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Civil wars and arms trade Facebook X (Twitter) WhatsApp LinkedIn Pinterest Copy link Yemen- a neglected humanitarian crisis Last updated: 03/05/26, 17:20 Published: 15/05/25, 07:00 Civil wars and arms trade This is article no. 3 in a series about global health injustices. Previous article: Civil war in Sudan . Next article: Injustices in Lebanon and Syria . Introduction Welcome to the third article of the Global Health Injustices Series. Building on the last article on Sudan , the focus is now on Yemen, by analysing the health inequalities and inequities the broader Yemeni population encounters. Similar to Sudan, there is a civil war between the government and the Houthis, among other political factions in Yemen, producing detrimental population health outcomes that will be delved into after an overview of Yemen's history and current state. Yemen: a distinct past and its current challenges Yemen is a country in the Middle East bordered by Saudi Arabia and Oman. Like Palestine and Sudan, Yemen is noteworthy for its distinct culture, languages and traditions. Moreover, Yemen has been part of trade routes with other surrounding countries for centuries and even now, as it is adjacent to the Red and Arabian Seas. However, as far back as the 1990s, when Yemen gained independence after varying degrees of resisting colonialism, internal friction within the government has led to civil wars even before this current one. At the moment, Yemen has one of the highest rates of mal- and undernutrition in the Middle East due to approximately half of the Yemeni people living in poverty and lacking access to clean water. Additionally, around 4.5 billion people are displaced in Yemen, and have been displaced in many instances since 2015. Furthermore, in spite of the ongoing civil war, Yemen has at least 97,000 asylum seekers and refugees from countries like Somalia and Ethiopia. Taking into account this important context, it is vital to support the Yemeni population as well as the refugees and asylum seekers. This is because they are facing injustices, which then lead to worsening outcomes for numerous people in Yemen. Although this crisis is ongoing, the Yemeni people, the refugees and asylum seekers stay resilient within their communities. Civil war and the consequences of the arms trade Unfortunately, Yemen has been noted by the WHO as an ignored humanitarian crisis, where approximately 20 million people need emergency healthcare. Specifically, 17.3 million people are driven to starvation, including 1.15 million children under 5 years old being acutely malnourished, having a 30-50% mortality risk. Although these statistics are driven by the ongoing civil war fueled by the arms trade between the Yemeni government, others in the Middle East and notably the United States, it is essential to highlight the other factors in Yemen driving childhood malnutrition. One study found that as maternal education, social and economic status increase, the likelihood of malnutrition in children decreases. Moreover, cigarette smoking during pregnancy increased the number of children with malnutrition. It could be inferred that there was a lot of internal instability within Yemen when this study occurred, leading to these health outcomes for the children, which have been currently worsened by the ongoing civil war, with further fuel from the arms trade. Regarding mental health in Yemen, one article noted how the COVID-19 pandemic, on top of the civil war, has impacted access to mental health care. Approximately 20% of Yemenis suffer from at least one mental health disorder, which includes anxiety, depression and schizophrenia. However, seeking help for mental health has been hindered by stigma and superstition, notably how people with these concerns may be described as dangerous. These gaps underline a lack of resources and facilities in Yemen attributed to damage from the ongoing civil war. Shifting to infectious diseases, the civil war in Yemen has contributed to a high burden of neglected tropical diseases (NTDs), which are diseases affecting low-income countries that lack healthcare resources, infrastructure and sanitation and hygiene facilities. The most notable include dengue fever, salmonella, and schistosomiasis ( Figure 1 ). The exact epidemiological data of NTDs in Yemen is difficult to find because there is a lack of infectious disease surveillance, and the healthcare system is fractured. Focusing on Yemen’s healthcare system, one review noted six key areas from the World Health Organisation that are involved in a strong healthcare system: health information systems, health workforce, governance, service delivery, access to essential medicines, and financing. Each area is weakened by the civil war, but here is a glimpse of each area, with some of the steps forward. Firstly, the review suggested that health information systems are deficient, so the authors urged the creation of a health survey system for Yemen. Since 2015, the health workforce has decreased by 50%, where more than half of workers left their jobs as they were not getting paid; retaining them could be through voucher programs and payment contracts. Also, access to essential medicines, particularly for chronic diseases, is scarce due to lack of funding, limited imports and damage to infrastructure. As for service delivery, at least 50% of healthcare buildings are operating, with airstrikes destroying more than 500 buildings, leaving vital services like emergency obstetric care very restricted. Although financing on healthcare has increased from 0.8% in 2004 to approximately 2.9-4.1%, with further investment to up to 12%, the population still has to pay out-of-pocket for healthcare. To move forward, the author noted how crucial it is to increase government spending on health. However, enhancing these areas must begin with improving governance, or the key leaders in Yemen congregating to make decisions that lead to a more robust healthcare system. Currently, there are issues due to bureaucracy, top-down management and friction between the Yemeni government, the Houthis and the other political factions. As mentioned above, one area of service delivery severely impacted by the ongoing war is obstetric care, along with newborn and child health. One case study noted that although these areas are a priority, there were instances, like tackling cholera outbreaks ( Figure 2 ) and treating malnutrition, which were offered priority over other forms of care. This imbalance reflects that more funding is required for all of the healthcare service areas to run optimally. One way forward is to include not only the leaders in Yemen, but also international NGOs to bring in their expertise to support the re-development of the healthcare system. The role of NGOs in supporting the Yemeni population NGOs have a vital role in supporting vulnerable populations, especially in Yemen. In a 2025 report from Amnesty International, they noted several breaches of international law and human rights: Parties to the conflict in Yemen continued to arbitrarily detain, forcibly disappear and unjustly prosecute people who criticized their human rights records and policies, including human rights defenders, journalists and humanitarian workers. All parties to the conflict failed to protect economic and social rights amid international funding cuts that further worsened the humanitarian crisis. Parties to the conflict contributed to environmental degradation. Other NGOs, such as the United Nations High Commissioner for Refugees (UNHCR), stated their provision of lifesaving aid to refugees, asylum seekers and displaced Yemenis, along with other forms of support through cash and essential supplies. The first way forward towards upholding the health and wellbeing of the broader population is to establish clearer governance among the leaders in Yemen. This could be facilitated by NGOs and other stakeholders, perhaps the other governments too, by stopping arms trade and increasing humanitarian aid. Conclusion: looking ahead at clearer governance Throughout this article, evidence indicates that the civil war in Yemen has devastating impacts on the health and wellbeing of the population. From individuals unable to seek appropriate mental health support, to a divided healthcare system with limited funding and other deficits. Consequently, the leaders in Yemen must come together to uphold international law and human rights, while NGOs are vital in facilitating this dynamic. My previous words on holding people in power worldwide accountable to human rights and international law are very relevant for Yemen. This is because they are responsible for enabling the ongoing civil war through the arms trade, so urging these people in power, particularly in Western countries, to stop would be a major step forward in de-escalating the humanitarian crisis. For the next article in the Global Health Injustices Series, it will be a collaborative endeavour that focuses on both Syria and Lebanon, two bordering countries that have diverging yet connected struggles; by understanding them, we can ensure that the populations in both countries obtain as much support as possible to improve their health outcomes. Written by Sam Jarada Related article: Understanding health through different stances REFERENCES UNHCR. Yemen Crisis Explained. 