— Charles Darwin, On the Origin of Species by Means of Natural Selection; or the Preservation of Favoured Races in the Struggle for Life (London: John Murray, 1859), Chapter III, “Struggle for Existence.” https://archive.org/details/darwin-online_1859_Origin_F373

“The greatest benefits will come from being better at preventing [disasters] and living with their effects than by trying to respond to them after they have happened.”

— The Economist, “Europe’s Fires Are Just the Start,” July 28, 2026. https://www.economist.com/leaders/2026/07/28/europes-fires-are-just-the-start

Abstract

The summer of 2026 has underscored the growing interconnectedness of global climate risks. Record-breaking wildfires across Europe have coincided with the emergence of a strong El Niño in the eastern equatorial Pacific, raising concerns about cascading ecological, public health, and economic impacts. In this note, I examine these converging climate shocks through an interdisciplinary lens that integrates climate science, conservation biology, public health, disaster-risk financing, and development policy, and discuss the risk posed for the unique and fragile ecosystem in Ecuador’s Galápagos Islands. Drawing on historical experience from the 1982–83 and 1997–98 El Niño events, contemporary scientific forecasts, and lessons from Ecuador’s institutional response, I argue that resilience depends not only on responding effectively to disasters but on investing in preparedness before they occur. The note reviews advances in early warning systems, conservation finance, adaptive public health strategies, and pre-arranged financial instruments such as the World Bank’s Catastrophe Deferred Drawdown Options (Cat DDOs), demonstrating how these mechanisms can strengthen anticipatory action. Although focused on the Galápagos Islands, the analysis offers broader lessons for climate-vulnerable regions confronting increasingly frequent and interconnected environmental shocks. It concludes that effective climate adaptation requires integrating scientific foresight, biodiversity conservation, resilient public health systems, flexible financing, and adaptive governance into a coherent framework for anticipatory resilience.

Keywords: El Niño; Galápagos Islands; climate change; anticipatory resilience; disaster-risk financing; Cat DDO; conservation finance; biodiversity; public health; One Health; climate adaptation.

I. Introduction

As the summer of 2026 unfolds, an extraordinary convergence of climate-related events has highlighted the increasingly interconnected nature of global climate risk. Recent travels to Ecuador to participate, as a Governing Member, in the General Assembly of the Charles Darwin Foundation for the Galápagos Islands (Marquez 2026c), followed by travel through Southern Europe and observations from my home in the United States, have brought me face to face with the human and ecological consequences of climate disruption unfolding almost simultaneously across three continents.

Developments during recent weeks have been equally alarming. France has experienced an unprecedented combination of successive heatwaves, prolonged drought, and destructive wildfires (Image 1 below). Temperatures reached as high as 44.4°C (112°F), while major fires advanced to the outskirts of Paris and threatened the metropolitan area of Bordeaux (Schwartz 2026). On 27 July 2026, President Emmanuel Macron convened an emergency cabinet meeting as a rapidly expanding wildfire approached within 15 kilometers of Bordeaux, a metropolitan region of approximately 850,000 inhabitants (Al Jazeera 2026a). Bordeaux’s mayor, Thomas Cazenave, described the blaze as remaining at the gates of the metropolitan area, while Interior Minister Laurent Nuñez told France 2 television that the fire was not under control and that the overall situation was unprecedented (Al Jazeera 2026b; Associated Press 2026). Jérôme Steffe, mayor of the nearby commune of Cestas, called it a fire of a size never seen before (IBTimes UK 2026). The blaze generated a fire-driven storm system producing winds and lightning that seeded further ignitions on already arid ground, hindering containment efforts.

The humanitarian consequences have been severe. Roughly 220,000 people were evacuated in the Gironde department alone, with a second fire in the Landes displacing a further 36,000 and the total across southwestern France exceeding 250,000 (Associated Press 2026). The Gironde prefecture reported 240 homes destroyed and 75 firefighters treated for injuries. The activation of the European Union Civil Protection Mechanism underscored the magnitude of the crisis, which President Macron described as a completely unprecedented wildfire and the toughest France has faced since the Second World War (Al Jazeera 2026b).

Across the Pyrenees, Spain is experiencing a similarly severe fire season. By late July 2026, more than 170,000 hectares had burned nationwide, according to the Ministry for the Ecological Transition—several times the area affected during the same period in 2025 (El País 2026; eldiario.es 2026). The largest fire area, spanning the provinces of Ávila and Madrid, exceeded 70,000 hectares and developed a perimeter of more than 160 kilometers. Spanish authorities describe this as the largest fire in the country’s recorded history, and regional president Isabel Díaz Ayuso called conditions endemoniada (hellish). A second major fire at Vall d’Uixó in Castellón had consumed some 4,300 hectares and forced the evacuation of more than 16,000 people from eighteen municipalities (eldiario.es 2026). Prime Minister Pedro Sánchez, visiting the affected areas, warned that difficult hours lay ahead as another heat wave approached. Combined evacuations in France and Spain surpassed 300,000 people, illustrating how prolonged heat, drought, and extreme fire events transcend national borders (Laizans and Pinedo 2026).

Figure 1: Racing to Curb Wildfires

Source: Photograph by Florion Goga/Reuters. Reproduced from Laizans and Pinedo (2026).

The fires represent the culmination of an extraordinary European heat season, which began in late May and has run in episodes far above seasonal norms across the United Kingdom, Ireland, France, Germany and the Iberian Peninsula (Copernicus Climate Change Service (C3S) 2026a). June 2026 was deem to have been the warmest June ever recorded in Western Europe, averaging 20.74 °C (69.3 °F)—3.05 °C (5.5 °F) above the 1991–2020 mean—narrowly surpassing the record set only twelve months earlier, when the region averaged 20.49 °C (68.9 °F), or 2.81 °C (5.1 °F) above that baseline (C3S 2026b, C3S 2025). Two consecutive years of record-breaking temperatures are more than statistical anomalies; they suggest that the climate baseline itself is shifting. Much of Europe’s urban infrastructure, including its housing stock, was designed under the assumption that widespread air conditioning would remain unnecessary. That assumption is rapidly being overtaken by an ominous climatic reality, with the greatest health impacts falling on older populations and vulnerable urban communities.

These climate-related disruptions extend well beyond Europe. During July 2026, Canada experienced 876 active wildfires simultaneously, while more than 3,500 fires had consumed over six million acres since the start of the 2026 fire season, spreading smoke across much of North America (CNN 2026; Clarity 2026). Air quality deteriorated dramatically across large areas of the United States. Chicago recorded a one-hour PM₂.₅ concentration of 471.8 µg/m³—fine particulate matter small enough to penetrate deep into the lungs and enter the bloodstream—against a U.S. 24-hour standard of 35 µg/m³ and a World Health Organization guideline of 15 µg/m³ (WHO 2021). That reading corresponded to an Air Quality Index (AQI) of 481, where values above 300 are classified as hazardous. The Baltimore–Washington metropolitan region, where my family and I reside, registered daily average PM₂.₅ concentrations approaching 200 µg/m³, nearly six times the U.S. National Ambient Air Quality Standard, prompting Code Purple alerts under which everyone—not only sensitive groups—is advised to limit outdoor activity (NASA 2026; Clarity 2026). At the peak of the episode, more than 100 million Americans were under air quality alerts (NBC News 2026).

The above events illustrate a broader transformation underway. As Wallace-Wells (2026) argues, climate change is turning extreme wildfires and hazardous smoke from episodic disasters into recurring features of everyday life. The implications extend beyond emergency response. They point toward a future in which resilience increasingly depends on anticipatory adaptation, adaptable infrastructure, ecosystem management, and preventive public health investments undertaken before climate shocks occur.

The public health consequences reinforce this conclusion. Recent analyses, as illustrated in Figure 1, estimate that exposure to wildfire-generated PM₂.₅ was associated with nearly 164,000 deaths in the United States between 2006 and 2020 (Climate Central 2025). Attribution studies further demonstrate that anthropogenic climate change has significantly increased wildfire-related smoke exposure and its associated mortality burden (Law et al. 2025). Looking ahead, Qiu et al. (2025) project that climate-driven wildfire smoke could eventually generate mortality-related economic losses exceeding those associated with all other climate-related causes combined in the United States.

The above findings underscore that investments in wildfire prevention, fuel management, ecosystem resilience, and cleaner indoor air are not simply environmental measures—they are also investments in public health and economic resilience.

Figure 2: Health Impact of Wildfire Smoke

Source: Reproduced from Climate Change Worsens Wildfire Smoke, Climate Central (2025). https://www.climatecentral.org/climate-matters/climate-change-worsens-wildfire-smoke-2025

These converging crises reveal a broader lesson. Even societies, such as those in Western European and North American countries, possessing substantial scientific, financial, and institutional capacity increasingly find that traditional disaster-response models are insufficient for managing accelerating climate risks. They point toward a common imperative: strengthening resilience before disasters occur rather than relying primarily on reconstruction afterward.

The same lesson is increasingly relevant beyond Europe and North America. While Europe experienced record temperatures, the Copernicus Climate Change Service also reported record global ocean temperatures associated with a developing El Niño (C3S 2026b; C3S 2026c). Attention is therefore shifting toward the equatorial Pacific, where forecasts indicate that El Niño is likely to strengthen during the second half of 2026, posing significant risks to ecologically fragile regions, including Ecuador’s Galápagos Islands and the Pacific coastal regions of Ecuador and Peru.

In this note I focus on that second shock: what four decades of scientific observation tell us about El Niño’s impact on the Galápagos archipelago and in Ecuador at large, and what response measures should be put in place before the event arrives.

II. The Forecast for the Equatorial Pacific

As of 9 July 2026, the U.S. National Oceanic and Atmospheric Administration (NOAA) has officially declared that El Niño is underway. According to the NOAA Climate Prediction Center, the El Niño–Southern Oscillation (ENSO)—the natural climate cycle that alternates between the warm El Niño phase and the cool La Niña phase—is at El Niño Advisory, the status used when an event is already occurring rather than simply expected.

Forecasters monitor the strength of El Niño by measuring sea surface temperature (SST) anomalies—departures from the 1991–2020 climatological average—in several fixed regions of the equatorial Pacific. The most widely used indicator is the Niño-3.4 region (5°N–5°S, 170°W–120°W), where sustained positive SST anomalies are summarized by the Oceanic Niño Index (ONI). NOAA defines El Niño conditions when the three-month running mean SST anomaly in this region is at least +0.5°C for consecutive overlapping seasons and is accompanied by the characteristic atmospheric response (NOAA Climate Prediction Center 2026a, b; UCAR Climate Data Guide 2025). As of the latest weekly observations, the Niño-3.4 SST anomaly stood at approximately +1.2°C (NOAA Climate Prediction Center 2026a,b) (see Figure 2).

For the Galápagos the most important indicator is the Niño-1+2 region—a standardized ocean-monitoring area in the eastern equatorial Pacific that includes the waters off the Ecuadorian coast and around the Galápagos Islands. Scientists divide the tropical Pacific into several numbered regions (Niño-1+2, Niño-3, Niño-3.4 and Niño-4) to track where ocean temperatures are changing. Niño-1+2 is closest to Ecuador and the archipelago and therefore gives the best indication of the conditions that directly affect them. There, sea surface temperatures are already +2.7 °C above average—more than twice the anomaly in the central Pacific. This warming is closely associated with the weakening of the natural rise of cold, nutrient-rich deep water that fuels the Galápagos marine ecosystem (NOAA Climate Prediction Center 2026a, b).

The forward outlook is unusually firm. The NOAA Climate Prediction Center assigns a 97 percent probability that El Niño persists through early spring 2027, and an 81 percent probability of a very strong event during October–December 2026—an event that would rank among the largest in the historical record maintained since 1950 (NOAA Climate Prediction Center 2026a, b). The International Research Institute for Climate and Society (IRI) at Columbia University reaches essentially the same conclusion: based on its mid-July forecast, which combines the results of 26 independent climate models, every model projects that El Niño will persist throughout the forecast period, and 23 of the 26 predict that it will reach very strong intensity between October and December 2026 (IRI 2026).

This convergence of forecasts sends a clear call to action for governments, conservation organizations, and development partners to strengthen preparedness before El Niño impacts intensify. Seasonal forecasts remain probabilistic, and even the strongest El Niño does not produce its typical impact everywhere. But the disagreement among modelling centers that would normally justify waiting has largely been resolved. The case for moving into a preparatory phase no longer depends on settling a scientific dispute; it depends only on the willingness to act on a signal that is already unambiguous.

Figure 3: Niño-3.4 Anomaly, 2026–27 Compared with the Three Strongest El Niños on Record

Source: Figure reproduced from ElNinoLive. (2026). El Niño in Peru and South America: Ground Zero, Then and Now. https://www.elninolive.com/impacts/south-america-peru

The developing El Niño has acquired broader significance in light of two important advances in contemporary climate science. Together, they suggest that the consequences of a major El Niño should no longer be viewed solely as temporary climatic disturbances but as events capable of interacting with a warming planet in ways that extend well beyond the duration of the event itself.

The first concerns the relationship between El Niño and global warming. Climate scientist James Hansen has argued that even a moderately strong El Niño during the next twelve to eighteen months could raise the global average temperature to approximately 1.7°C above the pre-industrial baseline, and that the Earth may not subsequently cool below the 1.5°C threshold established under the Paris Agreement (Berwyn 2026). Whether or not that specific threshold is permanently crossed remains the subject of scientific debate. The broader implication, however, is less controversial. Each successive El Niño now unfolds against a warmer climatic background than its predecessors, amplifying heat stress, drought, wildfire risk, heavy precipitation, and other climate-related hazards.

Crossing such thresholds should not be understood as triggering a single catastrophic rupture. Rather, it reflects the progressive transformation of climate systems that have historically fluctuated within relatively stable bounds. Forests, watersheds, rainfall regimes, and ocean ecosystems increasingly operate under conditions that differ from those experienced during earlier El Niño events. For policymakers, this distinction is important. It implies that historical analogues remain valuable but cannot be applied mechanically to future planning (Izurieta et al. 2026).

A second and particularly relevant advance comes from recent research examining the long-term consequences of super El Niño events. In a study published in Nature Communications, Xue et al. (2025) analyzed the three modern super El Niño events, 1982–83, 1997–98, and 2015–16, which they define as exceptionally intense El Niño episodes in which the normalized Niño-3 sea surface temperature anomaly during the mature phase (December–February) exceeds two standard deviations above normal.

Xue et al. (2025) found that super El Niño episodes of this magnitude can trigger climate regime shifts or persistent changes in regional climate systems that continue long after tropical Pacific sea-surface temperatures have returned to normal. Using observations together with climate-model simulations, the authors show that these shifts can alter surface air temperature, sea-surface temperature, precipitation, soil moisture, and atmospheric circulation, with effects persisting for years and, in some regions, even decades. Their simulations further indicate that the likelihood of such regime shifts is projected to increase under continued greenhouse warming (Xue et al. 2025).

The study also identifies several climate regime-shift hotspots. In the oceans, these include the central North Pacific, southeastern Indian Ocean, southwestern Pacific, and Gulf of Mexico. On land, prominent hotspots occur in East Africa and the Maritime Continent, while particularly strong soil-moisture responses are projected for central South Asia, central Australia, western Greenland, and the Amazon Basin (Xue et al. 2025; Berwyn 2026).

Although the eastern equatorial Pacific, including the Galápagos Islands, is not identified as one of the principal climate regime-shift hotspots, this finding should not be interpreted as diminishing concern for Ecuador. Rather, it underscores that the Galápagos faces a different category of risk: severe ecological disruption associated with exceptionally warm ocean temperatures and reduced marine productivity during strong El Niño events, rather than the long-lived post-event climate regime shifts identified by Xue et al. (2025). The well-documented responses of coral reefs, marine iguanas, Galápagos penguins, and other endemic species to previous extreme El Niño episodes remain a compelling basis for anticipatory action (Xue et al. 2025; Izurieta et al. 2026).

More broadly, the study offers an important lesson. The significance of a super El Niño lies not only in its immediate impacts but also in its potential to alter the environmental conditions upon which ecosystems and societies depend. As climatologist Jong-Seong Kug, senior author of the study, observed, a super El Niño “can shift the background climate conditions that people and ecosystems rely on” (Berwyn 2026). In other words, the consequences of an extreme El Niño may persist long after tropical Pacific sea-surface temperatures have returned to near-average conditions (Xue et al. 2025).

For Ecuador, the inclusion of the Amazon Basin among the regions exhibiting heightened susceptibility is particularly significant. It underscores that the implications of a super El Niño are not confined to the Pacific coast or the Galápagos Islands. Rather, they may extend across the country’s diverse ecological regions, influencing hydrological processes, soil moisture, biodiversity, agriculture, and human wellbeing on both sides of the Andes (Xue et al. 2025). This reinforces the need for preparedness strategies that recognize climate risks as interconnected across ecosystems rather than as isolated regional hazards.

