Global spending on health increased during 2021 at the height of the COVID-19 pandemic, reaching a record $9.8 trillion or 10.3% of global gross domestic product (GDP) – mostly as a result of governments devoting more domestic resources to health,

Country spending was highest on hospitals, accounting for 40% of expenditure, followed by ambulatory care (outpatients) providers (19%–24%) and pharmacies (16%–23%). 

The fastest growth in spending was on preventive care providers, such as public health institutions and disease control agencies. 

This is according to the World Health Organization’s (WHO) Global Health Expenditure Report 2023, based on data from 50 countries.

However, the per capita spending was “unequal”, the report notes, with high-income countries spending an average of $4001 per person in comparison to a mere $45 in low-income countries. Upper-middle-income countries spent $531, which was substantially more than the $146 per person in lower-middle-income countries.

“The distribution of global spending on health remained highly skewed in 2021: 79% was in high-income countries, which are home to less than 16% of the world population,” according to the report. 

“Low-income countries accounted for only 0.24% of the global health expenditure, despite having an 8% share of the world’s population.”

Spending on COVID-19 rose in real terms in 39 of 48 countries with data, accounting for 11% of government and compulsory insurance health spending in 2021, up from 7% in 2020. 

There was “no evidence” that the additional COVID-19 spending meant countries spent less on other diseases, or that spending on COVID-19 vaccines meant less money for testing and treatment, the report finds, stating: 

“The analysis suggests that the increased spending for COVID-19 did not crowd out spending for other health needs, although it might have affected the rate of growth of spending for these other purposes.” 

In addition, out-of-pocket spending on health in low-income countries fell in 2020 and 2021 but rose to pre-pandemic levels in high, upper-middle and lower-middle-income countries in 2021 after a decline in 2020.

Lack of data on spending patterns

The WHO said that action is still needed at the domestic and international levels to improve data collection on spending patterns. 

“While most countries regularly report aggregated health spending data, few consistently report the critical details that underpin these high-level results. Accordingly, only a partial view of the spending dynamics during the COVID-19 pandemic – by provider, function, and disease and condition – is possible in this report.”

The report also notes the lack of information on health capital investment “which limits the insights into this critical area of health policy”. 

“More effort is needed, therefore, to improve data collection and increase the number of countries developing and reporting disaggregated health account data. Key to this is institutionalising health account practices at the country level.”

Hard to sustain higher spending levels

External aid was “crucial” in supporting government spending in 2021 in low and lower-middle-income countries. However, sustaining government health spending and external aid at 2021 levels may be challenging given “the deterioration in global economic conditions and the rise in debt-servicing obligations”.

“Amid this more difficult financing environment, a key challenge for countries will be to resist the urge to de-prioritize government spending on health. Doing so risks rolling back progress towards universal health coverage,” according to the report.

Image Credits: WHO African Region , WHO PAHO.

Dr Anshu Banerjee, WHO director for maternal, newborn, child, adolescent health and ageing, described the new guidelines as “a tool to support a holistic approach to chronic low back pain care”.

The World Health Organization (WHO) has released its first guidelines for addressing low back pain, a condition affecting an estimated 619 million people, or one in 13 worldwide.

The new guidelines are designed to enhance care quality for millions suffering from the condition, offering healthcare professionals a range of non-surgical treatments applicable in primary and community care settings. The guidelines also list treatments to avoid, including lumbar braces, traction-based physical therapies, and opioid painkillers.

The prevalence of low back pain is expected to surge as the global population ages, with estimates predicting a rise to 843 million affected individuals by 2050. Low back pain currently accounts for 8.1% of years lived with disability globally, according to the WHO.

“To achieve universal health coverage, the issue of low back pain cannot be ignored, as it is the leading cause of disability globally,” said Dr Bruce Aylward, WHO assistant director-general for universal health coverage and life course, in a press release accompanying the guideline launch.

Nine out of ten cases of low back pain are chronic, deeply affecting patients’ ability to work and stay active in family and social life, often leading to broader economic and mental health consequences. The guidelines emphasise mental health care as crucial in treating these conditions.

Chronic low back pain also has significant economic repercussions at the national level, pushing individuals out of the workforce and straining health systems.

The annual global costs associated with low back pain exceed $50 billion and potentially reach up to $100 billion at the upper end of estimates, according to the British Medical Journal. This financial impact is especially pronounced in low- and middle-income countries (LMICs), where 80-90% of employment involves heavy labour, significantly increasing the prevalence of LBP compared to high-income nations.

The WHO guidelines provide a multifaceted approach to treatment, emphasising patient education in self-care techniques, structured exercise programs, spinal manipulative therapy, and massage, while cautioning against certain treatments like traction and therapeutic ultrasound.

WHO officials emphasised that while the guidelines provide a general framework, adapting them to local clinical practices is essential for effective implementation.

“Addressing chronic low back pain requires an integrated, person-centred approach,” said Banerjee. “This means considering each person’s unique situation and the factors that might influence their pain experience.”

Recognising low back pain as a national health priority is crucial for optimising healthcare management in this area, WHO stressed – a step many countries have yet to take.

Image Credits: Adam McGuffie.

Vidya Kishnan and Garry Aslanyan on "Dialogues," a new series from the Global Health Matters podcast.
Vidya Kishnan and Garry Aslanyan on “Dialogues,” a new series from the Global Health Matters podcast.

The elimination of tuberculosis cannot be achieved if medicines are locked in a “patent panoply,” according to Indian author and journalist Vidya Kishnan.

Speaking to Garry Aslanyan on the most recent episode of Dialogues, a new series from the Global Health Matters podcast, the author of “Phantom Plague: How Tuberculosis Shaped History” said that “everything that happened in COVID has been happening for decades with TB.

