The 2022 edition of the Lancet Countdown report warned that “global health lies at the mercy of fossil fuels”. The 2023 report, published on Wednesday, finds “few, if any” signs that the world has taken heed of the impending health crisis.

A new report from the Lancet Countdown, an annual assessment of progress toward the climate targets of the 2015 Paris Agreement, paints a grim picture of the escalating health risks associated with a warming planet.

The report, compiled by an international consortium of 114 scientists, health experts, and researchers, warns that the world is on track for a “dangerous future” where climate-linked health crises from extreme weather events, including deadly heatwaves, drought-driven food insecurity, and the spread of infectious diseases, will become the daily reality for millions.

The report’s grim findings underscore the urgent need for immediate and decisive action to curb greenhouse gas emissions and avert the worst consequences of climate change on human health. If the world warms by 2°C above pre-industrial levels, human health faces an “intolerable future with rapidly growing hazards,” the report warns.

Extreme heat is already driving death and food insecurity around the world, with heat-related deaths of people over 65 increasing by 85% since 1990, the report found. The average person now experiences 86 days of “health-threatening high temperatures every year”, 60% of which are attributable to climate change. 

“Global mean temperatures are rising and we’re increasingly exposed to extreme heat,” said Dr Marina Romanello, executive director of the Lancet Countdown and lead author of the report. “Extreme heat is particularly dangerous for elderly populations, populations living with underlying health conditions such as heart disease, lung disease and kidney disease, and pregnant women, their unborn children, [as well as] very young children and those with neurological conditions.”

The higher frequency and intensity of heatwaves are also exacerbating food insecurity, with an estimated 127 million more people experiencing moderate or severe food insecurity compared to the 1981 to 2010 period, placing “millions of people at risk of malnutrition and potentially irreversible health effects”, according to the report.

A devastating drought in Somalia, part of a wider crisis across the Horn of Africa, has claimed the lives of 43,000 people, with half of those deaths being children under five, according to a March report by Somalia’s Ministry of Health. The drought has also pushed nearly half of the country’s children under five – 1.4 million children – into acute malnutrition, according to UNICEF.

The report further highlights the contributions of climate change to the proliferation of infectious vector-borne diseases such as Dengue and West Nile Virus, as climate change makes people more vulnerable to the diseases and the world more hospitable to the mosquitoes that carry them. Warmer temperatures are extending the geographical range where disease-borne mosquitoes can survive and thrive, as well as extending their mating season, allowing them to reproduce in greater numbers.

“The climate crisis is escalating the severity of extreme weather events, increasing food insecurity, exacerbating respiratory diseases, and fueling the spread of infectious diseases,” declared Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO). “The world is moving in the wrong direction, unable to curb its addiction to fossil fuels and leaving vulnerable communities behind in the much-needed energy transition.” 

The World Health Organization (WHO) has long advocated for a more prominent role for health considerations in international climate negotiations, emphasizing the substantial health benefits of decisive climate action. In the wake of the Paris Agreement’s ratification in 2015, the UN health agency hailed the treaty as ‘potentially the strongest public health agreement of the century.’

However, the 1.5°C temperature goal enshrined in the agreement is swiftly fading from reach. The health consequences of the already elevated global temperature, averaging 1.14°C above pre-industrial levels, are already impacting millions of lives worldwide.

“Our data shows us that a thriving future still lies within our reach,” said Romanello. “The most concerning thing is that we’re accelerating in the wrong direction.”

Developing countries excluded from green transition as finance falters

As developing nations bear the brunt of climate change’s devastating impacts, financial support from wealthy countries for climate adaptation remains woefully inadequate, leaving them ill-equipped to cope with intensifying extreme weather events and rising health risks. The report highlights the persistent lack of “access to funding and technical capacity” in low- and middle-income countries, further exacerbating deep-seated health inequities within and between nations.

The Lancet’s findings echo the conclusions of the UN Environment Programme’s Adaptation Gap report, released last week, which found that adaptation finance flows to developing countries fell to just $21 billion in 2022, compared to the $367 billion required every year through 2030.

“The most vulnerable and minoritised communities are left the least protected, and the deep within-country and between-country health inequities are further exacerbated,” the report states. “This scarcity is aggravated by the rising economic losses from climate change impacts, and the persistent failure of wealthier countries reach the promised sum of $100 billion annually to support countries most affected by climate change.”

The consequences of this financial shortfall are stark: developing countries are being largely excluded from the accelerating shift to green energy technologies, despite their urgent need for these solutions. While clean renewable energy sources are gaining ground globally, their share in the world’s electricity generation still stands at a mere 9.5%. In low Human Development Index (HDI) countries, this figure plummets to just 2-3%, with 92% of domestic energy still derived from polluting fossil fuels.

“By and large, it is the very high human development index countries that are leading the way in the adoption of these green technologies in this new economic [era],” said Romanello. “Once again, we’re seeing that it is the most vulnerable countries that are being left behind in the zero-carbon transition and remain reliant on dirty fuels and exposed to health homes and energy poverty.”

Fossil fuel expansion threatens perilous future for human health

Change in fossil fuel lending in the years after the Paris Agreement, compared to the years preceding it. More than half of the 40 banks that lend most to the fossil fuel sector have increased lending since the Paris Agreement was signed.

The report’s predictive section, a new addition this year which projects the future impact of a warming climate on human health worldwide, underscores the alarming trajectory of global emissions which is “putting our collective future at risk”.

“Last year, the 2022 report said that our health was at the mercy of fossil fuels. Well, this report shows us is that it is even worse today,” said Romanello. “Looking at the 20 largest oil and gas companies around the world, we see that their plans today would lead to their share of emissions exceeding the targets of the Paris Agreement by 173% in 2040 – this is 61 percentage points more and last year when they were on track to exceed [1.5C levels] by 112%.”

This unabated fossil fuel expansion has placed the world on a perilous path towards a catastrophic 2.7 degrees Celsius of warming by the end of the century. The Lancet findings echo those of the UN Environment Programme, which said in its Production Gap report last week that government plans to expand fossil fuel production despite the climate crisis were “throwing humanity’s future into question”. 

The health implications of this scenario are profound and far-reaching. Even a 2-degree Celsius warming scenario would bring unbearable health consequences, with heat-related deaths projected to surge by 370%, heat-related labour loss by 50%, and an additional 524.9 million people facing moderate to severe food insecurity, according to the report. The potential for dengue transmission is also expected to rise by up to 37%.

The health threats posed by fossil fuel burning are further exacerbated by government subsidies, which effectively incentivize the industry. Moreover, agricultural emissions continue to rise, alongside a global food system that promotes unhealthy, carbon-intensive diets.

Health consequences of a 2C warming scenario in 2040.

The finance sector is playing a significant role in perpetuating this crisis. Average annual lending to the fossil fuel sector grew from $549 billion in 2010–16 to $572 billion in 2017–21. More than half of the 40 banks that lend most to the fossil fuel sector have increased lending since the Paris Agreement was signed.

This expansion of fossil fuel production has also been driven by high energy prices, which have yielded $4 trillion in profits for oil and gas companies in recent years. As a result, these companies are allocating more capital to fossil fuel projects than to renewables, on which they spend just 4% of their budgets.

Despite the mounting evidence of the climate crisis, the world remains woefully off track. A U.N. assessment of global climate commitments published on Tuesday found that even if all were met, which is a significant uncertainty, emissions may only be about 5% lower in 2030 than in 2019. The world is currently on track to reduce emissions by just 2% by 2030, according to the report. To limit global warming to 1.5 degrees Celsius above pre-industrial levels, emissions need to be 43% lower.

“The world remains massively off track,” U.N. chief Antonio Guterres said.

The Lancet Countdown report’s findings further align with those of a concurrent World Meteorological Organization (WMO) report, which revealed on Wednesday that greenhouse gas concentrations in the atmosphere reached a new record high in 2022.  

Another major climate report released concurrently, State of Climate Action 2023, concluded that “global efforts to limit warming to 1.5°C are failing across the board.” Across 42 indicators tracked in the report, published by Climate Action Tracker, only one – electric vehicle sales – is on track, while six – including deforestation, the carbon intensity of steel, and public financing for fossil fuels – are accelerating in the wrong direction.

“There is no end in sight to this trend,” warned WMO Secretary-General Petteri Taalas. “Despite decades of warnings from the scientific community, thousands of pages of reports and dozens of climate conferences, we are still heading in the wrong direction.”