The implications for the Galápagos are equally important, although of a different nature. The archipelago’s extraordinary biodiversity has evolved under relatively stable oceanographic conditions shaped by the convergence of major Pacific currents and persistent nutrient-rich upwelling. Strong El Niño events temporarily disrupt that stability by suppressing upwelling, reducing marine productivity, and triggering cascading effects throughout the food web. While Xue et al. (2025) do not identify the eastern equatorial Pacific as a principal climate regime-shift hotspot, their findings nevertheless reinforce the importance of considering the cumulative effects of increasingly intense El Niño events occurring against a warmer global climate. Under such conditions, recovery intervals between disturbances may shorten, potentially affecting ecosystem resilience, species interactions, and long-term conservation outcomes (Xue et al. 2025; Izurieta et al. 2026).

Figure 4: Drought in an El Niño Year

Note: A wooden boat is seen stranded on the dry cracked riverbed of the Dawuhan Dam during drought season in Madiun, Indonesia's East Java province. October 28, 2015. Photograph © ANTARA FOTO/Reuters/Corbis

Source: Reproduced from van Trotsenburg, A. (2015). We must prepare now for another major El Niño. https://blogs.worldbank.org/en/eastasiapacific/we-must-prepare-now-another-major-el-nino

The significance of these scientific findings is not that catastrophic outcomes are inevitable. Scientific uncertainty remains an inherent feature of climate forecasting, and neither seasonal predictions nor climate-model projections can determine precisely how individual ecosystems will respond. Rather, the evidence demonstrates that uncertainty should not be confused with inaction. On the contrary, the convergence of independent seasonal forecasts indicating a strengthening El Niño, together with growing evidence that super El Niño events can produce persistent climatic changes in vulnerable regions and that such risks increase under continued greenhouse warming, strengthens the case for anticipatory planning (IRI 2026; NOAA Climate Prediction Center 2026; Xue et al. 2025).

For the Galápagos Islands, this is more than an oceanographic forecast. It is an early warning that one of the world’s most distinctive ecosystems may soon experience one of its most severe recurrent natural disturbances under a warmer global climate than prevailed during previous major El Niño events. Although the archipelago is not identified as one of the principal climate regime-shift hotspots by Xue et al. (2025), its exceptional ecological sensitivity to ENSO-driven disruptions of ocean productivity is well established. The combination of increasingly warm baseline conditions, recurrent marine heat stress, and the prospect of another strong El Niño underscores the importance of strengthening ecological monitoring, protecting vulnerable species and habitats, and ensuring that institutional and financial preparedness measures are in place before impacts occur (Xue et al. 2025; Izurieta et al. 2026).

The appropriate response, therefore, is neither alarm nor complacency. It is informed preparedness—grounded in the best available science, supported by robust monitoring and early-warning systems, strengthened through effective institutions, and translated into anticipatory action before the next El Niño reaches its peak. That principle extends beyond the Galápagos. As recent research increasingly demonstrates, resilience depends not only on responding effectively to climatic shocks, but also on anticipating how a warming world may amplify their consequences and preparing accordingly.

III. What the Historical Record Shows

The ecological consequences of El Niño in the Galápagos follow a well-understood chain of events. Figure 5 illustrates the oceanographic processes that underpin these ecological impacts. The 1997–98 super El Niño dramatically altered sea-surface temperatures and ocean circulation across the tropical Pacific, disrupting the nutrient-rich upwelling that normally sustains the Galápagos Marine Reserve and one of the world's most productive marine ecosystems.

Figure 5: The 1997–98 El Niño’s Dramatic Impact on Ocean Biology

Note: The 1997-98 El Niño was truly a global event. The sequence shows a superposition of sea surface temperature anomalies on anomalies of the sea surface elevation. Warmer than normal temperatures are shown in red and cooler than normal temperatures are shown in blue.

Source: Reproduced from NASA Scientific Visualization Studio, n.d.

As the eastern Pacific warms, the normal flow of cold, nutrient-rich water from the deep ocean to the surface driven by the Cromwell Current and the Humboldt Current is greatly reduced. Without this continuous supply of nutrients, microscopic marine plants (phytoplankton), which form the base of the food web, decline sharply. Fish populations either migrate in search of cooler waters or suffer high mortality, and the seabirds and marine mammals that depend on them soon face food shortages.

The effects have been dramatic during the two strongest El Niño events on record. Marine iguanas (Amblyrhynchus cristatus), which feed almost exclusively on marine algae, lost as many as 70 percent of individuals in some colonies during the 1982–83 event. During the 1997–98 El Niño event, catalogued as the strongest of the 20th century, surpassing the anomalies and impacts associated with the 1982-83 event, mortality reached 90 percent on some islands (Steinfartz et al. 2007; Galápagos Conservancy 2024). On Genovesa Island alone, the population fell from roughly 15,000 individuals to only 900 in a single El Niño cycle (Wikelski and Nelson 2004; Steinfartz et al. 2007).

Galápagos penguins (Spheniscus mendiculus) experienced equally severe declines. Their population fell by 77 percent during the 1982–83 event and by 65 percent during 1997–98. More than two decades later, the species has still not fully recovered, helping explain its current classification as endangered (Galápagos Conservancy n.d; Steinfartz et al. 2007; Wikelski and Nelson 2004; Xue et al. 2025; Galápagos Conservation Trust 2023).

Other marine wildlife responds in similar ways. Sea lions, flightless cormorants, boobies, and frigatebirds frequently suspend breeding during severe El Niño events because food becomes too scarce to raise young successfully. Among sea lions, mortality is especially high among pups and dominant breeding males (Galápagos Conservancy 2024; Xue et al. 2025; Steinfartz et al. 2007; Wikelski and Nelson 2004; and Izurieta et al. 2026).

Perhaps the clearest example of the long-term ecological consequences comes from the coral reefs. The 1982–83 El Niño destroyed approximately 97 percent of Galápagos coral cover. Four decades later, those reefs have still not recovered, leaving the few remaining coral communities among the ecosystems most vulnerable to another extreme El Niño (Robinson and del Pino 1985; Charles Darwin Foundation 2024a).

Not all impacts are negative. On land, the heavier rains associated with El Niño stimulate plant growth that benefits giant tortoises, land iguanas, and Darwin’s finches. Yet those same wet conditions also favor invasive species. Fire ants, blackberry, guava, and invasive rodents expand rapidly during and immediately after El Niño years, increasing competition with native species and hindering conservation efforts (Charles Darwin Foundation 2024b). Thus, the same rains that temporarily benefit some native wildlife also strengthen one of the archipelago’s greatest long-term threats.

Figure 6 places these ecological impacts in their geographical context by identifying the principal long-term monitoring sites across the Galápagos Marine Reserve. These locations form the core of the archipelago's ecological surveillance system, providing the baseline information needed to detect changes in coral reefs, marine iguana populations, and Galápagos penguins as El Niño conditions develop.

These historical comparisons are instructive, but they should not be read as a blueprint for what will happen in 2026–27. Izurieta et al. (2026) caution against mechanically extrapolating either the ecological impacts or the policy lessons of the 1982–83 and 1997–98 events to the present. They argue that the context has changed in important ways, and not all of those changes point in the same direction.

On the one hand, several factors increase the archipelago’s vulnerability. Long-term climate change has raised the ocean’s thermal baseline, meaning that the same El Niño anomaly now occurs in a warmer sea. At the same time, decades of growing tourism, fishing pressure, and the establishment of invasive species have reduced the ecological buffer that helped absorb earlier shocks. Plastic pollution, which was negligible during the 1982–83 event and only a marginal concern in 1997–98, has become an additional stressor (Marquez 2019). It now harms seabirds and marine organisms directly, while warmer waters and stronger wave action accelerate the formation and dispersal of microplastics during El Niño conditions (Izurieta et al. 2026).

Figure 6. The Galápagos Islands and principal ecological monitoring sites.

The map illustrates the archipelago’s location in the eastern equatorial Pacific and selected sites monitored for coral reefs, marine iguanas, and Galápagos penguins.

Source: Charles Darwin Foundation; Galápagos National Park Directorate.

On the other hand, Ecuador enters this event better prepared than it did three decades ago. Scientific monitoring is more sophisticated, conservation institutions are stronger, and the country now has access to financing and emergency response mechanisms that did not exist during previous ENSO cycles. The challenge, therefore, is not simply greater risk, but greater risk alongside greater capacity to respond.

Izurieta et al. (2026) make an important point that deserves emphasis: El Niño should not be viewed simply as a disaster. It is a major ecological disturbance that produces both losses and opportunities, with impacts that vary across species and ecosystems. Increased rainfall, for example, can improve breeding success for some terrestrial species, alter species distributions, and create opportunities for new colonization. The appropriate way to understand El Niño is therefore as an ecological disturbance with uneven and often contrasting consequences, rather than as a uniformly catastrophic event.

This broader perspective, however, does not diminish the central conservation concern. For the Galápagos’ most vulnerable species—including the marine iguana, the Galápagos penguin, the flightless cormorant, the waved albatross, the Galápagos fur seal, and shallow-water coral and invertebrate communities—the risk of severe population declines and, in some locations, local extinction during a strong 2026–27 El Niño remains real (Izurieta et al. 2026).

The Charles Darwin Foundation has been equally clear about these concerns. Its Executive Director, Rakan Zahawi, has described witnessing the increasing frequency and intensity of ENSO-related disruptions and the additional pressures they bring, particularly the expansion of invasive species that threaten the ecosystems the Foundation was established to protect (Climate Fund Managers 2024).

A substantial body of modelling research suggests that greenhouse warming is likely to increase the frequency of extreme El Niño events and the variability of eastern Pacific events (Cai et al. 2014; Cai et al. 2018). The Intergovernmental Panel on Climate Change (IPCC 2021), however, concludes that there is still no scientific consensus that El Niño events themselves will become systematically stronger. Similarly, the World Meteorological Organization notes that there is no clear evidence that climate change is increasing the frequency or intensity of El Niño events, while emphasizing that a warmer ocean and atmosphere amplify the impacts those events produce (WMO 2026a, WMO 2026b).

The practical implication is straightforward. Scientists continue to debate how El Niño itself may evolve in a warming world. They do not debate that when a strong El Niño occurs, its impacts unfold on a warmer, more stressed, and more vulnerable planet. That distinction is critical. It reinforces the case for acting on today’s evidence rather than waiting for tomorrow’s certainty.

IV. Human Systems Are Not a Separate Emergency

Discussions of El Niño frequently emphasize its ecological consequences because they are immediate and highly visible. Yet the same climatic forces that disrupt marine and terrestrial ecosystems simultaneously expose vulnerabilities within human systems that ultimately determine both the effectiveness of conservation efforts and the resilience of affected communities. Public health, water and sanitation, transportation, education, tourism, fisheries, agriculture, and local economies are all affected as environmental disturbances cascade through interconnected ecological, social, and economic systems. Protecting biodiversity and protecting people are therefore complementary rather than competing objectives.

Ecuador's experience during the 1997–98 El Niño offers a good illustration of this interdependence. While the event caused extensive ecological damage, it also generated a multisector development challenge requiring coordinated action across public health, infrastructure, environmental management, social protection, and fiscal policy.

A. Public Health Impacts

Public health is not a secondary consequence of a major El Niño. It is a parallel emergency, and it arrives on the same schedule.

World Bank climate and health analyses have documented that ENSO events in Latin America affect human wellbeing through at least five interconnected pathways (World Bank 2017, 2018):

• Increased vector-borne disease risk as changes in temperature and rainfall alter mosquito ecology.

• Increased waterborne disease following floods that compromise drinking water and sanitation systems (see Figure 7 below).

• Food insecurity and malnutrition arising from losses in agriculture, livestock, and fisheries.

• Disruption of essential health services caused by damage to health facilities, communications failures, and interruptions in medicine supply chains.

• Displacement-related health risks, including communicable diseases, maternal and child health challenges, and psychosocial impacts associated with population displacement.

These pathways are mutually reinforcing rather than independent. Ecological disruption rapidly translates into public health challenges, while weaknesses in health systems amplify the human consequences of environmental shocks (Marquez 2022a; Marquez 2022b; Marquez 2023).

Regional analyses of malaria and dengue between 1996 and 2006 identified the 1997–98 El Niño as a period of elevated disease transmission across Latin America and demonstrated that temperature increases of only 1–2°C can alter transmission dynamics in equatorial ecosystems such as the Peruvian Amazon (World Bank 2010, 2014). The operational implications for Ecuador—and particularly for the Galápagos—are therefore clear. El Niño preparedness must extend beyond environmental conservation and infrastructure protection. It also requires strengthening epidemiological surveillance, laboratory and vector-monitoring capacity, safe water and sanitation, resilient primary health care services, emergency logistics, and continuity plans that ensure essential health services remain operational during floods and population displacement.

Figure 7. Flooding in Guayaquil during the 1997–98 El Niño.

Source: El Universo (2023), “¿Cómo afectó el fenómeno de El Niño de 1997 y 1998 al Ecuador?” [How Did the 1997–1998 El Niño Affect Ecuador?], including the archival photograph “Inundaciones en la ciudad de Guayaquil por el fenómeno de El Niño” [Flooding in the City of Guayaquil Caused by the El Niño Phenomenon], photograph taken February 19, 1998.

B. Learning from Ecuador’s Health Response to the 1997–98 El Niño

Ecuador’s health response to the 1997–98 El Niño provides a relevant historical precedent for the preparedness challenges the country faces today. I write about this experience not as an observer, but as an active participant. The response demonstrated that acting early and effectively does not always depend on new funding. By adapting existing development operations and reallocating available resources, Ecuador was able to launch a quick response while additional financing and broader recovery efforts were being mobilized (World Bank 1997b; World Bank 1999).

From 1992 to 1999, I served as the World Bank Task Manager for the Ecuador Second Social Development Project—Health and Nutrition (FASBASE), a US$102 million operation designed to expand access to essential health, nutrition, and water and sanitation services for Ecuador’s poorest and most vulnerable populations (World Bank 1992). The project was prepared in 1992 under Dr. Plutarco Naranjo, Minister of Public Health in the Rodrigo Borja administration, and began implementation as the Sixto Durán-Ballén government took office in August of that year. Although conceived as a long-term social development operation, FASBASE proved sufficiently flexible to become the principal vehicle for the health-sector response when the 1997–98 El Niño struck. In doing so, it demonstrated how well-designed development operations can be adapted rapidly to address emerging crises while maintaining their longer-term development objectives (World Bank 1999).

As the impacts of El Niño intensified, Ecuador did not wait for additional emergency financing before acting. Between November 1997 and June 1999, approximately US$12 million was reallocated within the existing FASBASE operation under a health-sector contingency plan led by Dr. Guillermo Wagner and Dr. Asdrúbal de la Torre, successive Ministers of Public Health, and their teams during the Fabián Alarcón administration (World Bank 1999). These resources financed health services for displaced populations and residents of temporary shelters across the coastal provinces of Guayas, Los Ríos, El Oro, Manabí, and Esmeraldas. They also supported intensified epidemiological surveillance, malaria and dengue prevention and control, vector control, essential medicines and medical supplies, emergency public health interventions, nutrition support, and other measures designed to prevent communicable disease outbreaks in communities affected by flooding and population displacement (World Bank 1999).

Additional financing followed once the full scale of the crisis had become clear. In September 1999, the World Bank approved a US$20.2 million Supplemental Loan, prepared under Dr. Edgar Rodas, Minister of Public Health, and his team during the Jamil Mahuad administration (World Bank 1999). By then, the devastation caused by El Niño had been compounded by collapsing oil export prices and the international financial crisis, while reported malaria cases had exceeded 45,000 during the first half of 1999 alone. The supplemental operation sought not only to restore essential health services but also to strengthen resilience through nutrition programs, water and sanitation interventions, and a dedicated US$2.9 million malaria prevention and control program serving approximately two million people in 42 high-risk cantons. Its integrated approach combined community participation, strengthened laboratories and local health facilities, early diagnosis and prompt treatment, insecticide-treated bed nets, disease surveillance, and environmental management. Notably, after assessing costs and benefits, the operation deliberately chose not to finance synthetic chemical pesticides, relying instead on biological and environmental approaches to vector control (World Bank 1999).

Looking back nearly three decades later, the principles underpinning this health-sector response remain strikingly relevant. The strategy emphasized acting early rather than waiting for the crisis to deepen, integrating public health, nutrition, water and sanitation, and vector control instead of treating them as separate interventions, decentralizing implementation to local health services, and placing communities at the center of prevention and response. Together, these principles continue to define climate-resilient health systems and anticipate many of the elements that today underpin the One Health approach, including integrated surveillance, environmental management, and community-based prevention (World Bank 2018; Marquez 2022a).

The rapid adaptation of FASBASE and the subsequent mobilization of additional health-sector financing were not isolated interventions. They formed part of a broader national effort in which the Government of Ecuador, supported by the World Bank and other development agencies, launched a multisectoral emergency recovery program to reduce the loss of human life and livelihoods, protect and rehabilitate economic and social infrastructure damaged by flooding and heavy rainfall, and strengthen the country’s capacity to forecast and respond to future El Niño events (World Bank 1997b). This emergency recovery operation complemented sector-specific actions already underway in health, social protection, transport, water supply, agriculture, and other sectors, demonstrating the value of combining flexible sectoral programs with dedicated emergency financing to address a complex climatic crisis.