2024. Available from: https://www.unrefugees.org/news/yemen-crisis-explained/ WHO. Achieving health for all in Yemen. 2023. Available from: https://www.emro.who.int/images/stories/yemen/achieving-health-for-all-in-yemen.pdf Capitalizing on Conflict: How U.S. arm sales fuel the humanitarian crisis in Yemen. OpenSecrets. 2024. Available from: https://www.opensecrets.org/news/reports/capitalizing-on-conflict/yemen-case-study Sunil TS. Effects of socio‐economic and behavioural factors on childhood malnutrition in Yemen. Maternal and Child Nutrition. 2009 Feb 3;5(3):251–9. Available from: https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1740-8709.2008.00174.xm Waleed Alhariri, Mcnally A, Knuckey S. The Right to Mental Health in Yemen: A Distressed and Ignored Foundation for Peace. Health and Human Rights. 2021 Jun;23(1):43. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8233030/ Ahmed A, Rahmat Dapari, Dom NC. Neglected tropical diseases in Yemen: a systematic review of epidemiology and public health challenges. BMC Public Health. 2025 Feb 7;25(1). Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-025-21700-z#Fig3 Ali Alraimi A, Shelke A. Strengthening Health Systems in Conflict: Evidence-Based Policies for Quality Care in Yemen. Journal of Cardiovascular and Cardiology. 2024 Mar 31;1–4. Available from: https://oaskpublishers.com/assets/article-pdf/strengthening-health-systems-in-conflict-evidence-based-policies-for-quality-care-in-yemen.pdf Tappis H, Elaraby S, Shatha Elnakib, Abdulghani A, Huda BaSaleem, Saleh A, et al. Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study. Conflict and Health. 2020 May 27;14(1). Available from: https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-020-00269-x Human rights in Yemen. Amnesty International. 2023. Available from: https://www.amnesty.org/en/location/middle-east-and-north-africa/middle-east/yemen/report-yemen/ Project Gallery

Uncovering the truth behind the origins of the virus Facebook X (Twitter) WhatsApp LinkedIn Pinterest Copy link Origins of COVID-19 03/05/26, 17:31 Last updated: Published: 08/10/23, 16:07 Uncovering the truth behind the origins of the virus The quest for the crime of the century begins now! Suspicion of the Wuhan Institute of Virology Since the early epidemic reports in Wuhan, the origin of COVID-19 has been a matter of contention. Was SARS-CoV-2 the outcome of spontaneous transmission from animals to humans, or scientific experimentation? Although most of the recorded initial cases occurred near a seafood market, Western Intelligence Agencies knew that the Wuhan Institute of Virology (WIV) was situated nine miles to the south. Researchers at the biosafety centre combed Yunnan caves for bats harbouring SARS-like viruses. They have been extracting genetic material from their saliva, urine, and faeces. Additionally, bat coronavirus RaTG13 (BatCoV RaTG13) shared 96% of its genome with SARS-CoV-2. Suspicion increased when it was discovered that WIV researchers dealt with chimeric versions of SARS-like viruses capable of infecting human cells. However, similar "gain-of-function" studies in Western biosecurity institutions have shown that such slow virulence increases may occur naturally. The coincidence that the pandemic began in the same city as the WIV outbreak was too obvious to ignore. According to two Chinese specialists , "the likelihood of bats flying to the market was quite remote". Chan and Ridley's "Quest for the Origin of COVID-19" Chan and Ridley have created a viral whodunit titled "Quest for the origin of COVID-19" to excite the curiosity of armchair detectives and scientific sceptics. Both need clarification as to why a virus of unknown origin was detected in Wuhan and not in Yunnan, 900 kilometres to the south. The stakes could not be more significant; if the virus were deliberately developed and spread by a Chinese laboratory, it would be the crime of the century. They are prudent in not going that far. They are, however, within their rights to cast doubt on the findings since their concerns were shared by numerous coronavirus experts who openly discounted the possibility of a non-natural origin and declared that the virus displayed no evidence of design at the time. Is this the impartial and fair probe the world has been waiting for? They present no evidence for the development of SARS-CoV-2. For example, Chan asserts that it seemed pre-adapted to human transmission " to an extent comparable to the late SARS-CoV-2 outbreak ". This statement is based on a single spike protein mutation that appears to "substantially enhance" its potential to connect to human receptor cells, meaning it had "apparently stabilised genetically" when identified in Wuhan. Nonetheless, this is a staggeringly misleading statement. As seen by the alphabet soup of mutations, the coronavirus has undergone multiple alterations that have consistently increased its suitability. Additionally, viruses isolated from pangolins attach to human receptor cells more efficiently than SARS-CoV-2, indicating the possibility of additional adaptation. According to two virologists, although the SARS-CoV-2 virus was not wholly adapted to humans, it was "merely enough". Evidence for design of SARS-CoV-2 and possible natural origins of the virus Another concerning feature of SARS-CoV-2 is a furin cleavage site, which enables it to infect human cells by interfering with the receptor protein. The identical sequence is present in highly pathogenic influenza viruses and was previously utilised to modify the spike protein of COVID-19. Chan and Ridley explain that this is the kind of insertion that would occur in a laboratory-modified bat virus. As a result, 21 leading experts have concluded that the furin sequence is insufficient. Coronaviruses have been shown to possess " near identical " genomes that often can infect humans and animals. Because the furin cleavage site characteristic is not seen in known bat coronaviruses, it is possible that it evolved naturally. Surprisingly, Chan and Ridley do not suggest that the SARS virus's high human infectivity feature was inserted on purpose since "there is no way to determine". There is also no way to determine if a RaTG13 is the pandemic virus's progenitor since history is replete with pandemics that began with zoonotic jumps. This argument is based on the strange fact that WIV researchers retrieved the bat isolate in 2013 from a decommissioned mine shaft in Yunnan. Six people were removing bat guano from the cave that year when they suffered an unexplained respiratory ailment. As a consequence, half of them perished. The 4% genetic diversity between RaTG13 and SARS-CoV-2, on the other hand, is similar to 40 years of evolutionary change. While exploring caves in northern Laos, researchers discovered three more closely related bat coronaviruses, which have a higher affinity to attach to human cells than the early SARS-CoV-2 strains. This indicates an organic origin, either through another animal host or directly from a bat, maybe when a farmer went into a cave. This is arguably the most reasonable explanation since it is consistent with forensic and epidemiological data. The food sample isolates collected from the Wuhan seafood market are similar to human isolates, and the majority of original