Editorial

We have many new case studies, reports and links to videos in the EQUINET updates and useful resources in this issue, and issued a special editorial on protecting health and health services in conflict in February. In this issue we thus use this editorial space briefly to invite you to read these publications. The February editorial responded to the conflict and violence in different global regions, and particularly the violations against the specific protections provided in international conventions of civilian health, health services and health workers in conflict zones. The extreme situation in Gaza, still continuing, prompted the WHO Director General Dr Tedros Adhanom Ghebreyesus to say “Without a ceasefire, there is no peace. And without peace, there is no health.”

At the same time we present in this newsletter many case studies of inspiring action in different urban sites in our region. They address the rising challenges and health risks posed by urbanisation for unmanaged waste and food insecurity, especially for low income communities. They turn challenge to opportunity, such as by linking waste recycling to incomes and to fertiliser for urban agriculture and food security. They change zones of polluting waste dumping and burning into urban green zones through ‘whole of society’ approaches. They show concretely the possibility of and measures for taking on issues such as climate justice and inclusive circular economies. For those affected they show that they can produce change.

These local level initiatives yield optimism, even as frustration and social disempowerment is fostered over global and international level actions on key challenges affecting wellbeing, such as climate, conflict and inequity. As another paper in this issue discussing the Africa Continental Free Trade Agreement asks, can we at national and regional level better protect space and support for such initiatives within our countries, rather than reproducing global trade and economic frameworks that block them? We invite you to contribute evidence and publication to the newsletter, and to explore, debate, analyse and share on these and other health equity issues with us in 2024, and wish you a year of peace, health and progress.

The violent attacks and hostage-taking in Israel on 7 October 2023, and the subsequent and ongoing military onslaught in Gaza, West Bank and military attacks in that region add to conflicts in Ukraine, Yemen, eastern DRC, Sudan, Myanmar and other countries. Yet the intensity in Gaza has been a shock globally, including in our region. For example, WHO reports the number of children killed in the three weeks following 7 October to have surpassed the annual number of children killed in all conflict zones since 2019. As a health network, we focus this statement only on the health dimensions of the situation reported in United Nations evidence, that is the attacks on health personnel, the destruction of health services and the denial of medicines, health technologies, water and food. We write this to raise attention to whether we can better and more rapidly fulfill our duties to protect these health issues in conflict, in Gaza and elsewhere.

The major United Nations International Covenants on human rights (the ICCPR ratified by 172 countries and ICESR ratified by 171 countries) protect the right to life and to health. In situations of conflict, the Geneva and Hague Conventions provide further that there should be ‘no obstacle to humanitarian activities’, and that the wounded and sick should ‘be respected and protected in all circumstances’. Access to health services are vital to provide this respect and protection, and these conventions state that hospital and medical facilities should not be attacked. The only exception to the latter is if civilian hospitals are actively used to commit ‘acts harmful to the enemy’.

That accessible, well equipped health care and humanitarian relief is needed in Gaza is unquestionable. While attacks have taken place in Israel, Gaza and other areas, the scale of the situation in Gaza is extreme. Between October 7 and 19 January, 24 762 people in Gaza were reported by Reliefweb and UN sources to have been killed, including over 7,729 children, with a further 62 108 injured, and over 7 780 others missing, presumed dead under rubble. Teresa Zakaria, a World Health Organisation (WHO) Health Emergencies official, notes the largest proportion of recorded fatalities to be children (45%) and women (30%).

United Nations (UN) reports provide evidence of the mounting deprivations of the basics for life and health. A UNICEF official warned in January 2024 that “silent, slow deaths caused by hunger and thirst risk surpassing those violent deaths already caused by Israeli bombs and missiles.” In mid-January 2024, WHO reported the entire population of Gaza – roughly 2.2 million people- to be ‘in crisis or worse levels of acute food insecurity’, with 1.9 million people displaced from their homes, and over 1.4 million staying in overcrowded shelters. The conflict has damaged or destroyed essential water, sanitation and health infrastructure, with the World Food Programme reporting in December 2023 only 1.5 to 1.8 litres of clean water to be available per person per day, for all uses, below even the daily ‘survival threshold’ of 3 litres. Beyond the mental ill health impact of military conflict on civilians, WHO report soaring rates of infectious disease, with a 25-fold escalation in case rates of diarrhoea, and rising cases of upper respiratory infection, meningitis, scabies, jaundice and chickenpox. Hunger increases the risk of mortality from these conditions. The effects are not only short-term. UNICEF estimated 1,000 children having lost one or both legs during the conflict and a combination of disease and a 30% rise in wasting that risks survival and their longer-term development.

