diseases. Africa is particularly vulnerable to extreme weather events, and Africa CDC believes that “climate change poses the biggest health threat” this century.

“As I speak, we have 18 countries affected by cholera with more than 4,000 deaths,” Dr Jean Kaseya, Director General of Africa CDC, told the conference.

“We have multiple West African countries affected by dengue. The flooding in a number of countries including Libya, the earthquake in Morocco, and a number of other natural disasters, are showing the linkage between climate change and health in Africa,” said Kaseya. 

When Cyclone Freddy battered Mozambique, Madagascar and Malawi in February, the devastating storm was followed by the largest and most deadly cholera outbreak in Malawi’s history. Mozambique and Madagascar were not spared either, as massive flooding displaced millions and destroyed primary health care services across the two countries. 

Yet many health officials are so overwhelmed with current diseases that preparing for climate change seems “futuristic”, according to Dr Eduardo Samo, Director General of Mozambique’s National Institute of Health.

He appealed for fragile health systems to become resilient to extreme weather events, particularly at the community level, added Samo.

 “This can be a simple thing like making sure that the roof of a health facility is built so that it does not get blown off and the facility is flooded during a storm,” he explained.

Under-funded and under-skilled health workforce

The 55 African states spend an annual average of $50 per person on health – far too little to cover all people’s health needs. In addition, their already vulnerable health systems were severely affected by COVID-19.

Back in 2001, African Union members committed to allocating at least 15% of their budget each year to the health sector in what became known as the Abuja Declaration. Virtually none have done so.

But Sara Hersey, director of collaborative intelligence at the WHO’s Hub for Pandemics and Epidemic Intelligence in Berlin, says that there have been significant improvements as a result of COVID-19.

The pandemic brought “an influx of capacity, support and focus on health security”, said Hersey.

“We’ve seen substantial changes in the capacity for surveillance. Risk communication has improved dramatically as has health service provision and health emergency management,” she said.

“We need to keep this momentum and sustain the capacity that we have already built. Critical to this is the role of the national public health agencies, including national health institutes, CDCs and institutes that lead pandemic preparedness and response.”

Since 2017, 18 African countries have established national public health agencies or are in the process of doing so – including even one of the continent’s poorest countries.

New public-private collaborations

‘Saving Lives and Livelihoods’ is a collaboration between Africa CDC and the Mastercard Foundation to improve pandemic preparedness.

While money is always a challenge, several promising collaborations have emerged.

Earlier this year, Africa CDC and the WHO’s Africa (AFRO) and Eastern Mediterranean (EMRO) regions launched a Joint Emergency Preparedness and Response Action Plan (JEAP) to address emergency preparedness and response in Africa. 

JEAP outlines the responsibilities of each organisation – significant due to the past history of territorial disputes between Africa CDC and the two WHO Regional Offices that manage WHO operations in the sub-Saharan and north African regions of the continent respectively.  JEAP furthermore outlined six areas of collaboration, including assistance to countries with genomic sequencing, stockpiling of emergency supplies, and workforce readiness and deployment.

Meanwhile, the Mastercard Foundation announced at the conference that it was entering the second phase of its $1.4 billion collaboration with Africa CDC to better prepare countries for the next pandemic. Phase 2 of the joint ‘Saving Lives and Livelihoods’ collaboration will focus on completing the vaccination of healthcare workers and vulnerable groups, training community health workers, bolstering national public health institutions, laboratory capacities and local manufacturing of vaccines, therapeutics and diagnostics.

Earlier this month, Africa CDC also announced that had set up a continental structure to train and integrate two million community health workers into national health systems.

In 2022, the African Union (AU) resolved to set up an Africa Epidemics Fund, and this is expected to be launched in February 2024, according to Devex. South Africa’s President Cyril Ramaphosa is the continent’s pandemic envoy and is expected to spearhead the fundraising for this.

The US government is also supporting continental pandemic preparedness efforts.

Partnership for African Vaccine Manufacturing ramps up ambition

Meanwhile, the Partnership for African Vaccine Manufacturing (PAVM) is driving the continent’s lofty ambition to rapidly ramp up vaccine, medicines and diagnostic production. At the start of the conference, Kaseya described the African Union’s ambition to produce 60% of the vaccines that it needs on the continent by 2040 as “the second independence” for the continent.

“Many African countries got their independence [from colonisers] in the 1960s, but we saw in COVID that we are not independent,” Kaseya told a media briefing at the start of CPHIA. “Other continents locked their doors and we were left beyond.”

The glaring inequity that emerged during the pandemic has galvanised the African health sector and donors, while the current WHO negotiations for a pandemic treaty are keenly focused on equity measures.

At the close of the conference co-chair Professor Margaret Gyapong stated: “Collective leadership is critical to fight the next health crisis. Listen, trust each other, and work together. We have the tools and we must use them now. And yes, invest in women.” 

Heatwaves and air pollution exacerbate existing chronic diseases and cause new ones, worsening the noncommunicable disease (NCD) burden, experts at COP28 said.

As the world continues to burn fossil fuels, heatwaves and air pollution are getting worse, and increasing the pressure on human health. This is exacerbating the burden of non-communicable diseases (NCDs), which comprise the lion’s share of the world’s disease burden, experts at COP28 said on the opening day of the summit on Thursday.

“We all know that climate change is a health crisis. But if you combine this with NCDs, this is certainly a double crisis,” said Bente Mikkelsen, director of the Department of NCDs at the World Health Organization (WHO). She was speaking at an event on the COP28 sidelines called, “Unbearable Heat, Unbreathable Air – Finding Win-Win Solutions for Climate and Health.”

Deaths from non-communicable diseases comprise 75% of premature mortality (under age 70) globally. This number is only increasing as the world’s population ages, Mikkelsen noted. But most people don’t understand how global warming or what UN Secretary General Antonio Guterres called “global boiling” is adding to the NCD burden in multiple ways, she added.

Many NCD conditions, from kidney disease to cardiovascular conditions, are exacerbated by extreme heat exposures, Mikkelsen explained. While heatwaves killed 60,000 people in Europe alone in 2022, the global toll is not well known due to data gaps.

The combined death toll from heatwaves, vector-borne disease, and malnutrition could cause up to nine million deaths by the turn of the century, WHO has said based on assessments by the Intergovernmental Panel on Climate Change.

Air pollution is estimated by WHO to kill seven million people annually, although research published this week in The BMJ put the number much higher at 8.34 million deaths for outdoor air pollution alone.

This air pollution is caused by the same sources driving climate change – the burning of fossil fuels, waste, as well as heating and cooking with coal, kerosene, and biomass in traditional stoves.

“It is probably not that well known that 85% of air pollution [mortality] again, is attributed to non-communicable diseases,” Mikkelsen said, referring to the cardiovascular, respiratory, and cancers that are recorded as causes of death.