“It takes thousands of years to remove carbon from the system once it’s emitted into the atmosphere,” said Taalas. “We must reduce the consumption of fossil fuels as a matter of urgency.”

Image Credits: Matt Howard/ Unslash.

Director Generals Ngozi Okonjo Iweala (WTO), Dr Tedros Adhanom Ghebreyesus (WHO) and Daren Tang (WIPO) at their trilateral meeting on climate and health.

In anticipation of coming climate crises, developing countries should put in place “effective mechanisms in their domestic laws” that allow them to use the TRIPS flexibilities, asserted Dr Ngozi Okonjo Iweala, Director-General of the World Trade Organization (WTO) on Tuesday.

TRIPS flexibility refers to space allowed in the WTO’s Trade-related Aspects of Intellectual Property (TRIPS) Agreement for governments to relax patent rights to address public health needs, including issuing compulsory licenses to make medicines without the permission of a patent-holder.

“Let me emphasise that many developing country governments have not yet put in place the legal mechanisms or tools that allow the use of existing or future flexibilities. With the impact of climate change on health becoming more evident, this is the time to get ready,” Iweala told the trilateral climate change and health symposium convened by the WTO, World Health Organization (WHO) and World Intellectual Property Organization (WIPO).

 

The three bodies have agreed to step up their support for developing countries to “analyse their options to use TRIPS flexibilities” and update their laws to enable the use of these flexibilities alongside “enhanced procurement programmes”, she added.

“As you all know, at the WTO we have also been grappling with sensitive issues around intellectual property (IP) and technology transfer,” added Iweala.

“To solve problems in public health and the climate, breakthrough technologies must be incentivized, invented, developed and widely diffused. Innovation and access must go together. That is why the IP system was designed with ideas of balance and public interest at its core. Governments have legitimate scope to intervene when necessary to protect the public interest.”

Ngozi Okonjo Iweala, Director-General of the World Trade Organization (WTO)

Fossil fuel addiction ‘an act of self-harm’

WHO Director-General Dr Tedros Adhanom Ghebreyesus appealed for both “advanced technologies” and “trade arrangements” to protect lives in the event of climate crises.

“In the same way that we have been fighting for global equitable access to COVID-19 vaccines, we need to ensure that intellectual property and trade rules are not a barrier to accessing greener and healthier technologies,” said Tedros.

“The world’s addiction to fossil fuels is an act of self-harm,” he added. “This addiction not only drives the climate crisis but is a major contributor to air pollution, which kills almost seven million people every year – a death every five seconds. The health community has a critical role to play in protecting people from the escalating climate threats to health.”

However, countries had the responsibility to build health systems that can both withstand climate shocks and reduce their carbon footprint, added Tedros, referring to the WHO’s framework for building climate-resilient and low carbon health systems released last week. 

WIPO Director General Daren Tang

Warning that Africa would bear the brunt of climate-related deaths, projected to account for over half these deaths by 2050, WIPO Director-General Daren Tang said that “this cannot be our future”.

Tang added that, while some saw IP rights as an obstacle to achieving a better, fairer and more sustainable world, WIPO hopes that IP will “unleash the innovative and creative potential of our people around the world” to realise the sustainable development goals (SDGs).

Tang also referred to WIPO Green, a free online platform matching providers and seekers of green technologies around the world to address climate change.

“In the past 10 years, this platform has grown to cover 130,000 technologies from over 140 countries, becoming the biggest green tech exchange matching platform that the UN offers today,” said Tang. 

However, the challenge is to ensure that these technologies “create impact on the ground”, said Tang. 

“WIPO will continue to build innovation and tech transfer capabilities in member states so that tech transfer can lead to actual deployment on the ground, and homegrown innovation solutions can move from mind to market and be deployed and diffused across the world.”

Tobacco industry interference in governments’ tobacco control policies has increased in 43 out of 90 countries analysed over the past two years.

This is according to the Global Tobacco Industry Interference Index 2023 released on Tuesday by tobacco watchdog STOP, and the Global Center for Good Governance in Tobacco Control (GGTC).

“No country has been spared from the interference, and there is a worsening trend,” said Mary Assunta, CGTC’s head of research and advocacy. “More countries deteriorated in their scores compared to countries that improved” – with only 29 countries improving efforts to push back against industry.

Countries with the highest level of interference are the Dominican Republic, Switzerland, Japan, Indonesia and Georgia – and this is also reflected in “poor tobacco control measures in their countries”, according to the report.

Governments that are party to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) are obliged to protect their health policies from the commercial and other vested interests of the tobacco industry.

But the report exposes a range of interfering behaviour – including governments accepting tobacco corporate social responsibility (CSR) contributions, politicians accepting campaign contributions and officials weakening controls in the face of industry scare tactics.

The CSR handouts focused on post-COVID recovery programmes, environmental protection, such as cigarette butt cleanups and tree planting. 

“Non-health departments, especially finance, commerce and customs, continued to be targeted by the industry and were persuaded by exaggerated claims of industry’s contributions to the economy,” Assunta told the media briefing to launch the report.

“They believed the industry’s narrative that illicit trade will worsen if taxes are increased. Hence, in some countries – Colombia, Mongolia, Malaysia and Turkey – there was no [cigarette] tax increase, while in others there were delays in tax payments.”

Global Tobacco Industry Interference Index 2023

Politically compromised

“Policymakers in many countries became vulnerable to industry interference when they placed themselves in situations of conflict of interest. This happens either through accepting industry donations for political campaigns or investing in the tobacco business, a revolving door situation of retiring senior government officials joining tobacco companies, or industry executives taking up senior government positions,” said Assunta.

In Uruguay, although tobacco sponsorship including political donations is outlawed,  Montepaz, which controls 85% of the Uruguayan tobacco market, contributed to the financing of the president’s election campaign.

In Colombia, the former Director of Regulation at the Ministry of Commerce joined Philip Morris International (PMI) as its head of external affairs for Colombia and Perú.

In Bangladesh, a British American Tobacco (BAT) director is the senior secretary in the Prime Minister’s Office. In Gabon, the chair of the board of a tobacco body, CECA-GADIS, is currently a political advisor to the Head of State. In Switzerland, a member of the National Council (the larger house of the Swiss legislature) is also the salaried president of the Swiss Tobacco Trade Association. Switzerland has not ratified the FCTC, neither has the US.

Mary Assunta, CGTC’s head of research and advocacy.

The governments of Bangladesh, Jamaica, Korea and Zambia still invest their pension funds or national insurance funds in the tobacco business. The Bangladeshi government holds a total of 9.4% shares in BAT Bangladesh, the Korean government owns 7.7% shares in tobacco company KT&G,  and Zambia’s pension schemes have shares in BAT Zambia.

Meanwhile, in many African countries, tobacco companies gain prominence through charity.

“In countries like Zambia, Uganda, Tanzania, Nigeria, Madagascar, Gabon, Ghana, Cameroon and Nigeria, the tobacco industry engages in activities like granting scholarships, providing classrooms, training young people in agriculture or promoting young entrepreneurship,” said Leonce Sessou, executive secretary of the African Tobacco Control Alliance.

Sessou added that the industry supported a number of NGOs to promote itself, particularly in the youth sector.

Impact of industry influence

The growing influence of industry was experienced very directly in many countries.

Malaysia’s Wency Bui told the launch that her government had de-listed nicotine as a poison after lobbying by Japan Tobacco International (JIT). This enabled the company to market nicotine products such as e-cigarettes.

Tobacco companies also successfully lobbied for the end of bans on e-cigarettes, heated tobacco products (HTPs) and/or nicotine pouches in Egypt, Kenya and Uruguay. In Uruguay, the Ministry of Public Health even used information provided by Philip Morris International (PMI) instead of its own experts.

Five countries – Bolivia, Guatemala, Jamaica, Tanzania, and Zambia – reported that the tobacco industry sabotaged efforts to pass comprehensive tobacco control legislation. 

Applying pictorial health warnings on tobacco packs was delayed in Chad, Bangladesh, Laos and Nigeria, and the implementation of standardised tobacco packaging has been undermined by the tobacco industry in Georgia, Myanmar and Uruguay. 

Some progress

Global Tobacco Industry Interference Index 2023

However, Brunei, New Zealand, France, the Netherlands and Botswana are the top five countries that performed well in pushing back against the industry. Meanwhile, Ukraine improved the most in its push-back against industry despite fighting the Russian invasion.