human cases had a history of market exposure, in contrast to the absence of an epidemiological connection to the WIV or any other Wuhan research institution. Lack of evidence for a laboratory origin If scientists could demonstrate prior infection at the Wuhan market or other Chinese wildlife markets that sell the most likely intermediary species, including pangolins, civet cats, and raccoon dogs, the case for a natural origin would be strengthened. Although multiple animals tested positive for sister human viruses during the SARS epidemic, scientists have yet to find evidence of earlier infections in animals in the instance of Sars-CoV-2. Nonetheless, the absence of evidence does not confirm the absence and may indicate that samples were not taken from the appropriate animal. The same may be said of the lab leak argument's lack of evidence. However, even though history is littered with pandemics, no significant pandemic has ever been traced back to a laboratory. In other words, the null hypothesis is a zoonotic occurrence; Chan and Ridley must demonstrate otherwise. The irony is their drive to construct a compelling case for a laboratory accident. They are oblivious to the much more pressing story of how the commerce in wild animals, global warming, and habitat degradation increase the likelihood of pandemic viral development. This is the most plausible origin story that should concern us. Summary and future direction Although Chan and Ridley's "Quest for the Origin of COVID-19" has cast suspicion on the Wuhan Institute of Virology, there is still insufficient evidence to support the lab leak theory. There is, however, growing evidence for a natural origin of SARS-CoV-2, with multiple animals testing positive for sister human viruses during the SARS epidemic and the discovery of more closely related bat coronaviruses in northern Laos. A World Health Organization advisory group in 2025 has concluded its independent assessment of how the COVID pandemic started . As mentioned, most of the peer-reviewed scientific evidence supports the hypothesis that SARS-CoV-2 has a zoonotic origin. "But," the group say, "until requests for additional information are met or more data become available, there can be no certainty about when, where and how SARS-CoV-2 entered the human population. There is a continued need for a thorough, unbiased investigation". As such, we should be more concerned with the increasing likelihood of pandemic viral development due to the commerce in wild animals, global warming, and habitat degradation. Written by Sara Maria Majernikova Project Gallery

Health in Syria and Lebanon are hindered by inequities and inequalities stemming primarily from warfare Facebook X (Twitter) WhatsApp LinkedIn Pinterest Copy link Syria and Lebanon’s diverging yet connected struggles Last updated: 03/05/26, 17:23 Published: 19/06/25, 07:00 Health in Syria and Lebanon are hindered by inequities and inequalities stemming primarily from warfare This is article no. 4 in a series about global health injustices. Previous article: Yemen- a neglected humanitarian crisis . Next article: Injustices in conflicted Kashmir . Introduction Welcome to the fourth article of the Global Health Injustices Series. The previous article discussed Yemen, specifically how the health and well-being of the population are affected by the intricate geopolitics at play. In this article, I collaborated with Jana Antar , to discuss Syria and Lebanon. Although these countries border one another, they encounter distinct challenges. Similar to previous articles, the health and wellbeing of the Syrian and Lebanese people are hindered by the inequities and inequalities stemming primarily from warfare. Impact of war on healthcare: Syria's deliberate destruction Since the onset of the Syrian conflict in 2011, the country’s healthcare system has been systematically dismantled. Beyond the direct casualties of war, the destruction of hospitals, clinics, and medical supply chains has led to a secondary crisis, one where preventable deaths become inevitable. Between 2011 and 2020, Physicians for Human Rights documented nearly 600 attacks on healthcare facilities. Since 2 March 2026, 92 attacks on health care have been reported in Lebanon, resulting in 137 injuries and 53 deaths. The deliberate targeting of hospitals and medical personnel has rendered healthcare not just a casualty of war, but a weapon of war itself ( Figure 1 ). This destruction has had catastrophic consequences. Maternal and infant mortality rates have soared, vaccination coverage has plummeted, and chronic disease management has become nearly impossible. In the northwest of Syria, where displaced populations reside in makeshift camps, infectious diseases such as cholera and tuberculosis continue to spread due to poor sanitation and lack of medical oversight. The COVID-19 pandemic only exacerbated these challenges, whereby 46% of reported cases in Northwest Syria resulted in death due to the collapse of medical infrastructure. As of early 2025, only 57% of hospitals and 37% of primary healthcare centres in Syria remain fully functional. The remaining facilities operate under severe constraints due to damage from attacks and resource shortages. In 2024 alone, there were 77 attacks on healthcare facilities, further disrupting access to trauma care, maternal health, and treatment for chronic illnesses. Overcrowding in displacement camps and poor sanitation have also heightened the risk of outbreaks such as tuberculosis, making urgent intervention critical ( Figure 2 ). Impact of war on healthcare: Lebanon's fragile healthcare system Lebanon, a country once regarded as a regional medical hub, has borne the brunt of Syria’s refugee crisis. With an estimated 1.5 million Syrian refugees seeking shelter within its borders, the country has faced a 50% surge in demand for healthcare services. The healthcare system, already strained before the crisis, has since crumbled under the weight of economic collapse, political instability, and donor fatigue. The Lebanese economic crisis, which began in 2019, had devastating effects on healthcare delivery. The Lebanese pound has lost over 90% of its value, placing essential medical supplies out of reach for hospitals and individuals. Pharmacies frequently run out of life-saving medications, power outages disrupt critical care units, and the departure of healthcare professionals has left hospitals understaffed. The situation has worsened due to escalating hostilities, starting from the south of Lebanon and later expanding, displacing over 112,000 people as of February 2025. The violence has led to the closure of 130 primary health centres and seven hospitals, with 15 out of 153 hospitals either non-functional or operating at reduced capacity. In Nabatieh Governorate alone, 40% of hospital bed capacity has been lost. Attacks on health workers and facilities continued to mount between January and November 2024, when 137 attacks were reported, nearly half of which resulted in fatalities. These disruptions create a ripple effect, limiting immediate medical care and undermining public health initiatives such as vaccination programs and maternal health services. NGOs: the last line of defence In the face of government inaction, non-governmental organisations (NGOs) have become the backbone of healthcare provision in Syria and Lebanon. International and local NGOs have mobilised to provide vaccination campaigns, mental health support, and medical supplies to those in need. For example, WHO and UNICEF have facilitated vaccination drives, reaching 250,000 children under five years old, 30% of whom were displaced Syrians. However, while NGOs have played a crucial role in mitigating healthcare crises, their efforts remain primarily reactive rather than systemic and preventative, addressing immediate needs without long-term sustainability, and not adequately focusing on precautionary measures to avoid these undesirable situations. In fact, NGOs face mounting challenges. The overwhelming demand for services, lack of sustainable funding, and security threats have made it increasingly difficult for organisations to operate. Moreover, while NGOs are stretched in their deliverables, the humanitarian workers encounter frequent targeting, making their mission even more perilous. Conclusion: the role