Bente Mikkelsen of the WHO said the worsening heat waves and air pollution, both a result of the changing climate, are worsening the NCD burden. This means the world is not on track to reducing the NDC burden by a third by 2030 which is the Sustainable Development Target, she said.

Health is not a formal part of the UN Climate process 

DUBAI, UAE -Despite being a pillar of the 1992 UN Framework Convention on Climate Change, health has never been a formal part of the agenda of UN Climate negotiations or the Conference of Parties (COP) process.

This year, health has gained a foothold as a COP thematic day, December 3, during which 63 health ministers are expected to arrive in Dubai. This is the first-ever such gathering at a climate conference.

While this may be an important symbolic event, climate change, air pollution, and the NCD epidemic – all major crises in themselves – need to be much more deeply interlinked, experts said.

Far more needs to be done to promote “integrated” solutions that also prevent global temperatures from exceeding the limits of human survivability across large swathes of the planet, experts at the side event, co-sponsored by the World Health Organization, the World Bank and the Clean Air Fund, said.

They called for a reduction in fossil fuel burning and subsidies to the industry along with increased investments in renewable energy broadly and within the health sector.

More formal moves to include health-related indicators and objectives in climate policies could also help the world meet a wide range of the 2030 Sustainable Development Goals, from reducing NCD deaths (SDG3) to healthier cities (SDG 11) and clean energy for all (SDG7), said panellists at the event, which was held at the SDG Pavilion.

Using clues from human physiology to improve climate strategies

Tony Capon from Monash University said the conversation on reducing the impact of heat needs to account for human physiology as well which is currently missing in the conversation.

“It’s likely that we’re under-estimating the thresholds [of heat tolerance] because we aren’t bringing human physiology into the discussion, because we all have different responses to extreme heat. Perhaps we have a non-communicable disease. Perhaps we’re aging and we’re more at risk,” Tony Capon, of Australia’s Monash University, a member of the World Meteorological Organization’s Heat and Health Network, said.

Tolerable levels of heat vary widely with the level of ambient humidity and ventilation, he pointed out, referring to the body’s sweat response. Simply moving air around with a fan can also cool people down, allowing them to tolerate higher temperatures safely.

Air conditioning, whose use is soaring in hot countries, is a “maladaptive response” to climate, said Capon. Not only does it increase carbon emissions, but it pushes hot air out of the homes and offices of the wealthy and out into the streets and neighbourhoods of the city, exacerbating the urban heat island effect for poorer communities and vulnerable groups.

Air pollution and heat wave deadly synergies  

A dense toxic smog in New Delhi blocks out the sun. (8 November 8, 2017).

Policymakers also need to pay closer attention to the interplay between air pollution and heat, Capon added.

“When we think about air pollution and heat together, our body’s response to heat can actually exacerbate the health impacts of air pollution. Because we breathe more deeply when it’s hot. And that means we breathe the pollution more deeply into our lungs, our hearts also working harder. And so it’s pumping those pollutants around our body more than it otherwise would be if it wasn’t a hot day,” he explained.

Based on such basic knowledge, health and climate actors can build more integrative solutions if they look at the full spectrum of health impacts from proposed climate strategies, he said. That also means focusing not only on greener energy but on investments in more low-carbon buildings, with good ventilation and on more sustainable cities and transport systems.

Solutions: Renewables, multisectoral response and finance

A traditional brick factory in Tozeur, southern Tunisia. In Africa and South Asia brick making and waste burning are major sources of air pollution.

More sustainable solutions also need finance, and that’s still sorely lacking, said Arunabha Ghosh, CEO of India-based think tank Council on Energy, Environment and Water (CEEW). He noted that while Africa has vast solar energy potential, only 2% of climate finance is invested in the continent.

Multiple barriers are stifling Africa’s green energy expansion. Most climate finance supports mega energy projects, while much of Africa’s entrepreneurship is small and medium businesses. Smaller, distributed grid energy projects would be more suitable to many underserved communities, far removed from big cities but these are not getting the required attention currently. Countries where credit ratings make them poor bets for investors often are the most in need of these investments.

However, there are some hopeful signs of change, Ghosh said, noting that the World Bank was in a “seminal moment” in terms of prioritizing its climate and air pollution policies.

“If we can have air quality as one of those global challenges around which new programming for the World Bank will emerge, I think that really gives us a leg up,” he said. “We’ve got to start thinking about the linkages between health, the economy, climate and the broader SDGs as part of that new economic paradigm. And then look at the hierarchy of solutions.”

Providing further details on some of the new investment trends, the World Bank’s Jostein Nygard described moves afoot in Southeast Asia to support countries’ investment in air pollution solutions.

World Bank initiatives on better air quality involving South Asian countries along the Indo-Gangetic Plain and Himalayan foothills.

One key focus of that initiative is the heavily polluted Indo-Gangetic plain and Himalayan Foothills region, which extends from Pakistan across northern India and southern Nepal to Bangladesh. South Asia suffers from some of the heaviest air pollution in the world, with an estimated 4 million deaths annually from air pollution across countries in the region.

Bringing the environment and health departments of the countries to work together has been a challenge, but things are improving.

“We can now see that we gradually are getting an entry point that we need to further enhance the collaboration between environment and health,” Nygard said. “We are pretty optimistic about being able to move this process forward.”

Tax the windfall profits of the oil and gas sector to fund health facilities

Salvatore Vinci, an energy advisor to the WHO said that fossil fuel profits should be taxed to support investments in renewable energy and bring electricity to the one billion people around the world who live without it.

Along with speaking out more forcefully about health and climate harmful policies in other sectors, the health sector can also show the way by shifting health facilities to renewables, Salvatore Vinci, an energy consultant for WHO, said.

He noted the recent WHO findings that nearly one billion people in lower-income countries lack access to a health facility with adequate energy infrastructure to power basic health services, he pointed out. An estimated 450 million people worldwide lack access to a health facility with any electricity at all.

Many health facilities in low-income countries are heavily reliant upon diesel fuel or expensive and unreliable grid conditions, he said, noting that in Somalia, the cost of electricity is $1 per kilowatt hour and in Yemen, the cost of diesel is $1.14 per litre of diesel. Those costs could be reduced by two-thirds if renewable power was installed, he said.

“Africa is the place with 60% of the best solar resources, but there is 1% of the solar installation,” Vinci said. “So we will talk about electricity and energy transition first, let’s talk about the most vulnerable population,”

The scale of investments needed is large, but they pale when compared to the profits the fossil fuel industry is making, he pointed out. “In 2022, the global oil and gas industry made a profit of $4 trillion, more than doubling the income of the previous years,” said Vinci. “If we have to electrify all the healthcare facilities in the world, we would need just $4.9 billion.”

See related story: COP28: Will a Petrostate Lead the Fight Against Climate Change?

Image Credits: Unsplash, Wikipedia, WHO/Diego Rodriguez.