WHO stated last December: “The people of Gaza, who have already suffered enough, now face death from starvation and diseases that could be easily treated with a functioning health system. This must stop”.

Yet access to health services across Gaza has also plummeted with the destruction of health services. As reported by UNICEF by January 2024, there had been 590 direct attacks on healthcare in Gaza and West Bank since the war began, with 291 ambulances damaged, including those marked with the Red Cross or Red Crescent emblem. Missiles have also been fired on health facilities in Israel, with the WHO Surveillance system for attacks on health care reporting on 31 January 2024 that there had been 64 attacks on health facilities in Israel, 18 impacting on facilities, 38 impacting personnel and 13 impacting patients. However, the attacks in Gaza have been significantly more widespread and destructive of health services. By last December, WHO reported more than 238 attacks on healthcare in Gaza alone, damaging or destroying over 61 hospitals and other healthcare facilities. For example, Al-Indonesi hospital was reported by a UN official last December to have been bombed 35 times since 28 October. The military attacks have targeted hospital generators, hospital solar panels, and life-saving equipment, such as oxygen stations and water tanks. As a result, only 13 out of 36 hospitals and 18 out of 72 healthcare centres are reported to still be functioning — some of them barely — despite the overwhelming need for these services. In December last year, WHO reported 21of Gaza’s 36 hospitals to be closed, and of the remaining 15, eleven to be only partially functional and four ‘minimally functional’. Those that are open are operating at multiple times their bed capacity. They lack fuel supplies, food and clean water, which with accumulating medical waste raises a public health risk for patients and the thousands of displaced persons sheltering in hospital grounds. Direct bombing of health services has endangered patients and those sheltering in hospital grounds, with WHO reporting in December 2023 that at least 570 Palestinians have been killed at hospitals and healthcare centres in Gaza, and a further 746 injured by Israeli military strikes or snipers.

As noted earlier, international law does not protect health services that are actively used to commit acts of war. In January 2024, Israeli authorities alleged in its case in the International Court of Justice that hospitals in Gaza were used as sites of military action, with militants using some hospitals to retreat to, to hold hostages in, or to fire on Israeli forces. In the same month a WHO official observed that there was no evidence that hospitals in the Gaza Strip were being used for purposes other than providing healthcare. The consequence remains that the wounded and sick are left without respect and protection, in contrast to international norms.
Many health workers in Gaza did not leave their patients and continued to serve despite the risk to their own lives. In December 2023, UNICEF reported over 311 doctors, nurses and other health workers, including doctors and ambulance drivers killed on duty, while WHO has reported medics and first responders to have been repeatedly detained by Israeli forces, many of these detained incommunicado at unknown locations. Tlaleng Mofokeng, UN Special Rapporteur on the right to health stated, “We are in the darkest time for the right to health in our lifetimes,” She said. “For people to have access to quality healthcare, they must have access to healthcare workers, and those healthcare workers must be safe and free to provide care.” “We bear witness to a shameful war on healthcare workers”.

Those injured in attacks find insufficient staff and resources for adequate care, raising the risk of infected, necrotic or gangrenous wounds, and deaths from what should be treatable conditions. However, the denial of health care does not only affect those injured in conflict. It affects those needing other forms of care. Patients have to cross long distances in dangerous conditions to find an open facility. Existing triage criteria in emergency departments have to give precedence to war injuries over non-emergency cases, undermining other forms of care. WHO reported in November 2023 an estimated 5,500 Palestinian women in Gaza giving birth each month in unsafe conditions, often with no medical assistance or clean water. UN News report operations, including amputations and caesarean sections, taking place without anaesthetic.

There have been efforts to respond. Since the start of the hostilities, WHO, other UN agencies and partners have been supporting the health system and humanitarian relief in Gaza with high-risk missions to deliver medical equipment and supplies, medicines, fuel, coordination of emergency medical teams, and disease surveillance. Agencies have also delivered food and water to people inside Gaza. The UN estimated in November 2023 that the Gaza population required at least 500 humanitarian aid trucks every day, a need that is estimated to have doubled recently, given the prolonged attacks, destruction, and interruption of adequate aid distribution. At the same time, UN OCHA report that the response capacity is hindered by damaged roads, delays at checkpoints ‘security risks, mobility constraints, delays, denials and a constant risk of distribution in a conflict zone where aid workers have been killed and some convoys shot at.