C. From Lessons Learned to Integrated Preparedness

Ecuador’s response demonstrated that resilience is built before disasters reach their peak. Institutional flexibility, integrated planning, decentralized implementation, and effective coordination proved as important as emergency financing itself. Environmental disturbances rapidly cascade through interconnected ecological, social, economic, and institutional systems, transforming environmental shocks into multidimensional development challenges.

These cascading impacts underscore that the conservation challenge is inseparable from the development challenge. Healthy ecosystems, resilient livelihoods, sustainable public finances, and effective health systems are mutually reinforcing components of a single socioecological system. This integrated perspective increasingly underpins the World Bank’s work on climate resilience, disaster risk management, and Small Island Developing States (World Bank 2017, 2024a, 2025e).

It is equally applicable to the Galápagos, where tourism and fisheries depend directly on healthy ecosystems. Severe El Niño events simultaneously reduce marine productivity, disrupt wildlife populations, damage infrastructure through heavy rainfall, and diminish the visitor experience. Artisanal fishers lose access to key commercial species precisely when coastal communities become more dependent on them for income, while demand for social services rises just as public revenues and household livelihoods come under increasing pressure. For an archipelago whose two principal settlements, Puerto Ayora and Puerto Baquerizo Moreno, already experience pressure on water, sanitation, and waste-management systems under normal conditions (Marquez 2024), the inclusion of these services cities in a response program is far from incidental.

The lesson is clear: adaptation strategies that address ecological, economic, fiscal, or public health risks in isolation are unlikely to achieve lasting resilience because each depends on the others. Effective preparedness requires integrated planning that recognizes the interdependence of environmental sustainability, economic resilience, public health, and institutional capacity.

Viewed from today’s perspective, the response anticipated many principles that now underpin anticipatory action: adaptive implementation, multisectoral coordination, rapid repurposing of financing, and the capacity to act on emerging risks before additional resources become available.

As climate-related disasters become more frequent and severe, these principles remain highly relevant—not only for Ecuador as it prepares for the potential impacts of the developing 2026–27 El Niño, but also for other countries seeking to strengthen resilience before future shocks occur (UNEP 2025).

Table 1 synthesizes these operational lessons and provides the empirical foundation for the integrated anticipatory resilience framework developed in Section V.

Table 1: Lessons from Previous El Niño Events

Source: Elaborated by Patricio V. Marquez (2026) for this note. Synthesis based on World Bank (1999, 2000, 2017, 2026); Charles Darwin Foundation (2024a, 2024b); Galápagos Conservancy (2024); Galápagos Conservation Trust (2023); Izurieta et al. (2026); and sources cited throughout this paper.

V. From Reactive Response to Anticipatory Resilience

The central proposition advanced in this note is that climate resilience should be understood not primarily as the capacity to recover after disasters occur, but as the capacity of institutions to anticipate risks, reduce vulnerability before ecological and social thresholds are crossed, and mobilize coordinated action while there is still time to influence outcomes.

Figure 8 presents the integrated anticipatory resilience framework proposed in this note, illustrating how climate forecasting and scientific monitoring, ecological stewardship, public health preparedness, adaptive governance, and innovative financing function as mutually reinforcing components of a single socioecological system. The framework is conceptual and illustrates the institutional relationships through which these components interact to strengthen anticipatory resilience before climate shocks evolve into ecological, public health, and socioeconomic crises.

Figure 8:

Source: Elaborated by Patricio V. Marquez (2026) for this note. Synthesized from World Bank (1999, 2000, 2017, 2025a, 2025b, 2026); UNEP (2025); Cai et al. (2014, 2018); Izurieta et al. (2026); and other sources cited throughout this paper.

A. Building the Institutional and Financial Architecture

Scientific knowledge and institutional preparedness are necessary but insufficient without timely financing. Modern disaster-risk financing instruments—including contingent financing, Cat DDOs, parametric insurance, conservation finance, and dedicated resilience funds—should be viewed as complementary components of a layered institutional architecture supporting anticipatory action.

For the Galápagos, strengthening ecological monitoring, establishing pre-event baselines, reinforcing biosecurity, protecting ecological refugia, and linking financing to operational preparedness are essential elements of anticipatory resilience.

Three decades of institutional learning underpin this approach. The 1997–98 El Niño prompted World Bank emergency operations in Peru, Ecuador, and Bolivia that began shifting disaster management from post-disaster reconstruction toward prevention, forecasting, and preparedness (World Bank 1997a, World Bank 1997b; World Bank 1998). A subsequent World Bank study concluded that improved forecasts create value only when institutions can convert information into timely action (World Bank 2000). Later assessments done by the World Bank’s Independent Evaluation Group reinforced this lesson by emphasizing the importance of pre-trained personnel, simplified procurement procedures, retroactive financing for preventive investments, and contingent financing for recovery (Independent Evaluation Group 2022).

By 2025–26, this evolution had crystallized into a new generation of financing instruments. The World Bank’s disaster risk financing toolkit now includes Development Policy Financing with Catastrophe Deferred Drawdown Options (Cat DDOs), Contingent Emergency Response Components (CERCs), catastrophe-risk insurance and catastrophe bonds, the Rapid Response Option (RRO), and climate-resilient debt clauses—mechanisms that integrate financing into preparedness and resilience rather than treating it solely as a source of post-disaster assistance (World Bank 2025a; World Bank 2025b; World Bank 2025c; World Bank 2025d; World Bank 2025f).

For Ecuador, this institutional foundation is stronger than at any previous point in the ENSO cycle. On 26 November 2025, the World Bank’s Board of Executive Directors approved Ecuador’s first US$200 million Disaster Risk Management Development Policy Financing with a Catastrophe Deferred Drawdown Option (Cat DDO) (World Bank 2025b). The operation is designed to strengthen the country’s capacity to manage climate, geophysical, and public health risks while incorporating disaster preparedness, disease control, health security, health-system strengthening, biodiversity protection, and One Health approaches into its policy framework, thereby providing immediate contingent financing should a major disaster or public health emergency occur.

B. Anticipatory Response and Financing in the Galápagos

Against this backdrop, five clusters of action in the Galápagos deserve priority before El Niño reaches its projected peak.

First, the Charles Darwin Foundation's long-term subtidal ecological monitoring program already provides a strong foundation for anticipatory action. Across the Galápagos Marine Reserve, it tracks coral health using large-area imagery and oceanographic data to identify sites most vulnerable to ENSO and improve the capacity to anticipate ecological impacts (Charles Darwin Foundation 2024a; Izurieta et al. 2026). However, the opportunity to establish robust pre-event baselines for coral reefs, marine iguana colonies, and Galápagos penguin populations is rapidly narrowing as sea-surface temperatures continue to rise. That window should extend landward as well. Recent conservation gains, as observed by Standford University Professor, William H. Durham (2026), are the most reversible: native terrestrial species recovering under sustained invasive control — among them the Galápagos rail (Laterallus spilonotus) and the Scalesia tree species — warrant explicit listing among the biota in greatest danger, with mortality and reproductive performance tracked through the event. Recognizing that monitoring effort is finite, a short sentinel list of such species is preferable to archipelago-wide terrestrial coverage. Locking in these baselines — marine and terrestrial — through Q3 2026 is the foundation on which post-event quantification, attribution, and recovery planning depend.

Second, invasive-species containment as climate adaptation through strengthened biosecurity, surveillance, and rapid response before the expected increase in invasive pressures associated with wetter conditions (GEF 2024; Izurieta et al. 2026).

Third, protection of ecological refugia, particularly western Isabela and Fernandina, where persistent upwelling has historically buffered marine ecosystems during strong El Niño events and facilitated post-event recovery (Houvenaghel 1984; Snell and Rea 1999; Izurieta et al. 2026).

Fourth, climate disaster-risk financing linked to Ecuador’s Cat DDO (World Bank 2025b; World Bank 2025f). Ecuador’s newly approved Cat DDO provides a pre-arranged contingent line of credit that becomes immediately available once the government declares an eligible natural, climate-related, or public health emergency. Unlike conventional reconstruction loans, which are negotiated after a disaster has occurred, a Cat DDO is approved in advance and can be rapidly disbursed to provide liquidity during the critical first days or weeks of a crisis while additional domestic and international financing is mobilized (World Bank 2025b; World Bank 2026). The instrument therefore reduces delays in emergency response and supports governments in maintaining essential public services when fiscal pressures are greatest.

A possible next step for the Galápagos would be to complement this sovereign contingent credit with a Galápagos-specific parametric insurance mechanism. Unlike traditional indemnity insurance, which requires field assessments to estimate actual losses before compensation can be paid, parametric insurance is triggered automatically when predefined physical thresholds are exceeded. These triggers could include, for example, sustained anomalies in Niño 3.4 or Niño 1+2 sea-surface temperatures, exceptionally high sea-surface temperatures around the archipelago, extreme rainfall, or other scientifically validated indicators associated with severe El Niño impacts. Once those agreed thresholds are reached, payouts would be released automatically according to pre-established formulas, eliminating lengthy damage assessments and allowing funds to become available within days rather than months (World Bank 2025a; GFDRR 2025).

Such a mechanism could be linked to pre-arranged disbursement protocols agreed before the onset of an event. Rather than entering the general government budget, payouts could flow through predetermined allocation channels to finance specific emergency activities undertaken by entities such as the Galápagos National Park Directorate, the Charles Darwin Foundation, the Galápagos Life Fund, the Ministry of Public Health, and local emergency management authorities. Eligible expenditures could include intensified ecological monitoring, rapid invasive-species control, emergency wildlife rescue and rehabilitation, continuity of health services, epidemiological surveillance, vector control, laboratory diagnostics, emergency water and sanitation measures, and the repair of critical conservation and public-health infrastructure. Establishing these allocation rules before an event would minimize administrative delays and ensure that resources reach operational agencies when they are needed most.

Viewed together, Ecuador’s Cat DDO, a future Galápagos parametric insurance facility, catastrophe bonds, and other disaster-risk financing instruments would constitute a layered financial protection strategy. The first layer would consist of regular government budgets and reserve funds; the second would provide rapid contingent liquidity through the Cat DDO; the third would transfer the financial consequences of extreme, low-probability events to insurance and capital markets through parametric insurance and catastrophe bonds. This layered approach enables governments to match financing instruments to different levels of disaster risk, ensuring that predictable, moderate, and catastrophic losses are financed through the most appropriate mechanisms while reducing fiscal disruption and accelerating recovery (World Bank 2025a; GFDRR 2025).

Fifth, sustained conservation finance through innovative mechanisms such as the Galápagos debt conversion, the Galápagos Life Fund, PROBLUE, and the World Bank’s Global Program on Nature-Based Solutions. Together, these initiatives demonstrate how long-term financing can become an integral component of ecosystem resilience rather than simply a source of post-disaster recovery (DFC 2023; World Economic Forum 2023; World Bank 2024b; World Bank 2025e; World Bank 2025g).

Connected to these international instruments are revenue mechanisms embedded within Ecuadorian fiscal policy arrangements. The 2024 increase in the Galápagos National Park entry fee from USD 100 to USD 200—the first adjustment since 1998, which I previously analyzed as an example of tourist taxation for financing public goods (Marquez 2026a), creates a new revenue stream that could, in part, be earmarked for an El Niño contingency reserve. Such a reserve could provide pre-committed financing for emergency wildlife interventions, accelerated invasive-species response, continuity of essential health services, and rapid repair of critical infrastructure. If adopted, this would represent another example of a “win-win-win” policy approach: generating sustainable financing from tourism while simultaneously strengthening biodiversity conservation, public health preparedness, and climate resilience.

The concept is not new. For example, the World Bank’s pro-health taxation program, which I led between 2014 and 2019 with support from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation, was established following the same principle (Marquez and Moreno-Dodson 2017): increasing taxes and prices on tobacco products to reduce consumption and its associated health risks, improve public health, reduce environmental pollution, and generate additional public revenue to finance priority investments benefiting society as a whole.

The same logic applies to climate resilience in the Galápagos. Financing mechanisms should generate resources from activities that place pressure on fragile ecosystems and reinvest those resources in protecting biodiversity, strengthening public health systems, and building resilience before the next El Niño or other climate shock arrives. This preventive, risk-based philosophy also underpins the World Bank’s work on the blue economy and disaster-risk financing (World Bank 2025a; World Bank 2025f).

Figure 9:

Source: Photos by author, Puerto Ayora, Santa Cruz Island, Galapagos, June 2026.

C. A Good Practice in Anticipatory Conservation

Financing alone cannot build resilience. Equally important is the capacity of institutions to translate scientific knowledge, technological innovation, and multi-sector partnerships into preventive conservation before ecological thresholds are crossed. Increasingly, conservation initiatives around the world demonstrate that the most effective responses are those that anticipate ecological risks rather than reacting after irreversible losses have occurred. These experiences offer valuable lessons for the Galápagos as it prepares for another major El Niño event.

One particularly instructive example is the collaborative effort to conserve the pronghorn (Antilocapra americana) in California’s Carrizo Plain (Barkats 2026). The pronghorn is North America’s fastest land mammal—capable of reaching speeds approaching 60 miles (97 km) per hour—and the sole surviving representative of an ancient mammalian lineage dating back to the Pleistocene era. Often regarded as an indicator of the ecological integrity of North America’s remaining native grasslands, the species has experienced a dramatic decline in the Carrizo Plain, where fewer than 60 individuals remain as a consequence of prolonged drought, climate change, habitat fragmentation, roads, and conventional livestock fencing (Barkats 2026).

Rather than waiting until the population reaches the point where emergency recovery measures become the only option, conservation partners have adopted an anticipatory management strategy. The initiative brings together The Nature Conservancy, the California Department of Fish and Wildlife, California Polytechnic State University (Cal Poly), local ranchers, and artificial intelligence developers working through the open-source ANIML platform (Barkats 2026). This partnership integrates ecological science, technological innovation, private land stewardship, and public-sector leadership to reduce climate-related risks before they translate into irreversible biodiversity losses.

Preventive actions under the California’s Carrizo Plain initiative include: restoring habitat connectivity through wildlife-friendly fencing; replacing conventional cross-fencing with GPS-enabled virtual fencing systems in which cattle wear satellite-linked collars that respond to digital boundaries rather than physical barriers; removing or reducing unnecessary physical fencing to improve wildlife movement and landscape connectivity; expanding strategically located water sources to increase drought resilience; applying artificial intelligence to ecological monitoring and wildlife surveillance; and working collaboratively with ranchers to improve landscape management while maintaining productive agricultural systems (Barkats 2026).

Beyond improving habitat connectivity, replacing extensive physical fencing with virtual fencing may also contribute to wildfire resilience by reducing combustible fence infrastructure and enabling strategically managed grazing that creates fuel breaks capable of slowing wildfire spread (Oregon State University Extension Service 2025; Bennett et al. 2026). Collectively, these interventions strengthen ecosystem resilience by improving landscape connectivity, reducing climate-related risks, and maintaining ecological functions under increasingly variable environmental conditions.

The objective therefore extends well beyond preventing the extinction of a single species. It is to enhance the adaptive capacity of an entire ecosystem before climate stress pushes it beyond critical thresholds. This preventive philosophy closely parallels the disaster-risk financing principles discussed earlier in this note: investments made before a crisis are generally more effective—and considerably less costly—than efforts to restore ecosystems after severe damage has occurred.

VI. Moving Forward

The institutional responses to previous El Niño events in the Galápagos were largely reactive. The responses to the 1982–83 and 1997–98 events were important but improvised (Izurieta et al. 2026; Snell and Rea 1999; Marquez 2026b). The socioeconomic damage caused by the 1982–83 El Niño was exacerbated by inadequate environmental monitoring, weak urban planning, and poor risk communication. The response to the 2015–16 event was better coordinated, reflecting important institutional progress, but it remained constrained by the absence of dedicated, pre-arranged financing. The critical question in 2026, therefore, as posed by Izurieta et al. (2026), is whether meaningful progress has been made in addressing these longstanding weaknesses.

The implications of that question extend well beyond Ecuador. Across the world, climate change is increasing the frequency, intensity, and interconnectedness of extreme events that interact with existing social, economic, and environmental vulnerabilities. As discussed in this note, the record-breaking European wildfires and heatwaves of the summer of 2026 illustrated how climate risks are becoming both more widespread and more complex. As The Economist (2026) argues, the greatest gains will come not only from strengthening emergency response but, more importantly, from investing in anticipatory risk reduction, landscape management, early warning systems, preparedness, and public health protection before disasters occur.

The same logic applies to El Niño. The greatest returns come from acting before climate hazards escalate into humanitarian, health, environmental, and economic crises. More than a decade ago, Axel van Trotsenburg of the World Bank identified a central lesson from previous El Niño events: resilience is built through anticipation rather than reaction by investing in early warning systems, disaster risk management, climate-resilient infrastructure, and pre-arranged financing that protect lives, livelihoods, and development gains before disasters strike (van Trotsenburg 2015).