HIV activists protesting against patent laws that pushed up costs of essential medicines in Cape Town in  2014.

I endured a dreary weekend in a Paris hotel while others rushed home. As the junior English speaker of a task force of United Nations (UN) member states, it fell to me to finalise our report. It was the early 1990s and we had travelled across Asia, Africa and Latin America collating confusing evidence and conflicting opinions that now required urgent synthesis and circulation to the world.   The question before us concerned the relatively new HIV/AIDS.

Incontinent patients overflowing Malawian hospitals, mountains of roadside coffins in Uganda, lost orphans in Johannesburg, emaciated drug users under Beijing flyovers, terrified migrants in Mumbai slums, panic-stricken sex workers in Nairobi, stigmatised gay men in Rio de Janeiro, contaminated blood recipients in New York, and later, raped women from the Rwanda genocide. These were some observations from the first-ever task force world tour of the HIV scourge.

Alongside unpicked harvests, collapsed businesses, and infected armies destabilising nations. It convinced us that the business-as-usual mode of UN agencies would not do. 

But what might a transformed global AIDS effort look like?  There was unanimity that a whole-of-society approach was urgent. Our findings led to the 1993 World Health Assembly and 1994 UN Economic and Social Council resolutions. The Joint United Nations Programme on HIV/AIDS (UNAIDS) duly opened its doors in 1996. 

HIV probably originated early in the 20th century by jumping from apes to humans in Africa and spread slowly through travel. The virus was identified in 1983  as the epidemic got going. Since then, 86 million people have been infected and 40 million have died. 

Remarkable struggle against HIV

Community Health Workers attend a training session on HIV in Kirehe, Rwanda.

The forty-year struggle against HIV/AIDS has been remarkable. It sparked unprecedented global unity that we can only envy nowadays – with numerous UN resolutions including unanimous support at the Security Council in 2000, the first time a health matter reached so high.   

HIV stimulated unprecedented institutional innovation.  UNAIDS pioneered UN reform with 11 quarrelsome UN agencies joining hands. It made consultation fashionable and welcomed civil society, including patient groups, onto its governance. Unprecedented generosity was unleashed with the 2002 formation of the Global Fund’s dedicated financing channel for HIV/AIDS, tuberculosis and malaria.  The bilateral US President’s Emergency Plan for AIDS Relief (PEPFAR) was formed in 2003. 

HIV turbo-charged research with the first antiretroviral treatment becoming available in 1987, averting 21 million deaths till now.  Subsequent therapeutic advances including post-exposure prophylaxis turned HIV from an assuredly fatal condition to one that causes less than one death per 10,000 population. 

Prevention – a controversial matter of sexual abstinence, condoms, and clean needles –  got a boost in 2012 with pre-exposure prophylaxis alongside a revolution in diagnostics including tracking the immune status of patients.

Nowadays, treated HIV is akin to a chronic disease with almost normal life expectancy.  Although the holy grail of an HIV vaccine remains elusive, promising innovations underway include six candidate vaccines in Phase 1 clinical trials. The benefits of scientific investments in HIV have been profound. They accelerated  COVID-19 and malaria vaccines development and even personalised cancer therapy. 

Human rights values underpinned HIV struggle

Delegates at the 2022 International AIDS Conference calling for the end to criminalisation of key populations most vulnerable to HIV/AIDS.

But even more, the values underpinning the HIV struggle transformed society. People with HIV refused to be victimised and taught marginalised communities such as LGTBQ+ to stand up for their rights and win basic legal entitlements in many places. Religious orthodoxies performed theological gymnastics to sanction condom use thereby benefitting the reduction of other sexually-transmitted infections and contributing towards cervical cancer prevention.  

HIV education strategies countering stigma enabled people with TB  and the mentally ill to come out of the shadows.  The skills to manage AIDS  brought compassion and courage to overcome the fear of contagious conditions such as Ebola.   

 The human rights gains triggered by HIV/AIDS established the primacy of inclusion in public policy such as for refugees and migrants. Of course, such rights are not universally realised and often threatened. But HIV showed the worth of struggling and how to do it.

HIV  widened public health ambitions, and birthed health diplomacy to create the modern global health movement. The bold demand for antiretrovirals for all with HIV disease was a precursor of the COVID-19 slogan, “no one is safe until all are safe”.  The universalist vision of HIV treatment negotiated far-reaching flexibilities in the Trade-Related Intellectual Property Rights (TRIPS) regimen allowing treatment costs to drop by a staggering 99 per cent.  This got the generic medicines genie out of its over-priced bottle.

The HIV emergency is an inspiring battle against today’s emergency around non-communicable diseases (NCDs) – diabetes, cancers,  cardiovascular and respiratory conditions – that cause  74% of global deaths. And so NCD treatment costs have tumbled including insulin.

New paradigm of accessibility

Thus, HIV gave rise to a new paradigm of availability, accessibility, and affordability  for all essential drugs and diagnostics. That makes feasible, Universal Health Coverage (UHC), the core of  Sustainable Development Goal 3.  HIV has shown what is doable against the odds, given the vision, will, partnerships, and resources. 

It is the last aspect – resources – that raises new questions, considering HIV’s trajectory.  There were 39 million people living with HIV in 2022 giving a global median prevalence of 0.7 per cent among adults  aged 15-49 years. In the same year, 1.3 million were newly infected (reduced by 59% since the 1995 peak) and 630,000 died (reduced by 69% from its 2004 peak).

A 2021 UN General Assembly  Political Declaration called for ending AIDS  by 2030 through sufficient HIV reduction to remove it as a population threat. The associated strategy centres on prevention through testing and treatment, a creative approach that could also work with some other conditions. 

The key targets are that 95% of people living with HIV should know their HIV status, 95% of the latter should be on antiretroviral treatment, and 95%  of treated people should be virally suppressed, and therefore unable to transmit infection to others.  

By 2022, 89% of people who were aware that they had HIV were on antiretroviral treatment.

There is impressive progress. By last year, 86%  of people living with HIV knew their status, 89%  of HIV-aware people were accessing treatment of which 93% were virally suppressed. 

The 2030 targets should be achievable with several countries already reaching or exceeding the 95/95/95  benchmarks.  From being a global pandemic,  HIV has been geographically contained. Africa still accounts for most (38 per cent)  of new infections with HIV’s gender dimension most evident in sub-Saharan African women who bear the brunt.

The global decline is bucked by parts of Eastern Europe and Central Asia, Middle East and North Africa, and Latin America showing rising incidence. Nevertheless, HIV is increasingly concentrated in key populations such as gay and transgender persons, and in vulnerable settings such as sex work, injecting drug use, and prisons.  Certainly, there is more to do especially with authorities whose retrogressive and prejudiced policies fuel virus spread.  That reinforces the case for targetted, not generalised, approaches. 