of the international community The crises in Syria and Lebanon are not isolated events; they are a reflection of global health injustices that demand international attention and intervention. Providing short-term aid is no longer enough, so long-term solutions must be prioritised to rebuild these destroyed healthcare systems. Moreover, de-escalating both crises would improve health outcomes for the vulnerable communities in Syria and Lebanon. The next article will focus on the population in conflicted Kashmir; addressing their injustices is crucial because of the profound impact and lack of coverage in mainstream discussions. Written by Jana Antar and Sam Jarada Related articles: Understanding health through different stances / Ethnic , and Socioeconomic health equalities REFERENCES A Decade of Destruction: Attacks on health care in Syria. The IRC. 2025. Available from: https://www.rescue.org/report/decade-destruction-attacks-health-care-syria-0 The Syrian Conflict: Eight Years of Devastation and Destruction of the Health System - PHR. PHR. 202. Available from: https://phr.org/our-work/resources/the-syrian-conflict-eight-years-of-devastation-and-destruction-of-the-health-system/ Ammar W, Kdouh O, Hammoud R, Hamadeh R, Harb H, Ammar Z, et al. Health system resilience: Lebanon and the Syrian refugee crisis. Journal of Global Health. 2016 Dec;6(2). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5234495/ Lebanon 2025 Indicators and Targets Lebanon Multi-year Strategy 2023 -2025. Available from: https://reporting.unhcr.org/sites/default/files/2025-01/Lebanon%20-%20Strategy%202023%20%E2%80%93%202025_0.pdf Lebanon | Humanitarian Action. Humanitarianaction.info . 2024. Available from: https://humanitarianaction.info/document/global-humanitarian-overview-2025/article/lebanon-1 WHO. WHO’s Health Emergency Appeal 2025 [Internet]. 2025. Available from: https://cdn.who.int/media/docs/default-source/documents/emergencies/2025-appeals/2025-hea-lebanon.pdf?sfvrsn=45f2a018_5&download=true Lebanon’s Pharmaceutical Sector: Challenges, Opportunities, and Strategic Solutions. LCPS. 2025. Available from: https://www.lcps lebanon.org/en/articles/details/4903/lebanon%E2%80%99s-pharmaceutical-sector-challenges-opportunities-and-strategic-solutions Sousa C, Akesson B, Badawi D. “Most importantly, I hope God keeps illness away from us”: The context and challenges surrounding access to health care for Syrian refugees in Lebanon. Global Public Health. 2020 Jun 12;1–10. Syrian refugee access to healthcare in Lebanon - Lebanon. ReliefWeb. 2020. Available from: https://reliefweb.int/report/lebanon/syrian-refugee-access-healthcare-lebanon World. Lebanon: a conflict particularly destructive to health care [Internet]. Who.int . World Health Organization: WHO; 2024. Available from: https://www.who.int/news/item/22-11-2024-lebanon--a-conflict-particularly-destructive-to-health-care Project Gallery

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This requires a strategy accounting for different factors, as well as other wider determinants of health Facebook X (Twitter) WhatsApp LinkedIn Pinterest Copy link Addressing Health Inequalities Last updated: 03/05/26, 17:09 Published: 02/04/26, 07:00 This requires a strategy accounting for different factors, as well as other wider determinants of health This is the fourth and final article in a series on health inequalities. Previous article: Ethnic health equalities. Welcome to the final article in a series of articles about health inequalities. This article will look more in detail at how to address health inequalities. Introduction Health inequalities are systematic and avoidable differences in health outcomes. They carry heavy human and economic costs, including over £31bn in lost productivity annually. Previous articles in this series explored how factors like geography, income, and ethnicity drive these disparities. However, addressing healthcare inequalities requires a strategy accounting for these factors, as well as other wider determinants of health. The impact of the environment Scientists have published research which found that environmental factors, including smoking, physical activity, and socioeconomic status, have a greater impact on a person’s health and premature death compared to their genes. They analysed data from the UK Biobank, a dataset of biological, health and lifestyle information. Their analysis showed that environmental exposure explains 17% of the variation in risk of death, while genetic predisposition explains less than 2%. Of the 25 factors that were analysed, smoking was linked to 21 diseases, followed by 19 diseases for socioeconomic factors like household income, home ownership, and employment status. While genetics still dominates for specific conditions like dementia and breast cancer, these findings emphasise that the vast majority of health outcomes are determined by our environment rather than our biology. Therefore, to address health inequalities, targeted strategies and collaborative methods like co-design need to be used to ensure interventions meet the genuine needs of the most vulnerable communities. Core20PLUS5 The NHS’s Core20PLUS5 is one of these targeted strategies, defining a target population (the “Core20PLUS”) and identifying 5 areas of healthcare that require improvement. For both groups (adults, children and young people), the target population is the same: CORE20 refers to the most deprived 20% of the population identified by the national Index of Multiple Deprivation, while the PLUS population includes those who experience health inequalities the most, such as ethnic minority groups, individuals with a learning disability, autistic individuals, and individuals with multiple long-term health conditions. The differences between the strategy for adults and that for children and young people are in the 5 areas of healthcare requiring improvement. As seen in Figure 1 , for adults, the 5 areas are continuity and improvement of maternity care (specifically for women from Black, Asian and ethnic minority groups and from the most deprived groups), improved services for individuals with severe mental illness, improved services for those with chronic respiratory disease, early cancer diagnosis, and improved management of hypertension. Smoking cessation is another area of focus that covers all the 5 priorities. For children and young people, the 5 areas of healthcare improvement are specific to this population: asthma care, diabetes care, epilepsy care, oral health, and mental health, as seen in Figure 2 . Co-design for addressing health inequalities Another method to address health inequalities is through co-design, which is a participatory methodology where stakeholders, including service users (e.g., patients, their carers, etc) and providers (healthcare professionals and other staff), collaborate to jointly create and refine services, products, or solutions. A diagram of three key factors needed in co-design can be seen in Figure 3 . This joint approach helps to ensure that interventions align with the genuine needs and preferences of the people who will be using that service, and the findings that providers see coming up frequently from comments by service users. Co-design can be used to address health inequalities by co-producing strategies with people from those communities and backgrounds. For example, individuals from ethnic minority groups can participate, so researchers can genuinely understand and try to address racism's impact on health. This is supported by research published in the BMJ , where co-design with service users and providers from ethnic minority groups found that more culturally appropriate mental healthcare was needed, and that there needed to be more open discussions about the impacts of ethnicity, culture and racism in mental health. In the context of Figure 3 , this study involved “committed” ethnic minority groups with the “capability” of sharing their lived experience with researchers. This shows how co-design can be used as a tool that allows others to share their experiences for the benefit of themselves and others. Conclusion There needs to be a cross-government strategy that aligns current policy, funding, and practice around health equity. Because these inequalities are systematic and avoidable failures, they require a holistic approach that moves beyond clinical care to address the PLUS populations who experience the greatest disadvantage. Trust in the healthcare system has been eroded among ethnic minority groups due to repeated negative experiences, cultural insensitivity, and discriminatory treatment. To rebuild it, lived experiences need to be accounted for, and solutions need to be co-designed. Furthermore, determinants of good health, like stable housing, fair pay, and high-quality education, must be provided to the people most affected by health inequalities. These inequalities must be addressed to ensure everyone has the ability and opportunity to have a long and healthy life. Written by Naoshin Haque Related article: Reflection on global health injustices Project Gallery