Ecuador now has an opportunity to demonstrate that this shift from reactive crisis management to anticipatory resilience is not merely an aspiration but an operational reality. The 2026–27 ENSO arrives under circumstances fundamentally different from those of previous major events. The scientific evidence is robust and remarkably consistent in warning of a potentially severe El Niño. Financing instruments to support anticipatory action exist, have been tested internationally, and, in Ecuador’s case, are already operational at the national level. At the same time, the Galápagos conservation community possesses far more sophisticated ecological monitoring systems and scientific knowledge than were available during earlier ENSO episodes. Moreover, three decades of World Bank experience—from the emergency operations following the 1997–98 El Niño in Ecuador, Peru, and Bolivia, to the development of the Cat DDO instrument and broader disaster-risk financing architecture—have produced a framework in which forecasting, prevention, health-system preparedness, adaptive social protection, ecosystem management, and pre-arranged financing are designed to operate as an integrated system rather than as sequential responses after disaster strikes.

What remains, therefore, is not a lack of knowledge or financing instruments, but the political and institutional commitment to translate preparedness into action. That means moving decisively from improvisation to anticipation and ensuring that resilience planning protects not only the Galápagos’ unique and fragile ecosystems but also the health, livelihoods, and wellbeing of the communities that depend on them.

Ultimately, the central question is no longer whether El Niño events will continue to recur with increasing intensity in a warming climate. Rather, it is whether the governance, financing, and public health systems built between events are capable of meeting the challenges those events inevitably bring. The answer will shape not only the future resilience of Ecuador but also the protection of Galápagos, one of the world’s most extraordinary ‘laboratories of evolution’ (Lewis 2026)—an archipelago whose unique biodiversity inspired the insights Charles Darwin (1839) gained during his visit to the islands in 1835 and later developed into his theory of evolution by natural selection in his landmark work, On the Origin of Species (1859).

Today, the Galápagos remains a global public good entrusted to Ecuador, with the support of the international community, for the benefit of present and future generations. Protecting this UNESCO World Heritage Site will depend not on how effectively Ecuador and the international community respond after disaster strikes, but on how wisely they anticipate risk, prepare in advance, and invest in resilience before El Niño and other climate-related shocks unfold.

Source: Card produced and distributed by Friends of the Charles Darwin Foundation, 2026.

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Disclaimer: The views expressed in this essay are those of the author in his personal capacity and do not represent the official position of the Charles Darwin Foundation, the World Bank Group, or any other institution with which the author is or has been affiliated. References were verified as of July 31, 2026; readers are encouraged to consult primary sources directly.

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— Charles Darwin, The Voyage of the Beagle (1839), p. 359

“It is interesting to contemplate an entangled bank, clothed with many plants of many kinds, with birds singing on the bushes, with various insects flitting about, and with worms crawling through the damp earth, and to reflect that these elaborately constructed forms, so different from each other, and dependent upon each other in so complex a manner, have all been produced by laws acting around us. These laws, taken in the largest sense, being Growth with Reproduction; Inheritance which is almost implied by reproduction; Variability from the indirect and direct action of the external conditions of life, and from use and disuse; a Ratio of Increase so high as to lead to a Struggle for Life; and as a consequence to Natural Selection; entailing Divergence of Character and the Extinction of less-improved forms.”

— Charles Darwin, On the Origin of Species (1859), p. 490

“In a world marked by growing environmental pressures and increasing uncertainty, the role of science in guiding effective conservation has never been more critical.”

— Yolanda Kakabadse, Charles Darwin Foundation 2025 Impact Report, President of the Board of Directors, Charles Darwin Foundation for the Galápagos Islands, p. 5.

Introduction

Ahead of my participation in this year’s General Assembly of the Charles Darwin Foundation (CDF) for the Galápagos Islands — where I have the privilege of serving as an elected governing member — I spent time reviewing the Foundation’s 2025 Impact Report (CDF 2026a), along with other institutional documentation and financial reports prepared for the Assembly.

This year’s General Assembly takes place on May 31-June 2, 2026, at the Charles Darwin Research Station in Puerto Ayora, Santa Cruz Island, Galápagos, Ecuador.

Source: Photo by author, Charles Darwin Foundation/Charles Darwin Research Station in Puerto Ayora, Galapagos, Ecuador, June 2, 2026.

The Impact Report was presented and discussed during the Assembly's opening sessions and released publicly thereafter. This post summarizes key findings from my reading of the Impact Report, covering both work activities and results achieved over the past twelve months.

Source: Photo by Mara Speece, Charles Darwin Foundation General Assembly, Puerto Ayora, Galápagos Islands, Ecuador, June 1, 2026.

A Year of Resilience and Achievement

Overall, what emerges from the review of the Impact Report is more than an institutional snapshot. It is a reflection on the Foundation’s evolving role in supporting science-based conservation in the Galápagos Islands, including its work on ecosystem restoration, marine protection, biodiversity research, and environmental education; its provision of scientific information and technical advice; the partnerships it sustains; and the long-term stewardship challenges facing one of the world’s most extraordinary natural laboratories.

CDF’s sustained work shows that, in a world increasingly defined by ecological instability, geopolitical uncertainty, climate pressure, erosion of international funding, and fragmented political attention, scientific research and knowledge generation remain essential for informing policy development and the design and implementation of programs that address existing and emerging conservation challenges.

The Impact Report covers a year that tested the institution in multiple ways — from the dismantling of bilateral funding streams that affected key marine programs, to evolving operational and governance challenges within the Galápagos context itself. Yet the broader story is one of resilience, institutional maturity, scientific credibility, and growing strategic relevance. Across land, ocean, and community programs, the Foundation continued not only generating knowledge, but increasingly translating that knowledge into conservation action, ecosystem restoration, policy guidance, environmental governance, education programs, and international scientific collaboration (CDF 2026a).

Equally important, as highlighted in the Impact Report, the Foundation's work does not occur in isolation. For more than 60 years, it has operated in close collaboration with and in support of the State of Ecuador and the Galápagos National Park Directorate—its most important institutional partner—contributing evidence and long-term monitoring as critical inputs for conservation decisions and actions across the archipelago.

The Impact Report also underscores the critical role played by strategic institutional partners, the Galápagos Life Fund and other philanthropic initiatives, corporate supporters, foundations, and more than one thousand individual donors whose contributions in 2025 helped sustain and expand core programs amid an increasingly uncertain global funding environment (CDF 2026a; Marquez 2025).

Source: Photo taken by the author, León Dormido (Sleeping Lion), off San Cristóbal Island, Galápagos Islands. Ecuador, November 2019.

Source: Photo taken by the author, sunset in Puerto Ayora, Santa Cruz, Galápagos Islands. Ecuador, June 1, 2026.

Science as Infrastructure for Conservation

One of the clearest messages emerging from the Impact Report is that science in Galápagos can no longer be understood merely as observation or documentation. Increasingly, it functions as operational infrastructure for conservation decision-making.

In 2025, the CDF strengthened its role as the leading scientific institution supporting conservation in Galápagos by advancing from knowledge generation to a more integrated, systems-based understanding of how ecosystems function and respond to change.

CDF researchers work across more than 80 study areas spanning the Galápagos Marine Reserve and the terrestrial protected areas of the archipelago. Their work linked biodiversity, ecosystem dynamics, climate pressures, fisheries management, invasive species control, a one health approach to safeguard recovery, and community education and participation into a more integrated understanding of ecological resilience (CDF 2026a).

This shift matters as the future of conservation, not only in Galápagos but globally, depends less on isolated species interventions and more on understanding systems: how oceans, forests, invasive species, climate variability, governance, tourism, fisheries, and human communities interact over time. The Impact Report shows that CDF is increasingly positioning itself at that intersection between science and applied knowledge.

That role is also visible internationally. During 2025, the Foundation contributed to the first Ocean Account for Ecuador’s insular waters presented at the United Nations Ocean Conference, strengthened regional collaboration through the Deep Ocean Alliance within the Eastern Tropical Pacific region, and advanced science-based coral conservation planning and fisheries management (CDF 2026a).

Source: Photo by Joshua Vela, Charles Darwin Foundation. Penguins and marine iguanas at Punta Vicente Roca, a remote marine site located on the northwestern tip of Isabela Island, Galapagos, Ecuador.

A Landmark Investment in Scientific Capacity

Perhaps a visible achievement documented in the Impact Report is the completion of the Wijnand Pon Natural History Collections Building, a major investment in the scientific infrastructure of Galápagos.

Source: Photo by author. Wijnand Pon Natural History Collections Building, Charles Darwin Foundation and the Charles Darwin Research Station in Puerto Ayora, Galapagos, Ecuador. June 3, 2026.

The building is named in honor of its main benefactor, Wijnand Pon, a Dutch entrepreneur, investor, and philanthropist, and made possible through the support of the COmON Foundation, a Netherlands-based philanthropic organization dedicated to supporting large-scale ecosystem restoration, biodiversity conservation, and landscape regeneration initiatives around the world.

Housing more than 137,000 specimens representing over 7,500 species—endemic, native, and introduced—from across the archipelago, the CDF collections are among the world’s most important repositories of island biodiversity safeguarded on behalf of the State of Ecuador. The new facility does more than protect specimens. It secures institutional memory, strengthens Ecuador’s long-term scientific capacity, and creates a platform for future generations of research (CDF 2026a).

Source: Photo taken by the author, visit to Wijnand Pon Natural History Collections Building, Charles Darwin Foundation Research Station, Puerto Ayora, Santa Cruz, Galápagos Islands. Ecuador, June 1, 2026.

Importantly, the project was completed in a remote and logistically difficult environment on time, on budget, and relying heavily on local expertise and craftsmanship. That operational accomplishment deserves to be highlighted and recognized as a good institutional practice.

What I found especially important is the Impact Report’s emphasis on opening science to the broader community. Through external observation corridors and public-facing collection spaces, the building is expected to transform what could have remained a closed scientific archive into a living educational platform connecting visitors and residents alike with the extraordinary biodiversity of the islands.

At a deeper level, the new collections building symbolizes something larger: the understanding that scientific institutions themselves are part of the conservation infrastructure required to protect global public goods over the long term.

Source: Photo by Alma Suarez, CDF. The Bryde’s whale skeleton hanging over the visitor passageway at the new Wijnand Pon Natural History Collections Building, located within the campus of the Charles Darwin Foundation and Charles Darwin Research Station in Puerto Ayora, Galapagos, Ecuador.

Floreana Island: Restoration at Ecosystem Scale

As I wrote last year following the CDF's 54th General Assembly, the Foundation's 2024 Impact Report documented what sustained, science-driven conservation actually achieves in the Galápagos (Marquez 2025).

The 2025 Report, in turn, reflects on a major institutional milestone: the formal designation of the CDF as a co-executor of the Floreana Ecological Restoration Project, part of a broader effort, decades in the making, with an estimated cost of about $15 million. The Project is led by the Galápagos National Park Directorate and the Galápagos Biosecurity Agency, and co-executed by Island Conservation, Fundación Jocotoco, and the CDF, with support from numerous partners and donors. Within this collaboration, the CDF plays a key scientific role, contributing research, monitoring, and technical expertise to guide one of the most ambitious ecosystem-restoration initiatives ever attempted in the Galápagos.

Historically, Floreana was among the first Galápagos islands inhabited by humans, serving as a stopover for pirates in the late seventeenth century and, from the late eighteenth century into the nineteenth century, for British and American whalers (Stewart 2007). It became the first island colonized by Ecuador in 1832 and was home to some of the archipelago’s earliest permanent settlers, who introduced livestock — cattle, goats, and donkeys — along with cats and rats. These introductions profoundly altered the island’s ecosystems, leaving Floreana as one of the most environmentally degraded islands in the archipelago.

Following the eradication of invasive goats in 2007, conservation efforts turned to restoring native wildlife, including the critically endangered Floreana mockingbird — extinct on the main island but surviving on two nearby islets, and now the focus of ambitious reintroduction and ecosystem-restoration programs (Galápagos Conservancy 2026; Island Conservation 2026).

Source: Photo by Carlos Espinosa, Charles Darwin Foundation (CDF). Floreana Mockingbird (Mimus trifasciatus) on Champion Islet, Galapagos, Ecuador.

Now well into its second decade, the Floreana Ecological Restoration Project ranks among the largest island-restoration efforts underway anywhere in the world. What sets it apart is its reach beyond single-species protection toward full ecosystem recovery, combining invasive-species control, habitat restoration, scientific monitoring, species reintroductions, and community engagement within a single integrated framework.

As noted in a Science article (Quaglia 2026), the effort has already produced encouraging results. After being considered extinct since the mid-nineteenth century, giant tortoises of Floreana lineage (Chelonoidis niger niger) have been bred through a long-term program built on genetic descendants discovered elsewhere in the archipelago. In 2024, nineteen tortoises were transferred to a protected area on Floreana as a precursor to their release into the wild.

In February 2026, giant tortoises returned to the landscapes of Floreana: 158 juveniles of Floreana lineage were released into their ancestral habitat (CDF 2026b; Island Conservation 2026). Their return opens a new phase of rewilding on Floreana — and signals, for the island's roughly 160 residents, that a recovery long thought impossible is now underway.

Source: Photo by Carlos Espinosa, Charles Darwin Foundation (CDF). Galapagos Giant Tortoise Species, Cerro Fatal on Santa Cruz Island, Galapagos, Ecuador.

At the same time, scientists have documented the recovery of native wildlife across Floreana, including beetles, butterflies, snails, geckos, and lava lizards. Particularly noteworthy was the rediscovery of the Galápagos Rail (Laterallus spilonota), locally known as the Pachay — a rare, secretive ground bird not recorded on Floreana since Charles Darwin documented it in 1835, nearly 190 years earlier (CDFb).

Researchers also reported improved breeding success among several endangered landbird species, while long-term monitoring has begun to track the island’s ecological recovery and the land–sea connections through which restoration on land may, over time, benefit adjacent marine ecosystems (CDF 2026a).

These are early but important signs that ecological recovery is possible when restoration is sustained over time and guided by rigorous science.

The Project also reflects a broader evolution in conservation thinking. Increasingly, success is measured not only by the protection of individual species, but by the recovery of ecological processes, food webs, and the resilience of entire systems.

Landbirds, Invasive Species, and the Long Horizon of Conservation

Few sections of the Impact Report better illustrate the patience that conservation science demands than the work on the Avian Vampire Fly (Philornis downsi), one of the most destructive invasive species threatening Galápagos landbirds. For more than a decade, CDF scientists and partners have pursued biological control that is both scientifically robust and safe for native species. In 2025, after years of laboratory and field work, researchers submitted a comprehensive dossier on a candidate parasitoid wasp for regulatory review (2026a).

A One Health approach is being followed as part of the work of the CDF to treat species recovery as a matter of preventing hidden threats, not just boosting numbers. Because Galápagos landbirds share habitat with domestic poultry and human settlements, disease surveillance is essential to catch spillovers that could quickly undo conservation gains. In 2025, CDF researchers screened 421 blood samples from 14 landbird species across five islands for Mycoplasma spp., adenovirus, and herpesvirus, identifying seven novel adenoviruses and three novel herpesviruses — expanding the archipelago’s disease baseline and sharpening insight into emerging risks (CDF 2026a).

The above reflects how conservation often works in practice: not through dramatic headlines, but through years of incremental research, monitoring, experimentation, and science-based regulation.

Additionally, the Impact Report documents encouraging progress for the Little Vermilion Flycatcher, whose population in Santa Cruz Island is showing gradual signs of recovery as blackberry removal restores foraging habitat and the treatment of nests against parasitic fly larvae lifts fledgling survival. For the critically endangered Mangrove Finch — fewer than 100 individuals confined to two patches of mangrove forest on Isabela Island— the work remains a holding effort: intensive nest protection and monitoring aimed at stabilizing a population that is still acutely vulnerable (CDF 2025; CDF 2026).

There is a broader lesson that comes out across the different sections of the Impact Report: ecosystem restoration is rarely linear. Success in one area can create unexpected ecological dynamics elsewhere. Recovery requires adaptive management, long-term financing, and institutional continuity — precisely the capacities that institutions like CDF help to sustain.

Source: Photo taken by the author, November 2019. Blue-footed Booby (Sula nebouxii), Galapagos, Ecuador.

Source: Photo by Carlos Espinosa, Charles Darwin Foundation (CDF). Pájaro Brujo — Darwin's flycatcher (Pyrocephalus nanus). This Galápagos bird is protected inside the Pájaro Brujo Preserve on Santa Cruz Island.

Restoring the Endangered Giant Scalesia Forests

Scalesia forests are the only tree-dominated ecosystem endemic to the Galápagos archipelago, supporting communities of plants, insects, and birds found nowhere else on Earth. Today, less than 1% of their original range survives, and what remains is fragmented and degraded by invasive plants — particularly blackberry (Rubus niveus) — across several islands.

In 2025, the Galápagos National Park Directorate, with the CDF and other partners, accelerated restoration on Isabela and Santa Cruz, pairing advanced mapping and invasive-plant control with targeted reforestation. The results have been quite significant: the work done has successfully controlled invasive species plants and planted thousands of Scalesia pedunculata and S. cordata on Santa Cruz and Isabela islands (Jäger 2026). The challenge now is to scale up this effort.