It necessitates decentralised, focused spending by re-orienting global flows towards low- and middle-income countries. They currently spend $20-22 billion annually on HIV, of which around 60%  comes from their own budgets. External aid from PEPFAR, Global Fund, and others provide the rest.

UNAIDS projects a $29.3 billion global investment requirement in poorer countries in 2025. Meanwhile, as a sign of success, more and more people live long healthy lives on permanent HIV treatment. The sustainable financing of an increasingly endemic condition needs figuring. 

The last mile is always the most expensive to traverse. Especially at a time when the going is harder due to many conflicts and climate change disasters that increase population displacement and vulnerability.  But more HIV funding will not defuse underlying causes while making a marginal difference to mitigating the symptoms.

Should UNAIDS close by 2030?

UNAIDS Executive Director Winnie Byanyima addressing the UN.

With HIV already out of the list of top 10 killers by 2019, how cost-effective is our array of HIV-focused bodies?  It implies getting HIV out of the current vertical campaign mode and integrating it into UHC systems.  Why wait till 2030 to make the transition?

There is a reluctance to move faster because such change poses an existential threat to HIV-centered institutions. Do we still need UNAIDS and its $210 million annual budget? Can we justify the individual HIV units and separate programme spends of the 11 co-sponsoring agencies of UNAIDS? Can we continue to spend $15.7 billion bi-annually on just three diseases – HIV, TB, and malaria, as the Global Fund does? Not to forget the billions on HIV via the World Bank and bilateral donors, including PEPFAR’s $6.9 billion in 2023. 

A fundamental re-ordering is needed. Perhaps downsized UNAIDS staff could return to their original home at WHO which should continue its normative guidance and country support technical roles.  Thanks to the aid localisation movement and the maturing of civil society over the past decades, there are plenty of groups on the ground to keep running with the psychosocial and human rights aspects of the HIV struggle.

And the Global Fund, while continuing to finance HIV, TB, and malaria, should extend value-for-money by taking on additional challenges worthy of its clout (say dementia and cancer).

There are many examples of organisations adjusting their work in the face of altered requirements. But never has a UN agency closed shop voluntarily. UNAIDS, at its start, pioneered  UN reform. It could trail blaze again by closing its doors, say in 2030. 

A  commemorative monument could be erected at its spacious Geneva headquarters. The new occupants – putting their great minds to tougher tasks – will be inspired by walking past the exhibition in the foyer on one of our greatest public health triumphs. 

Perhaps they will pause for reflection at the display containing the medal of  the Nobel Prize for Medicine – a fitting way to bid farewell to UNAIDS, the only world agency with the foresight to do itself out of business.  

Mukesh Kapila, Health Policy Watch editor-at-large, is a physician and public health specialist who has held senior positions at the World Health Organization, United Nations, and as Under-Secretary-General at the International Federation of Red Cross and Red Crescent Societies. He began his public health career as the Head of Conflict  & Humanitarian Affairs for the UK’s Foreign Office.  

This is the first of a series of periodic “stocktake” papers reflecting on progress made and constraints faced on the journey to achieving the Sustainable Development Health Goal, SDG 3.

 

Image Credits: Louis George 2011 , Cecille Joan Avila / Partners In Health, Marcus Rose/ IAS, Flickr.

RANA executive director Aggrey Aluso and Pandemic Action Network executive director Eloise Todd.

LUSAKA, Zambia — A new African civil society network to address pandemics and climate crises was introduced publicly on Wednesday on the sidelines of the Conference on Public Health in Africa (CPHIA). The Resilience Action Network Africa (RANA) has been established by over 30 African organizations that are part of the global Pandemic Action Network (PAN), which was formed during COVID-19.

“This journey started a long time ago,” RANA executive director Aggrey Aluso told Health Policy Watch. “The voices of the global South and the concerns of low- and middle-income countries, particularly in Africa, do not inform global policies. But ‘the people who wear the shoe know where it pinches most.’”

The resilience agenda has come to characterise Africa’s challenges, including surging climate change challenges, disease outbreaks, gender inequality, food insecurity, and financial instability, Aluso explained.

“If we continue to address these challenges in isolated silos, we will not be strong enough,” Aluso said.

At the heart of RANA’s strategy to dismantle these silos is a collaboration with the Pandemic Action Network (PAN). Leveraging PAN’s proven track record in networked advocacy for pandemic prevention, preparedness, and response, the partnership will adopt a “whole-of-society” approach to bridging policy gaps at the national and regional levels in Africa, while empowering local institutions and agencies to bolster health systems.

RANA’s partnership with PAN seeks to establish connections between pandemic issues and advocates and networks across the resilience agenda, encompassing gender, climate, finance, food systems, health, and nature. RANA’s affiliates are primarily engaged in pandemic and climate threats, gender and debt.

RANA is more than 30 civil society partners (CSO) strong, and growing — including those representing the gender, climate, finance, food systems, health, and nature agendas.

“The idea is that PAN and RANA will work really closely in the pandemic prevention, preparedness and response, and climate and health crisis space,” PAN executive director Eloise Todd told Health Policy Watch. “We will basically work in lock-step to ensure that community voices and African countries are presented in global processes.” 

“If you think about the INB [Intergovernmental Negotiating Body] negotiating the pandemic treaty, for example, we want to make sure that we insert the voices of the low and middle-income countries,” said Todd. “We want to do that more deliberately and invest more to have this separate, independent entity and really walk the walk and take our lead from an independent, partnered organisation.”

One of RANA’s first campaigns is to advocate for African leaders to commit to an agenda for pandemic action. This includes calling on African countries to allocate long-term domestic financing to “close critical pandemic prevention, preparedness, and response funding gaps in Africa”; to expand the local production of health products including diagnostics, medicines and vaccines; and to make African health systems gender-responsive, and pandemic and climate-resilient.

These demands are part of the Africa Centres for Disease Control and Prevention’s (Africa CDC) Africa’s New Public Health Order, a long-term vision for a more resilient, inclusive, and equitable African public health system.

“Humanity is facing two major existential threats: climate change and pandemics. These global threats are highly interconnected, and their risk to lives, livelihoods, human progress, and human rights is growing,” said Todd. “We must shift our policy thinking and our investments to strengthen the resilience of our countries, our communities, and our people.”

Aluso, who will continue to serve as PAN’s Africa Director and Global Policy Lead, said that the multiple crises “require bold thinking, bold collaboration, and bold action”.

“Our vision is a resilient and healthy Africa, safeguarded by African-led solutions, informed by African needs, and driven by African leadership,” he said.

24th International AIDS Conference, Montreal, Canada.

As donors withdraw from HIV, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has chosen to focus on the importance of community-led interventions to end the AIDS pandemic for World AIDS Day on 1 December.