The current situation worsens a health system already weakened by the 16-year-long blockade of Gaza prior to October 7, with restrictions since 2007 at Israel-controlled crossing points of supplies and services, and on access to medical care outside Gaza. Already by 2020, a UN Special Rapporteur described the impact of this blockade as having turned Gaza “from a low-income society with modest but growing export ties to the regional and international economy to an impoverished ghetto with a decimated economy and a collapsing social service system”.

The long-term and immediate situation signals that despite the global treaties protecting health, healthcare and human dignity in conflict zones, we do not yet have the measures to operationalise them before significant harm occurs. In December, 2023 WHO’s Executive Board adopted by consensus a draft resolution on “Health Conditions in the Occupied Palestinian Territory” calling for “immediate, sustained and unimpeded passage of humanitarian relief, including the access of medical personnel,” and for “all parties to armed conflict to comply fully with the obligations applicable to them under international humanitarian law related to the protection of civilians in armed conflict and medical personnel.” The consensus adoption was noted to reflect ‘the importance of health as a universal priority, in all circumstances, and the role of healthcare and humanitarianism in building bridges to peace, even in the most difficult of situations’.

The efforts of UN and other agency personnel to deliver support and the WHO reports and engagement in various forums have been important and valued, including to document and report violations. The recent South African Case at the International Court of Justice (ICJ) has triggered provisional legal measures to protect access to adequate food and water; medical care; hygiene; sanitation; and other forms of humanitarian relief. Israel asserted at the ICJ that it is eager to expand humanitarian aid to the fullest extent of its capacity; and to support rather than interfere with the work of medical personnel. However, attacks on and deaths of civilians have continued since the ICJ hearing at a rate of 145 people per day. On 17 January, the Jordanian field hospital in Khan Yunis was targeted during an Israeli bombing, injuring one of the health crews and a person receiving treatment in the intensive care unit; and lighting bombs were dropped over the Nasser Medical Complex in Khan Yunis.

The most obvious measure for Gaza’s health system and population is that called for by the UN Secretary General, the WHO and other UN agencies and countries, an immediate ‘humanitarian’ ceasefire and work to stop the war, safely provide humanitarian relief and rebuild key infrastructure and services. As WHO Director-General Dr Tedros Adhanom Ghebreyesus said on the adoption of the WHO Executive Board resolution “Without a ceasefire, there is no peace. And without peace, there is no health.”

However, we should not stop there. International norms are now easier to monitor globally, and within regions and countries, so lack of information cannot be a cause of inaction. However, it appears that we may draw little comfort from the specific protection of civilian health, health services and health workers in conflict zones in international conventions, if they can be breached over a sustained period with impunity, and without resolution, including from a paralysed response to human security at the level of the UN Security Council. Responses are rightly now preoccupied with ending the immediate traumas. But the situation in Gaza also sends a strong signal that, in moving forward, we must proactively strengthen the domestic and regional policy articulation of and preparedness to apply international norms on protection of health and health care in conflict in all regions globally. We need to profile and strengthen the level and speed of response of the national and international systems that ensure compliance with these norms, and where needed penalty and remedy for breaches, when this concerns access to health services, humanitarian activities and protection of the wounded and sick in conflict zones.

The intricate tapestry of Uganda's food system, woven over centuries, underwent a tectonic shift due to colonialism. The reverberations of this historical trauma continue to shape the country's food landscape, underscoring the pressing need to untangle the threads of colonization and breathe new life into an ailing system.

Before it was colonised, Uganda's land was a patchwork of kingdoms and chiefdoms, in a communal system where land wasn't just a resource, but a collective heritage. It provided fertile ground for families to cultivate food and other crops for their subsistence and to share with their communities, an arrangement steeped in tradition, reciprocity and co-existence.

Colonial geo-political shifts shattered this communal system. The establishment of the British Protectorate of Uganda in the 1900s changed the relationship between society, land and food. A treaty signed between the British Protectorate government and the Buganda Kingdom in 1900 segregated land into two categories: In one, over 9100 square miles of game reserves, forests, mineral-rich expanses, and water bodies were seized as ‘Crown Land’, by the Imperial British East Africa Company, and transferred in the 1930s to various private and state landholders.

In the other segment, 10000 square miles share of less fertile ‘mailo land’ was allocated as private land to the king (Kabaka) and his family, chiefs, and religious institutions, making over 1.5 million indigenous residents squatters on the land, requiring permission and having to pay taxes to live on or farm the land. Ordinary Ugandans, once stewards of their land, were thus displaced, marginalised, and impoverished. Forced migration, and violent conflicts with the colonial government intensified displacement, famine, human and livestock disease, poverty and death.