Source: Photo by author, June 2023. Visit to Scalesia forest restoration in Santa Cruz, Galapagos, Ecuador.

Ocean Science in an Era of Climate Change

The marine section of the Impact Report underscores that the future of Galápagos conservation is inseparable from the broader Eastern Tropical Pacific. New international partnerships are strengthening protection for endangered Scalloped Hammerhead Shark populations across this interconnected marine corridor, reflecting the growing recognition that safeguarding migratory species requires coordinated action that extends well beyond the boundaries of any single protected area or nation.

The rediscovery of the coral Rhizopsammia wellingtoni, thought extinct after the 1997–98 El Niño event, offers a powerful reminder of both ecological fragility and resilience. Similarly, research tracking hammerhead shark migration, deep-ocean ecosystems, mangrove ecology, seabird health, and green turtle responses to climate variability highlights the importance of sustained monitoring in an era of accelerating environmental change, and to deal with the impacts of El Niño events, which alter temperature and rainfall patterns across regions and typically exert a warming effect on the global climate (CDF 2026a; WMO 2026).

Source: Photoby Joshua Vela. Charles Darwin Foundation. Vertical coral gardens at Guy Fawkes Islets, a small group of volcanic islets located northwest of Santa Cruz Island within the Galápagos Marine Reserve, Ecuador.

Source: Photo by Carlos Espinosa, Charles Darwin Foundation (CDF). Galápagos penguin (Spheniscus mendiculus) at Bartolome, Galapagos, Ecuador.

These findings matter not only for Galápagos. They contribute to a growing body of knowledge about how marine ecosystems respond to warming oceans, biodiversity loss, ocean acidification, and mounting human pressures across the tropical Pacific.

In many ways, the Galápagos Marine Reserve has become both a sanctuary and a living laboratory — a place where the future challenges facing marine biodiversity worldwide can already be observed in real time.

Conservation Ultimately Depends on People

The Impact Report points out that conservation and human development are deeply interconnected. The work of the CDF places strong emphasis on sustainable fisheries, local livelihoods, education, youth engagement and the preparation of the next generation of leaders, recognizing that enduring conservation outcomes depend not only on protecting species and ecosystems but also on fostering informed, resilient, and engaged communities.

That perspective is essential. Protected areas do not endure simply because boundaries are drawn on maps. They endure when institutions remain credible, when science informs decision-making, when communities recognize tangible benefits from conservation, and when each generation develops a sense of responsibility for the natural heritage it inherits.

Viewed through that lens, the Impact Report offers a lesson that extends far beyond the Galápagos. Effective conservation is not only about safeguarding species and habitats; it is equally about building and sustaining the scientific, institutional, and social foundations that convert conservation science into shared learning, and knowledge into lasting conservation impact (Kerblat-Bonnet 2026).

Final Reflections

Reading the CDF’s 2025 Impact Report and related Assembly documentation, I was reminded that the Galápagos Islands continue to occupy a unique place in the global imagination — not only because of Darwin or evolutionary theory, but because they remain one of the few places on the planet where humanity still has an opportunity to demonstrate that large-scale ecological restoration is possible.

Realizing the benefits of this opportunity, however, requires institutions capable of sustaining scientific excellence across generations, as exemplified by the CDF’s work in support of the Galápagos National Park Directorate’s mission. It also requires partnerships that transcend political cycles, communities willing to balance conservation and development, and donors who recognize that protecting biodiversity is not an act of charity but an investment in global public goods.

As the Impact Report documents, the CDF continues to play that role. At a time when biodiversity loss, climate change, and ecosystem degradation intensify worldwide, the Foundation’s work serves not only the Galápagos Islands but also the broader international community. The lessons generated, the science produced, and the conservation capacity strengthened in Galápagos contribute to a larger effort to understand, protect, and sustain the natural systems upon which all societies ultimately depend.

A Call to All to Get Engaged and Support the CDF

The Galápagos Islands are not only Ecuador’s natural heritage; they are part of the world’s. Their future will not be secured by good intentions alone, but by the capacity to translate knowledge into effective stewardship — a capacity that rests on the organizations, expertise, and partnerships that sustain conservation over time.

Sustaining that work requires resources. At a time when research and environmental organizations worldwide face mounting financial pressure, expanded resource mobilization and predictable, sustained funding streams are critical (Marquez 2026). The work of the CDF depends on donors, partners, and supporters who recognize that protecting biodiversity is not merely an environmental cause but an investment in a global public good whose benefits reach all of us.

Those interested in learning more about the work of the Charles Darwin Foundation, supporting its mission, or contributing to ongoing conservation and scientific efforts can do so through the Foundation’s official website:

https://www.darwinfoundation.org

All donations via the Charles Darwin Foundation website are tax-deductible in the United States and securely processed by its charitable partner, Friends of the Charles Darwin Foundation, a 501(c)(3) non-profit organization (EIN: 86-2660112).

References

Charles Darwin Foundation (CDF). 2025. Historic Breeding Season for Galápagos Landbirds. May 28, 2025. https://www.darwinfoundation.org/en/news/all-news-stories/historic-breeding-season-for-galapagos-landbirds/.

Charles Darwin Foundation (CDF). 2026a. 2025 Impact Report. Puerto Ayora, Galápagos Islands: Charles Darwin Foundation. Available at: Impact Report 2025 - Charles Darwin Foundation

Charles Darwin Foundation (CDF). 2026b. 158 Endangered Tortoises Released onto Floreana Island, Galápagos for First Time in over 180 Years. February 20, 2026.

Darwin, Charles. 1839. Journal of Researches into the Geology and Natural History of the Various Countries Visited by H.M.S. Beagle under the Command of Captain FitzRoy, R.N. from 1832 to 1836. London: Henry Colburn. Available at: https://www.gutenberg.org/ebooks/944

Darwin, Charles. 1859. On the Origin of Species by Means of Natural Selection. London: John Murray. Available at: https://archive.org/details/darwin-online_1859_Origin_F373

Galápagos Conservancy. 2026. A Homecoming for Floreana. February 2026. https://www.galapagos.org/newsroom/a-homecoming-for-floreana/.

Island Conservation. 2026. Endangered Tortoises Released onto Floreana Island, Galápagos. February 20, 2026. https://www.islandconservation.org/floreana-tortoise-release/.

Jäger, Heinke. 2026. Of Frogs, Plants, and Invertebrates. Presentation delivered at the Charles Darwin Foundation General Assembly, Puerto Ayora, Santa Cruz, Galápagos Islands, Ecuador, June 2, 2026.

Kerblat-Bonnet, Pablo. 2026. Building the Local-Global Bridge for Conservation: Education at the CDF. Presentation delivered at the Charles Darwin Foundation General Assembly, Puerto Ayora, Santa Cruz, Galápagos Islands, Ecuador, June 2, 2026.

Marquez, Patricio V. 2025. Science in Action at the Equator: Highlights from the Charles Darwin Foundation's 2024 Conservation Efforts in the Galápagos Islands. Substack, June 16, 2025.

Marquez, Patricio V. 2026. Tourist Taxes as Public Goods Financing: A Global Survey with Lessons for Ecuador's Galápagos Islands. Substack, May 12, 2026.

Stewart, Paul D. 2007. Galápagos: The Islands That Changed the World. New Haven, CT: Yale University Press. Available at: https://archive.org/details/galapagos00paul

Quaglia, Sofia. 2026. A difficult rebirth. Science: Vol. 391, Issue 6782. Available at: https://www.science.org/content/article/galapagos-island-restoration-project-on-steroids

World Meteorological Organization (WMO). 2026. "WMO: Likelihood Increases of El Niño." April 24, 2026. https://wmo.int/media/news/wmo-likelihood-increases-of-el-nino.

Source: Photo by author, Exhibition Hall, Charles Darwin Foundation and Charles Darwin Research Station, Puerto Ayora, Galapagos, Ecuador. June 2, 2026.

Understanding Disability

Disability is an umbrella term for impairments, activity limitations and participation restrictions. Impairments refer to specific decrements in body functions and structures--often symptoms or signs of health conditions, including visual impairment (far-sightedness and near-sightedness); hearing impairment (hearing loss affecting one or both of ears); intellectual disability (significantly reduced ability to understand new or complex information and to learn and apply new skills); and physical disability (physical impairment or reduced mobility). Activity limitations refer to difficulties in executing activities – for example, walking or eating. Participation restrictions refer to problems with involvement in any area of life – for example, facing discrimination in employment or transportation.

The International Classification of Functioning, Disability and Health (ICF) advanced the understanding and measurement of disability by emphasizing the environmental factors that create disability. Disability arises from the interaction of health conditions (diseases, injuries, and disorders) with contextual factors, both environmental (e.g., products and technology; the natural and built environment; support and relationships; attitudes; and services, systems, and policies) and personal (e.g., a person’s capacities to perform actions and the actual performance of those actions in real life).

The ICF covers all human functioning and treats disability as a continuum rather than categorizing people with disabilities as a separate group: disability is a matter of more or less, not yes or no.

Global Burden of Disabilities

According to World Health Organization (WHO) estimates, there are more than 1 billion disabled people in the world (about 15 percent of the world’s population), 20 percent of whom live with great functional difficulties in their day-to-day lives, and some experiencing multiple disabilities. Recent UNICEF figures indicate that there are nearly 240 million children with disabilities around the world. The number of people with disabilities is increasing because reductions in mortality mean that people are living longer and because an epidemiological shift in disease burden is occurring, from communicable to non-communicable diseases in a globally aging population.

Mental Disorders are an “Invisible” Disability

The concept of invisible disability refers to forms of disability that are not apparent but that impact the quality of life. Mental and substance use disorders are a widespread but often “invisible” disabilities. These conditions affect mood, cognition, motivation, and all aspects of life, including employment, relationships, housing, and personal care, and they represent a growing burden of disease worldwide.

As shown in Figure 1 below, the global burden of disease attributable to mental disorders (primarily through years lived with disability and led by depressive and alcohol use disorders) has increased steadily since the 1990s. In 2016, mental ill-health affected more than 1 billion people globally, and mental health conditions caused 7 percent of all global burden of disease as measured in disability-adjusted life years (DALYs) – closer to 10 percent if substance use disorders are included – and 19 percent of all years lived with disability.

Depression was associated with the most DALYs for both sexes, with higher rates in women, whereas other disorders such as substance abuse had higher rates in men. Suicide, which is frequently caused by mental disorders, exacts an enormous toll on society. Almost one million people die each year due to suicide, which is the fourth leading cause of death among 15–19-year-olds. In some countries, suicide has overtaken complications from pregnancy and childbirth as the leading cause of death among women aged 15 to 49. For every suicide there are many more people who attempt suicide.

Dementia is another major cause of disability and dependency among older people globally. Currently more than 55 million people are estimated to live with dementia worldwide, and there are nearly 10 million new cases every year. Alzheimer’s disease is the most common form of dementia and may contribute to 60-70 percent of cases.

Mental disorders are a major risk factor for developing alcohol dependency. Globally, 107 million people or 1.8 percent of the total population are estimated to have an alcohol use disorder. The results of a study on mental health and alcohol use in developing countries showed that the consumption of alcohol is heavily gendered and is characterized by a high proportion of hazardous drinking among men. Hazardous drinkers not only consume large amounts of alcohol, but also do so in high-risk patterns, such as drinking alone and binging, which are associated with depressive and anxiety disorders as well as suicide and domestic violence. In terms of drug use, it is estimated that globally around 71 million people had a drug use disorder in 2017. Most of these have an addiction to opioids, it accounts for around 55 percent of drug use disorders globally.

Data from WHO show that around half of all mental disorders start by age 14; more than 1 in 5 people living in settings affected by conflict have a mental illness; and people with severe mental disorders die 10-20 years earlier than the general population. Sadly, due to widespread global inaction, there is still limited or no access to integrated mental health services in most countries, which leaves mental health services under-resourced and creates a major problem for accessing appropriate care. Stigma and discrimination only compound the problem.

Figure 1: The rising burden of mental and substance use disorders, Alzheimer’s disease and other forms of dementia, and suicide (self-harm) by socio-demographic index (SDI) groups

Source: Adopted from: Patel, V. et al. (2018), “The Lancet Commission on global mental health and sustainable development”, Lancet (London, England), Vol. 392/10157, pp. 1553-1598, http://dx.doi.org/10.1016/S0140-6736(18)31612-X. Data are Global Burden of Disease health data. SDI is a summary measure of a geography’s sociodemographic development and is based on average income per person, educational attainment, and total fertility rate. SDI=sociodemographic index. DALY=disability-adjusted life-year.

The Economic Impact of Mental Disorders

A growing body of evidence shows that the social and economic losses related to unattended mental conditions, including substance use disorders, are staggering.

The economic costs of mental ill health begin before individuals enter the workforce, as mental health problems typically have their onset in childhood or adolescence, accounting for the most significant disease burden amongst children and young people. However, often there is not appropriate care and treatment at this life stage, or it does not occur right away. This can have a lasting impact, as children and young people with mental ill health are more likely to stop full-time education early and have poorer educational outcomes.

If countries want to improve their relative ranking in the World Bank Group’s Human Capital Index, they must start investing seriously in integrated programs to promote mental well-being and prevent and treat mental ill health in communities, maternal and child health and nutrition programs, in schools, in their health systems, in prisons, and in the workplace. Investing in mental health promotion is also value-for-money, as it is much more effective to take action while people are still in school or the workplace than wait until they have dropped out of schools or from the labor market or fall into a revolving door of homelessness and incarceration.

In the world’s most advanced economies – the 36 OECD countries – mental ill health affects an estimated 20 percent of the working-age population at any time, and its direct and indirect economic costs are estimated to account for more than 4.2 percent of GDP in OECD countries. In the wealthy OECD countries, which spend on average 9 percent of GDP on health care, the high economic cost associated with mental conditions is largely driven not by mental health care expenditure, but by lost productivity in the working-age population (Figure 2). Indeed, people suffering from mental ill health are less productive at work, are more likely to be out sick from work, and when they are out sick are more likely to be absent for a longer period. Around 30 to 40 percent of all sickness and disability caseloads in OECD countries are related to mental health problems, according to a 2015 OECD report.

Figure 2: Measures of productivity loss: Sickness absence incidence and duration and proportion of workers accomplishing less than they would like because of a health problem, 2010

Source: OECD (2012), Sick on the Job? Myths and Realities about Mental Health and Work.

While most people with a mental illness do work, people living with mild-to-moderate mental disorders, such as anxiety or depression, are twice as likely to become unemployed. Premature mortality is another tragic driver of lost human potential and productivity; in the typical OECD country, people with bipolar disorder or schizophrenia, for example, have a mortality rate 4 to 6 times higher than that of the general population.

Takeaways

This year’s observance of the International Day of Persons with Disabilities offers a good opportunity to shine a light on some of the myths surrounding mental and substance use disorders, particularly at the workplace where we tend to spend most of our waking hours.

As discussed above, we need to be clear and accept the reality that ill mental health is not limited to persons with severe mental disorders confined to psychiatric hospitals: ill mental health is a widespread but often “invisible” phenomenon. Many of us or our parents, partners, sons, and daughters have at times felt a sense of loss or detachment from families, friends, and regular routines. We also have experienced nervousness and anxiety about changes in our personal and professional lives, as well as real or imagined fears and worries that have distracted, confused, and agitated us. While these episodes tend to be transitory for most of us, some of these conditions force us to take frequent breaks from our work, or we need time off or a leave of absence because we are stressed and depressed, or because the medication that we are taking to alleviate a disorder makes it difficult to get up early in the morning or concentrate at work. And on occasion, because of these disorders, some fall into alcoholism and drug use, further aggravating “fear attacks” or sense of alienation from loved ones and daily routines.

The COVID-19 pandemic has also negatively impacted the mental wellbeing of people. Specifically, social restrictions, unemployment, financial instability, and school closures are among the several COVID-19-related factors that have contributed to worsened mental health outcomes. The pandemic has highlighted the importance of integrated mental and physical health care, as all signs point to both possible lasting psychological impacts for COVID-19 patients, especially those who experienced long hospitalizations or those living with ‘long COVID’, as well as increased risks of contracting COVID-19 and experiencing complications for individuals living with severe mental illnesses.

Alcohol misuse, already a public health concern in many countries, has the potential to further complicate the COVID-19 pandemic in multiple ways. Excessive alcohol consumption can influence COVID-19 susceptibility and severity, as it both activates the immune system, causing inflammation, and interferes with the body’s immune response to viral and bacterial infections. In a vicious cycle, the broad effects of the pandemic are also likely to lead to excessive alcohol consumption. As documented in a previous post, people are more likely to drink more as a coping mechanism “during times of uncertainty and duress,” particularly in the face of rising unemployment and loss of income.

To advance the disability-inclusive development agenda, we need to pay attention to common mental disorders of children and adolescents, workers, the unemployed, and their families, and not only on the provision of services for people with a severe mental disorder. Since mental disorders have multifaceted underlying factors, the path to improvement requires an integrated approach, moving away from siloed-thinking and developing strong coordination and integration of policies and services across all sectors.

