H5N1

Counting the dead in Gaza: difficult but essential

Via The Lancet: Counting the dead in Gaza: difficult but essential. Excerpt, with my bolding:

By June 19, 2024, 37 396 people had been killed in the Gaza Strip since the attack by Hamas and the Israeli invasion in October, 2023, according to the Gaza Health Ministry, as reported by the UN Office for the Coordination of Humanitarian Affairs. The Ministry's figures have been contested by the Israeli authorities, although they have been accepted as accurate by Israeli intelligence services, the UN, and WHO. These data are supported by independent analyses, comparing changes in the number of deaths of UN Relief and Works Agency (UNRWA) staff with those reported by the Ministry, which found claims of data fabrication implausible. 

Collecting data is becoming increasingly difficult for the Gaza Health Ministry due to the destruction of much of the infrastructure. The Ministry has had to augment its usual reporting, based on people dying in its hospitals or brought in dead, with information from reliable media sources and first responders. This change has inevitably degraded the detailed data recorded previously. Consequently, the Gaza Health Ministry now reports separately the number of unidentified bodies among the total death toll. As of May 10, 2024, 30% of the 35 091 deaths were unidentified. 

Some officials and news agencies have used this development, designed to improve data quality, to undermine the veracity of the data. However, the number of reported deaths is likely an underestimate. The non-governmental organisation Airwars undertakes detailed assessments of incidents in the Gaza Strip and often finds that not all names of identifiable victims are included in the Ministry's list. Furthermore, the UN estimates that, by Feb 29, 2024, 35% of buildings in the Gaza Strip had been destroyed, so the number of bodies still buried in the rubble is likely substantial, with estimates of more than 10 000. 

Armed conflicts have indirect health implications beyond the direct harm from violence. Even if the conflict ends immediately, there will continue to be many indirect deaths in the coming months and years from causes such as reproductive, communicable, and non-communicable diseases. The total death toll is expected to be large given the intensity of this conflict; destroyed health-care infrastructure; severe shortages of food, water, and shelter; the population's inability to flee to safe places; and the loss of funding to UNRWA, one of the very few humanitarian organisations still active in the Gaza Strip. 

In recent conflicts, such indirect deaths range from three to 15 times the number of direct deaths. Applying a conservative estimate of four indirect deaths per one direct death to the 37 396 deaths reported, it is not implausible to estimate that up to 186 000 or even more deaths could be attributable to the current conflict in Gaza. Using the 2022 Gaza Strip population estimate of 2 375 259, this would translate to 7·9% of the total population in the Gaza Strip. 

A report from Feb 7, 2024, at the time when the direct death toll was 28 000, estimated that without a ceasefire there would be between 58 260 deaths (without an epidemic or escalation) and 85 750 deaths (if both occurred) by Aug 6, 2024.

An immediate and urgent ceasefire in the Gaza Strip is essential, accompanied by measures to enable the distribution of medical supplies, food, clean water, and other resources for basic human needs. At the same time, there is a need to record the scale and nature of suffering in this conflict. Documenting the true scale is crucial for ensuring historical accountability and acknowledging the full cost of the war. 

It is also a legal requirement. The interim measures set out by the International Court of Justice in January, 2024, require Israel to “take effective measures to prevent the destruction and ensure the preservation of evidence related to allegations of acts within the scope of … the Genocide Convention”. The Gaza Health Ministry is the only organisation counting the dead. Furthermore, these data will be crucial for post-war recovery, restoring infrastructure, and planning humanitarian aid.

It’s not just bullets and bombs. I have never seen health organisations as worried as they are about disease in Gaza

In The Guardian, Devi Sridhar writes: It’s not just bullets and bombs. I have never seen health organisations as worried as they are about disease in Gaza. Excerpt, with my bolding:

Tragically, the nearly unprecedented death and injury we have seen so far is likely to only be the beginning. From looking at similar conflicts across the world, public health experts know that we are likely to see more children dying from preventable disease than from bullets and bombs. 

While the Israeli government has spoken about safe zones for families to flee to, these aren’t anywhere near what we would consider safe public health zones. They don’t have clean water, functional sanitation and toilets, enough food, or trained medical staff with medicine and equipment. These are the basic needs that any human, especially babies and children, need to stay healthy and alive.