Landless, indigenous people were compelled to work as poorly paid wage labour for foreign plantation owners, mostly British and Asian, producing cash crops for export, including food, coffee, cotton, tea, and cocoa. Poor wages, substandard conditions, colonial expansion wars and landlessness drove urbanisation. Those migrating to towns and cities often lived in informal settlements, in racially segregated cities, within crowded, substandard living conditions. That situation has evolved into today's unplanned, poorly-serviced areas of towns and cities. The food system also changed. The indigenous food culture, with a diet of nutritious of millet and sorghum slowly yielded to imported influences and local economic pressures.

Between 1910 and Uganda’s independence in 1962, smallholder farmers who were the backbone of local food subsistence would sell to exploitative local middlemen. The meagre payments they received drove farmers towards better-paid non-food crops such as cotton, coffee, tea, and tobacco. Low investment and a fall in indigenous food production led to intermittent famines in many regions in the early 1900s. In response, the colonial government introduced fast-growing crops like cabbages and potatoes (locally referred to as ‘Irish Potatoes’ given their Irish origin) to contain famines. Urban communities increasingly depended on commercial and informal food markets, with poor food hygiene and high levels of additives in imported fast-foods exposing them to communicable and nutritional diseases.

Landless people joined the struggle for Uganda’s independence, seeking change to these forms of exploitation. Independence brought them political change, but limited socio-economic change. Colonially confiscated ‘crown land’ became national public land, still producing cash crops, without restoring land to or compensating original inhabitants who were displaced from their land. Despite key new constitutional political freedoms, a priority for development over decolonisation, and adoption of a neoliberal economic model sustained inequalities in wealth and weakened economic self-determination.

Today’s burgeoning urban population grapples with exorbitant food prices, in commodified food markets. Food prices are affected by international commodity prices, conflicts, emergencies and pandemics like COVID-19 that destabilise food supply chains, particularly as where imported foods such as wheat or rice have supplanted local staples. Climate change compounds this vulnerability, with water-stressed regions facing challenges in producing food from rain-fed agriculture. Under-investment in largely female smallholder farmers constrains their ability to generate livelihoods or to apply technological innovation, at a time when commercial seeds demand increasingly costly synthetic fertilisers and pesticides.

Policy deficits related to food systems extend down other policy corridors. Neoliberal economic policies in the last three decades, influenced by international financial institutions, have focused on finance and export sectors, while starving the food sector. The formal private sector, pivotal in shaping the policy landscape, focuses on export-oriented production at the expense of indigenous, locally-consumed food. Trade liberalisation has promoted a further surge in unhealthy, food imports, further disconnecting people from their indigenous dietary roots. Markets flooded with ultra-processed foods catalyse a rise in food-related non-communicable diseases (NCDs) such as hypertension and diabetes, from 22% of total national deaths a decade ago to 35% today. Kampala contributes to nearly 50% of all cases of NCDs.

The urgency to halt this trajectory cannot be overstated. Systemic transformation hinges on a multifaceted, people-centred approach towards food sovereignty. Closing knowledge and resource gaps to facilitate appropriate modern farming techniques, protecting indigenous seed stocks, and implementing inclusive land reforms are pivotal, as is recognising and supporting the role of urban agriculture. Restoring indigenous seeds, practices and foods in ways that prevent local resource depletion can make healthier, affordable foods available and accessible. Legal and tax measures can curb marketing of unhealthy foods, together with promotion of a seismic shift in public awareness to alter consumption patterns.

Reclaiming a healthy and self-determined food system isn't confined to Uganda's borders.
The trends outlined are found in other African countries, and the Alliance for Food Sovereignty in Africa has engaged on their global corporate drivers. A global forum on food sovereignty is bringing together thousands of indigenous, small-scale farmer, worker and other movements in a ‘Nyeleni process’ to advance food sovereignty at all levels (https://www.foodsovereignty.org/nyeleni-process/) In east and southern Africa (ESA), as noted elsewhere in this newsletter, we need to and can collaborate regionally to dismantle the colonial and neo-colonial features of our food systems and to strengthen food sovereignty, supported by updated and harmonised food system laws, taxation to discourage harmful foods and by promotion of climate-relevant healthy approaches for farming, producing, processing and promoting consumption of healthy foods.

Uganda stands at a pivotal juncture in its food system trajectory. The path to decolonising its food system and building food sovereignty may raise challenges. It is, however, a path that can and must be traversed, to reach a future where food is not just to survive, but a testament to self-determination.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. You can read further information on EQUINET work on issues raised in this oped on the EQUINET website.

Research is key to promoting and health and preventing disease to the extent that international human rights law recognises the right of everyone to benefit from scientific progress. But what if health research is subverted from its aim by the presence of conflict of interest?