The Netherlands has a protocol for civil servants interacting with the tobacco industry their  Code of Conduct on Integrity (Gedragscode Integriteit Rijk) contains guidelines on interacting with tobacco lobbyists.

Botswana is in the process of finalising regulations to implement its Tobacco Control Act in 2021, which prohibits any partnership, agreement or contributions from the industry to any public body. 

The report was launched at the start of the 10th Conference of the Parties (COP10) meeting on the Framework Convention on Tobacco Control (FCTC) in Panama City, which will assess countries’ progress on tobacco control.

Image Credits: PAHO.

Alcohol has had a fairly easy pass from public health authorities – although the World Health Organization (WHO) recently asserted that there is no safe level of drinking, upending many people’s cherished illusion that a glass of alcohol at the end of the day is harmless.

RESET Alcohol, a new public health initiative led by Vital Strategies, aims to tackle alcohol’s ubiquitous influence primarily by working with governments to increase taxes.

The $15 million initiative will focus initially on Brazil, Colombia, Mexico, Kenya, the Philippines and Sri Lanka.

“We were looking for governments that are committed to doing alcohol policy work and could demonstrate that they were willing to go forward and, particularly, raise taxes,” said RESET director Jacqui Drope of the choice of countries. 

Population size and alcohol abuse burden were also factors, she added in an interview with Health Policy Watch.

Most of these countries already have alcohol taxes. In the Philippines, for example, alcohol taxes already help to pay for universal health care, while in Kenya, civil society advocates are fighting to make sure alcohol tax rates keep pace with inflation.

Following the tobacco control example

“The primary focus has always been on increasing alcohol taxation as it’s one of the most effective things you can do,” added Drope, who has a long history in tobacco control.

Cigarette taxes have been shown to curb smoking, particularly in young people. For example, in New York state cigarette taxes are the highest in the US and the state has seen youth smoking rates drop by more than 90% since 2000 as a result. 

RESET Alcohol will work mainly by supporting governments, civil society and research groups to build their capacity to implement and strengthen alcohol policy. 

It will do so in part by mentoring people in policy and regulation development, taxation research, strategic communication and advocacy, and alcohol data and monitoring systems.

RESET Alcohol Director Jacqui Drope

Not prohibition

The initiative isn’t about prohibition, Drope stressed: “We’re coming at this from a harm-reduction standpoint. That is why it is about policy and what we can do at the population level. We aren’t working at the individual level and prescribing what individuals do.

“We know this is an unhealthy product, and there’s good evidence from the WHO to show that there is no safe level [of consumption]. What we’re trying to do is reduce the harms through policy, rather than saying that people should never drink again. This isn’t what we’re trying to accomplish.”

‘War of perception’

For adults aged between 25 and 49, alcohol is the leading cause of death and disability globally based on the Global Burden of Disease analysis. 

“Often the underlying connection of alcohol consumption between these deaths – from liver disease, heart disease, cancer, violence, vehicle crashes, falls, tuberculosis, HIV/ AIDS, and other conditions – is overlooked,” according to Vital Strategies.

People calling for more alcohol oversight is “cast as a buzzkill”, according to the global health organisation.

“It’s a war of perception that claims millions of lives each year. Alcohol use remains stubbornly rooted as a cultural norm in most of the world, and few recognise it as a public health threat.”

Drope acknowledged that alcohol is so deeply entrenched that even the health sector has been complicit in perpetuating the notion that moderate alcohol consumption is healthy: “We have a lot of work to do and think about to change norms, and change how we talk about alcohol.”

At risk ‘from the first drop’

Recent data that shows half of all alcohol-attributable cancers in the WHO European Region are caused by “light” and “moderate” alcohol consumption – less than 1.5 litres of wine or less than 3.5 litres of beer or less than 450 millilitres of spirits per week. 

“This drinking pattern is responsible for the majority of alcohol-attributable breast cancers in women, with the highest burden observed in countries of the European Union (EU),” according to the WHO European Region.

“We cannot talk about a so-called safe level of alcohol use. It doesn’t matter how much you drink – the risk to the drinker’s health starts from the first drop of any alcoholic beverage. The only thing that we can say for sure is that the more you drink, the more harmful it is,” explained Dr Carina Ferreira-Borges, WHO regional advisor for alcohol and illicit drugs. 

Alcohol consumption and related deaths in different regions of the world

Globally, the WHO European Region – which includes heavy-drinking countries such as Czechia, Latvia, Lithuania, Russia and Germany – has the highest alcohol consumption level and the highest proportion of drinkers in the population. Over 200 million people in the region are at risk of developing alcohol-attributable cancer.

“Although it is well established that alcohol can cause cancer, this fact is still not widely known to the public in most countries. We need cancer-related health information messages on labels of alcoholic beverages, following the example of tobacco products; we need empowered and trained health professionals who would feel comfortable informing their patients about alcohol and cancer risk; and we need overall wide awareness of this topic in countries and communities,” added Ferreira-Borges.

In early November, WHO Europe Regional Director Dr Hans Kluge and the Director of the International Agency for Research on Cancer (IARC), Dr Elisabete Weiderpass, issued a joint statement to the European Parliament calling for more awareness about the link between alcohol and cancer.

“The contribution of alcohol consumption to cancer incidence and mortality should be clearly recognized without the use of any qualifiers or misleading adjectives such as ‘harmful’ or ‘heavy’ consumption of alcohol or ‘responsible drinking’,” they noted.

“Measures should be taken to clearly inform the public of this risk, which is not well known among the general population,” they added, pointing out that two WHO health plans “recommend the use of health warning labels on alcoholic beverage containers to inform the public about the health consequences of alcohol use”.

Image Credits: Unsplash, WHO .

Lab technicians at work in Cape Town’s Afrigen Vaccines & Biologics, one of the core partners in the WHO co-sponsored mRNA vaccine technology transfer hub, founded by WHO in 2021.  Much more needs to be done to foster local manufacturing of vaccines and health products, said participants at the Second World Forum.

A new Health Technology Access Pool (H-TAP), which aims to broaden the scope of IP and patent-sharing with low- and middle-income countries and a new African Union co-sponsored ‘manufacturing support platform’ were among the initiatives announced this week at the Second World Local Production forum in The Hague.

The global forum, the second ever to be convened, brought together industry, governments, civil society and multilateral organizations, including WHO, in a quest to bolster the local production of medicines and vaccines in underserved regions, particularly Africa, which was last in line to get COVID treatments during the pandemic.

The new H-TAP aims to overcome the shortcomings of the COVID-19 Technology Access Pool, C-TAP, which failed to gain significant buy-in from the industry. It also will include medicines and vaccines beyond COVID products, said Dr Yukiko Nakatani, Assistant Director-General for Access to Medicines and Health Products, at the Forum.  However, whether the new mechanism can really overcome the shortfalls seen in C-TAP, which drew little industry support, remains to be seen.

“Six license agreements for 15 health products have been agreed upon with Covid-19 technology holders – including from one private sector manufacturer. A serological test license from the Spanish National Research Center (CSIC) led to a sub-license to Biotech Africa to develop their diagnostic technology,” said Nakatani at the Local Production Forum, in his review of the slim achievements of the C-TAP pool.

“A review of C-TAP has been undertaken and a new technology access pool operating model is being developed and will be launched end of 2023. Stakeholders consultations will be held to help in the refinement and implementation of the model,” Nakatani said.

H-TAP and the WHO Pandemic Accord – interface unclear

As for further details on the H-TAP initiative, WHO did not comment.  However Ellen ‘t Hoen, head of the non-profit Medicines Law and Policy,  said that she expected the ongoing WHO member state negotiations on a new pandemic accord would also have to “address the need for the expansion of such a mechanism to enable the sharing of IP, including know-how and trade secrets.”

Meanwhile, in an open letter published at the start of the three-day Forum, a coalition of 30 prominent medicines access organizations, including Oxfam, the People’s Vaccine Alliance, Unitaid, and Public Citizen, warned that efforts to strengthen local medicines production in LMICs without addressing IP to “building a bridge to nowhere”.

“Plans and seed resources for building a bridge to local manufacturing abound, but they all have one feature in common – they systematically refuse to address the intellectual property barriers,” the open letter states.