The WHO spokesperson Dr Margaret Harris has said that diarrhoea rates among children in refugee-like camps (sheltered housing) in Gaza were, in early November, already more than 100 times normal levels, and with no treatments available, children can become dehydrated and die quickly. Diarrhoeal diseases are the second leading cause of death in children under five worldwide, and they are caused by contaminated water sources and lack of access to oral rehydration fluids. 

Upper respiratory infections, chickenpox, and painful skin conditions have also increased, and there are fears that the recent floods may result in untreated sewage mixing with fresh water used for drinking and cooking, and cause a cholera outbreak. 

Disease has played a role in battle for centuries. During the American civil war, two-thirds of the estimated deaths of soldiers were caused by pneumonia, typhoid, dysentery and malaria. In 1994, two diseases, cholera and dysentery, linked to unclean water and conflict zones, killed more than 12,000 Rwandan refugees in only three weeks in June 1994.  

An estimated 85% of Gaza’s inhabitant are already displaced according to the UN Relief and Works Agency. Experts analysing previous refugee displacements estimate in the Lancet that crude mortality rates (that is deaths per 1,000 people) were more than 60 times higher than when each conflict began, on average.  

Extrapolating this to the current situation in Gaza, where the crude death rate before the conflict was 3.82 in 2021 (relatively low because of its young demographic), mortality rates could reach 229.2 in 2024 if the conflict and displacement continue at the current level of intensity, and Gazans continue to lack access to sanitation, medical facilities and permanent housing.  

Ultimately, unless something changes, the world faces the prospect of almost a quarter of Gaza’s 2 million population - close to half- a million human beings - dying within a year. These would be largely deaths from preventable health causes and the collapse of the medical system. It’s a crude estimate, but one that is data-driven, using the terrifyingly real numbers of deaths in previous and comparable conflicts. 

International organisations are trying to raise the alarm about this situation, with Harris lamenting: “It seems the world has lost its moral compass.” Unicef has warned: “Lack of water, food, medicine and protection is a bigger threat than bombs to the lives of thousands in Gaza.”  

I have been working in global public health for 20 years, and I have never heard health and aid organisations as forthright and concerned as they are about the level of suffering and deaths in Gaza. It is an unprecedented conflict, breaking the most tragic records, and while experts might debate whether it’s a genocide or not, the truth is we’re witnessing the mass killing of a population, whether by bomb, bullet, starvation or disease.

The Lancet Commission on 21st-Century Global Health Threats

Via The Lancet, December 15, 2022: The Lancet Commission on 21st-Century Global Health Threats. 

The world has lived through an extraordinary global health threat, the COVID-19 pandemic, leading to nearly 20 million deaths, staggering economic losses, a generational decline in human capital, and the first decline in global life expectancy since 1950 (the first year when UN estimates were published). Another major threat, climate change, now has broad scientific, political, and social recognition. The spectre of nuclear confrontation has re-emerged as a serious threat during the ongoing Russian invasion of Ukraine. 

The three Cs—COVID-19, climate change, and conflict—highlight that the steady global health progress of the past 70 years will not necessarily continue in the next 70 years. But there are many other threats beyond the three Cs that threaten to undermine future global health progress, including rising antimicrobial resistance, increasing obesity, inverted population pyramids, eroding sexual and reproductive rights for women, food insecurity, and fraying multilateralism. How global health advances or retreats will depend crucially on the multiplicity of these threats and how they intersect. 

The global community and many nations have launched commissions, task forces, and panels to draw lessons from the COVID-19 pandemic. The Pan-European Commission on Health and Sustainable Development explored the post-pandemic world for Europe and made far-reaching recommendations based on a One Health lens. The Independent Panel for Pandemic Preparedness and Response and the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response called for the creation of new institutions and financing mechanisms to prepare the world for new pandemics and other threats. 

Multiple commissions, task forces, and panels have addressed climate change, including two Lancet Commissions, and the Intergovernmental Panel on Climate Change produces regular multistakeholder assessments. These global convenings have been mirrored by multiple national reviews. Although there are high-profile initiatives for pandemics and climate change, other threats have received less widespread attention or have been debated largely in academic subdisciplines.  

Governments, international organisations, and local communities will need to manage multiple threats at the same time. Many of these threats interact and lead to complex health, economic, social, and geopolitical consequences. Climate change, population growth, and political fragility may coincide leading to large-scale migration. Food systems can be designed to improve health, reduce poverty, and slow climate change, or the reverse.  