Health inequalities and inequities amid the ongoing civil war Facebook X (Twitter) WhatsApp LinkedIn Pinterest Copy link Healthcare challenges during civil war in Sudan Last updated: 03/05/26, 17:15 Published: 17/04/25, 07:00 Health inequalities and inequities amid the ongoing civil war This is article no. 2 in a series about global health injustices. Next article: Yemen: a neglected humanitarian crisis . Previous article: Life under occupation in Palestine Introduction Welcome to the second article of the Global Health Injustices Series. My previous article focused on the Palestinians and the injustices they face, notably the blockade of food, water and medical supplies in Gaza. This one will focus on Sudan by examining the health inequalities and inequities the wider Sudanese population faces, mainly due to the ongoing civil war between the Sudanese Armed Forces (SAF) and the Rapid Support Forces (RSF). This carries direct and indirect consequences ( Figure 1 ); some of these will be discussed in this article, along with ways forward to advocate and support the Sudanese people after an overview of Sudan’s history and current state. Sudan: a rich history to modern challenges Sudan is a country in North Africa bordered by South Sudan, Egypt, the Central African Republic, Libya, Chad to the northwest, Eritrea and Ethiopia. Sudan has had shifts in political power over centuries, notably the joint Egyptian-Ottoman rule beginning over 200 years ago, before the British government took control of Sudan during the first half of the 20th century. After that, Sudan became independent, and South Sudan gained independence in the 21st century. Through these different shifts, there has been a struggle for representation and power in Sudan, leading to various crises, including the current civil war ( Figure 2 ). Despite this, Sudan maintains its multiple languages and cultural traditions through its resilient population. Aside from the SAF and RSF, the civil war in Sudan has arms trade and exports from external governments, particularly the United Arab Emirates (UAE), Russia, and China, have accelerated the civil war. This expansion is crucial because it illustrates how much geopolitics has severe consequences on the health and wellbeing of the Sudanese people. Health in Sudan: the consequences of civil war and geopolitics In a public health situation analysis (PHSA) by the World Health Organisation (WHO) published in 2026, they highlighted four major emergencies in Sudan: food insecurity, displacement, epidemics and conflicts, which are intrinsically linked to detrimental health outcomes like non-communicable diseases (NCDs), trauma and injury, measles and malaria. Moreover, several mortality indicators were noted in the PHSA. For example, the mortality rate among infants is 39.1 per 1000 people and for children, it is 50.1 per 1000, both originating from the United Nations Children's Fund (UNICEF). These outcomes among infants and children are attributed to health conditions, such as those occurring neonatally and lower respiratory infections. Nonetheless, there has been increased vaccine coverage in Sudan to fight the spread of infectious diseases. For example, COVID-19 vaccination reached approximately 12.6 million people (28% of the population) in March 2023, along with improved polio and rotavirus vaccination. However, all of these outcomes highlight the magnitude of the civil war in Sudan, with the impact of the arms trade adding fuel to it. Looking at Sudan’s healthcare system, there are several pressures to highlight. One commentary article noted that in conflict areas, less than one third of hospitals are operational, while 70% of them are not. Additionally, the operating hospitals stopped for various reasons, mainly shortages in electricity, medical equipment and healthcare workers. With the aforementioned geopolitical context, these gaps in the healthcare system are amplified and lead to the worsening health outcomes outlined in the PHSA, such as the rise in NCDs. Not only are NCDs rising in Sudan, but infectious diseases are exacerbated in Sudan with the civil war. One of them is drug-resistant tuberculosis (DR-TB), caused by bacteria. One systematic review found that the prevalence of TB with resistance to drugs was 47%; the ones that are not working on TB with the highest resistance include isoniazid at 32.3%, streptomycin at 31.7% and rifampicin at 29.2% resistance. These values are likely to be higher nowadays, given that arms trade exports into Sudan are increasing and leading to more patients not getting sufficient care to manage or treat DR-TB. Another infectious disease that is a significant health problem in Sudan is schistosomiasis, which is caused by parasites. One systematic review included two categories of the disease: Schistosoma haematobium (S. haematobium) and Schistosoma mansoni (S. mansoni) . S. haematobium prevalence was 24.83%, and for S. mansoni , it was 19.13%. These signify that although devising preventative strategies against these infections is crucial, it is paramount to consider the broader picture in Sudan: tackling schistosomiasis and other infections begins with understanding the geopolitical context. Looking at undernutrition among children in Sudan it is another significant health problem. For instance, a meta-analysis found that Sudan had the highest prevalence of stunting among North African countries at 36%; this was also true for wasting, where Sudan had a prevalence of wasting at 14.1% and a prevalence of underweight at 24.6%. Therefore, in a similar sentiment to tackling infectious diseases, understanding the geopolitical context in Sudan is vital to minimising the prevalence of undernutrition among children. Reflecting on all the data and sources I used above, gaps and perspectives still need to be addressed and highlighted, specifically in places within Sudan where the ongoing civil war severely impacts research. This signifies the importance of obtaining reliable information to support communities in Sudan facing numerous injustices. In turn, filling these information and perspective gaps may apply to other crises similar to Sudan. Protecting health in Sudan: crucial ways forward from NGOs To move forward, several NGOs, particularly Amnesty International, have made recommendations to protect the Sudanese people: As a part of their obligation to respect and ensure respect for international humanitarian law (IHL), all states are prohibited from transferring or permitting private actors to transfer weapons to a party to an armed conflict In light of the substantial risk that all arms and ammunition being transferred to Sudan….. will be used by parties to the conflict to commit grave human rights abuses, companies must immediately cease their involvement in this supply of arms to avoid causing or contributing to these abuses. If a company identifies that the products they sold have contributed to such abuses, they should provide for or cooperate in the remediation process to any persons harmed as a result. Therefore, taking these steps on board is essential to upholding human rights and ensuring that the health and wellbeing of the Sudanese people are sustained, particularly during the ongoing civil war. If not, these health inequities and inequalities will only be exacerbated. Moreover, the health outcomes from infectious and chronic diseases outlined are likely worse now, given how much weapons trading has occurred. Conclusion: call to action for the international community Overall, the civil war in Sudan has had devastating impacts