A sustained commitment and effort on this front, that should not only be directed towards countries striving to improve population health, but also within organizations, including the World Bank Group, seeking to promote the health of their staff, will help honor our common responsibility to become more compassionate and understanding of the daily challenges faced by people with disabilities, and to promote the rights and well-being of persons with disabilities in our communities.

Christiaan Barnard, South African cardiac surgeon who performed the world’s first human-to-human heart transplant operation on 3 December 1967

Sudden and unexpected, often appearing without previous symptoms or warnings, are terms that appropriately describe the utter shock that some of us feel when we learn after a relatively non-invasive angiogram test that we have a severe artery blockage that put us at high risk of suffering a deadly heart attack or stroke if no immediate action is taken. Similar reactions occur when a family member experiences a brain hemorrhage of an unknown cause, or friends or respected public figures collapse from a massive heart attack, ending their lives.

And, according to research findings, the irony involving these somber, often tragic events, that seem to come “out-of-nowhere”, is that they tend to occur more often during the holiday season, when risks are heightened due to extra disruptions to routines, diet, and sleep.

While such cardiac events are difficult to accept as a normal occurrence in the cycle of life, a new report in the Journal of the American College of Cardiology, based on the Institute of Health Metrics and Evaluation (IHME)’s Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study that has tracked trends in death and disability since 1990, shows that cardiovascular disease (CVD) continues to be the leading cause of death across the world.

A summary of the main findings of this report, complemented with information from other sources, is presented below to clearly illustrate the magnitude of this health burden that has a major impact on the quality of people’s lives, the health care system, and society as a whole.

Cardiovascular Deaths by Cause

· Overall, noncommunicable diseases (NCDs) accounted in 2019 for 7 of the world’s top 10 causes of death, according to the World Health Organization (WHO)’s 2019 Global Health Estimates. This is an increase from 4 of the 10 leading causes in 2000.

· An estimated 17.9 million people died from cardiovascular disease in 2019, representing 32 percent of all global deaths. Of these deaths, 85 percent were due to heart attack and stroke.

· Heart disease has remained the leading cause of death at the global level for the last 20 years. However, it is now killing more people than ever before. The number of deaths from heart disease increased by more than 2 million since 2000, to nearly 9 million in 2019. Heart disease now represents 16 percent of total deaths from all causes.

· The data from WHO show that about three-quarters of CVD-related deaths happen in low- and middle-income countries. This is mainly because people in these countries usually do not have the same access to primary health care programs as in the developed world. This makes the early detection and treatment of people with risk factors for CVD all the more challenging. Hence, due to the late detection, many people die at a young age from CVD, during their most productive years, further eroding the human capital of countries.

Table 1 presents the global ranking of CVD deaths by cause as of 2021. The leading conditions are:

· Ischemic heart disease, or heart disease that reduces the flow of blood and oxygen to the heart, is the leading cause of cardiovascular death, accounting for 9.44 million deaths in 2021 and 185 million Disability-Adjusted Life Years (DALYs; the sum of years of life lost due to premature mortality and years lived with disability).

· Ischemic stroke, intracerebral hemorrhage, hypertensive heart disease, rheumatic heart disease, atrial fibrillation and flutter, subarachnoid hemorrhage, other cardiomyopathy, other cardiovascular diseases, and aortic aneurysm follow as the second to the tenth leading causes of cardiovascular death.

· It is estimated that over 80 percent of cardiovascular disease is preventable by addressing behavioral risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, and harmful use of alcohol.

Source: Adapted from Vaduganathan M, Mensah G, Turco J, et al. The Global Burden of Cardiovascular Diseases and Risk. J Am Coll Cardiol. 2022 Dec, 80 (25) 2361–2371.

Leading Causes of CVD

As highlighted in the report, the leading modifiable cardiovascular risk factors globally are:

High systolic blood pressure remains the leading modifiable risk factor for premature cardiovascular deaths, accounting for 10.8 million CVD deaths and 11.3 million deaths overall in 2021. The all-cause DALYs due to high blood pressure were 2,770 per 100,000 people. Controlling blood pressure with a healthy lifestyle might prevent, delay, or reduce the need for medication. It includes losing extra pounds and watching waistlines, exercising regularly, eating a diet rich in whole grains, fruits, vegetables and low-fat dairy products and low in saturated fat and cholesterol, reducing salt intake, limiting alcohol intake, quitting smoking, improving sleep quality, reducing stress, monitoring blood pressure at home, and getting regular checkups.

Dietary risks accounted for 6.58 million CVD deaths and 8 million deaths overall in 2021. Dietary risks include food types that are under-consumed (fruits, vegetables, legumes, whole grains, nuts and seeds, milk, fiber, calcium, omega-3 fatty acids, and polyunsaturated fatty acids) and over-consumed globally (red and processed meats, sugar-sweetened beverages, trans-fatty acids, and sodium). All-cause DALYs due to dietary risks were 2,340 per 100,000 people.

Air pollution in the form of ambient particulate matter with an aerodynamic diameter smaller than 2.5mm (PM2.5) and household air pollution (HAP) from cooking fuels represents the leading environmental risk factor for premature CVD and mortality. In 2021, 4.75 million cardiovascular deaths and 8.54 million deaths overall were attributable to air pollution. In 2021, the all-cause DALYs due to air pollution were 2,990 per 100,000.

Elevated low-density lipoprotein cholesterol (LDL-C) is another leading modifiable risk factor and one of the most closely linked markers of atherosclerotic CVD. In 2021, 3.81 million cardiovascular deaths and 3.81 million deaths overall were attributed to elevated LDL-C levels. In 2021, the all-cause DALYs due to high LDL-C were 1,090 per 100,000 people. High cholesterol and triglycerides can be prevented by reducing risk factors that are under the control of people. As discussed above, healthy lifestyle decisions, such as choosing healthier foods with less saturated fat and quitting smoking, help. Medicines can also be prescribed to help lower high blood cholesterol. Statins are the most common medicine used to treat high blood cholesterol. Studies have shown that statins lower the risk of heart attack and stroke in people with high LDL-C.

Tobacco, including smoking and secondhand smoke, is the fifth leading specific cause of cardiovascular death. In 2021, 3.01 million cardiovascular deaths and 7.61 million deaths overall were attributable to tobacco use. In 2021, the all-cause DALYs due to tobacco were 2,460 per 100,000. Given the increased risk of CVD for smokers, cigarette smoking is one of the leading causes of preventable death that deserves priority action, particularly to prevent children and adolescents from getting hooked on tobacco early in their lives as a result of the aggressive promotion and marketing of cigarettes, e-cigarettes, and vape products. Accumulated scientific evidence shows that nicotine, a chemical in tobacco, is highly addictive, activates biological pathways that increase risk for disease, and adversely affects maternal and fetal health during pregnancy. Smoking or chewing tobacco can also immediately raise blood pressure, albeit temporarily, as the chemicals in tobacco can damage the lining of artery walls, causing arteries to narrow, increasing blood pressure. As shown in another global study, tobacco use not only increases an individual’s risk of death from all vascular diseases two- to three-fold, but 10–30 percent of all CVD deaths are attributable to tobacco worldwide. Among men aged 30–44 years, however, 48 percent of cardiovascular deaths are attributable to tobacco use. Smokers’ risk of heart failure is twice the risk of non-smokers, and smokers with heart failure have a worse prognosis than non-smokers.

The need to confront the CVD burden globally provides the opportunity to recommit and strengthen global efforts to support countries in sharply raising taxes on tobacco products, adjusting for inflation and increased affordability due to growing incomes. Hiking up tobacco product prices and making these products unaffordable has been shown to reduce tobacco use and the health risks associated with tobacco-related diseases, including CVD. Also, tobacco-free investment is a way for investors to contribute to save millions of lives each decade, support climate action, reduce poverty, and boost development investment needed to construct a ‘new normal’ in the post-pandemic era.

High body mass index (BMI): Obesity is highly prevalent worldwide, closely associated with multiple health risks, and directly contributes to the pathogenesis and progression of CVD. In 2021, 1.95 million cardiovascular deaths and 3.7 million deaths overall were attributable to elevated BMI. In 2021, the all-cause DALYs due to high BMI were 1,560 per 100,000. Across the world, the most cost-effective interventions to prevent and treat obesity centers on lifestyle modification, dietary interventions, and increases in physical activity. The implementation of these interventions is faciliated by the construction of an environment conducive to healthy behaviors, as has been shown by the Finnish North Karelia Project, that targeted cardiovascular disease risk factors, including elevated serum cholesterol, hypertension, and smoking. Through the adoption of a socio-behavioral framework utilizing community-based interventions and national-level policy changes and legislation, the project targeted lifestyle changes (e.g., minimizing the use of saturated fats and decreasing salt intake, reducing the prevalence of smoking), as a means to reduce these cardiovascular disease risk factors.

High fasting glucose tracks closely with high burden of prediabetes, diabetes, and obesity worldwide. In 2021, 2.30 million cardiovascular deaths and 5.4 million deaths overall were attributable to elevated fasting plasma glucose. In 2021, the all-cause DALYs due to high fasting plasma glucose were 1,910 per 100,000. Among the effective interventions to deal with this risk factor are population strategies to improve glycemic risk that overlap with approaches to other primary risk factors including low physical activity and adverse dietary profiles. In addition, continuous glucose monitoring helps to improve glycemic control, along with efforts to faciliate access to insulin, an essential treatment for many living with diabetes, as the price of insulin has increased substantially across the world in recent years, particularly in the United States.

Taxing sugar-sweetened beverages also helps to reduce consumption and prevent the onset of related chronic diseases such as cardiovascular diseases, cirrhosis of the liver, obesity, and diabetes.
Evidence reported by the World Bank consistently identifies net positive economic impacts from sugar-sweetened beverages taxes, including overall employment and productivity gains and increased government spending.

Reduced kidney function contributed in 2021 to 1.87 million cardiovascular deaths and 3.47 million deaths. In 2021, the all-cause DALYs due to kidney function were 1,040 per 100,000.

Lead exposure remains a silent but significant contributor to CVD mortality and health loss. Lead is an underrecognized environmental factor that is linked with hypertension, stroke, coronary artery disease, peripheral artery disease, and other types of CVD. In 2021, 1.57 million cardiovascular deaths and 1.64 million deaths overall were attributed to environmental lead exposure. In 2021, the all-cause DALYs due to other environmental risks were 451 per 100,000. It has been estimated that substantial decreases in environmental lead exposure may result in large population health benefits in adults. The most important step to take is to prevent lead exposure before it occurs. This can be achieved via primary and secondary lead exposure prevention. Primary prevention is the removal of lead hazards from the environment before a person is exposed to lead (e.g., eliminating lead-based paint and lead from water pipes). It is the most effective way to ensure that people do not experience harmful long-term effects of lead exposure. Secondary prevention includes blood lead testing and follow-up care and referral.

Non-optimal ambient temperatures, an aggregate of the burden attributable to low and high temperatures, are important contributors to global, regional, and national mortality burdens. Although widespread attention is often paid to the mortality burden of extreme cold or hot temperatures, milder but non-optimal ambient temperatures account for far greater mortality burden. Exposure to non-optimal temperatures has been linked to cardiovascular deaths. In 2021, 1.17 million cardiovascular deaths and 1.81 million deaths overall were estimated as attributable to non-optimal temperatures. In 2021, the all-cause DALYs due to non-optimal temperatures were 420 per 100,000. In dealing with this risk factor, efforts in the health sector need to be fully aligned with and support climate change mitigation and adaptation actions. This is because climate change impacts a wide range of health outcomes, including CVD. For example, as highlighted the 2022 The Lancet Countdown report, climate change, by increasing the average global temperatures and the frequency, intensity, and duration of heatwaves, raises the exposure to extreme heat which is associated with several health conditions (e.g., acute kidney injury, heatstroke, adverse pregnancy outcomes, worsened sleep patterns, impacts on mental health, worsening of underlying cardiovascular and respiratory disease, and increases in non-accidental and injury-related deaths). Exposure to extreme heat also affects health indirectly by restricting people’s capacity to work and exercise, particularly impacting the elderly and other vulnerable populations.

Low physical activity levels represent an important threat to cardiovascular health. In 2021, 0.397 million cardiovascular deaths and 0.686 million deaths overall were estimated as being attributable to inadequate physical activity. In 2021, the all-cause DALYs due to low physical activity were 193.0 per 100,000. The evidence is clear: even small amounts of vigorous physical activity are associated with substantially lower mortality due to CVD. Recent research findings show that brief bursts of vigorous intermittent lifestyle physical activity (VILPA), that is embedded into everyday life, led among study participants to a 48-49 percent reduction in CVD mortality risk. Moreover, the sample median VILPA duration of 4.4 min per day was associated with a 26-30 percent reduction in all-cause and a 32-34 percent reduction in CVD mortality risk.

Heavy alcohol use, especially as alcohol consumption exceeds 100 g weekly, leads to substantial years of life lost and reduction in life expectancy. While data regarding the cardiovascular health effects of low-level or moderate alcohol consumption have been mixed, cardiovascular risks associated with increased blood pressure and arrhythmias are seen with higher alcohol use, and dangerous or binge alcohol use remains common. In 2021, 0.407 million cardiovascular deaths and 1.88 million deaths overall were due to high alcohol use. In 2021, the all-cause DALYs due to high alcohol use were 915 per 100,000. As in the case of tobacco, the most cost-effective policies or “best buys” to reduce alcohol use include increasing taxes on alcoholic beverages, enacting and enforcing bans or comprehensive restrictions on exposure to alcohol advertising across multiple types of media, and enacting and enforcing restrictions on the retail availability of alcohol. Other effective interventions include the enactment and enforcement of drunk-driving laws and blood alcohol concentration limits via sobriety checkpoints.

COVID-19 has had a profound impact on health worldwide. Patients with CVD faced among the highest risks of mortality and complications when infected by COVID-19. COVID-19 may trigger acute cardiovascular events, such as myocardial infarctions or strokes, and the longer-term cardiovascular health implications of COVID-19 infection are increasingly recognized. Also, as smoking and e-cigarette use increase the risk and severity of pulmonary infections because of damage to upper airways, lung inflammation, and reduced lung and immune function, it should not surprise us that initial evidence suggests that smoking, a leading cause of CVD, is a risk factor for COVID-19, with smokers having 1.91 times the odds of progression in COVID-19 severity compared to non-smokers. This finding is reinforced by another review showing that COVID-19 infection was associated with substantially higher severity and mortality rates in patients with chronic obstructive pulmonary disease and among current smokers.

In addition, reports of myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the outer lining of the heart) after SARS-CoV-2 messenger RNA (mRNA) vaccination have emerged. In both cases, the body’s immune system causes inflammation in response to an infection or some other trigger. Case reports, surveillance data, and other reports from the US, Israel, and Canada indicate an increased risk of myocarditis after vaccination with SARS-CoV-2mRNA vaccines, higher after the second dose, especially in younger men. Likewise, the results of a Nordic Cohort Study of 23 million people indicated that both first and second doses of mRNA vaccines were associated with increased risk of myocarditis and pericarditis. For individuals receiving 2 doses of the same vaccine, risk of myocarditis was highest among young males (aged 16-24 years) after the second dose. This risk, however, should be balanced against the benefits of protecting against severe COVID-19 disease.

The Need to Act Quickly and Effectively

The data presented above should alarm us, as the numbers are staggering. Indeed, CVD is the number 1 killer in the world, accounting for one-third of all deaths. While IHME data show that rich countries such as the United States, Canada, Australia, New Zealand, Japan, South Korea, and others in Western Europe, have experienced steep declines in CVD mortality over the past two decades, the countries with the greatest number of cardiovascular deaths, after accounting for population size, are found in the low income and emerging economies in Eastern Europe, Central Asia, the Middle East, South America, sub-Saharan Africa, and Oceania. The growing skewed global distribution of the CVD burden is ominous, particularly because the effective policy and institutional responses that need to be mounted stand to be undermined by a limited resource base, severe economic constraints and fiscal deficits, and underdeveloped health systems that have been overwhelmed by the COVID-19 pandemic in the past three years.

So what to do? Waiting to treat affected individuals after the onset of CVD is not a medically efficacious nor a financially sustainable course of action, particularly in low- and middle-income countries that are struggling to implement ambitious agendas to attain universal health coverage (UHC) post-pandemic. The time has come, therefore, for a drastic paradigm shift to embrace primary and secondary prevention as critical pillars of service provision under UHC. Indeed, health promotion and disease prevention are not less valuable or secondary to treatment for controlling the spread of CVD since both are two sides of the same coin, complementing and reinforcing each other, along a continuum of interventions.

The sustained improvement of cardiovascular health globally, therefore, will require prevention, detection, and treatment of modifiable risk factors; early identification and treatment of heart attacks and strokes; and prevention of recurrent cardiovascular events. The operationalization of these actions will depend on dedicated and balanced investment in all available intervention approaches, from policy and environmental changes designed to prevent risk factors to assurance of quality care for the victims of heart disease and stroke, including improving clinical performance in emergency medical services for these conditions, monitoring the safety of medicines and vaccines, as well as communication and education to support individual efforts to prevent or control risk factors.