“There has been an unprecedented backsliding in financial commitments to community-led organisations, and it is costing lives,” according to UNAIDS Executive Director Winnie Byanyima, writing in her organisation’s annual World AIDS Day Report released on Tuesday.

“Crackdowns on civil society and on the human rights of people from marginalised communities are obstructing the progress of HIV prevention and treatment services, putting the fight against AIDS at risk,” she added.

“Harmful laws and policies towards people from populations at risk of HIV threaten the lives of community activists trying to reach them with HIV services. Too often, decision-makers treat communities as problems to be managed, rather than as leaders to be recognised and supported.”

The report is “an urgent call to action for governments and international partners to enable and support communities in their leadership roles”, according to UNAIDS.

People living with and affected by HIV have been particularly influential in the HIV response, according to the report.

“They are the trusted voices. Communities understand what is most needed, what works, and what needs to change.”

A United Nations high-level meeting on AIDS in 2021 adopted a political declaration that contains various commitments to recognise community initiatives. These include that, by 2025, community-led organisations should deliver 30% of testing and treatment services, 80% of HIV prevention services for people from populations at high risk of infection, and 60% of programmes to support societal changes that enable an effective and sustainable HIV response. 

In addition, they agreed on the 10–10–10 targets to remove punitive laws against LGBTQI people, people who use drugs, sex workers and people from other often criminalised populations, and to reduce stigma and discrimination, gender inequality and violence experienced by people living with HIV and people from key populations and priority populations

The report includes nine guest essays by community leaders that show how they have been able to drive change, how they experience obstacles in their way, and the actions they are urging governments and international partners to take to enable communities to lead us to the end of AIDS by 2030.

Image Credits: Marcus Rose/ IAS.

COP28, the 28th Conference of the Parties to the United Nations Framework Convention on Climate Change (UNFCCC), will take place from November 30 to December 12, 2023, at the Expo City complex in Dubai, United Arab Emirates.

Negotiators at the upcoming UN Climate Change Conference (COP28) must accelerate the end of fossil fuels, eliminate trillions in fossil fuel subsidies, and swiftly transition to clean, renewable energy to reap the health benefits of climate action, senior World Health Organization (WHO) officials urged at a press briefing on Tuesday.

Despite the absence of explicit mention of fossil fuels in the draft “Health Declaration” to be signed by UN member states at the climate conference, which begins on Thursday, negotiators working on the outcome document must recognise that “we need to halt emissions and accelerate the transition to clean, renewable energy for the sake of health,” stated Dr. Maria Neira, director of WHO’s Department of Climate, Environment, and Health.

“The more we postpone action on reducing emissions and accelerating this transition to clean, renewable sources of energy, the more we rely on fossil fuels, the more our health will be paying the price that is very high,” Neira said. 

‘Healthwashing’ or real progress? 

While this year’s COP is poised to host the first-ever ministerial level “Health Day”, with a strong commitment from the COP Presidency and UAE hosts to highlight the issue, civil society groups have expressed concerns that these moves could amount to a “greenwash” of a conference hosted by a petrostate, where oil and gas lobbyists will have a prominent presence.

Meanwhile, other sources have informed Health Policy Watch that the decision to set aside ‘fossil fuels’ language in the health declaration was made deliberately to ensure that the issue is thoroughly addressed in the core negotiations by member states rather than being relegated to a single thematic area, regardless of health’s importance.

Exclusive: COP28 Climate and Health Draft Declaration Ignores Fossil Fuels as Driver of Health Harms 

Addressing the briefing, WHO officials were adamant that they are carrying an unequivocal message on the issue to COP negotiators. 

“What we are telling the negotiators is the more you postpone action, the more you are taking responsibility for not addressing the health consequences,” said Neira.

Dr Diarmid Campbell-Lendrum, who leads the climate change and health unit at WHO, added that achieving the 2015 Paris Agreement’s climate goals sooner rather than later would also save approximately 1 million lives annually by reducing air pollution-related mortality. Conversely, delaying action will result in more avoidable deaths from warming and an increase in air pollution-related deaths.

“We believe that the health argument supports the case for rapid action because there is a significant difference between waiting until 2029 to attempt a rapid reduction in admissions and waiting until 2049 to do the same,” Campbell-Lendrum explained.

“For one thing, you’ve left a lot of carbon in the atmosphere by not starting earlier, accumulating much more carbon in the process. Additionally, you’ve missed the opportunity to save a lot of lives if you leave it until the last minute to intervene. The economics of this are clear,” he stated.

Dr Diarmid Campbell-Lendrum, head of the WHO’s Climate and Health team

“The health argument is also clear on this – the sooner we act, and the more ambitiously we act, the more affordable it is to address the climate crisis but also to save more lives,” Campbell-Lendrum said.

Campbell-Lendrum acknowledged that the financial cost of climate policies is often raised as the main counterargument to action. “it costs money,” he said.

However, he countered that this argument is not valid given the trillions currently allocated to fossil fuel subsidies. Taxpayers worldwide shouldered an additional cost of approximately $600 per household last year to subsidize fossil fuel consumption, Campbell-Lendrum said.

When factoring in the health detriments caused by fossil fuel consumption, the IMF estimates that the true subsidy is closer to $3,500 per household globally.

“The money is there. We’re just not spending it in the right place,” he said. “Part of the message we’re taking to COP is we need to invest in a healthier, greener future for everybody.”

What to expect at COP28

Along with a full-fledged Health Day on December 3, attended by some 65 ministers of health, dozens of health-related events are planned to unfold throughout the two weeks of the climate conference.

At the WHO’s COP28 Pavilion, some 40 thematic events are planned on topics such as climate change and health, while other health-related climate events will be staged in the pavilions of the Climate and Clean Air Coalition, the SDGs, the World Bank, and even the pavilion of the Cryosphere.

An innovative model health clinic powered by renewable energy will also be on display at the COP, showcasing the potential for health facilities to operate sustainably and contribute to climate change mitigation.

“We will be demonstrating that even healthcare facilities that are currently not contributing to a carbon footprint can access clean energy without exacerbating climate change,” said Dr Maria Neira, Director of WHO’s Department of Climate, Environment, and Health.

Approximately one billion people worldwide are served by health facilities that lack access to adequate and reliable electricity for essential health services, including emergency care, disease control, and childbirth according to a WHO report published earlier this year.. Over 430 million people are served by primary care facilities that have no electricity at all.

On the other end of the spectrum, healthcare services in middle- and high-income countries are among the largest energy consumers of any economic sector, accounting for about 5% of global carbon emissions.

WHO’s alliance on transformative action on climate and health (ATACH)

Dr Maria Neira, WHO Director of Climate, Environment and Health, lays out plans for health events at COP28.

WHO also has established a new platform, called the Alliance on Transformative Action on Climate and Health (ATACH). Through ATACH, member states can make voluntary declarations on plans to make health facilities more climate-resilient and sustainable, and they can also access technical support, quality assurance, and financing for decarbonizing health systems.