on the health and wellbeing of the whole population, particularly the infants and children, among the other injustices. Unfortunately, this crisis has not received a lot of mainstream attention compared to others currently, such as Palestine, which is also a significant injustice. Therefore, Sudan must be addressed just as openly through discussions of justice and advocacy through the voices of the Sudanese people. Moreover, my statement in the previous article on Palestine rings true: It is crucial always to nudge those in positions of power worldwide to fulfil their responsibilities as civil servants and defend human rights for everyone. This is essential to maintain the health and wellbeing of the Sudanese people, particularly to facilitate the recommendations from NGOs such as Amnesty International. In my next article, I will discuss Yemen because this population is also encountering civil war as one of the many injustices which have been occurring for more than a decade, and Yemen is considered to be going through one of the worst humanitarian crises of our time. Similarly, these impacts on the health and wellbeing of the Yemeni people still need awareness and discussion. Written by Sam Jarada Related articles: A perspective on well-being / Understanding health through different stances / Impacts of global warming on dengue fever REFERENCES Crisis in Sudan: What is happening and how to help. The IRC. 2025. Available from: https://www.rescue.org/article/crisis-sudan-what-happening-and-how-help Khogali A, Homeida A. Impact of the 2023 armed conflict on Sudan’s healthcare system. Public Health Challenges. 2023 Oct 28;2(4). Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/puh2.134 Elamin A, Abdullah S, ElAbbadi A, Abdellah A, Hakim A, Wagiallah N, et al. Sudan: from a forgotten war to an abandoned healthcare system. BMJ Global Health. 2024 Oct;9(10):e016406. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11529772/ New weapons fuelling the Sudan conflict. Amnesty International. 2024. Available from: https://www.amnesty.org/en/latest/research/2024/07/new-weapons-fuelling-the-sudan-conflict/#:~:text=Shipment%2Dlevel%20trade%20data%20indicates,into%20lethal%20weapons%20in%20Sudan . PHSA -Sudan Complex Emergency 030424 SUDAN CONFLICT. World Health Organisation (WHO); 2024. Available from: https://cdn.who.int/media/docs/default-source/documents/emergencies/phsa--sudan-complex-emergency-030424.pdf?sfvrsn=81039842_1&download=true Alaa Dafallah, Osman, Ibrahim ME, Elsheikh RE, Blanchet K. Destruction, disruption and disaster: Sudan’s health system amidst armed conflict. Conflict and Health. 2023 Sep 27;17(1). Available from: https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-023-00542-9 Hajissa, K., Marzan, M., Idriss, M.I. and Islam, M.A. (2021). Prevalence of Drug-Resistant Tuberculosis in Sudan: A Systematic Review and Meta-Analysis. Antibiotics, 10(8), p.932. doi: https://doi.org/10.3390/antibiotics10080932 . Yousef Alsaafin, Omer, A., Osama Felemban, Sarra Modawi, Ibrahim, M., Mohammed, A., Ammar Elfaki, Abushara, A. and SalahEldin, M.A. (2024). Prevalence and Risk Factors of Schistosomiasis in Sudan: A Systematic Review and Meta-Analysis. Cureus. doi: https://doi.org/10.7759/cureus.73966 . Nagwa Farag Elmighrabi, Catharine, Dhami, M.V., Elmabsout, A.A. and Agho, K.E. (2023). A systematic review and meta-analysis of the prevalence of childhood undernutrition in North Africa. PLoS ONE, 18(4), pp.e0283685–e0283685. doi: https://doi.org/10.1371/journal.pone.0283685 . Project Gallery

A vital fluid Facebook X (Twitter) WhatsApp LinkedIn Pinterest Copy link Blood 03/05/26, 17:35 Last updated: Published: 07/09/23, 10:16 A vital fluid A guide to the human blood system and alternatives Human blood Blood is a vital fluid for humans and vertebrates. It transports nutrients, including oxygen, to cells and tissues. Blood is made of different components: red blood cells, white blood cells, platelets and plasma. Red blood cells (also called erythrocytes) contain haemoglobin, which gives blood its red colour. Haemoglobin helps to carry oxygen to the body from the lungs. White blood cells (also called leukocytes) defend the body against infections. Lymphocytes are a type of white blood cell, and the two types are T lymphocytes and B lymphocytes. T lymphocytes target infected cells and regulate the function of other immune cells. B lymphocytes, on the other hand, create antibodies, which are proteins that can destroy foreign substances like bacteria and viruses. Platelets (also called thrombocytes) are small cell fragments. They are essential in blood clotting, a process known as coagulation. Platelets also help wounds heal and contribute to the immune response. Plasma is the liquid component in blood, made of water, ions, proteins, nutrients, wastes and gases. Its main role is transporting substances such as blood cells and other nutrients throughout the body. Artificial blood There are two main types of artificial blood: haemoglobin-based oxygen carriers (HBOCs) and perfluorocarbons (PFCs). HBOCs are synthetic solutions designed to carry oxygen. They are usually a smaller size than RBCs. The haemoglobin is modified and covered with carriers to ensure the HBOCs do not break down inside the body. They can be used for blood transfusions that need to be done immediately or when there is too much blood loss. PFCs are derived from fluorine-containing and carbon-containing chemicals, and have a high capacity for carrying and delivering oxygen. Advantages and disadvantages of artificial blood Artificial blood can be beneficial because it can be used for any patient who needs a blood transfusion, regardless of their blood type, if the substitute has the universal O blood group. There is also less chance of diseases being passed to patients using artificial blood. However, artificial blood has been shown to have adverse side effects, including high blood pressure and a higher chance of heart attacks. The future of artificial blood There have been experiments in the NHS with laboratory-grown RBCs in the RESTORE randomised controlled clinical trial, which aims to see if RBCs produced from stem cells in a lab can survive longer in the body than normal donated cells. As part of the trial, scientists created lab-grown RBCs to be given to healthy volunteer participants in small doses. In February 2026, the final batch of RBCs produced as part of the trial was given to volunteers. This trial highlights the potential for artificial blood to be used in clinical settings, especially when supply is low or for patients with rare blood types, diseases, or complex transfusion requirements. The results of this trial are planned to be shared in late 2026 or early 2027. Written by Naoshin Haque Related articles: Sideroblastic anaemia / Kawasaki disease Project Gallery

Known as microbial endocrinology, it is a complex field Facebook X (Twitter) WhatsApp LinkedIn Pinterest Copy link Investigating the interplay of hormones and the microbiome 03/05/26, 17:05 Last updated: Published: 08/11/24, 12:00 Known as microbial endocrinology, it is a complex field The microbiome The human body hosts a vast ecosystem of bacteria, with trillions crawling on our skin, colonising our gut, and living throughout our bodies. Most of these microbes serve to protect us against infections influencing our metabolism and even our behaviour. However, scientists have started to question the mechanisms by which these bacteria affect our bodily functions and characteristics. Scientists have studied these communities of microorganisms residing within our bodies and the genes they contain, yielding new and exciting perspectives… …Welcome to the human microbiome. The microbiome is the dynamic community of microorganisms (like fungi, bacteria and viruses) that exist in a particular environment. In humans, the term is most often used to describe the collection of microorganisms that inhabit a particular body area, such as the gastrointestinal tract, mouth or skin. While a person’s core microbiome is established within the first few years of life, its composition can shift over time in response to factors like medication, such as potent antibiotics and environmental factors. Researchers have uncovered that the gastrointestinal microbiota can influence some physiological processes, including