At the World Health Summit in Berlin last month, German Health Minister Karl Lauterbach stated that any agreement without strong IP protections would “not fly” for Germany and its fellow EU countries, comparing IP to part of the EU’s “DNA.”

That stance was further reinforced at the start of the seventh round of INB negotiations on Monday when European countries asserted that any changes to IP rights should be thrashed out at the World Trade Organization (WTO) – not the WHO.

Tedros acknowledges the shortcomings of C-TAP model

WHO Director-General Dr Tedros Adhanom Ghebreyesus and Dutch Minister of Health Ernst Kuipers at the second World Local Production Forum in The Hague, Netherlands.

It took a staggering three years for a vaccine license to be shared with C-TAP, long after its potential to save lives had diminished. Aside from one Taiwanese firm, noit’s some private pharmaceutical company shared vaccines or therapeutics with the platform.

In his opening remarks, WHO Director General Dr Tedros Adhanom Ghebreyesus acknowledged the shortcomings of the C-TAP, the WHO’s ambitious platform aimed at facilitating patent-sharing for COVID-19 vaccines, treatments and medical technologies during the pandemic.

“The COVID-19 pandemic demonstrated the incredible power of vaccines, tests, treatments, and other medical technologies to save lives, but it also exposed the vast inequalities in our world,” Dr. Tedros stated. “Of course, this is not the first time.

“When HIV emerged over 40 years ago, life-saving medicines were developed, but more than a decade passed before the world’s poor got access to them,” he lamented. “When the H1N1 influenza pandemic struck 14 years ago, vaccines were developed, but by the time the world’s poor got access, the pandemic was over.”

However, the wakeup call provided by the pandemic also marked a turning point, Tedros and other speakers noted. That led to the creation of WHO’s mRNA vaccine technology transfer hub, launched in 2021 in South Africa.  Another global training hub in biomanufacturing capacity was also launched by WHO in collaboration with The Republic of Korea.

Local manufacturing has become more prominent on agenda now

Mapping of existing and planned manufacturing initiatives in Africa, as of December 2022.

The issue of local manufacturing was ignored for decades when UN-backed initiatives like The Global Fund to Fight TB, HIV/AIDS and Malaria, and Gavi, The Vaccine Alliance, channeled most contracts to a handful of large, well-established manufacturers in China, India, Europe or North America – ostensibly to reduce costs.  The concentration of their procurement, however, also tended to disadvantage local startups in other low- and middle-income countries, which could not compete with pharma giants in economies of scale, or pricing.   

Technology transfer and local production of medicines was first included on the agenda of the World Health Assembly (WHA) in 2018. During the WHA that year, Medecins Sans Frontières representative Elena Villanueva-Olivo condemned the failure of global research and development efforts and unequal access to affordable health technologies as “crises of international concern.”

Belatedly the pandemic cast a sharp light on the dearth of local manufacturing, particularly in Africa. It highlighted the long-term damage of concentrating procurement amongst only a handful of manufacturers, and highlighted how over time, more local manufacturing of essential medicines and vaccines could offer greater affordability and improved access to life-saving treatments, as compared to reliance on imports.

Since then, a flurry of new initiatives have been announced by WHO, the African Union and pharma companies themselves, including giants like Pfizer.  Big questions remain, however, regarding the durability and sustainability of the new projects in planning or already underway. 

New platform launched to support African manufacturers

The new Health Products Manufacturing Support Platform, launched at the Forum by Unitaid, the African Union Development Agency, and WHO aims to address some of those sustainability issues.

The platform will provide technical assitance to African manufacturers along the entire “health products manufacturing value chain,” its promoters said.

The support could range from technical assistance in “business management, sales and operations”, to support for the acquisition and development of active pharmaceutical products, and preparation of drug dossiers to ensure compliance with regulatory standards, the project initiators said.

The initiative calls upon African manufacturers, R&D centers and centers of excellence, as well as “market actors” including industry associations to collaborate in the initiative.

Over 79% of African pharma products are imported, while Africa supplies only 3% of global production of medicines and vaccines, it’s developers note.

Sidestepping IP issues? 

Filling vials for vaccine R&D at South African’s vaccine manufacturer Afrigen.

While developed countries and the private sector have emphasized the need to create a broad “ecosystem” to foster local manufacturing of health products, including investments in training, knowledge transfer and procurement preferences of global agencies and countries, civil society have long contended that IP restrictions constitute the key barriers:

“All of these hopes for local and regional production hinge on whether low- and middle-income countries (LMICs) have access to IP-protected research tools, technology platforms, product and process inventions, trade secrets, regulatory data, biologic resources (such as cell lines), and other knowledge essential to product development,” said the CSO  signatories to Monday’s letter. 

“We cannot be complacent – or resigned – to the siren song of purely voluntary measures and continued private hegemony over tools and knowledge by which the right to health is realized,” the letter states.

“We learned the painful costs of knowledge privatisation during the COVID-19 pandemic when major vaccine producers, including leading participants in the World Local Production Forum, refused to license their IP and share their breakthrough technologies and manufacturing know-how with capable producers in LMIC regions,” the coalition of civil society groups wrote in their letter to the forum.

“Instead of building bridges to nowhere, international and multilateral institutions … must finally commit to supporting countries in their collaborative efforts to overcome IP barriers that will otherwise stifle local manufacturing,” the signatories added.

A draft set of recommendations from the Forum, seen by Health Policy Watch recommends “four interrelated elements to an ecosystem that need to be present,” to stimulate local manufacturing, including:

  • The essential components of supplies, infrastructure, skills and technologies for manufacturing capacity.
  • Financial investments for procurement, the scaling up of production and the equitable distribution of health products.
  • Skilled and trained policy makers and regulatory authorities for product quality, safety and predictability.
  • Information on, for example, actual production capacity and market demand.

It also recommends the “establishment of a network for synchronizing training resources and facilities for building private and public sector capacity in manufacturing, technology transfer, R&D, policy, regulation and implementation. For the moment, access to IP and other know-how needed for R&D and manufacturing is not on the map.

Stefan Anderson contributed reporting for this story. 

Image Credits: Rodger Bosch for MPP/WHO, Netherlands MoH, Clinton Health Access Intiative , Health Products Manufacturing Support PlatformMSP , Rodger Bosch/ MPP & WHO.

Pandemic agreement negotiations are underway again this week

An effective pandemic agreement will need to include “accountability mechanisms” to ensure that countries implement the terms – and these will need to be independently monitored, according to new research published in BMJ.

“Accountability mechanisms are used through a variety of methods across global treaties and governance mechanisms to varying degrees of effectiveness,” argue the researchers, based on their evaluation of other global treaties and interviews with experts. 

“The pandemic agreement should have accountability mechanisms built into it from the start to increase the likelihood of countries complying with the obligations they sign up for.”

 

‘Soft incentives’ for compliance

While finding consensus is the current imperative for the INB, there is a risk that countries will simply fail to implement the terms of a pandemic agreement.  During the COVID-19 pandemic, for example, many countries did not comply with the  International Health Regulations (IHR), despite the fact that they are legally binding.

To enhance compliance with a pandemic agreement, the researchers – mostly from Spark Street Advisors – argue for the provision of “soft incentives” such as “technical and material resources” to help countries.

“Reputational incentives” could also assist with compliance, they add, arguing against “the harms of sanctions and benefits-based incentives”.

But compliance with the terms of the agreement should not simply rely on countries’ self-reporting, as is the case with many international agreements.

“The pandemic agreement should establish, as part of its institutional arrangements, an independent monitoring committee, tasked with producing regular assessments of state parties’ compliance with the pandemic agreement and the timeliness, completeness and accuracy of self-reporting,” they argue.

This monitoring committee “should be politically, financially, technically and operationally independent of the WHO and donors”, and able to” triangulate” information from a diverse range of sources including civil society about countries’ compliance.

It would report to a high-level political body to promote compliance with the pandemic agreement.

‘Find common ground between public health and profit’

Meanwhile, Dr Tedros Adhanom Ghebreyessus, the Director-General of the World Health Organization (WHO), appealed to member states negotiating a pandemic agreement to find “common ground”  between equitable access and innovation; protecting public health and making a fair profit; global health security and national or regional interests. 

Addressing a closed session of the seventh meeting of the intergovernmental negotiating body (INB) in Geneva on Wednesday, Tedros warned that “a pandemic agreement that fails to ensure collective security and equity in all its forms, fails”. 