“In India, the entire TB program got ‘Covidized,’ down to the helpline of the Ministry [of Health], and infections and respiratory diseases don’t simply go away,” Kishnan said. “So, the first thing we need to do is look at how technology is transferred because vaccines and drugs first and foremost, it’s technology. It’s somebody’s intellectual property. And I feel like TB elimination cannot, will not be achieved if the medicines, the latest most humane therapy, is locked in a patent panoply.”

The most exasperating aspect, according to Kishnan, is that the advancements in tuberculosis therapies resulted from a sincere collaboration within the public domain. Universities, student funds, and philanthropic contributions collectively supported these efforts. Notably, several late-stage clinical trials for bedaquiline took place in India and South Africa, with patients actively contributing to the process.

“It’s really unfair that you use patients for research, but then when … all of these drugs came out of industrial scale subsidies to pharmaceutical companies, and others in patent panoplies.”

Throughout her writing career, Kishnan has dedicated considerable effort to investigating and documenting the profound impact of tuberculosis on individuals from various backgrounds in India. In her book, she delves into critical questions concerning the intersection of race and caste within policies that shape the dynamics of tuberculosis spread and control in the contemporary context of her home country.

Kishnan tells Aslanyan that in India, people live in congested cities and are still segregated by race, caste, and class. Pathogens do not respect these boundaries. However, the rich generally access medicines, whereas the poor are left behind.

In India, tuberculosis has reemerged as the foremost infectious disease killer. She said the lessons from previous pandemics underscore a fundamental truth: No one can be considered safe until everyone is protected from the threat.

“I feel like a stuck record saying this over and over again everywhere I speak. But it was quite surreal to see the science denialism and the racism and casteism in my country, all of the things I had read about, the xenophobia, all of it just came to life in the past three years,” Kishnan said. “If we are greedy and if we think in these myopic ways, I don’t see any way we will prevail over these pathogens despite all the fruits of modern medicine.”

Aslanyan concluded: “This conversation reminds us, as global health professionals, of many challenges on the long road ahead toward the ultimate goal of tuberculosis elimination and the importance of community engagement.”

Listen to previous episodes of Dialogues on Health Policy Watch.

Image Credits: Global Health Matters (TDR), Global Health Matters Podcast (TDR).

Dr Olivi Ondchintia Putilala Silalahi, WHO Indonesia national professional officer for routine immunization, inspects a COVID-19 vaccination site in Indonesia.

A spike in COVID-19 cases in Southeast Asia has prompted Indonesia, Singapore and Malaysia to reintroduce screening for travellers at airports.

In the past week, Indonesia has installed thermal body scanners at Jakarta International Airport and the main ferry line.

The Bali Port Health Office has also implemented thermal checks at three border entry points: Benoa Port, Celuk Bawang, and I Gusti Ngurah Rai International Airport, and appealed to travellers to wear masks – particularly if they are feeling unwell.

Should a tourist or foreign national test positive for COVID-19 upon arrival, they will be immediately quarantined in a designated health facility or referral hospital in Bali, according to a circular issued this week by the Ministry of Health.

The Indonesian health authorities have also urged citizens to wear masks, ensure they are fully vaccinated and postpone travel to areas that are reporting a spike in COVID-19 cases.

https://twitter.com/BloombergAU/status/1735242493136920598

Jump in cases in Singapore

In Singapore, COVID cases increased by 10,000 in a single week, jumping from 22,000 to 32,035 in the week ended 2 December, according to the health ministry.

“The increase in cases could be due to a number of factors, including waning population immunity and increased travel and community interactions during the year-end travel and festive season,” said the Ministry of Health. 

“We urge the public to exercise precaution, personal and social responsibility,” said the Singaporean Health Ministry.

“When travelling overseas, stay vigilant and adopt relevant travel precautions, such as wearing a mask at the airport, purchasing travel insurance, and avoiding crowded areas with poor ventilation.”

“Everyone is advised to keep up to date with their COVID-19 vaccinations. This includes an additional dose around one year after their last vaccine dose for those aged 60 years and above, medically vulnerable persons, and residents of aged care facilities,” it added.

Malaysia COVID cases: 14 December 2023

Meanwhile, cases in Malaysia doubled in a week, jumping from 6,796 cases at the end of November to nearly 13,000 by 9 December, according to the New Strait Times.

Malaysian Health Minister Dzulkefly Ahmad recommended on Thursday that people wear masks and get a COVID-19 booster if they were elderly or had co-morbidities, according to the Strait Times.

Image Credits: WHO Indonesia.

Rush hour traffic in Ho Chi Minh City in Vietnam.

Ten countries have slashed their road traffic deaths in half between 2010 and 2021, while  35 others have reduced deaths by between 30% and 50%, according to the World Health Organization’s (WHO) Global Status Report on Road Safety 2023 released this week.

The big achievers are Belarus, Brunei, Denmark, Japan, Lithuania, Norway, Russia, Trinidad and Tobago, United Arab Emirates and Venezuela.

Meanwhile, there was an overall global reduction in deaths of 5% over the period, with 1.19 million people dying per year.

“Yet with more than two deaths occurring per minute and over 3,200 per day, road traffic crashes remain the leading killer of children and youth aged 5–29 years,” according to the WHO.

“The tragic tally of road crash deaths is heading in the right direction, downwards, but nowhere near fast enough,” says WHO Director-General, Dr Tedros Adhanom Ghebreyesus. “The carnage on our roads is preventable. We call on all countries to put people rather than cars at the centre of their transport systems, ensuring the safety of pedestrians, cyclists and other vulnerable road users.”

The majority of road traffic deaths occurred in the WHO’s South-East Asia Region (28%), followed by the Western Pacific (25%), African Region (19%), the Americas (12%), and the Eastern Mediterranean Region (11%). The least occurred in the European Region (5%).

Some 90% of deaths occur in low- and middle-income countries (LMICs), and the risk of death is three times higher in low-income than high-income countries despite low-income countries only having 1% of the world’s motor vehicles.