To date, 78 countries have joined the Alliance, with 71 committing to become “sustainable, low-carbon” health systems and 29 pledging to reach net zero in the health sector by 2030, 2040, or 2050.

“We, as the health sector, can reduce our own carbon footprint by decarbonizing our interventions that at the moment contribute to 5% of the global emissions,” Neira said.

Image Credits: Dennis Sylvester Hurd.

CPHIA co-chair Professor Margaret Gyapong, Africa CDC Director General Dr Jean Kaseya and Zambian Health Minister Sylvia Maseko address the media shortly before the conference opening.

LUSAKA, Zambia – Ensuring that Africa can manufacture its own vaccines will represent “the second independence of Africa”, Dr Jean Kaseya, Director General of the Africa Centre for Disease Control and Prevention (Africa CDC), said at the start of the Conference for Public Health in Africa 2023 (CPHIA) on Monday.

“Many African countries got their independence [from colonisers] in the 1960s, but we saw in COVID that we are not independent,” Kaseya told a media briefing shortly before CPHIA’s opening. “Other continents locked their doors and we were left beyond.” 

With over 5,000 in-person delegates and an additional 20,000 virtual participants in attendance, Kaseya described CPHIA23 as the largest global public health event outside the annual World Health Assembly.

Stung by Africa’s inability to access COVID-19 vaccines during the pandemic’s peak as wealthy countries hoarded supplies, African heads of state have committed the continent to manufacture 60% of the vaccines it needs by 2040. 

This is a mammoth task considering Africa currently produces only 1% of its vaccines. Although many believe this impossible to achieve, Kaseya said he would not be in his current position if he did not believe it was possible.

The Partnerships for African Vaccine Manufacturing (PAVM) is driving this ambition, which recently received a huge shot in the arm from the global vaccines platform, Gavi, according to Kaseya.

Gavi’s policy committee has approved a $1 billion investment in a partnership with the Africa CDC to support the development of African vaccine manufacturers. This decision will be discussed by the body’s board in December, Kaseya added.

The Mastercard Foundation is also playing a major role in supporting Africa CDC and African countries to build their capacity to vaccinate their populations.

The Mastercard-sponsored ‘Saving Lives and Livelihoods initiative’ is focused on vaccinating high-risk populations, integrating the COVID-19 response into routine immunisation and preparing for potential future pandemics.

Full house at the opening of CPHIA2023

One more step to ‘decolonise’ research

However, Dr John-Arne Røttingen, Norway’s Ambassador for Global Health and Wellcome Trust CEO designate, said that improving manufacturing “isn’t enough” as Africa needs to build an entire “biomedical system”.

Addressing the opening plenary, Røttingen said that global health had come a long way since the era of colonial researchers but that this process of “decolonisation” needed one more step – “African health research systems led by Africans”.

“It is not just about the undoing but the doing,” urged Røttingen.

Also addressing the plenary, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyusus said that he was elected as the first African head of the global body because the continent stood together to support one nomination.

Subsequently, this unity had enabled Africans to be elected to head the World Trade Organization, UNAIDS, the International Labour Organisation and other UN bodies, he added.

“It is very important for Africa to continue to be united,” Tedros urged.

Meanwhile, Kaseya said that the Africa CDC had built “health diplomacy” between African countries.

“Even if you are fighting politically, even if you are fighting military a disease outbreak will cross the border without your permission. This is why Africa CDC has a global diplomacy department to facilitate dialogue between countries between communities and to ensure that all of them have access to support to commodities when they need them.”

African-led health initiatives

Zambia’s Minister of Health, Sylvia Maseko, said that the purpose of the conference is “to reposition Africa in the global health architecture”.

“Some of the key achievements that we have made so far include approval and launch of the Africa CDC strategic plan 2023 to 2027, which outlines a clear roadmap to address the continent’s health challenges, strengthen public health systems, and ensure a coordinated response to emerging threats,” said Maseko.

“Secondly, we have done the formation and inauguration of the new Africa CDC advisory and technical Council and we have inaugurated the new governing board of the Africa CDC, which saw me as the new chairperson,” said Maseko. 

Meanwhile, CPHIA co-chair Professor Margaret Gyapong said that the continent had made major scientific advances in the last few years, including in digital disease surveillance, and building public-private partnerships.

“African scientists and researchers are leading the charge in developing groundbreaking vaccines tailored to address regional disease burdens, including malaria, tuberculosis and HIV and AIDS,” said Gyapong, who directs the Institute of Health Research at the University of Health and Allied Sciences in Ghana.

“Groundbreaking initiatives such as the RTS,S malaria vaccine demonstrates the significant contribution of African scientists and researchers in collaboration with national centres and organising for address regional disease burdens.”

Gavi’s interim CEO, David Marlow, said that the vaccine platform had set up the African Vaccine Manufacturing Accelerator to assist with the development of manufacturing capacity on the continent “and it would be ideal if malaria was a priority antigen”.

Professor Margaret Gyapong, Africa CDC Director General Dr Jean Kaseya and Zambian Health Minister Sylvia Maseko

Massive debt repayment challenges

Despite the upbeat tone of the speakers, some of the challenges facing the continent were also acknowledged. Only 28% of health facilities have electricity, for example, 70% of maternal deaths happen in Africa and the continent has a significant shortage of skilled healthcare workers.

In addition, COVID-19 has decimated the already weak economies of many of the 55 African member states and many simply don’t have money to invest in their health systems. 

In 2021, CPHIA host country Zambia was the first to default on its debt repayments as a result of COVID, although last month announced that it has restructured $3 billion of its international bonds with creditors. Mali briefly defaulted by has resumed payments, but Ghana has also stopped servicing its debt. 

Chad, Ethiopia, and Malawi have opted to restructure their debt. However, in the process of doing so, Malawi devalued its currency by 44% earlier this month and this is likely to drive citizens in one of the world’s poorest countries further into poverty.

Climate change is also a major threat to the continent, with the African Development Bank estimating that it is losing between 5-15% of its GDP due to climate change.

“Do you know that we have 18 countries today affected by cholera, and that is the effect of climate change with 4,000 deaths? Do you know that dengue in West Africa is also the effect of climate change?” Kaseya asked the media briefing.

“You saw the flooding in Libya. Climate change is affecting us. And this is why Africa CDC decided to implement a One Health approach to address the issue of climate change, animal health and human health.”

Aerial view of Accra, Ghana. Traffic, waste burning and desert dust all combine to make pollution a problem in this fast-growing city.

Africa is home to many of the world’s fastest-growing urban centres – and a crisis of air pollution faces the continent’s rapidly expanding cities, according to a new Clean Air Fund report released Thursday. 

Africa, home to the world’s youngest population, is expected to see its population nearly double by mid-century, reaching 3.9 billion by 2100. 