Referring to “numerous meetings” in the almost two years since a special session of the World Health Assembly decided to establish the INB, Tedros said “I believe strongly that this [negotiating] text may help you come closer together on the path towards consensus.

“No one is pretending your work is easy. I know it is not. It is not surprising that, with 194 member states, reaching consensus is not straightforward. But that does not mean it is unachievable,” said Tedros, whose INB speech was released by WHO.

Sovereignty ‘nonsense’

Tedros also appealed to member states to counter the “torrent of fake news, lies, conspiracy theories and mis- and disinformation”. 

“There are those who say – whether they believe it themselves or not – that the accord will cede sovereignty to WHO; that it will give the WHO Secretariat power to impose lockdowns or vaccine mandates on countries, and other nonsense. 

“You know and we know that the agreement will give WHO no such powers.  We need your support to put this nonsense to rest.  We need your support to counter these lies, by speaking up at home and telling your citizens that this agreement will not, and cannot, cede sovereignty to WHO. Period.”

The seventh INB meeting started on Monday, will break on Friday, and then resume on 4-6 December.

As the world teeters on the brink of climate catastrophe, major fossil fuel-producing nations plan to expand production.

Amidst a global chorus calling for urgent action on climate change, major fossil fuel producers are doubling down on their plans to expand production, defying climate science and “throwing humanity’s future into question”, a UN report revealed on Wednesday.

The report, compiled by the United Nations Environment Programme (UNEP) in collaboration with academic partners, scrutinized the plans of the 20 largest fossil fuel-producing countries, responsible for a staggering 84% of global carbon emissions and roughly three-quarters of the world’s fossil fuel consumption in 2021. 

The findings paint a grim picture: governments’ plans show they intend to produce, in total, 110% more fossil fuels in 2030 than are compatible with the 1.5°C limit set out in the Paris Agreement, and 69% more than is consistent with 2°C of warming.

The analysis found national fossil fuel plans would result in 460% more coal, 83% more gas, and 29% more oil production in 2030 than the world can afford to burn on its increasingly miniscule 1.5 C carbon budget.

The findings underscore the persistent gap between national climate pledges and fossil fuel production, a worrisome trend that has remained largely unchanged since the UN first quantified it in 2019.

“The addiction to fossil fuels remains deeply entrenched in many nations,” said Inger Andersen, Executive Director of UNEP. “Governments must stop saying one thing and doing another … [these] plans to expand fossil fuel production are undermining the energy transition needed to achieve net-zero emissions, throwing humanity’s future into question.” 

“The fossil fuel production gap, the difference between governments’ plans and projections and levels consistent with limiting warming to 1.5°C and 2°C, remains large and expands over time,” the report found.

None of the top 20 fossil fuel-producing countries have committed to aligning their output of oil, coal and gas to limit warming to 1.5°C, despite 17 committing to net-zero emissions pledges, the report found. All continue to subsidise, support and plan expanded fossil fuel production. 

The combined levels of coal, oil, and gas production planned by 10 high-income countries alone would already exceed 1.5°C-consistent pathways for each fuel by 2040, the report found.

The lack of progress by major polluters in realigning their production of fossil fuels with global climate targets comes against a backdrop of new records for global greenhouse gas emissions, sea levels, and fossil fuel subsidies set in 2022. In 2023, one-third of days have seen average global temperatures exceeding 1.5°C over pre-industrial levels.

“The whole world is clinging to the handrails on a boat that is lurching through increasingly turbulent seas,” said Andersen. “Nations must unite behind a managed and equitable phase-out of coal, oil and gas — to ease the turbulence ahead and benefit every person on this planet.”

UN Secretary-General Antonio Guterres, a vocal critic of fossil fuel interests, expressed dismay at the report’s findings. “Governments are literally doubling down on fossil fuel production,” he said, emphasizing the need for credible commitments to ramp up renewables, phase out fossil fuels, and boost energy efficiency while ensuring a just, equitable transition.

India, Saudi Arabia, and Russia lead fossil fuel expansion surge

Government plans and projections would lead to an increase in global coal production until 2030, and in global oil and gas production until at least 2050, the end of the time frame covered by the report. These findings contrast with those of the IEA, which forecast a peak in demand for all three fossil fuels by 2030.

India, Saudi Arabia, and Russia are spearheading the global surge in fossil fuel production, with their expansion plans accounting for the largest share of carbon emissions for coal, oil and gas, respectively, according to the report. 

India’s coal production plans dwarf any other nation, with its Ministry of Coal projecting domestic coal production to more than double to 1.5 billion tonnes by 2030. In March 2022, the Indian government set a goal of increasing production by state-owned Coal India Limited (CIL) alone to one billion tonnes by 2024.

Saudi Arabia, which relies on oil and gas production for half of its GDP, is planning the largest single-country increase in oil extraction. Documents from state-owned Saudi Aramco, which controls nearly a fifth of global oil output, suggest a 47% increase in production by 2050. Aramco also plans to ramp up natural gas production to meet future demand.

Russia, the world’s largest gas exporter, also has ambitious expansion plans. The most recent government figures project coal production increases of between 11% and 53%, and between 6% and 31% for gas by 2035. 

Russia’s energy exports have become a lifeline for the country’s foreign reserves and economy, which have been severely strained by international sanctions and wartime expenditure stemming from its invasion of Ukraine in February 2022.

The United States, Canada, Australia, Norway, and the United Kingdom also play a significant role in fossil fuel expansion plans. According to a recent analysis by Oil Change International, these five countries account for 51% of planned new oil and gas extraction by 2050. 

The United Arab Emirates, hosts of the upcoming UN climate summit starting on November 30, plans to boost its oil production by one million barrels per day by 2027 and increase its natural gas production by 259% by 2028 as part of a $150 billion investment plan in its national oil company, ADNOC. Sultan al Jaber, president of the UN climate summit, serves as the president of ADNOC.

“Governments offer a variety of rationales for increasing production: reducing import dependency, generating government revenue … and winning out as one of the last producers in a shrinking market,” Michael Lazarus, a lead author of the report, said at a closed-door media briefing on Monday.

“But when you take all these reasons together, that’s what leads to the production gap itself – the desire for each country to maximize their own production,” Lazarus added.

Money, money, money

The top 10 countries in extraction-based greenhouse gas emissions account for 75% of the global total, while the top 35 countries account for 96% (data represents 2021 levels).

The report’s findings underscore the crux of the fossil fuel crisis: governments and private companies continue to reap massive profits from fossil fuel production, creating a disincentive for any party to exit the lucrative market. 

Amidst an energy crisis triggered by Russia’s invasion of Ukraine, which caused oil and gas prices to skyrocket, major oil companies more than doubled their annual profits to a record $219 billion in 2022. Buoyed by record profits, major petroleum companies have quietly retreated from their already modest climate commitments.

In October, American fossil fuel giants ExxonMobil and Chevron reaffirmed their expansion plans, both announcing acquisitions of smaller shale producers in the United States for a combined total of over $100 billion. The United States is the largest producer of oil and gas in the world. 

In India, low monsoon rainfall over the summer months led to a surge in electricity consumption. Adani, the country’s second-largest power producer, responded by amplifying coal generation, from which it raked in $792 million, compared to $84 million the year prior, Semafor reported this week.

The Organization of the Petroleum Exporting Countries (OPEC), the global oil cartel that supplies 51% of the world’s oil and controls 81% of proven oil reserves, forecast in its annual report released last month that it expects oil demand to increase by 17% by 2045.

In the foreword of the report, OPEC Secretary General and Kuwaiti oil executive Haitham Al Ghais cautioned against calls to halt investments in new oil projects, asserting that such measures could lead to “energy and economic chaos.”

Scientific consensus and expert bodies agree that new oil and gas field development is incompatible with all pathways for limiting global warming to 1.5 degrees Celsius.

“This is the heart of the problem,” said Ploy Achakulwisut, a lead author of the report. “Major producers are not willing to transition from fossil fuel production.” 

Expanding fossil fuels: Economic ‘insanity’ 

Despite plans by leading fossil fuel producers to expand output, the IEA projects fossil fuel demand will peak by 2030 due to the accelerating economic momentum of renewables.

The International Energy Agency’s (IEA) latest annual report, released in October, projects a significant shift towards renewable energy sources in the coming decade. By 2030, renewables, including solar, wind, and hydropower, are expected to account for nearly half of the global electricity mix, up from around 30% today.