a direct line of communication between the gut and the brain. But what facilitates this dialogue? What mechanisms enable the gut to relay signals to the brain? The answer is hormones. Hormones and the endocrine system The endocrine system is a network of glands that produce and release chemical messengers known as hormones. They travel via the bloodstream and bind to specific receptors on their target tissues. This binding of hormones to their receptors triggers a response in the target tissue. For instance, during stressful situations, epinephrine (also known as adrenaline) is produced by the adrenal medulla, the inner region of the adrenal glands. This hormone, released into the bloodstream, acts on target tissues such as the heart, where it increases heart rate. Hormones regulate most of the body’s vital functions through their release. Some of these crucial processes include growth, metabolism, and reproduction. In the following sections, however, we specifically focus on how hormones influence the microbiome. The interactions between hormones and the microbiome Exploring the relationship between hormones and the microbiome is known as microbial endocrinology; it is a complex field because there are numerous interactions to account for, and the effects of each one can have lasting impacts on human physiology. For example, epinephrine and norepinephrine can lead to more bacteria, notably E. coli and Pseudomonas aeruginosa , signifying that imbalance could harm humans. Also, parts of the host, ranging from mood to gender, impact hormones, bacterial presence and activity ( Figure 3 ). An emerging area of microbial endocrinology is how the microbiome and sex hormones engage with each other in disease and female health- this is called microgenderome (this describes "bidirectional interactions between human microbiomes, sex hormones, and immune systems"). This may help to explain why women are more prone to certain autoimmune conditions. One paper noted that disorders from metabolic syndrome (MetS) to type 2 diabetes (T2D) have distinctions in the levels of sex hormones and gut microbiota, indicating that they are essential to understanding in developing those conditions. The influence of gut microbiota on sex hormones can occur through various mechanisms, such as bacteria controlling the activity and expression of endocrine receptors and even bacteria metabolising sex hormones; this knowledge can help create treatments against polycystic ovarian syndrome and ovarian cancer, among other diseases that usually impact females due to gut microbiome imbalances ( Figure 4 ). Another part of microbial endocrinology being researched is how the microbiome impacts human growth. In one study involving adult male mice, decreased growth hormone (GH) led to undeveloped microbiomes, while surplus GH was linked to an expanded microbiome; this depicts that bacteria influences development via the growth hormone-insulin-like growth factor 1 (GH-IGF-1) axis; maintaining a steady dynamic between the microbiome and this axis is vital for development ( Figure 5 ), particularly in children. In puberty, hormones and the gut microbiome interact, as observed in obesity and precocious puberty. Hence, a deeper awareness of the bacteria and sex hormones during puberty is crucial to designing targeted medicines for growth disorders. Moreover, patients with GH-secreting pituitary adenoma (GHPA) have modified gut microbiota, like increased Alistipes shahii and Odoribacter splanchnicus . Still, more research is needed to investigate this. Conclusion The microbiome refers to the millions of microorganisms on and within the human body that influence various physiological functions ranging from digesting food to outcompeting pathogens for resources. Also, the microbiome can affect the endocrine system, which consists of hormones that control glucose and reproduction, among other processes. This bridge, known as microbial endocrinology, has critical applications for understanding women’s health and growth disorders (microgenderome); this emerging area is growing, so it can address knowledge gaps in diseases like cancer and even improve other medical treatments. Written by Sam Jarada and Fozia Hassan The interactions between hormones and the microbiome, and Conclusion sections by Sam The microbiome, and Hormones and the endocrine system sections by Fozia Related articles: The gut microbiome / Dopamine and the gut / The power of probiotics / Vitamins REFERENCES “The Human Microbiome and Its Impacts on Health - PWOnlyIAS.” PWOnlyIAS , 18 Jan. 2024, pwonlyias.com/current-affairs/gut-microbiome-and-health/ . Accessed 17 Oct. 2024. Mittal, Rahul, et al. “Neurotransmitters: The Critical Modulators Regulating Gut-Brain Axis.” Journal of Cellular Physiology , vol. 232, no. 9, 10 Apr. 2017, pp. 2359–2372, www.ncbi.nlm.nih.gov/pmc/articles/PMC5772764/ , https://doi.org/10.1002/jcp.25518 . Accessed 17 Oct. 2024. Neuman, Hadar, et al. “Microbial Endocrinology: The Interplay between the Microbiota and the Endocrine System.” FEMS Microbiology Reviews , vol. 39, no. 4, 1 July 2015, pp. 509–521, academic.oup.com/femsre/article/39/4/509/2467625 , https://doi.org/10.1093/femsre/fuu010 . Hiller-Sturmhöfel S, Bartke A. The Endocrine System: An Overview. Alcohol Health and Research World. 2024;22(3):153. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6761896/ Neuman H, Debelius JW, Knight R, Koren O. Microbial endocrinology: the interplay between the microbiota and the endocrine system. FEMS Microbiology Reviews [Internet]. 2015 Feb 19 [cited 2024 Sep 18];39(4):509–21. Available from: https://academic.oup.com/femsre/article/39/4/509/2467625?login=false Jose Antonio Santos-Marcos, Mora-Ortiz M, Tena-Sempere M, José López-Miranda, Camargo A. Interaction between gut microbiota and sex hormones and their relation to sexual dimorphism in metabolic diseases. Biology of Sex Differences. 2023 Feb 7;14(1). He S, Li H, Yu Z, Zhang F, Liang S, Liu H, et al. The Gut Microbiome and Sex Hormone-Related Diseases. Frontiers in Microbiology. 2021 Sep 28;12. Siddiqui R, Makhlouf Z, Alharbi AM, Alfahemi H, Khan NA. The Gut Microbiome and Female Health. Biology [Internet]. 2022 Nov 1;11(11):1683. Available from: https://www.mdpi.com/2079-7737/11/11/1683 Jensen E, Young JA, Jackson Z, Busken J, List EO, Ronan O’Carroll, et al. Growth Hormone Deficiency and Excess Alter the Gut Microbiome in Adult Male Mice. Endocrinology [Internet]. 2020 Feb 26 [cited 2023 Nov 9];161(4). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7341558/ Jensen EA, Young JA, Mathes SC, List EO, Carroll RK, Kuhn J, et al. Crosstalk between the growth hormone/insulin-like growth factor-1 axis and the gut microbiome: A new frontier for microbial endocrinology. Growth Hormone & IGF Research. 2020 Aug;53-54:101333. Project Gallery

Antimicrobial Resistance (AMR) is a growing concern for healthcare systems globally Facebook X (Twitter) WhatsApp LinkedIn Pinterest Copy link Are we doing enough to fight anti-fungal resistance? 26/04/26, 14:30 Last updated: Published: 04/11/24, 15:29 Antimicrobial Resistance (AMR) is a growing concern for healthcare systems globally Introduction to fungi Fungi are a fascinating yet relatively untouched area of microbiology. From growing in damp forest soil to the human body, these eukaryotes (surprisingly more closely related to animals than plants!) reproduce sexually and asexually, producing hyphae (long, branching filaments) to absorb nutrients. Even in the human body, fungal infections can range from athletes' foot to severe cases of invasive pneumonia. Despite its diverse and incredibly interesting nature, only 5% of all estimated fungal species worldwide have been discovered. There is a significant lack of knowledge regarding these amazing microorganisms. The challenge of antimicrobial resistance Antimicrobial Resistance (AMR) is a growing concern for healthcare systems globally. AMR is the process by which microbes develop decreased sensitivity to antimicrobial drugs, meaning they can evade drug and immune response, creating the potential for superbugs (i.e. Multi-Drug Resistant Staphylococcus Aureus/MRSA). An increasing number of resistant fungal species are emerging, with more than 90% of Candida Auris strains in the US now fluconazole resistant. Microorganisms can confer resistance