As we enter into a new year, 2023, let’s be guided in this endeavor, first and foremost, by the realization that CVD exacts a greater toll on global health than any other condition, often translating into early death, disability, personal and family disruption, losses of income and human capital, and increased medical care expenditures, that place individuals and families at the risk of impoverishment and bankruptcies, particularly in countries where UHC is a distant aspiration. We should also be cognizant, as was discussed above, that this task is doable as more cumulative knowledge and experience in CVD prevention exists today than ever before. But, we should be clear that the accumulated knowledge and experience need to be put into action now and over time through effective adoption, adaptation, and application to realize the potential public health benefit of CVD prevention across the world.

Peter F. Drucker

There is substantial concern in the United States (U.S.) today about growing income inequality and the dramatic increase in life expectancy inequality. As discussed below, tobacco use plays an important role in these disparities.

In their 2020 book, “Deaths of Despair”, Princeton University professors Anne Case and August Deaton (winner of the 2015 Nobel Prize in Economics) provide a groundbreaking account of the recent fall of life expectancy in the U.S.—a reversal not seen in any other wealthy country in modern times. Since 2010, life expectancy gains have been among the slowest on record for the U.S., declining for three consecutive years between over 2014-2017, when an opioid epidemic took hold. Between 2010 and 2018, life expectancy increased by less than a tenth of a year. More recent data from the CDC’s National Center for Health Statistics, that takes into account the impact of excess deaths due to COVID-19 and other causes, show that life expectancy at birth declined nearly a year from 2020 to 2021 – from 77.0 to 76.1 years –, the lowest level since 1996. The 0.9 year drop in life expectancy in 2021, along with a 1.8 year drop in 2020, was the biggest two-year decline in life expectancy since 1921-1923. The overall decline in life expectancy between 2019 and 2021, was 3.1 years for males and 2.3 years for females.

Considerable geographic, racial, ethnic, and gender variation underlies national-level trends in life expectancy. In 2015–2019, residents in metropolitan areas had higher life expectancies than people living in nonmetropolitan areas and specific regions, such as rural areas and the South and Appalachia regions, (79.6 years compared to 77.0 years).

Although there have long been racial and ethnic disparities in life expectancy, the gaps had been narrowing in recent decades. For example, the African-American–White life expectancy gap fell 48.9% over 1990-2018. Covid-19, however, did away with much of that progress, disproportionately affecting minority populations, who were more likely to be employed in risky, public-facing jobs during the pandemic — bus drivers, restaurant cooks, sanitation workers — rather than working from their homes. Increases in excess deaths led to a decline in life expectancy between 2019 and 2021 of 6.6 years among Native Americans and Alaska Natives, 4.2 years for Hispanics, 4.0 years for African-Americans, compared to 2.4 years for Whites and 2.1 years for Asian-Americans.

While it is long documented that life expectancy is lower for individuals with lower socioeconomic status (SES) compared with individuals with higher SES, recent studies provide evidence that this gap has widened in recent decades. A 2015 study by the National Academy of Sciences found that for men born in 1930, individuals in the highest income quintile (top 20%) could expect to live 5.1 years longer at age 50 than men in the lowest income quintile, and among men born in 1960, those in the top income quintile could expect to live 12.7 years longer at age 50 than men in the bottom income quintile. This study finds similar widening patterns for women: the life expectancy gap at age 50 between the bottom and top income quintiles of women expanded from 3.9 years for the 1930 birth cohort to 13.6 years for the 1960 birth cohort.

Findings from another study offer a more nuanced explanation by suggesting that the association between life expectancy and income not only varied substantially across geographic areas, but that the differences were correlated with health behaviors and local area socioeconomic and demographic characteristics, especially education, income, and race. For example, Professors Case and Deaton documented in their book a marked increase after 1998 in the all-cause mortality among middle-aged white men and women with low levels of education, that is largely accounted for by increasing death rates from accidental opioid overdoses, alcoholic liver disease, and suicide. The pandemic appears to have amplified the opioid crisis, with the majority of U.S. states reporting increases in opioid-related deaths.

Tobacco Use Contributes to Life Expectancy Inequality in the U.S.

Although cigarette smoking has declined over the past several decades in the U.S., yet nearly one in five adults continued to use combustible and noncombustible tobacco products according to data from the 2020 National Health Interview Survey (NHIS).

Among U.S. adults in 2020, 19.0% (estimated 47.1 million) currently used any tobacco product, 15.2% (37.5 million) used any combustible tobacco product, and 3.3% (8.1 million) used two or more tobacco products. Cigarettes were the most commonly used tobacco product (12.5%; 30.8 million), followed by e-cigarettes (3.7%), cigars (3.5%), smokeless tobacco (2.3%), and pipes (1.1%). From 2019 to 2020, the prevalence of overall tobacco product use, combustible tobacco product use, cigarettes, e-cigarettes, and use of two or more tobacco products decreased.

However, certain parts of the country and populations continue to smoke at high rates, highlighting uneven progress in preventing and reducing tobacco use. Adults that live in rural areas smoke at a rate of 19.0% compared to 11.4% among adults that live in cities. Adults in rural areas are also more likely to smoke heavily (i.e., 15 or more cigarettes per day), compared to those who smoke and live in cities.

Educational disparities in smoking have worsened over time in the U.S. Findings from a recent study revealed that lower educational attainment was associated with increased ever and current smoking prevalence over time across all racial/ethnic groups, and education-level disparities within each race/ethnicity widened over time. Disparities in ever and current smoking rates between the lowest and highest categories of educational attainment (less than a high school education vs. completion of college) were larger for African-Americans and Whites than Hispanics/Latinos. Non-Hispanic Whites had the highest cigarette consumption across all education levels over time. College graduates had the highest quit ratios for all racial/ethnic groups from 1992 to 2018.

Tobacco use is the leading cause of preventable disease, disability, and death. Cigarette smoking causes about one of every five deaths in the U.S. each year. Annually, nearly half a million people die prematurely of smoking or exposure to secondhand smoke, a number that is equal to about one-half of the total combined reported deaths from COVID-19 in the U.S. since the beginning of the pandemic. Another 16 million live with a serious illness caused by smoking. During the pandemic, strong evidence was also found that tobacco use increased risks of mortality and disease severity/progression among COVID-19 patients.

Overall, findings from a study by Jha et al., show that among participants 25 to 79 years of age who were interviewed in the U.S. National Health Interview Survey (NHIS) between 1997 and 2004, and related these data to the causes of deaths that occurred by December 31, 2006, life expectancy was shortened by more than 10 years among the current smokers, as compared with those who had never smoked. Most of the excess mortality among smokers was due to neoplastic, vascular, respiratory, and other diseases that can be caused by smoking.

Increasing geographic inequalities in mortality in the U.S. are partly due to geographic divergences in smoking patterns over the past several decades. The gap in life expectancy between metropolitan and nonmetropolitan areas, particularly in rural areas of the South and Midwest regions, increased by 2.17 years for men, and 19% of that increase was due to smoking, and for women, increased by 2.77 years, and 22% of that increase was due to smoking, over 1990 and 2019.

Smoking has also been responsible for a substantial portion of deaths across sex and race groups, with African-American men consistently having the highest proportion of deaths due to smoking. This outcome confirms continuing mortality differentials in the U.S. due to previous smoking exposure, especially among African-American who have disproportionately used menthol cigarettes. It is estimated that among men, smoking-attributable mortality caused almost 28% of the reduction in the difference in life expectancy at age 50 for African-Americans compared to Whites in 2000 and approximately 15% of the reduction in 2019. Among women the contribution of smoking to differences in mortality and life expectancy by race was somewhat smaller during the same period.

During a 2016 presentation at the World Bank, Jason Furman, the former Chairman of the Council of Economic Advisers during the Obama Administration, noted that differing trends in smoking rates by income in the U.S. are likely one important factor driving differences in the evolution of mortality rates among people in different income groups as lower-income individuals are more likely to experience higher rates of smoking-related disease and death. While adult smoking rates have dropped from 25.5% in 1990 to an estimated 13.9% in 2017, lower-income individuals have not seen as large a drop in smoking rates. In 2016, 25.3% of adults living below the poverty level smoked, compared with 14.3% of adults living at or above the poverty level. People living in poverty smoke cigarettes more heavily and smoke for nearly twice as many years as people with a family income three times the poverty rate. As a result, they suffer more from smoking-caused diseases. People living below the poverty level also have higher levels of exposure to secondhand smoke. In 2017-2018, 44.6% of people living below the poverty level were exposed to secondhand smoke, compared to 21.3% of people living at or above the poverty level.

Although the impact of cigarette smoking on mortality is diminishing in the U.S., new tobacco products aimed at youth are on the market. According to the 2020 National Youth Tobacco Survey, current use of any tobacco product was reported by 16.2% (4.47 million) of all students, including 23.6% (3.65 million) of high school (grades 9-12) and 6.7% (800,000) of middle school (grades 6-8) students. Electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high school (19.6%; 3.02 million) and middle school (4.7%; 550,000) students. Given their relatively recent introduction, the long-term health impacts of e-cigarette use are not yet well-established. But, early evidence suggests that vaping might serve as an introductory product for preteens and teens who then go on to use other nicotine products, including cigarettes, which are known to cause disease and premature death. Additionally, a study of adult smokers in Europe found those who vaped nicotine were less like to have stopped smoking than those who did not, and those who used e-cigarettes also smoked more cigarettes than those who did not. Another study of some e-cigarette products found the vapor contains known carcinogens and toxic chemicals, as well as potentially toxic metal nanoparticles from the device itself.

Smoking Costs the U.S. Billions of Dollars Each Year

Estimates show that cigarette smoking cost the U.S. more than $600 billion in 2018, as follows:

· More than $240 billion in healthcare spending, including by federal government programs (e.g., Medicare, VA health care) and federal and state programs (e.g., Medicaid) that are funded by taxpayers.

· Nearly $185 billion in morbidity-related productivity losses attributable to cigarette smoking. Absenteeism, presenteeism, home productivity, and the inability to work accounted for $9.4 billion, $46.8 billion, $12.8 billion, and $116.0 billion, respectively. State-level total costs ranged from $291 million to $16.9 billion, with a median cost of $2.7 billion.

· Nearly $180 billion in lost productivity from smoking-related premature death.

· $7 billion in lost productivity from premature death from secondhand smoke exposure.

Lost earnings due to smoking-attributable deaths are substantial in the U.S. and are highest in states with weaker tobacco control policies. For example, in 2019, the estimated person-years of life lost (PYLL) and lost earnings due to cigarette smoking-attributable cancer deaths among individuals aged 25 to 79 years in 2019, were 2 188 195 PYLL and $20.9 billion, respectively. States with the highest overall age-standardized PYLL and lost earning rates generally were in the South and Midwest.

Can Investing in the Tobacco Industry be an Ethical Investment?

In recent years, the performance of the tobacco industry has been impacted by a significant decline in tobacco consumption. In large measure, this development has been the result of the adoption of stringent regulatory and taxation policies, as well as higher awareness among the population of the health risks associated with smoking. In the U.S., as reported by the Federal Trade Commission (FTC), the tobacco industry has been experiencing an annual downward trend in sales since 2000, when sales volume to wholesalers and retailers was at 413.9 billion cigarettes, before dropping 202.9 billion in 2019. In 2020, sales increased by 0.4% from 2019, the first increase in cigarettes sold in 20 years, but decreased from 203.7 billion in 2020 to 190.2 billion in 2021. Also, the U.S. FTC data show smokeless tobacco sales decreased from 128.4 million pounds in 2018 to 126.0 million pounds in 2019, rebounding to only 126.9 million pounds in 2020, and decreasing from 126.8 million pounds in 2020 to 122 million pounds in 2021.

The downward trajectory experienced by the tobacco industry, is clearly illustrated by 2022 data from one of the Big Tobacco companies that show:

· “Smokeable products segment reported domestic cigarette shipment volume decreased 9.7%, primarily driven by the industry’s decline rate and retail share losses”

· When adjusted for calendar differences and trade inventory movements, smokeable products segment domestic cigarette shipment volume decreased by an estimated 9.5%.

· When adjusted for trade inventory movements, calendar differences and other factors, total estimated domestic cigarette industry volume decreased by an estimated 8%.

· Reported cigar shipment volume decreased 4.0%.”

Overall, the comparative total return (includes interest, capital gains, dividends, and distributions realized over a period) of Tobacco companies vs S&P500 companies for the past five years through early 2023 is not positive. With the exception of one company, the tobacco industry shows negative performance, compared to the S&P500 companies.

Figure 1: Total Return Trends: Tobacco companies vs S&P500 companies (in orange)

Source: https://seekingalpha.com/symbol/SP500-302030/charting?interval=5Y

In this context, the question posed in a recent Wall Street Journal article about whether investing in the tobacco industry is an ethical investment is not only appropriate but highly relevant for discussing socioeconomic and demographic challenges facing the country.

Hoping to improve its “toxic reputation with investors”, tobacco companies have announced the setting of new targets to shift to e-cigarettes away from cigarettes. However, there exists much skepticism about the industry’s transition claim. At the heart of the skepticism is the cold fact that the same tobacco industry which promotes e-cigarettes, as a ‘harm reduction’ product to replace cigarettes and “unsmoke the world”, continues to derive the bulk of its profits by promoting and selling cigarettes in low- and middle-income countries, where about 80% of the world’s smokers now live, tapping fast growing young populations, rising per capita incomes, weak governance systems, lax regulatory environments, and low tobacco taxation levels.

More ominous to the industry are signs of a shrinking pool of investors willing to buy tobacco industry shares. According to the Wall Street Journal (WSJ) article, this trend is illustrated by Bank of America data that show that select stocks based on environmental, social and governance (ESG) criteria attracted inflows of $194 billion in 2020, while Philip Morris and Marlboro’s U.S. manufacturer Altria are the second- and third-most underweighted stocks in ESG portfolios relative to their weighting in the S&P 500 index. The E in ESG, environmental criteria, includes the energy companies takes in and the waste it discharges, the resources it needs, and the consequences for living beings as a result. S, social criteria, addresses the relationships a company has and the reputation it fosters with people and institutions in the communities where it does business. G, governance, is the internal system of practices, controls, and procedures a company adopts in order to govern itself, make effective decisions, comply with the law, and meet the needs of external stakeholders. The WSJ article also notes that even tobacco companies’ generous payouts were not enough of a lure to investors--Philip Morris and Altria have dividend yields of 5.7% and 8.2%, respectively, compared with 1.5% for the S&P 500.

Excluding Tobacco from Investment Portfolios Can Help Arrest Mortality Inequalities in the U.S.

Given the toll of disability and premature death that the tobacco industry has caused and continues to cause in the U.S., excluding tobacco from investment portfolios is an ethical duty for institutional and individual investors. It also a sound financial decision given mounting regulatory and fiscal pressures, and raising awareness of the population about the health and environmental risks posed by tobacco use, that further impact the value of tobacco investments accelerating their downward trajectory.

Indeed, recent regulatory measures adopted by the U.S. Government bode ill to the future of the tobacco industry. In mid-2023, for example, the U.S. Food and Drug Administration issued marketing denial orders for two menthol e-cigarette products currently marketed by R.J. Reynolds Vapor Company. The currently marketed products include the Vuse Vibe Tank Menthol 3.0% and the Vuse Ciro Cartridge Menthol 1.5%. This implies that the company must not market or distribute these products in the U.S. or they risk FDA enforcement action.

The tobacco companies’ own claims about lower health risks associated with e-cigarettes have been further undermined by legal action. The announcement by the Attorney General of Connecticut, along with 34 states and territories in the U.S. on September 6, 2022, in reaching a landmark US$438.5 million agreement with JUUL Labs (until recently, the dominant player in the vaping market) that will end its advertising campaigns that relentlessly marketed vaping products to underage youth, manipulated their chemical composition to be palatable to inexperienced users, employed an inadequate age verification process, and misled consumers about the nicotine content and addictiveness of its products, will likely steer many investors further away from the tobacco industry.

As finance sector actors wield enormous power worldwide with their investment, lending, and insurance decisions, their active engagement can be a game-changing possibility for tobacco control. Indeed, institutional and individual investors ditching tobacco stocks over ESG concerns, and “voting with their wallets” towards tobacco-free investments, can have a major impact in reducing health risks and preventable deaths from tobacco-attributable diseases, helping arrest the drop in life expectancy, while contributing to the achievement of net zero environmental targets. More importantly, at the macro- economic level, longer, healthier lives, free of tobacco-attributable diseases and disability, can help secure the highest return on human capital, contributing to economic growth and wealth creation, boosting employment and incomes, productivity, and competitiveness, while reducing the fiscal burden of increased health expenditures and the negative impact of tobacco on the environment. Previous health improvements have been positive for the economy; the task now is to achieve the same outcome for the well-being of the entire population in the U.S.

The Tobacco-Free Finance Pledge, a global initiative with a mission to inform, prioritize, and advance tobacco-free finance with the end goal being a world free from tobacco, is a promising and innovative approach to firm up U.S. investors’ decisions. More specifically, investors can use their capital and influence to invest in a sustainable future helping reverse the decline of life expectancy and prevent further environmental degradation.