More than half of fatalities occur among pedestrians, cyclists and motorcyclists, in particular those living in LMICs. Pedestrian deaths rose 3% to 274,000 over the decade, accounting for 23% of global fatalities. Deaths among cyclists rose by nearly 20% to 71,000, accounting for 6% of global deaths. 

“Research indicates that 80% of the world’s roads fail to meet pedestrian safety standards and just 0.2% have cycle lanes, leaving these road users dangerously exposed. And while nine in 10 people surveyed identify as pedestrians, just a quarter of countries have policies to promote walking, cycling and public transport,” according to WHO.

The report also reveals an alarming lack of progress in advancing laws and safety standards. Only six countries have laws that meet WHO best practice for all risk factors, namely speeding, drunk driving, compulsory motorcycle helmets, seatbelts and child restraints.

The global motor vehicle fleet is set to double by 2030, but only 35 countries – less than a fifth of UN Member States – legislate on all key vehicle safety features, while only a quarter require vehicle safety inspections that cover all road users.

“Our mission at Bloomberg Philanthropies is to save and improve as many lives as possible, and one of the best ways to do that is to make more of the world’s roads safe for all,” said Michael R. Bloomberg, founder of  Bloomberg Philanthropies, which supports a substantial global road safety programme.

“For more than a decade now, we’ve made encouraging progress together with the WHO and our partners. Still, as this new report makes clear, road safety demands stronger commitments from governments worldwide – and we’ll continue to urge more leaders to take lifesaving action,” added Bloomberg, who is the WHO’s Global Ambassador for Noncommunicable Diseases and Injuries.

Image Credits: tph567/Flickr, Flickr/ M M.

The outsized effect of climate change on young children represents an “intergenerational injustice”, according to experts speaking at a side event on maternal and child health at COP28 in Dubai. 

“Nearly 90% of the global burden of disease associated with climate change is borne by children under the age of five,” according to UNICEF. 

“Climate change has already had an impact on heat-related child mortality in sub-Saharan Africa. The annual average heat-related child mortality for the period from 2005 to 2014 was approximately under 20% higher than would have been observed without climate change. This so-called ‘climate penalty’ will be worse over the coming years,” said Veronique Filippi, Professor at the London School of Hygiene and Tropical Medicine. 

There is also compelling evidence that heat can increase the risk of preterm births, stillbirths, hypertension as well as preeclampsia, she said.

“There are no physiological reasons why pregnant women or newborns are more vulnerable to the health impact of environmental disasters,” emphasized Filippi. “The main reason for vulnerability is the position of women in society, their limited agency and mobility.” 

Dr Anshu Banerjee, Director of Maternal, Newborn, Child and Adolescent Health and Ageing at the World Health Organization (WHO) said that while global carbon emissions have to be reduced, health facilities also have to be equipped with solar power and cooling facilities for patients. 

“For every climate-related project proposal, we should make sure that it has a maternal, child, adolescent health impact lens as well,” he said. 

WHO’s Dr Anshu Banerjee.

Evidence gaps

While there is growing evidence of the different ways climate change affects pregnant women and young children, there continue to be gaps which affect the response.

“Most of the evidence is related to the effects of air pollution, followed by temperature and the effect of disasters, food insecurity, and water access,” Filippi said. 

Angela Baschieri, UNFPA’s Technical Lead on Climate Change, reiterated that it was important to generate “evidence that helps us to inform how we design program as well as the evidence that we need to ensure that we are targeting and we are reaching those who are left behind or may be more exposed”. 

Only 23 national climate action plans out of 119 reviewed by UNFPA have made some reference to maternal and newborn health. These responses have largely been community-led interventions, Baschieri said.
Improving basics like water and sanitation, as well as involving community healthcare workers emerged as some of the key responses that experts said are known to deliver results.

Improve basics like water access

Nobel Prize-winning economist Michael Kremer from the University of Chicago said ensuring communities have basics like clean drinking water can go a long way in responding to worsening climate impacts.

“First, cyclones, floods and heavy rains spread pathogens into drinking water sources causing disease spikes,” he said. “Second, droughts can force people to move to less safe water sources. Finally, increased temperatures can accelerate the growth of pathogens and water,” he explained, elaborating on the climate change and poor water quality link. 

Kremer said water treatment provides a proven safe and cost-effective solution and could prevent a quarter of children’s deaths.

“Water treatment can save more lives than virtually any other health intervention,” he said. Kremer pointed out gains countries like India, Rwanda and Malawi have policies and pilot projects to improve the delivery of safe drinking water to populations. 

“Water treatment has historically been neglected because it falls between the health sector and the water sector. And as many people emphasize, we need to move beyond the silos, particularly as climate change increases threats to water safety and health,” Kremer said.

Working with community-based health workers to improve healthcare delivery is a direct way to provide relief to pregnant women and children.

Nobel Prize-winning economist Michael Kremer

Community-based response

In 2022, when extreme rainfall worsened by climate change caused devastating floods in Pakistan,  over 100,000 pregnant women were affected, primarily because they could not access services.

“The breakdown that had happened in continuity of care led to so many adverse outcomes in maternal health,” said Neha Mankani, a midwife and project lead at the International Confederation of Midwives. 

“They did not have a safe place to give birth. There were abortion care services that they weren’t able to get, and there were newborn feeding issues that were happening,” she said, adding that community-based healthcare workers were a solution in times of crisis.

Neha Mankani, a midwife and a Project Lead at the International Confederation of Midwives

“We should look at climate change through a rights and human capital development lens and ensure that meaningful engagement of the most vulnerable. Women and children need to be engaged in setting policies because they are the ones who know how it affects them,” said Banerjee.

Image Credits: Guillaume de Germain/ Unsplash.

Caged animals held for sale and slaughter in unsanitary conditions at Wuhan’s Huanan Seafood Market prior to the outbreak of COVID-19, from top left: King rat snake, Chinese bamboo rat, Amur hedgehog, Raccoon dog, Marmot and Hog badger.