Over 65% of Africa’s population will reside in urban areas by 2060, with the continent potentially hosting five of the world’s ten largest megacities by the end of the century, according to the report. The 600-mile coastline stretching from the Nigerian capital of Lagos to Abidjan in Cote d’Ivoire alone is projected to be home to around half a billion people by 2100. 

Africa’s rapid urbanization is providing an engine for its fast-growing economies, but there is a significant hidden cost: air pollution.

“The challenges that flow from rapid urbanization across the continent are immense, including drastic increases in air pollution and greenhouse gas emissions, which if unchecked will bring disastrous consequences for human and economic health,” Kevin Urama, Chief Economist at the African Development Bank, explained in a statement accompanying the report’s launch. 

Across the six cities, potential reductions in greenhouse gas emissions vary, with some achieving a reduction of up to 35%, resulting in a collective avoidance of 0.8 Gt CO2e. (BAU = business as usual)

The study focuses on six major and rapidly expanding African cities—Accra, Cairo, Johannesburg, Lagos, Nairobi, and Yaoundé. Air pollution led to over 56,400 premature deaths across the six cities in 2022, costing a minimum of $2 billion, the report found. Toxic air claimed an estimated 1.1 million lives across Africa in 2019—surpassing the combined toll of tobacco, alcohol, motor vehicle accidents, and unsafe water. 

Road traffic is identified as the largest contributor to PM2.5 air pollution concentrations across the six cities studied, accounting for 30% and 40% of PM2.5 concentrations in Lagos and Accra, respectively.

Other culprits include industrial activities, power plants, biomass fuels, and waste mismanagement. As the cities grow and their populations rise, emissions from these sources are set to skyrocket. More people will require more cars, energy, and fuels, and create more waste, leading to a spike in air pollution. 

If current trends persist, the financial toll of air pollution in Africa’s major cities could surge more than eightfold by 2040, the report found. The cost will also be paid in over one million premature deaths by 2040 – 109,000 of which can be saved by implementing policies to combat air pollution. 

“On the current trajectory, following a ‘business as usual’ approach means air pollution will collectively cost Accra, Cairo, Johannesburg, Lagos, Nairobi, and Yaoundé an estimated $138 billion in premature deaths and worker absenteeism over the next two decades,” said Urama.

Opportunities to change track 

Implementing policies to reduce air pollution could prevent a total of 109,000 premature deaths across the six cities between 2023 – 2040, according to the report.

Despite the grim outlook, the report presents a roadmap to avert the potentially catastrophic consequences of air pollution . It emphasizes the potential for substantial economic benefits—billions of dollars saved, reduced deaths, improved public health, lower emissions, and decreased poverty—of implementing policies promoting green growth.

The report urges African governments to review high-emitting sectors at the national level, including energy, transport, industry, power production, agriculture, and waste management.

By identifying ways to reduce air pollution in these sectors, governments can simultaneously address climate change, and create opportunities for green economic growth. The report emphasizes the need to enshrine air quality targets into national and district-level laws, ensuring long-term commitment beyond political cycles.

City mayors and local government leaders are urged to adopt low-cost, low-maintenance air quality monitoring devices to gather comprehensive data for evidence-based decision-making. These devices will enable cities to pinpoint pollution hotspots, track trends, and assess the effectiveness of mitigation strategies.

As more governments and municipalities embrace air monitoring technologies, data sharing can also be enhanced across borders and within countries, empowering local and national authorities to formulate evidence-based policies on air quality-related public health matters.

Accra could unlock $25m, Johannesburg $55m, Nairobi $23m and Yaoundé $27m in 2040 alone by implementing clean air measures.

Across Accra, Cairo, Johannesburg, Lagos, Nairobi, and Yaoundé, implementing clean air measures such as upgrading public transport and adopting cleaner cookstoves could save over $19.2 billion across the six cities by 2040.

In Accra, which will host the first-ever World Health Organization (WHO) air pollution summit in 2024, the economic impact of air pollution, including absenteeism and premature mortality, is expected to quadruple between 2019 and 2040. However, the city could unlock over $25 million in 2040 alone through implementing measures to reduce air pollution.

While the report’s financial projections are significant, it acknowledges that the true benefits could be even greater, considering the positive ripple effects on healthcare, agriculture, productivity, and the environment.

“The projected benefits from air quality action are expressed in this study in financial terms, but these financialised benefits should not be understood to mean tangible funds raised or costs saved,” the report notes. “The co-benefits gained from air quality action provide greater cost-effectiveness that recycles into local economies, strengthening health systems, businesses and government finances.”

By implementing clean air measures, such as upgrading public transport and cleaner cookstoves, these six cities could save over $19.2 billion between 2023 – 2040.

The report also highlights the startling lack of international and multilateral development funding to fight air pollution in Africa, with only 5% of total aid directed at reducing air pollution on the continent.

In Lagos, a city home to nearly 16 million people, the official development funding directed toward air pollution from 2015 to 2020 amounted to a mere $0.25 million. Air pollution claimed 70,000 in the city in 2019 alone. 

Between 2015 and 2021, donor governments provided a stunning 36 times more aid for prolonging fossil fuel use in Africa than tackling air pollution, despite the continent facing temperatures warming faster than the global average.

The report calls on international and multilateral development banks to provide increased technical support to assist countries in accessing green funds, dedicated funds for financing air quality data monitoring capacities are recommended, acknowledging the critical role such data plays in obtaining other climate financing.

“It is well understood that tackling poverty, bringing clean water to people everywhere, and investing in education are all critical to Africa’s development,” said Urama. “Ensuring our citizens can breathe clean air is also a vital, but too often neglected, piece of this puzzle.”

Image Credits: WHO/Blink Media, Nana Kofi Acquah.

Dr Margaret Chan former director of the World Health Organization, in a University of Geneva panel session with public health students Youjia Liu and Tingkai Zhang,

On her first visit back to Geneva since leaving her post as WHO Director-General in 2017, Dr Margaret Chan urged public health students to recognize “the power of collaboration” and to  “use their voice” to hold policymakers accountable for the changes that the promises that they make. 

“When I was in WHO, there were a lot of negotiations, a lot of resolutions.  But do you think countries kept their promises?” she asked. “We are waiting for the day when leaders of countries walk their talk. But you have a voice. Use your voice in a system that you know well, to advocate.” 

Chan, now Dean of the Vanke School of Public Health in China, was speaking at last week’s event “One Planet One Health”  co-sponsored by the University of Geneva and the Geneva Health Forum.  

The event brought together Chinese students from Vanke with counterparts from the University of Geneva’s Institute of Global Health – as part of an academic collaboration forged between the two institutions after Vanke opened its doors under Chan’s leadership in 2020.   

Geneva at the heart of ‘One Health’ efforts 

In a presentation preceding her panel discussion with three Geneva and China-based students, Chan declared that Geneva, home of the WHO, the World Meteorological Organization and countless other civil society and research institutions, needs to also be the heart of One Health efforts. 