IEA Executive Director Fatih Birol emphasized the irreversible nature of this transition, declaring it “unstoppable.”

“It’s not a question of ‘if’, it’s just a matter of ‘how soon’ – and the sooner the better for all of us,” said Birol. “Taking into account the ongoing strains and volatility in traditional energy markets today claims that oil and gas represent safe or secure choices for the world’s energy and climate future look weaker than ever.”

This rapid transition towards clean energy renders planned expansions in fossil fuel production economically questionable, according to experts.

“Government production plans and targets, help to influence legitimise and justify continued fossil fuel dependence,” said Achakulwisut. “At the same time, many of these investments and infrastructure are at risk of becoming stranded assets as the world decarbonises.” 

Despite the growing adoption of green technologies, the allure of fossil fuel profits continues to hold sway, preventing countries from decisively stepping away from these energy sources. This reluctance stems, in part, from fears of losing out on market share in a shrinking market. 

“Despite their climate promises, governments plan on ploughing yet more money into a dirty, dying industry, while opportunities abound in a flourishing clean energy sector,” said Neil Grant, an environment analyst at Climate Analytics and a co-author of the report. “On top of economic insanity, it is a climate disaster of our own making.”

Major fossil fuel producers resist loss and damage fund

The US, the largest producer of oil and gas in the world, threatened earlier this week to exit loss and damage fund negotiations altogether.

As the largest fossil fuel-producing nations refuse to halt their expansion of coal, oil, and gas production, they are also resisting calls to compensate vulnerable countries for the climate-related damages they are causing and help them prepare for the escalating dangers of a warming climate.

Tensions are escalating ahead of the crucial UN climate summit, COP28, over the establishment of a loss and damage fund, a cornerstone of the global climate response and the crowning achievement of last year’s UN climate summit in Egypt.

The fund, aimed at compensating developing nations for the impacts of climate change, was nearly derailed at a recent preparatory meeting in Abu Dhabi due to financing disagreements led by the United States, which signalled that it is unwilling to provide any funding beyond voluntary contributions.

Developing countries, bearing the brunt of climate change impacts, have staunchly opposed the US proposal to house the fund at the World Bank, citing the institution’s outdated structure and excessive US influence.

China is also playing a pivotal in discussions surrounding the fund, urging the United States to make substantial contributions while remaining careful to sidestep any financial obligations of its own.

Outi Honkatukia, co-chair of the Abu Dhabi negotiations, called reaching an agreement on the fund “mission impossible”. A shaky agreement was reached, but it fell short of consensus, leaving the fund’s future uncertain. For now, the fund will be housed at the World Bank, a key U.S. demand, but developing countries hope this is a temporary step toward an independent fund. The battle will continue at COP 28 in Dubai.

“The US’s inability to agree on even a watered-down text highlights their lack of commitment to establishing an effective fund,” Lien Vandamme, a senior campaigner at the Center for International Environmental Law, told Politico.

The fate of the loss and damage fund hangs in the balance, casting a shadow over the upcoming COP28 climate summit. Its failure to materialize could jeopardize the overall progress of climate negotiations.

Image Credits: UNEP, UNEP .

A tobacco crop in northern Malawi

BLANTYRE, Malawi – Boyden Ndlovu of Mzimba district, one of Malawi’s tobacco growing districts located in the northern region says that his lifetime has been synonymous with tobacco farming.

Tobacco has been a mainstay of Malawi’s economy, historically generating about 70% of export revenue and now accounting for over half – yet the country finally ratified the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) in August this year.

The FCTC, adopted by the World Health Assembly in 2003, is designed to protect present and future generations from the devastating impact of tobacco consumption and exposure to tobacco smoke by reducing both demand and supply of tobacco. 

Article 17 of the Convention requires signatories to promote economically viable alternatives to tobacco.

But Ndlovu, although knowledgeable about crop diversification, swears he will never quit tobacco farming because it’s the only “lucrative crop” in Malawi. 

“My parents educated us with proceeds from tobacco farming. I have never had a white-collar job in my life, I’m content being a farmer,” says Ndlovu, who has been a tobacco farmer for 35 years.

He believes tobacco farming has always been very profitable because the prices are in dollars, boasting that the 2022/23 farming year had better prices with an average selling price of $2.35 per kilogram. 

At first, Ndlovu explains, he farmed tobacco on all of his 35 hectares, but this has changed over the years due to fluctuating tobacco prices. He now farms tobacco on only eight hectares, growing food crops such as maize, legumes, fruits and vegetables on the rest.

“Many tobacco farmers have moved away from growing tobacco to legumes and other presumably cash crops. Most farmers were discouraged by the global anti-smoking lobbies and erratic profits threatening the industry,” Ndlovu tells Health Policy Watch.

There were a few farmers in the last tobacco growing season, he adds. “I believe this contributed to the few to make more profits. Many farmers who moved away didn’t make much money from legumes. I’m foreseeing an increase in tobacco growers this year.”

Tobacco farmer Boyden Ndlovu of Mzimba district in Malawi

Industry manipulation

But Ndlovu’s tobacco “lucrative” farming is partly supported by the tobacco industry’s contract farming system. Farmers are granted loans by commercial banks that enable them to buy what they need to produce quality tobacco, backed by the tobacco companies’ guarantee that they will buy their tobacco. The loan amounts are deducted at source and farmers are given the remaining amount as their profit.

Dr Lonjezo Masikini-Phiri, a social science lecturer at the University of Bath and an expert on tobacco production in Malawi, observes that Malawi’s tobacco production is heavily influenced by the industry’s multinational companies. 

These companies prefer to buy African tobacco as it is cheaper, thus enabling higher profits. In addition, tobacco growing has decreased in the United States and United Kingdom.

Masikini also observes tobacco multinational companies have supported tobacco farmers to grow legumes alongside tobacco – largely to enrich the soil for tobacco, and possibly also to counter the anti-tobacco lobby’s argument that tobacco farming is undermining food production.

“Malawi should look ahead on what the ratification of the FCTC means. The country should use this opportunity to lobby for tobacco-shifting diversity projects or funding so that the farmers are attracted to food crop farming. This however requires a political will to be implemented,” he says.

Production decline

Malawi is one of the top five producers of tobacco in the world. Malawian tobacco is found in blends of nearly every cigarette smoked in industrialised nations including Camel and Marlboro brands, according to the Malawi Investment and Trade Centre. 

The main tobacco-growing countries in Africa are Zimbabwe (25.9% of total output), Zambia (16.4%), Tanzania (14.4%), Malawi (13.3%) and Mozambique (12.9%). n.

But Malawi’s Minister of Agriculture, Sam Kawale, told Health Policy Watch that the FCTC is not a threat to the country and that his ministry and the health ministry are working together to find ways to protect the population from tobacco harm and ,at the same time, stimulate the economy.

 “We have been encouraging farmers to diversify their crop production. This is important, even now that we have climate change. We are encouraging them to grow drought-, pest-, and disease-resistant crops, as well as invest in irrigation,” he said.

Dr Rosemary Hiscock, a research associate at University of Bath’s Department of Heath,  says the amount of land used to grow tobacco in Africa appears to be declining.

Exports by tobacco leaf volume have been in decline since 2018 and export value has mostly been in decline since 2016.

The UN estimates that in 2019, 616 527 tonnes of tobacco leaf was exported from Africa. 

But in 2021, 519 121 hectares of land were used to grow tobacco and 564,960 tonnes were grown in Africa. Of this, 550 916 tonnes (98%) were estimated to be exported. 

The UN estimates that tobacco production took up less than 1% of land used for crop production in Africa.

Hiscock says Africa’s proportion of global leaf production is estimated to have increased slightly between 2012 and 2021 from 7% to 10%. 

“However the increase is related to a decline in the production of tobacco in the rest of the world rather than an increase in production in Africa,” she explains.

Clinging to ‘green gold’

Interestingly, farmers do not fear that the FCTC ratification could be Malawi’s economic suicide.  

Nixon Lita, CEO of the Tobacco Growers Association of Malawi (TAMA)

Nixon Lita, CEO of the Tobacco Growers Association of Malawi (TAMA), says farmers believe that Malawi being part of the discussions relating to tobacco through FCTC could offer alternative economic opportunities.