The powerful Group of 20 (G20) countries will host a high-level meeting on One Health in October 2024 to better prepare members to address the health of people, animals and ecosystems.

This was revealed by Alexandre Ghisleni, Brazil’s Global Health Ambassador, at a COP28 side event to launch an implementation guide for the One Health Joint Plan of Action devised by the four United Nations (UN) agencies.

Known as the quadripartite, the four are the Food and Agriculture Organization , UN Environment Programme (UNEP), World Health Organization (WHO) and World Organisation for Animal Health (WOAH).

“Brazil has been very supportive of the One Health approach,” said Ghisleni. “Evidence of this was the way we have handled the avian flu cases that we’ve had this year in our country.  It was only due to very close cooperation between the Ministries of Environment, Agriculture and Health, that Brazil was able to handle these cases satisfactorily.”

Brazil, which assumes the G20 presidency next year, will host the One Health meeting to “explore in detail and at length, all the aspects related to it so we can better face the challenges of our time”, he added. 

Alexandre Ghisleni, Brazil’s Global Health Ambassador

There has been heightened awareness about the need for a holistic approach to human, animal and environmental health since the deadly COVID-19 pandemic. Both SARS-CoV2, which caused COVID-19, and MERS-CoV originate in bats. Meanwhile, there is widespread speculation that the Huanan market in Wuhan, where wild animals were kept in unsanitary conditions, was the origin of the COVID pandemic.

Mpox and anthrax outbreaks, both originating in animals, have also surged over the past two years. There is growing awareness that countries need to contain zoonotic spillovers from animals to people, and One Health is featuring prominently in the current pandemic agreement negotiations being conducted under the auspices of the WHO.

Surging vector-borne diseases

On Tuesday, the European Food Safety Authority (EFSA) released a report on the most common zoonotic diseases in the European Union in 2022, noting that there had been a marked increase in West Nile virus, which is transmitted by mosquitoes.

“Climate change is increasing the surge of vector-borne diseases. That’s why today a One Health approach integrating human and animal risk assessments is the way forward” said Frank Verdonk, Head of EFSA’s Biological Hazards and Animal Health and Welfare unit.

The number of food-borne outbreaks in the EU increased by 44%, from 4,005 outbreaks in 2021 to 5,763 in 2022, associated with a wide variety of foods, ranging from meat and dairy products to fish and vegetables. 

Dr Ariane Hildebrandt, Director-General of Germany’s Ministry for Economic Cooperation and Development (BMZ)

Dr Ariane Hildebrandt, Director-General of Germany’s Ministry for Economic Cooperation and Development (BMZ), told the launch that a “multidisciplinary approach that considers the interconnection between health, climate and biodiversity is necessary” as,  “without a healthy environment, there cannot be health for human and animal life”. 

“We will continue to work towards the goal of reducing health risks in our partner countries, strengthening human and veterinary health systems, improving early warning systems, protecting biodiversity and thus contributing to epidemic and pandemic prevention,” she added.

The guide is an operational addition to the 2022 One Health Joint Plan of Action, and  outlines three pathways – governance, sectoral integration, and evidence and knowledge – and five steps to achieve One Health implementation.

“One of our main principles when developing the guide is to make it applicable to all countries, regardless of their status of One Health implementation, and acknowledges transdisciplinary and diversity of stakeholders.” Dr Amina Benyahia, WHO head of the One Health Initiative.

“The climate emergency has far-reaching consequences that threaten all life on earth. Direct factors like heat waves and floods as well as indirect factors like changes to disease spread due to changing weather patterns are just some of the risks to the health of animals, humans, and entire ecosystems,” said Doreen Robinson, the Head of Biodiversity and Land at UNEP.

Robinson added that an “early investment in inclusive and systemic One Health approaches ensures we’re tackling such interconnected, complex issues for a healthier, more resilient future for both people and planet.”

“Despite the growing awareness of the One Health approach in recent years, the world remains vulnerable to many global threats unless this approach is translated into policies and actions, and adequately and sustainably financed,” said Thanawat Tiensin, FAO’s director of Animal Production and Health Division.

At the first-ever health and climate day during COP28, 134 countries backed a Climate and Health Declaration to place health at the heart of climate action and accelerate the development of climate-resilient, sustainable and equitable health systems.

Image Credits: Nature .

DUBAI, United Arab Emirates – Black carbon is a super pollutant and its emissions are commonly seen anywhere you see black smoke – from a tiny kerosene lamp to a massive ship. The main sources include the burning of biomass, garbage dumps, diesel vehicles, coal-fired power plants, brick kilns, wood fires, wildfires and, on the high seas, ships.

Superpollutants are sometimes referred to as short-lived climate pollutants. Black carbon (BC) has a lifespan of just one or two weeks before it falls to the earth, in comparison to carbon dioxide which has a lifespan of a few hundred years in the atmosphere. 

But in this short span, its effects are devastating. Conversely, cutting its emissions can lead to rapid health and climate action benefits. 

Jane Burston is the CEO of Clean Air Fund (CAF), one of the four organisations that produced the report, The Case For Action On Black Carbon,  that was launched at COP28 over the weekend.

The other organisations were the Center for Study of Science, Technology, and Policy (CSTEP); Berkeley Air Monitoring Group, and Orbis Air.

She explains why, despite its short lifespan, BC’s global warming potential is as bad as carbon dioxide, the biggest contributor to climate change. 

“It’s black, so when it’s in the atmosphere, it radiates. It captures energy from the sunlight and radiates heat into the atmosphere. So even though it only stays in the atmosphere for up to a couple of weeks, it has a very high global warming potential. While it’s there, it’s as bad as a ton of carbon dioxide.”

Jane Burston, CEO of Clean Air Fund.