in various ways, such as the misuse of antimicrobial drugs and pesticides in healthcare and agriculture or random genetic evolution (secondary vs primary resistance). Biofilm formation can also contribute to this, particularly for those with inserted medical devices. This can be seen in Candidiasis, for example on inserted catheters, as can be seen in Figure 2 . AMR was thought to be responsible for 1.27 million deaths globally in 2019, with an 8% increase in resistant infections in the UK from 2021-22. Global efforts regarding resistance appear to focus on antibiotic resistance, much reflective of worldwide research efforts. This leaves us wondering, are we doing enough to fight antifungal resistance? Mechanisms of fungal resistance Fungal infections, although typically mild, often present most severely in the immunocompromised, particularly those with cancer or who have had recent organ transplants. Invasive infections are cleared using five classes of antifungal drugs: azoles, polyenes, allylamines, flucytosine, and echinocandins, the two most common being azoles and echinocandins. Azoles aim to inhibit ergosterol synthesis, which is crucial for cell membrane stability, whilst echinocandins interfere with beta-1,3-D-glucan synthesis (a major component of fungal cell walls). Fungi can come in two forms: mould fungi (multicellular units containing branching hyphae), and yeast fungi (unicellular with the ability to ferment carbohydrates). In yeasts, azoles target the Erg11 protein (or Cyp51A for mould fungi), which disrupts ergosterol synthesis and causes the build up of 14a-methyl sterols. In turn, this disrupts membrane activity. Azole resistance can develop through different pathways: changes in the Erg11 amino acid structure, changes in Erg11 expression, and alterations to drug efflux pathways. For Candida species, amino acid substitutions occurring at the Erg11 enzyme binding site often lead to azole resistance, whilst in Aspergillus fumigatus, changes occur at codons 54-220 in Cyp51A. Resistant Candida albicans can also overexpress Erg11, meaning a higher drug concentration is needed to combat infection. Some fungal species, such as Candida spp. confer azole resistance by utilising drug efflux systems, particularly the ABC transporter MDR1, where a gain of function mutation can lead to multidrug resistance. Loss of heterozygosity, for example, by aneuploidy, can lead to resistance if this occurs across Erg11 or MDR1 gene loci. Inhibition of the Hsp90 pathway (a component of the cellular stress response) can alleviate both azole and echinocandin resistance and regulate biofilm resistance. Hsp90 stabilises the terminal MAPK component, increasing cell wall integrity (most antifungal drugs target the fungal cell wall). Global nature of AMR Global schemes have emerged to combat AMR, with fungal efforts appearing to lag behind its bacterial equivalent; The WHO published its first priority bacterial pathogens list in 2017, which has been effectively used by pharmaceutical companies, researchers, and local health trusts to target bacterial species, asserting themselves as an increasing risk. WHO Fungal Priority lists didn’t emerge until 2022, which was the first global effort to establish fungal species of risk. The One Health approach, another global strategy, aims to combat AMR by emphasising collaboration between multiple sectors, increasing innovation and creating clear communication. Its main aims lay in identifying knowledge gaps, involving policymakers, creating networks and sharing data. In addition to global strategies, national ones exist. The UK government made its own five year AMR-combatting plan, implementing a One Health approach; Previous plans have proven successful; antimicrobial exposure was reduced by 8%, with a further 81% reduction in antibiotic sales for food-producing mammals. It is clear AMR (particularly fungal resistance) is becoming an increasingly worrying issue. In 2019, UK deaths directly arising from drug resistant infections nearly matched those from stomach cancer, with an estimated further 35,000 deaths indirectly resulting from resistant infections. Hence, measures must be in place to contain its potential for worldwide damage. Insufficient action against AMR was predicted to have long-lasting effects like the COVID-19 pandemic every five years. Since drug-resistant fungi have the potential to cause significant burden on healthcare systems globally, what is currently being done to combat Fungal AMR? What more can we do? Fungal infections are the fifth leading cause of death worldwide, yet less than 1.5% of infectious disease funding goes towards research of fungal infections. This could be because fungal infections present mildly in most healthy people. However, we cannot ignore the fatal consequences for those with pre-existing illnesses or the devastating effects that could ensue if we do not make significant efforts to eliminate fungal resistance. In its most recent five-year plan, the UK government stated its support for initiatives to increase agrochemical stewardship, particularly focussing on fungicides. The efforts outlined include establishing a pharmaceutical monitoring programme, funding research into AMR-driving chemicals, and a pilot AMR surveillance scheme. This is significant progress, however, it focuses on environmental fungal resistance, with a tendency to ignore research efforts and failing to actively address fungi in most sections. In April 2026, £4.5 million was awarded to an international collaboration including the University of Edinburgh, to help improve understanding of fungal diseases. This is a significant contribution, and can accelerate endeavours in research. To move forward, more efforts are needed to drive antifungal research - whether in expanding the number of antifungal classes available to patients or improving existing antifungal therapies (e.g. improvements in pharmacokinetics and efficacy). This is evidenced by the sheer number of antibiotics and respective classes compared to fungal counterparts; bacterial infections can be treated with a whopping two-fold more drug classes than their fungal equivalent. Moreover, the One Health approach emphasises the importance of diagnostics and testing; whilst most modern fungal testing methods are very sensitive and specific, some tests can only report positive results very late into disease progression (read more about One Health ). Hence, fungal diagnostic and testing approaches need to be optimised. This all can be achieved by pushing more funding towards fungal research and development, encouraged with government spending, and an emphasis on collaboration between academia and industry. How can we relay the importance of stewardship in agriculture, or bring more treatments to the bedside without collaboration and education? Written by Eloise Nelson Related article: The increasing threat of anti-microbial resistance REFERENCES Gaya E., Fungarium: Welcome to the Museum, 2019. Kundu R, Srinivasan R. Cytopathology of Fungal Infections. Current Fungal Infection Reports. 2021;15(3):81-92. The Role of Plant Agricultural Practices on Development of Antimicrobial Resistant Fungi Affecting Human Health: Proceedings of a Workshop Series.: Hearing before the National academies of Sciences, Engineering and Medicine (05.04.2023, 2023). Government U. Confronting antimicrobial resistance 2024 to 2029. In: Care DoHaS, editor. 2024. Fisher CM, Alastruey-Izquierdo A, Berman J, Bicanic T, Bignell ME, Bowyer P, et al. Tackling the emerging threat of antifungal resistance to human health. Nature Reviews Microbiology. 2022;20(9):557-71. Cowen EL, Sanglard D, Howard JS, Rogers DP, Perlin SD. Mechanisms of Antifungal Drug Resistance. Cold Spring Harbor Perspectives in Medicine. 2015;5(7):a019752. Fisher CM, Alastruey-Izquierdo A, Berman J, Bicanic T, Bignell ME, Bowyer P, et al. Tackling the emerging threat of antifungal resistance to human health. Nature Reviews Microbiology. 2022;20(9):557-71. WHO fungal priority pathogens list to guide research, development and public health action. WHO; 2022. Greener M. Why have we neglected fungal infections? Prescriber. 2022;33(8-9):20-3. Baker J, Denning WD. The SSS revolution in fungal diagnostics: speed, simplicity and sensitivity. British Medical Bulletin. 2023;147(1):62-78. Project Gallery