We have already seen this, such as in how some researchers failed to disclose their conflicts of interest when producing research that downplayed the health hazards of chrysotile asbestos (https://tinyurl.com/52hpah2p), findings that allowed this toxin and the asbestos industry an extended shelf-life at the expense of human lives.

The gatekeepers of ethical research are institutions – typically, science granting councils which allocate research funding and shape science policy at country level, and Research Ethics Committees (RECs), which provide oversight to ensure that health research is implemented in line with generally accepted ethical standards.

But in a context of scarce resources for health research, even these institutions can fail, when research funding provided by corporations, or sometimes even governments, with vested interests compromises the independence of the research process, producing research findings that undermine evidence-based policy. A 2020 study of the willingness of Schools of Public Health in the African, Eastern Mediterranean, European and US regions found widespread openness amongst respondents to the idea of accepting funding from corporate sources with vested interests in research on non-communicable diseases (https://tinyurl.com/nmpxcxwd). This is not surprising, given the pressures under which low-income country researchers operate, often with little or no research funding, in contrast to the immense power and financial resources available to corporates wishing to influence health policy to protect their profits.

Even the most powerful Science Councils can fall prey to conflict of interest. This was illustrated, for example, when the collusion was exposed between officials of the US National Institute of Health, contrary to NIH policy, and representatives of the alcohol beverage industry, in setting up a huge study of moderate alcohol consumption, called the MACH study. The study was plagued by questionable design and by a clear vested interest in choosing a research question that was likely to benefit industry sales, rather than generating evidence pertinent for health policy (https://tinyurl.com/ak57wdj2).

Empowering Science Council staff and REC members with the skills to identify, obviate and manage conflict of interest effectively is thus essential if health research is to realise the benefits of scientific progress for people most in need. This is particularly the case in sub-Saharan Africa, where research systems are fragile and starved of the resources needed to ensure researcher independence.

Conflict of interest (COI) is defined as circumstances in which professional judgment concerning a primary interest (such the validity of research) tend to be unduly influenced by a secondary interest (such as financial gain). It can be effectively addressed if systems are designed to insulate decision-making processes from vested interests, and to protect researcher independence, objectivity and impartiality. This is possible if the people in those systems can gain skills to manage COI better. This applies as much to research as to broader policy making, which may also be heavily influenced by corporate activities and strategies.

A collaborative initiative, funded by the IDRC, and involving researchers from South Africa, Kenya, Cameroon and Lebanon, developed over two years, an online course (https://tinyurl.com/dp9madje) and a toolkit (https://tinyurl.com/c742bb63) that aimed to empower REC members and Science Council staff to better manage COI in the research process. These resources are open access and available to all interested in improving the integrity of evidence used in health policy decisions.

The toolkit offers examples of how to identify and manage COI, ranging from prohibition and disclosure through to mitigation or resolution. It emphasizes that reliance on disclosure alone is insufficient. It may be counter-productive if it legitimises any kind of COI, including COIs that, in a traffic light analogy, should trigger red lights.

The toolkit outlines three scenarios. The first is where ‘moral certainty’ exists that that the research should not proceed, such as when the funding source is an organisation whose products are harmful and where the organisation holds a direct interest in the outcome of the research, as in the example of tobacco industry funding for tobacco-related research. In the second scenario, such as when the funding source has no interest in the study outcome and does not produce commodities harmful to health, it is also easy to conclude the study should proceed.

But usually, it is a third scenario where there is uncertainty on the interests.

In this situation, the toolkit proposes a series of key questions that could be used to identify COI and characterise its scope. Such questions include whether anyone on the REC or science council will benefit financially from the research, whether a financial loss will be avoided if the research is approved, or whether the research serves a marketing purpose for the funder. Depending on the case, different strategies may be applied. The strategies include recusal of a committee member or science council employee who has direct interest in the outcome of the decision, barring a funder from any say in publication decisions, or mandating an independent oversight committee to monitor study implementation. The toolkit also maps the elements of policy that institutions might adopt to manage COI more effectively. Coupled with skills development, such initiatives are important to finding the right balance between diversifying funding and retaining independence of the research process.

To continue the traffic light analogy, finding the green light for health research is the ultimate goal. But much of what we encounter in practice is amber. It is located in that space where careful reasoning, drawing on ethical principles is needed to ensure that health research findings can provide the necessary unbiased evidence, free from vested interests, to advance health in our region.

For further information on the Toolkit and online course visit the Conflict of Interest in Health Research website at the University of Cape Town, https://tinyurl.com/5bp4k8b7. Feedback to the team would be very welcome.