Threat to Polar Ice Caps, Himalayas, Andes 

While BC affects its immediate area the most, in the right conditions it can spread very far. It covers polar ice caps and glaciers in soot which in turn absorb more heat and trigger more melting. 

The retreat of the Himalayan glaciers has accelerated by 50% between 2012-14 because of BC warming and snow darkening, which in turn affects the monsoon. 

“It causes a different type of cloud formation and changes rainfall patterns. So we’ve seen black carbon in India changing monsoon rainfall pattern and in West Africa the Sahel similarly,” Burston told Health Policy Watch.

It’s not just Himalayan glaciers retreat that BC has been linked to, the report says it decreases Arctic sea-ice cover in summer, advances the western United States melting season, and increases run-off in the Andean glaciers.

Panel at COP28 on black carbon: (L-R) Dr Indu K Murthy, (CSTEP), Nina Renshaw (CAF), Michael Johnson (Berkeley Air Monitoring Group) and Paula García Holley (Clean Air Task Force).

Health impacts of black carbon

BC contributes to a significant chunk of PM 2.5, or particulate matter with a diameter of 2.5 microns or less which is microscopic. PM 2.5 is usually the most tracked air pollutant, according to the report. 

Annual deaths due to fine particulate and ozone air pollution are estimated to be 8.34 million, which is more than one in 10 deaths, according to a recent report in the BMJ. More than half (52%) of these deaths are due to heart attacks, strokes and pulmonary diseases including cancer. 

“The highest total attributable mortality occurs in China, with 2.44 million deaths per year, followed by India with 2.18 million deaths per year.” according to the BMJ, November, 2023.

BC is strongly correlated with increased blood pressure levels, a high-risk factor for cardiovascular disease and strokes. It affects pregnant women and has been linked to low birth weight. 

While it’s not clear exactly how many premature deaths are linked to black carbon, the report assumes two scenarios. If BC is assumed to be equally toxic as other PM 2.5 components then it is associated with 150,000 deaths worldwide. But if BC is “significantly” more toxic then widespread reduction of BC emissions has the potential to reduce premature mortality by as much as 400,000 annually over North India’s Indo-Gangetic Plain alone. 

Aerial view of a wildfire.

“I’ve been working on a study of household air pollution intervention that we’re proud of as it is the biggest randomised control trial looking at the health effects of transitioning from biomass stoves to clean cooking LPG,” said Michael Johnson, technical director of Berkeley Air Monitoring Group. “And we found the effects on birthweight to be more strongly linked with black carbon than with PM 2.5.”

Nina Renshaw, CAF’s head of health, has studied BC for two decades: “The thinking is that the black carbon within PM 2.5 may be actually more harmful than other components of PM 2.5. There’s still research to be done in that area. But what we do know is that black carbon is particularly damaging for cardiovascular health – heart attacks, disease, strokes, neurological damage, and so on. Black carbon has also proven to have an impact during pregnancy and birth outcomes, low birth weights and so on.”

‘No brainer’ – start cutting black carbon now 

The new report on black carbon fills a vacuum as there has been far less work on it than carbon dioxide, ozone and PM 2.5. There hasn’t been much global monitoring and there ought to be more studies on epidemiological evidence and toxicology for air quality regulations.

R Subramanian from the Center for Study of Science, Technology, and Policy (CSTEP)

R Subramanian, head of Air Quality at the Center for Study of Science, Technology, and Policy (CSTEP), Bengaluru, told Health Policy Watch: “As we are moving closer to the climate tipping points, we need more levers that we can control to avoid reaching those tipping points.” 

Renshaw says it’s a “no-brainer” to include cutting black carbon emissions as part of programmes to cut PM 2.5.

“Working on particulate matter, PM2.5 in particular, is a no-brainer. That is a WHO guideline, the International Agency on Cancer Research (IARC) says that this is carcinogenic and so on. We can begin to capture black carbon and do that. So let’s go down that route as an urgency and fill up the gaps as science allows.”

Indu K Murthy, CSTEP’s head of Climate, Environment, and Sustainability,  highlights another route, via government regulation: “We’re talking about cleaner energy and clean air which is a mandate of every government in any case. And you just have to kind of bundle it along with that till we get the metrics right.

Image Credits: Nick Sorockin/ Unsplash, Marc Szeglat/ Unsplash.

Anthrax of the skin, and anthrax bacteria.

Zambia is experiencing its worst anthrax outbreak in a decade, while four neighbouring countries – Kenya, Malawi, Uganda and Zimbabwe – have also reported outbreaks, according to the World Health Organization’s (WHO) Africa region.

By 20 November, four Zambians had died, with 684 suspected and 37 confirmed cases from nine of the country’s 10 provinces. Twenty-six people developed sores on their faces, arms, and fingers after eating the meat from three wild hippopotamus carcasses.

Beyond Zambia, a further 482 suspected cases have been identified, according to the WHO. Thirteen people have died in Uganda, three people have died in Kenya, and one in  Malawi. 

Anthrax is a zoonotic disease caused by a bacteria that occurs naturally in soil and mostly affects ruminants such as cows, sheep and goats. Humans develop the disease from infected animals or contaminated animal products, and almost always need to be hospitalised after infection as it causes serious illness.

People can start showing symptoms within hours or up to three weeks after exposure. By far the most common presentation is cutaneous (skin), with itchy bumps that rapidly develop into black sores. Some people then develop headaches, muscle aches, fever, and vomiting. These cases originate from people handling infected carcasses, hides, hair, meat or bones.

Gastrointestinal anthrax causes initial symptoms similar to food poisoning but can worsen to produce severe abdominal pain, vomiting of blood and severe diarrhoea.

Pulmonary anthrax is the most serious form, initially presenting as a common cold but can rapidly progress to severe breathing difficulties and shock. 