“We encourage farmers to diversify alongside tobacco but unfortunately tobacco production makes a lot of economic sense to farmers unlike most of the alternatives. Ratification does not demand a stop to growing,” he told Health Policy Watch.

Lita says that TAMA does not have data on tobacco farmers growing food, but notes that farmers usually reduce their tobacco production after a year of unsatisfying prices. 

“For example, 2023 good prices are likely to influence an increased production for the 2024 market. Previously, 2011 poor prices led to a slump in the production for the 2012 market,” he says.

“Farmers are attracted to tobacco upon being convinced of getting good profit after production and sales. Other alternative crops have failed to convince them of economic benefits, profitability and market access. There is a global demand for tobacco which Malawian farmers are failing to meet,” Lita stresses.

Malawian Agricultural expert Tamani-Nkhono Mvula says Malawi’s argument remains that if the amount of tobacco is reduced or halted, the livelihood of millions of people and national economy will be affected.

He notes that, although FCTC has led to a decrease in tobacco consumption in Europe and North America, it is increasing in countries like China.

“It’s the Chinese who are also buying a lot of Malawi’s burley tobacco.”

Nkhono-Mvula states that although farmers are encouraged to grow legumes, they are unlikely to be convinced of the same in the next farming season considering losses made in the last farming year.

He observes that tobacco’s biggest advantage is a well-organised value chain where farmers are guaranteed a market and a good price.

“If someone is growing soya, they are not sure of the market or profit. In such situations, it will be difficult for Malawi to stop growing tobacco as long as the tobacco market is going to be profitable and well structured,” Nkhono-Mvula said.

Vincent Kimosop, a Kenyan-based policy and governance expert, urges the Malawi government to progressively introduce measures to support farmers to adopt viable economic alternatives.

“This has been done in many countries including Brazil and there are lessons that can be borrowed by Malawi,” he observes. 

He cites the Kenyan example, where the government has taken steps to enlighten farmers that there is no future in tobacco farming although it is still struggling to find ready market alternatives.

Food crops quest

Nkhono-Mvula says that although tobacco is Malawi’s economic backbone, its agricultural land is geared towards maize, the staple crop, followed by cassava and sweet potatoes.

“It’s the estates that may have larger land for tobacco growing and not the small holder farmers. A tobacco crop in itself doesn’t deplete the soil, but it’s the chemicals used that do. They, in the long run, may have an effect on the soil. 

“The use of trees to dry the tobacco also leads to environmental degradation,” Nkhono-Mvula says.  

Hiscock suggests improving the supply chain for alternative crops, including building up extension services so farmers can grow other crops efficiently and ensuring there are guaranteed buyers for other crops.

She also suggests “educating farmers to understand that they rarely make long-term profits from tobacco”.

She also recommends tobacco control measures to reduce internal demand for tobacco, such as “tobacco taxes, ‘smoke free’ buildings, graphic picture warnings on packaging, plain packaging and banning flavoured tobacco products”.

Preparing to plant tobacco at Ndhlovu’s farmer. Tobacco farmers and workers are exposed to toxins from the fertiliser and nicotin.

Meanwhile, Malawi’s Ministry of Health (MoH) says the country ratified the FCTC to protect citizens  from the harmful effects of direct or indirect exposure to tobacco and its products, which is aimed at reducing lung cancer, cardiovascular and respiratory diseases.

“Malawi ratified to show high-level political commitment to reducing public health effects and from tobacco products. With that high level political commitment, Malawi can negotiate with investors on its diversity plans,” says MoH spokesperson Adrian Chikumbe.

Tobacco is also unhealthy for farmers, labourers and their families as well as factory workers who process it.

Dr William Maina from the WHO’s Africa Regional Office, points out that farmers have prolonged exposure to toxins in the chemicals used, and exposure to nicotine when picking the tobacco leaf.

“A tobacco farmer who plants, cultivates and harvests tobacco may absorb nicotine equivalent to 50 cigarettes per day,” said Maina.

Tobacco growing and manufacturing also threatens biodiversity, negatively impacts soil health by causing nutrient depletion and soil erosion which results in global deforestation and produces environmental harm such as toxic emissions, greenhouse gases and air pollution.

“Most of the tobacco-growing countries in Africa are suffering from food and nutritional deficiencies. However, most of the fertile and arable land has been put on tobacco growing instead of food production. Diverting prime land away from food production is contributing to world hunger.”

He suggests that countries whose economy relies on tobacco should assist their farmers to switch to alternative crops and other livelihoods that provide them with equivalent or higher returns compared to tobacco with reduced labour and exposure to health and environmental risks.

“Governments should stop providing direct tobacco subsidies to tobacco farming and reallocate these to tobacco control programmes including, where applicable, support to alternative livelihoods to tobacco programmes and agriculture extension services,” he advised.

Image Credits: Josephine Chinele.

In Pakistan, a healthcare worker listens to a child’s lungs for signs of pulmonary tuberculosis.

A massive 7.5 million people were diagnosed with tuberculosis in 2022, the highest number ever – but this is positive as it indicates that countries’ ability to detect the disease is recovering after the COVID-19 pandemic, according to the World Health Organization (WHO) 2023 Global tuberculosis (TB) report.

The two countries that contributed most to the global rebound in new diagnoses were India and Indonesia, together accounting for 56% of the increase between 2021 and 2022. They were followed by Philippines (11% of the global increase) and Pakistan (8.4%).

Meanwhile, an estimated 10.6 million people fell ill with TB in 2022 – 300,000 more than the previous year, with WHO’s South-East Asia Region (46%), Africa (23%) and the Western Pacific (18%) worst affected.

But the good news for those with TB is that treatment coverage has recovered to the pre-pandemic level of 70%, up from 62% in 2021.

Slight decrease in deaths

Dr Tereza Kasaeva, WHO’s Global TB Programme director,

TB was the second leading cause of death in 2022, beaten only by COVID-19 – despite being “completely preventable and curable”, said Dr Tereza Kasaeva, WHO’s Global TB Programme director, at the report’s launch on Tuesday.

“What is missing? Prioritisation and enough investment, as we have much better tools for successful treatment, even for the most severe forms of drug-resistant TB,” she added.

However, TB deaths were down to an estimated 1.3 million, in comparison to an estimated 1.4 million for 2020 and 2021, according to the report.

But the net reduction in deaths between 2015 to 2022 is only 19% – far from the WHO End TB Strategy milestone of a 75% reduction by 2025.

The WHO African and European regions have made the best progress in cutting deaths since 2015, while 47 countries have achieved reductions of at least 35%

Drug-resistant TB is a ‘public health crisis’

“Multidrug-resistant TB remains a public health crisis,” said Kasaeva, adding that only two out of five people with multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB) received treatment last year.

With around 410,000 people developing drug-resistant TB in 2022, Kasaeva described drug-resistant TB as “stable” with “no  clear progress toward the decrease of the burden”.

“The cumulative reduction in the TB incidence rate from 2015 to 2022 was only 8.7%, far from the WHO TB strategy milestone of over 50% reduction by 2025.”

Some 42% of the global burden of people with drug-resistant TB comes from just three countries – India (27%), the Philippines (7.5%) and Russia (7.5%). 

“The uptake of the latest recommendations of the WHO for the shorter treatment option is not fast enough,” said Kasaeva. “That’s why we can’t celebrate any progress. It’s stable, it’s concerning and should be improved significantly.

On the positive side, almost three-quarters (73%) of people diagnosed with pulmonary TB were tested for rifampicin resistance, up from 69% in 2021. Some 4.4% were diagnosed with MDR/RR-TB.

The cumulative number of people with MDR/RR-TB on treatment from 2018 to 2022 was 825 000 – 55% of the 5-year target of 1.5 million. For children, the cumulative number was 21 600 – a dismal 19% of the five-year target of 115 000.

But the report notes that there have been “steady improvements in the treatment success rate for people diagnosed with MDR/ RR-TB”, although its latest figures are from 2020, when the treatment success rate was 63%.

“By the end of 2022, 40 countries had started to use the new six-month BPaLM/BPaL regimen to treat people with MDR/RR-TB or pre-XDR-TB. A total of 92 countries were using the shorter nine-month oral regimens for the treatment of MDR/RR-TB,” the report notes.