Those efforts bring together action on climate change with action on new disease threats that are emerging at an evermore rapid pace, with changes in climate, deforestation and the loss of biodiversity, she said.  

“One cherished memory I have of my time in Geneva was the sight of my friends heading to ski,” she recalls, of her 15 years living in Switzerland, beginning with her first WHO appointment in 2003 as the director of the Department of Public Health and Environment.  

“Their faces were aglow with excitement as the world around them was painted in a pristine blanket of white. 

“Yet this year paints a different picture,” she said, referring to the weeks of rain that the city has seen this November. “The familiar white landscape … and the thrill of skiing is replaced by a visible absence of snow. 

“This … my friends, is climate change, reshaping the city and the world we all love. This is a reflection of a broader global shift -from the dwindling expenses of the Amazon rainforest and the melting Siberian permafrost to the receding snow cover of the Tibetan plateau and the vanishing ice sheets in West Antarctica. And these aren’t isolated incidents. They are interconnected sides of our earth’s transformation.

“As of 2023, we have surpassed nine out of the 14 tipping points of our earth’s system, changes that are irreversible and leading to abrupt shifts in our environment. 

“Climate change, as I have said many times, is a defining issue of the 21st century. Climate variables affect the air we all breathe, the water we drink, the food we eat and even where we are able to live.  Extreme weather events are becoming the norm and records are constantly being broken, she said ravages of the past summer in the northern hemisphere. 

“Beijing, the city I know better, suffered record-breaking heat waves. Then, Beijing again was inundated by the heaviest rainfall in 140 years. Another example. Hawaii. It is known for its beauty.  Now it is scarred by wildfires that ravaged Maui. Florida’s ocean temperature reaches a staggering 38 °C. And right here in Geneva, the World Meteorological Organization delivers sobering news of the hottest June ever recorded. 

“As UN Secretary-General Antonio Guterres commented, ‘The era of global warming has ended. The era of global boiling has arrived’.”

Nature never deceives us

From left to right: Dr. Ilona Kickbusch, moderator, with students Kailing Marcus, Youjia Liu, Tingkai Zhang, and former WHO Director General, Dr Margaret Chan.

“Grand challenges require grand actions,” Chan added. “In the historic 2015 Paris Agreement on climate change, countries made important commitments to cut greenhouse gas emissions and scale up adaptation, adaptation to climate change. 

“The Paris Agreement is not just a treaty for saving the planet from severe and irreversible damages. It is also a significant public health treaty with a huge potential to save lives worldwide,” added Chan, speaking just two weeks before the UN Climate Conference COP 28 in Dubai launches the third global “stocktake” of progress made, eight years on.  

And despite the critical importance of a more rapid fossil fuel phase-out, “the energy transition, switching from fossil fuels to renewable renewable energy are just a part of the solution,” Chan pointed out. 

Interconnected web

The other side of the climate coin is a ‘One Health’ approach recognizing that “humans along with the animals and plants around us, and the environment that nurtures us, are all part of a single interconnected web, Chan said. 

Even before arriving in Geneva, Chan had considerable experience with the threats that nature can unleash on human health.  As the Director of Public Health in Hong Kong, she had to meet the challenges there of the first H5N1 (Avian flu) outbreak in 1997, followed by the SARS outbreak in 2003.  

Arriving at WHO in 2003, she oversaw some of the agency’s early initiatives on climate, health and biodiversity as head of the Department of Public Health and Environment. Later, as Director-General, she was faced with the unprecedented challenge of the West African Ebola outbreak between 2014 and 2016, one of the most deadly seen on the continent in modern times. 

Recognizing the intricate relationship between animal-borne pathogens and human infections, she helped advance the early phases of the  “Tripartite” Collaboration on One Health involving  WHO, the Food and Agriculture Organization and the World Organization for Animal Health. 

“The majority of new pathogens are caused by diseases of animals that spread to humans, such as flu, rabies, SARS and COVID 19,” said Chan in her lecture. “This is especially an issue in the context of climate change.  Why?  Because climate change is a threat multiplier.  Existing threats can be spread to a new geographically area.  

“For instance, the emergence of Nipah virus and Hantavirus as human pathogens has been traced to extreme weather events that forced more animal hosts to leave their ecological niches and invade human settlements.

“In the past 30 years. of the new human pathogens identified, and an astonishing 75% can be traced back to animals,” she said.

“The message is loud and clear. We need to adopt the One Health approach recognizing and respecting a symbiotic relationship between humans, animals and our shared environment. 

“The one health approach is an integrated approach to tackle global health threats,” Chan declared. “Prevent, predict, and respond. It is high time we adopt a holistic perspective.”

Along with climate action and action to preserve the integrity of the natural world that is the fundamental basis for human life, equity is yet one more dimension to the One Health approach, said Chan. 

“We often delve into the deep interconnections between humans, animals and the ecosystem. Yet, at the core of this idea, lies another profound truth – the essence of not distinguishing one human from another,” she said. 

“Regardless of our diverse backgrounds, culture and beliefs, we are all Homo sapiens. It is high time we adopt a holistic perspective, looking at humanity as one cohesive unit right here in the heart of Geneva.

Dr Margaret Chan

From dean to student  

In a subsequent panel discussion, Chan and three students from Tsinghua University exchanged views on how they, as young people, could act on the challenges in public health, their own professional path and facing their generation. 

Youjia Liu, a student at Tsinghua University, described her experience last summer carrying out public health research in the remote mountain villages of Cambodia, which sensitized her to the difficulties of people accessing regular health care at a time when there is also a lot of migration along the border and changing patterns of malaria.

“We always talk about this access to health care,” she said. “And it seems like something that only local governments can really work on. But what can we do? This is related to the topic, One Climate, One Health. People live in remote areas and are actually very vulnerable groups.”

“I don’t really have a good answer for you,” said Chan, noting that the lack of healthcare workers in ‘last mile’ regions of the world is a longstanding problem happening in many countries of the world. 

“But you mentioned the local government. These people need to speak out. And your duty is to teach them to speak up. Okay? Don’t take things for granted. And of course, that is easier said than done. This is the reality we live in. 

Citing the collaboration between the two universities as an example of cross-cultural collaborations, Chan urged students to “take the lead to address these global challenges.

“In English, Tsinghua’s University’s motto translates into ‘self discipline and social commitment’,” Chan stated. 

“Young people in universities are privileged, and it is their duty to confront these challenges. The path may be arduous, but with determination and unity, there is no summit we cannot reach. 

“I urge you, don’t give up hope.  Can you imagine? I was Director-General in the era of the MDGs [Millennium Development Goals] remember? The world is a better world now compared to the time when we were dealing with MDGs. So continue to make the effort. Don’t give up.”