High risk of regional spread

“Due to the scale of the outbreak in Zambia, shared ecosystem with neighbouring countries and frequent cross-border animal and human movement, there is a heightened risk of regional spread of the disease,” according to WHO.

Anthrax cases are already spreading in areas along the basin of the Zambezi, Kafue, and Luangwa rivers.  Carcasses of wild animals that float on the rivers also increase the risk of international spread to neighbouring countries. 

“To end these outbreaks we must break the cycle of infection by first preventing the disease in animals. We are supporting the ongoing national outbreak control efforts by providing expertise as well as reinforcing collaboration with partner agencies for a common approach to safeguard human and animal health,” said Dr Matshidiso Moeti, WHO’s Africa Director. 

There is a vaccine for people and animals but there is limited stock, according to WHO. The Zambian government has vaccinated more than 122,000 cattle, sheep and goats with support from Food and Agricultural Organization (FAO).

A joint One Health task force comprising the Ministries of Health and Local Government has been conducting case finding in animals and humans. The country’s veterinary department is conducting meat inspections in abattoirs and butcher shops, while the Department of Wildlife and Parks is monitoring illegal animal movements and ensuring proper disposal of carcasses. 

“The outbreaks are likely being driven by multiple factors, including climatic shocks, food insecurity, low risk perception and exposure to the disease through handling the meat of infected animals,” according to the WHO.

Image Credits: Gavi.

WHO Executive Board meeting on the health and humanitarian situation in Gaza, Sunday

In a fragile show of unity, the World Health Organization Executive Board approved a draft resolution calling for “immediate, sustained and unimpeded” humanitarian relief to beleaguered Gaza, including safe passage of health personnel and supplies, as well as ambulances and patients. 

The WHO EB move, which will clear the resolution for approval by the May World Health Assembly, represents the first-ever consensus statement on the charged conflict so far in a UN body. The draft resolution  on “Health Conditions in the Occupied Palestinian Territory” carefully sidesteps any direct references either to Hamas or Israel in a charged conflict where both Israeli and Palestinian leaders, and their allies, have accused each other of genocide and war crimes. 

Sunday’s approval of the WHO EB resolution came just two days after another UN Security Council resolution calling for a humanitarian cease-fire in Gaza was vetoed by the United States because it did not condemn the initial Hamas 7 October attack on Israeli communities, which led to the deaths of some 1,200 people, mostly civilians, and the taking of more than 240 Israeli hostages. 

US deputy ambassador Robert Wood had called Friday’s UN resolution “imbalanced”, saying that a cease fire that left Hamas in power in Gaza would “only plant the seeds for the next war.” 

The WHO EB resolution, in contrast, focusses on humanitarian relief, making only one reference in the preamble to the broader UN “appeal for a humanitarian cease-fire.” Along with general calls for the free flow of aid and relief to besieged Palestinians, it also mandates WHO to lay plans for the rebuilding of Gaza’s shattered health system.

Operative paragraphs of the draft WHA resolution approved by the WHO EB on Sunday

Tedros: It is still possible to find common ground

“I commend you …. for being willing to collaborate and compromise … In our fractured and divided world it is still possible to find common ground on even the most difficult issues,” said Dr Tedros Adhanom Ghebreyesus at the close of the extraordinary day-long EB session. 

“Of course the adoption of this resolution is only a starting point. It doesn’t not resolve the crisis, but it’s a platform on which to build,” Tedros stated. 

Breaking with its own precedent in the UN Security Council, the US supported the resolution,  co-sponsored by Yemen, Morocco and Afghanistan – albeit with “reservations”.

Those reservations, said the US, also backed by fellow EB member Canada, included the omission from the text of references to the Hamas 7 October incursions, Hamas hostage taking, and its use of hospitals and civilians as shields for military activities – as well as the preamble reference to UN calls for an immediate cease-fire.

Convening an EB meeting devoted to a single health and humanitarian crisis was unprecedented in the annals of WHO. Although a resolution denouncing Russia’s invasion of Ukraine was approved by WHO’s World Health Assembly in 2022, it was addressed in the health assembly’s regular session, as were follow-up reports and motions in the February 2023 WHO EB meeting, and the May 2023 WHA session.

Gaza health system is ‘on its knees’ 

Gaza health system overview presented by WHO’s Dr Teresa Zakaria at the special EB meeting, 10 December 2023

In the debate just prior to Sunday’s EB vote, senior WHO officials provided a detailed report of the current health and humanitarian situation in Gaza, including a first-hand report from Gaza City.  

“More than 17,000 people are reported to have died in Gaza, including 7,000 children and we don’t know how many are buried under the rubble of their homes,” said Dr Tedros, in a summary of the WHO findings.

“More than 46,000 injuries have been reported. 1.9 million people have been displaced. Almost the entire population of the Gaza Strip is looking for shelter anywhere they can find it but nowhere and no one is safe in Gaza,” Tedros said.

Fighting between Israel and Gaza’s Hamas regime resumed on 1 December after the breakdown of Qatar- and Egyptian-mediated talks over further release of the 137 Israeli hostages still held by Hamas against Palestinian prisoners in Israeli jails and detention centres, estimated at some 7,000 people – a number that has swelled since the conflict began. 

The seven-day humanitarian cease-fire in late November saw the release of some 114 hostages, mostly Israeli women and children but also including 24 Thai and Filipino nationals, in exchange for some 240 Palestinians released from Israeli prisons. Many of the released Palestinian prisoners were also women and teenage minors, including some who had been detained but not charged. 

Nowhere to flee

View of Gaza destruction from the seat of a UN vehicle

The renewed fighting has seen a new Israeli thrust into Hamas strongholds deep in southern Gaza, where most of the enclave’s 2 million people fled during the first phase of hostilities, and are now living in tents, schools and on the streets. 

“As more and more people move to a smaller and smaller area, overcrowding combined with the lack of adequate food, water, shelter and adaptation are creating the ideal conditions  for diseases to spread,” Tedros said.