Specific and cross-cutting technologies and policies are needed to reduce the risk of emerging threats or to decrease the harms from threats as they unfold. The most important strategies for risk and harm reduction are unlikely to emerge if each threat is examined in isolation from the others.  

We have established the Lancet Commission on 21st-Century Global Health Threats to examine the broad set of threats facing the world over the rest of the century. This long perspective is needed since threats such as climate change, food systems, antimicrobial resistance, or inverted population pyramids require many decades for actions to alter future trajectories. The Sustainable Development Goal focus on 2030 is an important motivator for immediate policy action, but a longer-term perspective is needed to fully assess and respond to emerging threats.

This Commission's work will be informed by diverse expertise. The Commission members are drawn from many distinct groups: current and former heads of state, intergovernmental organisation leaders, leaders of public health institutions, global health funders, global health thought leaders, and civil society and youth organisations. The Commission represents a diverse group with gender parity and regional balance so that many perspectives are brought to bear on finding cross-cutting tools and solutions for future threats. The Commission will meet over the next 2 years to assess the evidence produced by various working groups and will release its analysis and recommendations by the end of 2024.

WHO sees October COVID surge in Ukraine, cites polio concerns

Via Reuters: WHO sees October COVID surge in Ukraine, cites polio concerns. Excerpt:

JERUSALEM, Sept 12 (Reuters) - The World Health Organisation expects a rise in COVID-19 in Ukraine to peak in October, possibly bringing hospitals close to their capacity threshold, WHO's director-general Tedros Adhanom Ghebreyesus said on Monday.  

"We are now seeing an increase in cases of COVID-19 in Ukraine. We project that transmission could peak in early October and hospitals could approach their capacity threshold," Ghebreyesus told WHO'S Regional Committee for Europe conference in Tel Aviv.  

"Oxygen shortages are predicted because major supply sources are in occupied parts of the country," he said. Oxygen is essential for patients with a range of conditions, including COVID-19 and those with other critical illnesses stemming from complications of pregnancy, childbirth, sepsis, injuries and trauma.  

Russia's February invasion of Ukraine has greatly impacted healthcare, with the WHO confirming more than 500 attacks on health infrastructure there, resulting in some 100 deaths. Ghebreyesus also said that the war could increase polio spread. 

"We are also deeply concerned about the potential for the international spread of polio due to the gaps in immunization coverage and mass population movement linked to the war," he said.  

Ukraine has low vaccination coverage for both COVID and polio, an infectious disease mainly affecting children that can cause paralysis and kill in rare cases. Two cases of polio were reported in Ukraine in 2021.

Cholera fears prompt quarantine in Ukraine's Mariupol

Via The Washington Post: Cholera fears prompt quarantine in Ukraine's Mariupol; country prepares for disease outbreaks. Excerpt:

In Mariupol — the ruined and Russian-occupied port city in Ukraine’s southeast — fears of constant bombardment have given way to silent threats: Bacteria-laced water and deadly cholera outbreaks.  

The city’s exiled local leaders have voiced concern about the water supply for weeks, and on Monday, mayoral aide Petro Andryushchenko said that decomposing bodies and piles of garbage are contaminating drinking sources, leaving residents vulnerable to cholera, dysentery and other ailments.

The Russian officials now running the city recently imposed a quarantine, Andryushchenko said in an appearance on Ukrainian television. He did not elaborate on the measures, and his statement could not be independently verified, but he said the humanitarian situation there was getting worse.  

“Spontaneous burials are still in almost every yard in Mariupol,” the city council wrote in an update on Telegram. “Bodies are rotting under the rubble of hundreds of high-rise buildings. And it literally poisons the air.”  

Public health experts have warned that warming weather and prolonged warfare could expose Ukraine — its soldiers and civilians — to infectious diseases, potentially ushering in a new phase of the conflict that forces authorities to contend with outbreaks of illness while fending off Russia’s invasion. The most at-risk areas, officials have said, are the country’s occupied regions, where long bouts of fighting have left sanitation systems in ruins.  

Cholera, which spreads through contaminated food and water, is an acute diarrhoeal infection that can be fatal if left untreated.  

The Mariupol council predicted thousands more civilian deaths if an outbreak were to rage uncontrolled, which would bring more tragedy to a city that has already endured some of the most brutal bombing of the Russian campaign. The near-constant shelling, which allowed Moscow to claim full control of Mariupol last month, reduced much of the city to rubble and has destroyed water and sewer infrastructure, along with medical facilities, the council said.  