Price reductions

However, Medecins sans Frontieres (MSF) notes that price reductions for the TB test GeneXpert MTB/RIF Ultra, key to diagnose TB, and the drug bedaquiline, an essential part of the new shorter and safer DR-TB treatment regimens,  has made the scale-up of these medical tools “significantly more achievable”.  

In September, US corporation Cepheid reduced the price of the GeneXpert MTB/RIF Ultra test in high-TB-burden countries by 20% (from US$9.98 to $7.97). 

Meanwhile, Johnson & Johnson decided not to enforce its secondary patents for bedaquiline in 134 low-and middle-income  countries. J&J also granted Stop TB Partnership´s Global Drug Facility`s (GDF) a licence that enabled it to tender, procure, and supply generic versions of bedaquiline to most LMICs. 

The WHO first recommended the GeneXpert MTB/RIF as the initial test to diagnose TB in December 2010, and the shorter, safer and more effective all-oral six-month DR-TB treatment regimens BPaLM and BPaL in December 2022. 

“Although today’s TB statistics once again highlight how TB, a neglected but curable disease, keeps killing millions of people year after year, there may be light on the horizon,” said Dr Gabriella Ferlazzo, TB Medical Adviser of MSF’s Access Campaign.

“Over the last three months, we’ve witnessed a striking string of good news for TB, with long-fought price reductions finally coming through for better tests and drugs, and governments meeting at the UN [at the high-level meeting on TB in September] to promise to ramp up TB testing, treatment and prevention for their people, including children.”

The UN High-Level Meeting on TB set new targets for 2023-2027, including reaching 90% of people in need with TB prevention and care services, using a WHO-recommended rapid test as the first method of diagnosing TB, providing a health and social benefit package to all people with TB, ensuring the availability of at least one new TB vaccine and closing funding gaps for TB implementation and research by 2027.

Ferlazzo called on governments to “use the WHO-recommended tools and strategies we now have to diagnose and treat everyone who needs it, and to increase funding for TB research and care.” 

Stop TB Partnership Executive Director, Lucica Ditiu, paid tribute to all those who had managed to diagnose and treat the 7.5 million people with TB.

“Now that we have shown what can be done – can we get the financial resources and the political commitment so that we are done once and for all with this disease? It is a matter of choice for the governments, donors, and all of us,” she added.

‘Catastrophic’ out-of-pocket costs

Handaa Enkh-Amgalan, a TB survivor from Mongolia.

The report also notes that more than half of TB patients and their households face “catastrophic health costs”  – medical expenses as well as indirect costs, such as travel expenses to pick up their daily medicines, income loss, food supplements and the cost of carers. 

“These costs amount to greater than 20% of total household income,” said Handaa Enkh-Amgalan, a TB survivor from Mongolia.

“Twelve years ago, I was one of those statistics where my family and I were affected by the same level of financial burden of TB that we are seeing in this report. My mom and I faced a tough choice to make. It was down to either affording bread for me and my siblings or going to a TB clinic to have an X-ray done for diagnosis,” said Enkh-Amgalan.

“My mom was able to make the decision to head to a clinic. But there are many more people who are simply unable to make that decision. TB patients are often labelled and stigmatised as irresponsible or non-compliant. These catastrophic costs and stigma are two of the many barriers that are driving millions of patients away from seeking diagnosis and treatment.”

Lack of funds

It’s not only TB patients that are short of cash, however. The entire sector is under-funded despite the impact of the disease.

“Less than half of the $13 billion needed for TB prevention, diagnosis, treatment and care to achieve the global targets was mobilised,” said Kasaeva.

Around  80% of spending on TB services in 2022 came from domestic sources, yet “for low and middle income countries, international donor funding remains crucial”, she added.

The US contributes about 51% of international donor funding for TB and Cheri Vincent, TB Division Chief at the US Agency for International Development (USAID), stressed her government’s “deepest commitment” to move forward on the UN targets.

Image Credits: Stop TB Partnership.

Saima Wazed (in black), along with her mother Bangladesh Prime Minister Sheikh Hasina, during an official visit to the United States to meet US President Joe Biden and First Lady Jill Biden. Wazed’s election as WHO-SEARO’s regional director has been dogged by allegations of nepotism, and her mother’s government is said to have relentlessly lobbied for her win.

Amidst a flurry of allegations of nepotism and political corruption, Saima Wazed, daughter of Bangladesh Prime Minister Sheikh Hasina, has emerged victorious in the race for the World Health Organization’s South-East Asia (WHO-SEARO) regional director.

Wazed’s limited international public health experience and expertise, confined to the narrow field of autism, have raised concerns among experts about her ability to effectively lead the region’s health agenda.

“It is a bit of an experiment to see if a non-public health qualified person with zero public health experience can actually provide the degree of inspiration that is needed to bring about significant shifts or strengthening public health policy,” Mukesh Kapila, a public health expert with experience working in 120 countries, told Health Policy Watch.

While acknowledging the possibility of improvements in the management and internal workings of WHO regional and country offices under Wazed’s leadership, Kapila remains sceptical.

“Can she improve the relevance, effectiveness and efficiency of the WHO in the region? Time will tell,” said Kapila.

Wazed’s dual Canadian citizenship has also drawn scrutiny, raising questions about potential conflicts of interest and her commitment to public health in Bangladesh and the wider South-East Asia region.

Politics wins over experience in WHO-SEARO backrooms 

Wazed’s victory is being attributed to a relentless campaign by her mother’s government, which mobilized its diplomatic network to secure her election. She will now be responsible for providing independent and impartial advice to Bangladesh from WHO.

“The fact [is] that professionals and staff, from my own conversations with them in SEARO, have no confidence in her,” said Kapila. “She’ll be trying her very best not to ruffle [them] too much as she will be trying to win them over. And that means she is unlikely to be much of a change agent.”

Her election opponent Shambhu Prasad Acharya is a veteran WHO official with three decades of experience with the UN health body. Acharya, who received immense support from Nepal’s civil society, was seen as a more qualified candidate but lacked support from other countries in the region.

Kapila attributed Acharya’s loss to Nepal’s position as a poor country that was unable to strike backroom deals to push its candidate, emphasizing that such tactics should not be necessary in the selection of WHO officials.

Of the 11 countries in the region, 10 were eligible to vote in a secret ballot, with Myanmar being disenfranchised because of the sanctions imposed on it. The Bangladesh High Commission shared that Wazed had received 8 out of the 10 votes.

Wazed will take charge in February next year and will be succeeding India’s Poonam Khetrapal Singh who has held the post for a decade now.

Outgoing WHO-SEARO Regional Director Dr Poonam Khetrapal Singh announced earlier this month that Bangladesh has become the world’s first country to eliminate visceral leishmaniasis.

The selection process of WHO’s regional offices has been in the news for a while now. In September, the medical journal The Lancet carried an editorial about the concerns about the candidate selection, and opacity of the election process. Wazed’s candidacy was also questioned on similar grounds.

Earlier this year WHO fired the regional director for the Western Pacific region on an enquiry into allegations of misconduct, as HPW reported in March this year.

Despite a quarter of the world’s population living in the SEARO region and the high number of COVID-19 deaths recorded during the pandemic, the SEARO office was hesitant to hold press conferences or provide regular updates on the situation. This contrasted with other WHO regional offices that were more proactive in communicating with the public.

Indian journalists faced difficulties in accessing accurate information about the country’s COVID-19 death toll at the height of the pandemic. The Indian government reportedly lobbied the WHO against releasing its excess deaths report, which would have revealed the country’s true death toll. The SEARO office remained largely silent on this matter, despite the significant public health implications.

Shenanigans in WHO South-East Asia as Politician’s Daughter Contests Regional Director Election

The region also has exceedingly high air pollution levels, an issue that WHO could get involved with more actively. Severe air pollution has once again engulfed Delhi, affecting health in the region. This year, cities like Mumbai with relatively clean air have also been hit hard.

While Singh was hesitant to take a stronger stand on the issue with the respective governments, Wazed is likely to follow suit, given how instrumental the Indian government’s support has been for her victory, experts HPW spoke to said.

“It was a victory not for global health or professionalism,” said Kapila. “It was a victory for state politics, and interstate politics and money and basically Bangladesh’s clout to get votes. But then I suppose that is politics for you.”

Experts also said that given Hasina’s government is in trouble in Bangladesh and Wazed is aware of her unpopularity within the WHO, she might not want to ruffle any feathers and is unlikely to take any strong policy stand.

Image Credits: X, WHO.