“As I have said repeatedly, I deplore the barbaric and unjustifiable attacks by Hamas on Israel on the seventh of October, which killed more than 1,200 people. 

“I’m appalled by reports of gender based violence during the attacks and by the mistreatment of hostages,” added the WHO director general, with reference to Israeli claims that women killed or kidnapped by Hamas on 7 October were raped and sexually abused.

“And I repeat my call for the remaining hostages to be released. I will understand the anger, grief and fear of the Israeli people following the horrific attacks two months ago,” he continued. 

“I also understand the anger grief and fear of the people of Gaza who had already suffered through 16 years of blockade and are now enduring the destruction of their families, their homes, their communities, and the life they knew. 

“It’s stating the obvious to say that the impact of the conflict on health is catastrophic. The Gaza health system is on its knees and collapsing.”

Gaza casualties still rising

Gaza fatalities continue to rise

While the majority of Israel’s 1,297 casualties were incurred during the initial Hamas attacks on Israeli communities on 7 October, within Gaza “the trend of fatalities continues to rise, placing a tremendous burden on the already weakened health system,” said Teresa Zakaria, WHO Health Emergencies official, reporting on the casualty trends.  

“The largest proportion of fatalities recorded were amongst children, 45%, and women, 30%,” Zakaria added, referring to the Hamas breakdown of Palestinian casualties. “The number of children killed in the three weeks following 7 October, surpassed the annual number of children killed in [all] conflict zones since 2019, she asserted, citing a recent Save the Children, report. 

There have also been over 250 fatalities amongst Palestinians in the Israeli-occupied West Bank, and 94 fatalities in Lebanon as the conflict spills over regionally, Zakaria noted. 

Hospital functionality and humanitarian aid

Overview of Gaza hospital bed capacity as of 9 December 2023

Against the flood of injuries, only 14 of Gaza’s 36 hospitals are still operating, and that only partially, Zakaria said.  Of those, 12 hospitals are in the southern part of the enclave, where most people have fled. Only three have surgical capacities, while other aspects of functionality are limited by lack of fuel supplies, food and clean water.  In addition several field hospitals are operating, under the auspices of foreign donors. 

According to Tedros, there have been a reported 449 attacks on health facilities in Gaza and the West Bank and another 60 attacks on health facilities in Israel.  

Added Zakaria, “the WHO surveillance system does not have a mandate to investigate attribution of attacks,” referring indirectly to critics who have said that some of the attacks on Gaza health facilities, attributed to Israel, involved misfired Hamas or Islamic Jihad missiles.  

The combined factors of displacement and crowded conditions, lack of adequate water and sanitation, and lack of medical capacity is leading to a rising level of respiratory and water-borne illness, meningitis, Zakaria added.

While humanitarian flows have increased, with a total of 3,000 aid trucks crossing into Gaza via Egypt’s Rafah cross since aid flows began in late October, “this is not nearly enough,” Zakaria said. 

“We needed 500 trucks per day. And even during the [humanitarian] pause only 220 trucks passed for one day to meet needs, we require more crossings,” she said, concluding that WHO is “glad to hear” that the Kerem Shalom border crossing between Israel and Gaza may reopen for humanitarian convoys.  

Scenes of devastation seen first-hand

Gaza City is “utter devastation” says the WHO Representative Rick Peeperkorn.

Speaking from Gaza, WHO representative to the Occupied Palestinian Territories, Dr Rick Peeperkorn, described the “scenes of utter devastation,” he had observed during his mission Saturday to Al Ahli Baptist Hospital, located in the epicentre of Gaza’s most war-battered northern district, which Israel now largely controls. 

“Gaza City has changed beyond belief,” Peeperkorn reported. “It’s utter devastation. It’s like a wasteland, even though there are still many people, children, old men and women around. There are not only patients in the wards, but also in the library, and even the church is crowded with patients on the floor, on stretchers, on chairs. 

“Having worked for more than seven years in Afghanistan, I’ve seen some grim situations.  I’ve never seen this before,” he said, describing doctors forced to perform amputations on wounded Palestinians because they lack the necessary surgical capacity, equipment and medicines to otherwise save the limbs. 

Palestine health minister: Israel targeting ever aspect of life in Gaza 

Palestinian Health Minister, Dr. Mai al-Kaila

Palestinian Health Minister Dr Mai el-Kaila, described the situation as an “unparalleled humanitarian catastrophe that defies international law and shatters the very sense of our shared humanity.”

“Israeli military occupation forces have relentlessly targeted every aspect of life in Gaza, sparing no one – from women, children, and disabled individuals to schools or hospitals, shelters, facilities and ambulances,” said el-Kaila, speaking from Ramallah, the seat of the Palestinian Authority, which has rallied to the side of its rival, Hamas, in the Gaza emergency. 

“Even the so-called safe corridors have not been spared, resulting in the loss of hundreds, of thousands of severe injuries, to forcibly displaced individuals,” el-Kaila said.  

She noted the risks posed by the degraded sanitary conditions where 160 people, on average,  share the same toilet and 700 people share a single shower.  

 “Some 400 tons of garbage per day are accumulating,” she noted, and “medical waste at hospitals is not removed. These factors lead to increased public health threats.

She called for the “unconditional and immediate entrance of humanitarian aid including food, water and medical supplies”; cessation to the “targeting [of] essential services such as health facilities, medical personnel, water, electricity and emergency services,” and a broader UN enquiry into the conduct of the war. 

“The international community must end impunity for Israeli occupied forces, and call the perpetrators accountable for the brutal actions and crimes. Now is the time for this action;  the word cannot stand neutral while innocent lives are lost and the basic rights of the Palestinian people are compromised,” she said. 

Israel: Hamas broke the ceasefire on 7 October 

Israeli Ambassador to the UN in Geneva, Meirav Eilon Shahar

Meanwhile, Israeli Ambassador to the UN in Geneva, Meirav Eilon Shahar, denounced what she described as the double standard being displayed by many countries, when it comes to Israel. 