To get access to clean water, Mariupol residents must queue for hours, Andryushchenko said on Telegram, and it has only been available every two days at most.  

In a news briefing Monday, Ukraine’s chief sanitary doctor, Ihor Kuzin, said national authorities began monitoring potential cholera outbreaks across the country on June 1. He said Mariupol’s situation is especially dire.  

“We can’t be 100 percent sure that there will be disease outbreaks,” he said. “But all prerequisites for them are already there.”

Ukraine: Almost 14 million displaced by war

Via Reliefweb: Statement by Amin Awad, Assistant Secretary-General and United Nations Crisis Coordinator for Ukraine marking 100 days since the onset of the Russian invasion of Ukraine on 24 February - Ukraine.

Today marks 100 days since the start of Russia’s invasion of Ukraine on 24 February. This invasion of Ukraine is a violation of its territorial integrity and of the Charter of the United Nations.  

This war has taken an unacceptable toll on people and engulfed virtually all aspects of civilian life. This war has and will have no winner. Rather, we have witnessed for 100 days what is lost: lives, homes, jobs and prospects. We have witnessed destruction and devastation across cities, towns and villages. Schools, hospitals and shelters have not been spared.  

Families and communities have been disrupted and uprooted. In just over three months, nearly 14 million Ukrainians have been forced to flee their homes, the majority women and children – a scale and speed of displacement not witnessed in history.  

More than 3 million children saw their education suspended – an entire generation of children whose future hangs in the balance. All over the country, hundreds of thousands of people do not have access to water and electricity, and millions do not know where their next meal is coming from. 15.7 million people are in need of humanitarian support now, with numbers growing.  

One hundred days on, the war ravages unabated especially in the east of the country. And with winter coming, millions of civilian lives could be in peril.  

The United Nations agencies and humanitarian partners in Ukraine continue supporting those whose lives have been shattered by war. In the past 100 days, we have provided immediate humanitarian aid to some 8 million people across the country, including in besieged cities in the east of Ukraine.  

At the same, the United Nations are pursuing every pathway to mitigate the global ramifications of the war’s devastating impact on food security by seeking to unblock critical grain and commodity trade.  

Our tireless efforts to respond to the war’s devastating impact will continue, robustly and stead-fast.  

But above all we need peace. The war must end now.

Canada is failing Ukrainians displaced by Russian invasion, former head of Doctors Without Borders says

Via The Globe and Mail: Canada is failing Ukrainians displaced by Russian invasion, former head of Doctors Without Borders says. Excerpt:

Ottawa needs to do more to help Ukrainian refugees navigate the complexities of paperwork and logistics to come to Canada, the former head of Doctors Without Borders says, lest it reprise past blunders.  

“We know the failures in Afghanistan of not living up to our promises. And we cannot repeat history,” said Joanne Liu, a Montreal emergency physician who returned recently from three weeks in Ukraine, where she was struck by the warm reception to her Canadian passport.  

Many in the country remember early Canadian promises to stand by Ukraine, making Canada “a place of promise, a place of hope,” Dr. Liu said. “We have to live up to our promise,” she added, pointing to bureaucratic obstacles Ukrainians must navigate before coming to Canada.  

“We absolutely need to lift the red tape. For people who are seeking to come here, it’s not good enough to just say, ‘Well, we have extended the hours of our consulates.’ ”  

For example, Ukrainians need better linguistic support to complete paperwork in an unfamiliar language, she said. “You have to facilitate it. That means you should staff better, you should have people who speak the language.”  

In early March, the Canadian government said it was creating a telephone hotline as “a dedicated service channel for Ukraine immigration inquiries.” That line offers service in French and English only, and suggests anyone who speaks another language write in using a web form. The Globe and Mail called the number six times on Friday, but was not able to reach anyone. When The Globe selected an option for callers “regarding the situation in Ukraine,” the hotline hung up each time.  

Global Affairs Canada referred questions to Immigration, Refugees and Citizenship Canada, which did not immediately respond to a request for comment on Friday.

COVID-19 is in for the long haul

Here's a screenshot of this evening's Johns Hopkins Coronavirus COVID-19 (2019-nCoV) dashboard:

It's notable for several reasons. First, the US is now far back in the 28-day case count—seventh, behind Germany, South Korea, Russia, Vietnam, France, and Brazil.

 

Second, almost all the case and mortality numbers are likely severe undercounts, since so many countries have simply abandoned any pretence of testing and contact tracing. I would not be shocked if the true number of cases were around 1.5 billion, and deaths close to 20 million.

 

The numbers for Russia (3.7 million cases in the last 28 days, 20,000 deaths) and Ukraine (458,000 cases, 3,800 deaths) are especially implausible, given the events of the past 15 days. But we'll surely see an explosive growth in cases as over 2 million Ukrainians move through Europe in search of refuge.

 

The early-success countries have largely succumbed to Omicron. While China pursues its zero-COVID policy, it's still recorded 539,000 cases and 2,600 deaths. Hong Kong has seen 533,000 cases in 28 days, and 2,600 deaths. Vietnam racked up 26 million cases in the last 28 days, and 2,400 deaths. New Zealand had 267,000 cases and 12 deaths; it had only 38,900 cases in the previous 23 months of the official pandemic.

 

The graphs on the right tell us that the Omicron spike has fallen sharply from its peak of 23,333,000 in the week ending January 23; we're now at 10,706,000 as of the week ending March 6. That looks impressive, but it's still about 5 million more than the three previous waves.

 

Omicron also drove a spike in deaths, peaking at 75,000 in the week of February 13 and now fallen to 50,400. Meanwhile, vaccinations have fallen from a recent high of 257,000 in the week of February 6 to 105,600 in the week ending March 6.

 

Yet many countries are effectively declaring the pandemic over, making masks and distancing optional, junking vaccine passports, and dropping regular reports by public health officials. Governments seem to think COVID-19 can now sink back into the background noise with other diseases, while we turn our attention to war and inflation and the next election.

 

On February 1, Johns Hopkins reported 381,232,070 cases, so we have seen almost 72 million cases of COVID-19 in the past six weeks alone. Even if the Omicron spike continue to drop, the next six weeks will see tens of millions more cases, and likely another 40 or 50 thousand people now alive will be dead before May 1. 

 

We are nowhere near the end of the pandemic. In fact, I expect it will in many ways get worse as healthcare systems really do collapse, and as sequelae like Long COVID affect more and more cases. The pandemic that began two years ago really is in the for long haul.

Thoughts on six million deaths

Above is a screenshot from this morning's Johns Hopkins COVID-19 dashboard. We have reached 6 million deaths in two years, and half a billion cases don't seem that far away. But the most alarming development in the pandemic is that we in the West, and many other countries, appear to have normalized COVID-19.

On January 30, the weekly case count reached 23 million; yesterday, March 6, it was down to 10,693,000. That's a dramatic fall, but it's still higher than any previous peak in the pandemic. The highest death count was 100,000 in the week ending January 21, 2021. This past week, it was 50,000.

 

These are of course official numbers; the true case counts and mortality are generally assumed to be two to three times higher.

 

Yet the US, Canada, and many other countries are dispensing with "restrictions." The US has dropped to fourth place in the tally of cases, well behind Germany, Russia, and South Korea. The Americans have endured almost 80 million cases and nearly a million deaths, but seem to think they can now go back to business as usual. 

 

Russia counted 4 million cases in the past 28 days, a quarter of its total 16 million cases, and has lost 350,000 lives to COVID-19. Yet it has launched a war against Ukraine that seems sure to result in far more deaths from disease than from combat. Over a million Ukrainians have sought shelter in neighbouring countries, whose healthcare systems will soon be overwhelmed yet again by rising case counts. 

 

No one seems to care. We appear to have decided that fighting a war is more interesting and important than fighting a pandemic, and it lets us ignore the suffering that continues in countries far from the Black Sea. 

 

It's quite an achievement for a coronavirus no one knew about a couple of years ago: worldwide spread, a Holocaust's worth of deaths, and now acceptance as just another fact of life in the 21st century. I will not be surprised if some preprint soon reports on a new neurological effect of SARS-CoV-2: the stupefaction of all human beings, whether they test positive or not.

Reducing the risks of nuclear war to humanity

Via The Lancet: Reducing the risks of nuclear war to humanity.

On Feb 27, 2022, Russia's President Vladimir Putin ordered Russian nuclear forces to be placed on “the special regime of combat duty”. This decision increased the alert status of Russian nuclear forces from a peacetime status to a pre-combat status, creating the legal conditions for any further instruction to launch missiles. Presumably Putin's move is intended to create fear and uncertainty, intensify pressure on Ukraine and the North Atlantic Treaty Organization (NATO) allies and partners, reduce resistance to Russian attacks in Ukraine, and extract concessions in negotiations.  