“Today’s session is the only session ever convened here in Geneva on a specific conflict,” she said. “No special session was called on the health situation in Syria, Yemen, Sudan or many other situations. Did the victims of these conflicts matter less or does the world play by a different rulebook when it comes to Israel?” she asked. 

“The reality  is that on October 6, there was a ceasefire with Hamas. On October 7, we woke up to a new reality when thousands of terrorists entered Israel and systematically tortured and mutilated, murdered women, men and children on an unimaginable scale. 

“They entered with one directive, spare no one, capture innocent people, rape women and girls. They directly targeted Israeli medical personnel, first responders. More than 240 people were taken hostage and 137 still remain in Gaza, including 11 months old Kfir Bibas, and his four-year-old brother, Ariel. 

“Since October 7 over 11,500 rockets have been fired indiscriminately at Israeli cities, and this continues every day, hitting hospitals, schools and residential buildings.  In response to October 7, Israel declared war on the terrorist organisation Hamas. Our operation is directed towards Hamas. It has never been against the Palestinian people. 

“I recognise the suffering in Gaza. Let there be no mistake. However, Hamas is responsible for this suffering… Israel is operating against the terrorist organisation, which operates from within, underneath, and adjacent to hospitals, schools and UN facilities. 

The Israeli ambassador also called out WHO: “Even after the scope and scale of Hamas brutality was exposed on October 7, many in the international community, including the World Health Organization, continue to give Hamas a massive free pass. WHO has shamelessly reiterated that it only knows what is happening above ground in the Al Shifa Hospital and not what is happening below…

“If this EB session serves any purpose, it will only encourage Hamas actions,” she concluded. “It  gives them a green light to use Gazans as human shields… It is a reward for Hamas disdain for the sanctity of human life. If we stop now, Hamas will carry out another October 7. They say so publicly….  This is the reality that the [EB] decision … will blatantly ignore.”

Cuba denounces alleged Israeli ‘war crimes’  

Responding to Israel’s remarks, Palestine’s Ambassador to the UN in Geneva, Ibrahim Khraishi, denied Israeli reports of Hamas missile misfires on Gaza hospitals, and Hamas tunnels and weapons caches in and around health facilities, homes and schools as “lies.” 

But he contended that Israel’s position in the conflict was not parallel to that of the Palestinians in any case. 

 “It all comes down to self determination and self-defence,” Khraishi said. “Self defence does not exist for Israel because it is an occupying power.”

During the hours’ long debate, over two dozen other nations, including India and Pakistan, Malaysia and Turkey, South Africa, Namibia and Angola, and states across the Middle East and North Africa, weighed in on the conflict, mostly focusing on Israel. 

Said South Africa, “These developments tragically form part of an ongoing pattern of over 75 years of oppression, occupation and conflict.” 

Cuba described the Israeli military actions as “genocide and a crime against humanity.”

“Namibia is deeply concerned over the increasing escalation of violence and the collective punishment of the Palestinian people by the occupying forces,” said Namibia’s delegate to the special EB session. “Basic infrastructure like housing have been reduced to rubble… The cutting of basic utilities has been weaponised to inflict further suffering on top of the bombs and bullets – and the insecurity of civilians being ordered at short notice from one place to the other, none of which are suitable for human habitation.

“But the gathering momentum is undeniable,” the delegate added, of the global political pressure being applied on Israel. “It is Namibia’s hope, having lived under similar conditions as the Palestinians are currently enduring, that justice will manage to prevail.”

US: Hamas has further genocidal intentions 

US Ambassador to the UN in Geneva, Bathsheba Nell Crocker in the 10 December EB debate over the Gaza humanitarian crisis.

Meanwhile, the US and Canada, as well as European countries such as Germany, Denmark and Paraguay, expressed varying levels of dismay, in turn, over what they described as insufficient criticism of Hamas actions in the WHO resolution. 

“We agreed not to block consensus on the text, but we do not agree with preambulatory  paragraph 8,” said US Ambassador to the UN in Geneva, Bathsheba Nell Crocker. She stressed that calls for a cease-fire,  “are not only unrealistic but dangerous. A ceasefire would simply leave Hamas in place and able to regroup and repeat what it did on October 7. Hamas does not dispute this.” 

Added the US in closing remarks: “Hamas actually does have genocidal intentions against the people of Israel, and have said so explicitly, that they would like to see Israel wiped off the map.”

Said Denmark, “We regret the resolution was not more balanced on the matter of hostages and the use by Hamas of hospitals as shields.”    

Added Germany, which described itself as the world’s largest donor to the Gaza emergency response: “Like any other state, Israel has the right to defend itself in accordance with obligations under international law.

“Hamas must unconditionally and immediately release all hostages and stop its rocket attacks, and refrain from using civilians as well as civilian infrastructure for military purposes, especially medical infrastructure, like hospitals or ambulances. We do regret that these aspects are not reflected in the current resolution.” 

Tedros’ conclusion: The medicine most needed is hope 

Despite the bitter polarisation seen, the WHO governing body remains the first in a UN fora to have made a consensus statement on the crisis, said Tedros in closing remarks following the vote by the 34-member body. But no resolution by the global health body can really address the deeper roots of the conflict, which are fuelling the crisis, he stressed. 

“I understand Israel’s need to protect it’s people from further and future attacks, and to live in peace and security,” Tedros said. 

“And I likewise understand the need of the Palestinian people to live in peace and freedom. 

“We must continue to believe that these are possible and not mutually exclusive.

“As always, the medicine that the people of Israel and the occupied Palestinian territory needs the most is not one we can deliver in a truck, or administer in a syringe.

“It’s the most precious medicine and often the most rare: hope.”

Image Credits: WHO report to the Executive Board , WHO/EMRO .