But these threats represent an absolutely unacceptable escalation of his invasion of Ukraine. The threat of nuclear weapons ratchets up tensions and increases the anxiety and stress that every soldier, resistance fighter, civilian, and politician is experiencing. This threat is also likely to affect analysis and decision making by all parties to the conflict in regard to the potentially far-reaching impacts of decisions. Indeed, history has shown us the risks that these types of situations can pose.  

Since the 1960s the assumption by nuclear armed states was that the prospect of mutually assured destruction would guarantee that nuclear weapons are never used. Nuclear war was believed to be so catastrophic that no leader would ever dare use their nuclear arsenals. More recently, in January, 2022, all the nuclear weapons states that are signatories to the Nuclear Non-Proliferation Treaty (China, France, Russia, the USA, and the UK) reiterated the Reagan–Gorbachev statement that “a nuclear war cannot be won and must never be fought”.  

Nonetheless, documentary research and testimonies have revealed occasions during the decades after the Cuban missile crisis when nuclear weapons were very nearly used as a result of misperceptions and misinterpretation of signals. In 1983, for example, the NATO Able Archer military exercise increased the fear level in the Soviet Union to such an extent that Russian nuclear forces were mobilised. Also in 1983, satellite signals that appeared to be incoming nuclear missiles from the USA to the Soviet Union nearly led to a launch-on-warning response from Moscow. The decision not to do so rested largely on the decisions of one individual, lieutenant colonel Stanislav Petrov. Even after the end of the Cold War, when tensions were low, a Norwegian rocket was initially feared to be an incoming nuclear weapons attack in Russia.  

In the case of nuclear weapons, such mistakes, if they lead to inadvertent use, can never be small or put right. Any use of so-called tactical nuclear weapons (in the low kiloton range) in battle situations would also risk rapid escalation to large-scale nuclear war. The overwhelming humanitarian catastrophic impact of a nuclear weapon is too great to allow these weapons into stressful conflict situations in which such mistakes will occur. Humanity has not avoided nuclear war thus far because of wise leaders, sound military doctrine, or infallible technology. As former US Defense Secretary Robert McNamara observed: “We lucked out. It was luck that prevented nuclear war.”  

An estimated 200 000 people died within 5 months of the nuclear bombs dropped on Hiroshima and Nagasaki, Japan, in 1945 and many survivors suffered long-term effects, including increased risk of leukaemia, other types of cancer, and effects on mental health. The world's nuclear armed states currently have a combined arsenal of around 12 700 nuclear weapons. According to the Federation of American Scientists, the USA deploys 1644 and Russia deploys 1588 strategic warheads on bombers and missiles, many with an explosive power of 100 kilotons or more. Both countries are modernising their nuclear delivery systems.  

If a single warhead of 100 kilotons exploded over a major city it would kill hundreds of thousands of people outright and injure many more, overwhelming the health-care system of an entire nation.  

Even a small-scale nuclear war, involving 250 of the deployed nuclear weapons in the NATO and Russian arsenals, or as might take place between India and Pakistan, would be expected to result in sufficient dust and smoke blocking solar radiation to cause major climate disruption that would trigger a global famine, putting billions of people at risk and destroying modern civilisation.  

A large-scale nuclear war would create a nuclear winter, with temperatures falling an average of about 10°C across the globe, and could kill most of humanity over 10 years. 

The threat by Putin has exposed the weakness of the belief system in nuclear deterrence. Such an approach can never be risk free and the consequences of failure of this strategy are catastrophic. This realisation should lead to more nations signing and ratifying the Treaty on the Prohibition of Nuclear Weapons (TPNW), which currently has 86 signatories and 59 states parties, but that will take time, even with political will. In the near term, it is essential that leaders refrain from exacerbating tensions by implying that such weapons have a military purpose and that immediate steps are taken to reduce the risks of miscommunication and error potentially leading to tragedy on a vast scale.  

NATO and Russia must explicitly renounce any use of nuclear weapons in the conflict in Ukraine. They must join with the other nuclear armed states, at the earliest possible moment, in support of the aims of the TPNW, to commence negotiations for the complete, verifiable elimination of all nuclear weapons.