While the Pledge focuses on tobacco, it intersects with and compliments many other important environmental initiatives, relating to ocean health, biodiversity, and deforestation, as well as to global public health initiatives such as the universal health coverage agenda and pandemic preparedness and response.

The Pledge has already been signed by almost 200 investors globally, representing over $16 trillion in assets under management. If more U.S. investors sign The Pledge and realize their commitment to exclude tobacco from investment portfolios as an integral part of business strategy and management, more will be motivated by the power of their example to embrace The Pledge and to make an impactful difference in the short-and long-terms.

Indeed, as observed by Columbia University Professor, Bruce Usher, author of the book Investing in the Era of Climate Change,

“The actions that investors take over the next few decades are going to change the planet…. How they go about doing that, how quickly that capital is invested and how effectively it’s invested is going to make all the difference…. The reality is that the capital exists, but mobilizing and investing that capital is a pretty significant challenge. In the context of many of the other great challenges that society faces, we actually have at hand the ability to solve this one”.

In doing so, paraphrasing Peter Drucker, the father of modern business management theory, business leaders will be embracing the “spirit of performance” by displaying high levels of moral and ethical integrity in their actions, focusing on results, empowering employees, going beyond financial obligations to shareholders, and ultimately serving the common good.

In my life, you were a tourist

Tú solo viste lo mejor de mí y no lo que yo sufría

You only saw the best of me and not what I was suffering

Te fuiste sin saber el porqué, el porqué de mis herida’

You left without knowing why, the reason for my wounds

Y no te tocaba a ti curarla’, viniste a pasarla bien

And it wasn’t your place to heal them; you came to have a good time

Y la pasamo’ bien

And we had a good time”

— Bad Bunny, TURiSTA, from Debí Tirar Más Fotos (2025)

“When the carriages which pass over a highway or a bridge, and the lighters which sail upon a navigable canal, pay toll in proportion to their weight or their tonnage, they pay for the maintenance of those public works exactly in proportion to the wear and tear which they occasion of them. It seems scarce possible to invent a more equitable way of maintaining such works.”

— Adam Smith, The Wealth of Nations, Book V, p.918 (1776)

“…in this world, nothing can be said to be certain, except death and taxes.”

— Benjamin Franklin, On the Affairs of France: Letter to Jean Baptiste Le Roy, pp. 265-266 (13 November 1789)

Introduction

Ahead of this year's General Assembly of the Charles Darwin Foundation for the Galápagos Islands (CDF 2026; Marquez 2025a), held in my native Ecuador, where I serve as an elected governing member, I examined available evidence on tourist taxes as a mechanism for financing public goods, and drew lessons from global experience relevant to the conservation of the Galápagos.

Source: Picture taken by author, Galapagos Islands. Ecuador, 2025.

My interest in this topic was influenced by my experience during the latter part of my career at the World Bank Group, where I coordinated the Global Tobacco Control Program. There, we supported the design and implementation of tobacco taxation as a “win–win–win” fiscal policy (Marquez 2017). The accumulated global evidence is unequivocal: well-designed tax increases, that raise prices and reduce affordability, lower consumption of a product that kills its users, protect non-users from harmful exposure in homes and public spaces, reduce health risks, and improve population health (Marquez 2019a; Marquez 2025b). At the same time, they help expand the tax base of a country and mobilize additional domestic revenue at relatively low administrative cost. Once health gains and avoided medical expenditures are accounted for, this policy measure generates progressive welfare effects—even if they may appear regressive when viewed narrowly through the lens of who pays the higher price (Fuchs, Marquez, et al. 2019). Subsequently, the scope of such fiscal policies was broadened to include alcohol and sugar-sweetened beverages, extending the same underlying logic to what are now widely recognized as pro–public health taxes, to align the harm they cause with taxes levied (Marquez and Dutta 2020; Marquez 2020; World Health Organization 2026; Van Oordt and Rosenberg 2026).

While preparing this post, “Turista”, the song by the Puerto Rican artist, Bad Bunny (2025), came to mind. Its lyrics resonate beyond the personal, offering a pointed social commentary on the common tendency of visitors to places like Puerto Rico to seek pleasure at the surface while leaving the territory’s deeper histories and enduring problems largely unseen.

As noted in a recent article (Wismayer 2024), mass tourism has transformed both social and physical landscapes. What was once the pursuit of a few is now a global industry, accounting for roughly 10% of GDP, employs 320 million people and accounts for one in every 10 jobs worldwide; contributes to 7% of global exports; and is responsible for about 9% of greenhouse gas emissions, whose democratic promise collides with a simple constraint: finite places cannot absorb infinite visitors (Wismayer 2024; Lenzen et al. 2018; Sun et al. 2024; Khatib 2023; World Economic Forum 2024; WTTC 2025; UNEP 2023).

At the level of the destination, the consequences are tangible. Infrastructure strains, ecosystems degrade, and local communities absorb the pressure (UNEP 2023). The pattern is consistent: the benefits of tourism are widely dispersed, while the costs are borne locally. That asymmetry lies at the heart of the problem, and increasingly at the center of the policy debate.

What to do? The answer is not new. Adam Smith, the father of modern economics, argued in his seminal book The Wealth of Nations (1776), that when impacts are collective and unavoidable, policy instruments such as taxes are justified to align use with cost—framing them as a matter of shared social responsibility rather than individual choice. Tourist taxes and similar user-based charges follow directly from this logic. They are not merely fiscal tools; they are instruments to internalize shared social and environmental costs, ensuring that those who benefit from the experience of a place also contribute to sustaining it.

As Rosselló-Nadal and Sard (2026) noted in a recent article, tourism taxes have become increasingly relevant as destinations seek to reconcile public revenue needs with the sustainability of local communities and the preservation of tourism competitiveness. The global spread of tourist taxes over the past decade represents an important development in how governments are addressing this problem. Dozens of destinations now charge visitors dedicated levies—not as a revenue grab by the state, but as a deliberate application of Adam Smith’s principle that those who use public works or enjoy protected national parks or land and marine reserves should pay for their conservation and maintenance in proportion to the wear and tear they incur. What may seem to some as an arbitrary imposition by governments, one that could hamper the development of the tourism industry, is, in Adam Smith’s logic, equitable.

In this post, I summarize the results of a review that I conducted focusing on the economic case for tourist taxes, surveying their application in a sample of countries around the world, and examining what has been done in Ecuador to protect and conserve the Galápagos Islands, both the land and marine reserves, as well as what more could still be done to safeguard this unique and fragile UNESCO Natural World Heritage Site for present and future generations (UNESCO 1978; UNESCO 2001).

Source: Photograph by the author, Bartolomé Island, Galápagos, 2024.

Economic Case for Tourist Taxes

The intellectual foundation for tourist taxes draws on four distinct traditions in public economics, each of which converges on the same conclusion, as follows:

Adam Smith’s toll principle provides a clear economic rationale that translates directly into today’s debate on tourist taxes (Smith, 1776). In Book V, Chapter I, of The Wealth of Nations, Smith identifies as the sovereign’s third duty the erection and maintenance of “those public institutions and those public works, which, though they may be in the highest degree advantageous to a great society, are, however, of such a nature that the profit could never repay the expense to any individual or small number of individuals” (Smith 1776). Examples include roads, bridges, harbors, navigable canals, and, by extension, the natural and cultural heritage on which a tourism economy rests. These public goods are essential to economic and social life but cannot be fully financed through private markets, which justifies public provision. Yet Adam Smith does not stop there. In the same chapter he argues that, where the beneficiaries of such works can be identified, they should bear the cost directly through user charges. His example is the toll: “A highway, a bridge, a navigable canal, for example, may in most cases be both made and maintained by a small toll upon the carriages which make use of them; a harbour, by a moderate port-duty upon the tunnage of the shipping which load or unload in it” (Smith 1776). The toll is fair, in his view, because “when the carriages which pass over a highway or a bridge … pay toll in proportion to their weight or their tunnage, they pay for the maintenance of those public works exactly in proportion to the wear and tear which they occasion of them. It seems scarce possible to invent a more equitable way of maintaining such works.”

Tourists are identifiable users: their presence generates wear on infrastructure, pressure on ecosystems, and demand for services. A tourist entry fee is, in essence, Adam Smith’s toll — the visitor generates the cost, and the visitor pays the fee. Taxing tourists is therefore justified on two grounds central to Adam Smith’s logic: it is fair, because it asks those who create and benefit from the costs to pay for them; and it is efficient, because it ties revenue to actual use, helping ensure that infrastructure is built and maintained where demand exists” (Smith 1776). In this sense, a tourist tax is not an arbitrary levy — it is a modern application of Adam Smith’s toll principle.

A century and a half after Adam Smith, the British economist Arthur Pigou, in his book The Economics of Welfare (1920), developed the analytical framework that underpins the concept of externalities — a cost imposed on third parties who neither consented to nor are compensated for it. Tourism generates classic Pigouvian externalities: visitors impose congestion, waste, water consumption, biosecurity risk, and environmental pressure on host communities and ecosystems. The Pigouvian remedy is a corrective tax equal to the marginal external cost — the additional damage that one more visitor imposes, measured at the margin rather than averaged across all arrivals. In a fragile destination, that cost rises as visitor numbers grow: the thousandth daily arrival strains water, waste, and reef systems more than the hundredth. A levy set at this level allows each visitor to bear the share of damage they actually generate — not to punish them, but to internalize the true cost of the visit. This is the foundation on which the modern case for tourism taxes in places like the Galápagos rests.

In 1954, the American economist Paul Samuelson refined the public-goods framework that Pigou's externality theory had set up. In The Pure Theory of Public Expenditure (1954), Samuelson defined a pure public good as one that is both non-excludable — no one can be prevented from using it — and non-rival — one person's use does not diminish another's. This definition explains why natural heritage is so difficult to finance: the asset behaves as a public good at low visitor volumes and as a congestible common-pool resource at high ones — a coral reef is unaffected by one diver but degraded by a thousand. Without a mandatory contribution, the result is the classic free-rider problem: every visitor benefits from the asset, none pays for its upkeep, and chronic underfunding degrades the very feature that drew them. The tourist levy is the mechanism that converts the free rider into a contributor.

James Buchanan, another American economist, extended this analysis with his theory of clubs. In the article An Economic Theory of Clubs (1965), James Buchanan observed that many public goods are in fact club goods — non-rival up to a point, but excludable, and subject to congestion once the sharing group exceeds an optimal size. The optimal membership is finite, determined by the trade-off between cost-sharing benefits and crowding costs: too few users and each bears too much of the upkeep; too many and the experience deteriorates for all. Sites such as Venice, Bali, and the Galápagos are textbook Buchananite cases: their value degrades at high visitor volumes, justifying entry pricing to manage demand and fund maintenance.

The Multilateral Case for Tourism Levies as Fiscal Instruments

The World Bank Group, IMF, IDB, and CTO have each, independently, arrived at the same conclusion on the value of tourist-taxes and other conservation levies.

The World Bank’s 2021 Banking on Protected Areas report demonstrated that for every dollar invested in protected areas and nature-based tourism, the economic rate of return is at least six-fold (World Bank 2021a b c). For example, country case studies have generated specific income multipliers for Brazil’s Abrolhos Marine Park, Fiji’s Mamanuca Islands, Nepal’s Chitwan National Park, and Zambia’s Lower Zambezi Park. Hence, it should be clear that “protected areas are not financial sinks but engines of growth.” This finding directly provides evidence to counter the most common political objection to conservation levies.

The International Monetary Fund (IMF) has approached the same problem from two complementary angles. IMF staff highlighted in a 2024 paper that nearly 38% of the loans of the world’s 100 largest banks are extended to sectors dependent on subsidies that harm nature, and that 44% are exposed to areas covered by the Kunming-Montreal Global Biodiversity Framework, the international agreement adopted in December 2022 at COP15 of the UN Convention on Biological Diversity, under which signatory governments committed to bring 30% of the world’s land and sea under conservation management by 2030 ((Gardes-Landolfini et al. 2024; UNEP 2022; CBD 2022). Nature loss, therefore, is no longer merely an environmental externality borne by third parties; it is a financial-stability risk that comes back to the lenders themselves, as the cash flows and collateral underpinning their loans erode when the ecosystems supporting them collapse. The paper explicitly identifies corrective Pigouvian taxes among the policy levers for nature-related risk management and domestic revenue mobilization. Separately, another article by IMF staff suggested that emerging-market and low-income economies carry an untapped tax potential of 8–9% of GDP — capacity that well-designed corrective taxes, including visitor levies, can help unlock (Benitez et al. 2023).

The IDB was the first multilateral development bank to use policy-based guarantees for a debt-for-nature transaction, both in Barbados (2022) and Ecuador (2023) (IDB 2022; IDB 2023). At COP16 in Cali in October 2024, the Regional Climate Change Platform of LAC Economy and Finance Ministries — with the IDB serving as technical secretariat — established a working group, chaired by Uruguay and Belize, to “build a fiscal policy agenda for biodiversity and natural capital” (IDB 2024a). In May 2025, the IDB and the World Travel & Tourism Council launched a Tourism Task Force under the Americas Business Dialogue, bringing together 22 founding industry partners — including Marriott International, Carnival Cruise Line, Copa Airlines, and Grupo Puntacana — to shape public policy and mobilize private investment in regional sustainable tourism across Latin America and the Caribbean (IDB 2025).

While the Caribbean Development Bank (CDB) projected 2025 regional GDP growth of 2.5% (excluding Guyana), with tourism and construction as the principal drivers (CDB 2025), the Caribbean Hotel and Tourism Association (CHTA) sounded a more cautionary note. Its industry performance survey found that although two-thirds of respondents reported a net profit, the one-third reporting a net loss represented the highest such share in nine years outside the 2020–2021 pandemic period — a margin attributed primarily to operating-cost pressure (Caribbean Hotel and Tourism Association 2025). The finding underscores the importance of revenue mechanisms — including well-designed visitor levies — that can fund the maintenance of the natural and cultural assets on which Caribbean tourism depends.

Adam Smith’s Four Maxims for Designing Tourist Taxes

Adam Smith did not merely justify user fees—he specified how they should be designed. His four maxims of taxation serve as a practical design checklist for assessing every tourist levy (Smith 1776):

1. Equality: contribute in proportion to ability to pay. This is achieved by tiered rates: for example, Edinburgh’s 5% levy is charged on the accommodation rate itself, so a guest paying £400 (≈US$545) a night at a luxury hotel contributes £20 (≈US$27), while a hostel guest paying £40 (≈US$55) contributes £2 (≈US$2.70) — a tenfold difference for the same night in the same city. The levy, however, is capped at the first five consecutive nights (City of Edinburgh Council, 2025). Other examples are: Greece’s Climate Resilience Fee, originally introduced in 2024 at €1.50–€10 per night by hotel star rating, was increased on 1 January 2025 to €2–€15 per night for hotels and short-term rentals (GTP Headlines 2025; Greek City Times 2025); and Barbados’s Room Rate Levy charges BDS $5.00 (US$2.50) per room per night at “B” Class properties (guesthouses and apartments), BDS $11.00 (US$5.50) at “A” Class hotels, and BDS $20.00 (US$10.00) at Luxury properties (Government of Barbados 2019). Tiering simultaneously satisfies the equality maxim — proportionality to benefit received — and maximizes revenue generation from high-willingness-to-pay visitors without pricing out budget travelers.

2. Certainty: clear, not arbitrary. Achieved by fixed published rates with digital pre-payment, as for example, Bali’s LoveBali app and portal — a flat IDR 150,000 (≈US$10) levy paid online and validated by a QR-code voucher scanned at entry checkpoints (Government of Bali Province, n.d.); New Zealand’s NZeTA, through which the NZ$100 (≈US$60) International Visitor Conservation and Tourism Levy is collected at the moment of travel-authority application (Immigration New Zealand, n.d.; MBIE, n.d.); Japan’s “sayonara” departure tax — ¥1,000 (≈US$6.40) today, rising to ¥3,000 (≈US$19.20) on the second half of 2026 — embedded automatically in airline and ferry tickets, so that nothing is paid separately at the airport (Japan National Tourism Organization. n.d.); and Bonaire’s online Visitor Entry Tax of US$75, paid in advance through the official government portal and confirmed by an emailed QR code scanned at Flamingo Airport (Government of Bonaire, n.d.). Venice’s 2024 pilot failed this test: across 29 fee days from April 25 through mid-July, the city collected roughly €2.19 million (≈US$2.58 million) from about 438,000 day-trippers paying €5 (≈US$5.90) each, yet no fines were issued to evaders, and average daily visitor counts actually rose by some 10,000 over comparable 2023 dates (Barry 2024; ETIAS.com, 2024). In the Venice case, therefore, the levy's visibility was high but its certainty of collection was not. Venice has since tightened enforcement — roughly 140 inspectors per fee day in 2025, with about 2,500 violators caught and fines ranging from €50 to €300 (≈US$355) plus the unpaid €10 fee (The Traveler, 2025) — but the lesson of the original pilot stands: a tax announced that is not collected is not a tax collected.

3. Convenience: levied at the moment convenient for the contributor — at point of entry or at checkout. The Dominican Republic’s US$10 tourist card, mandatorily incorporated into the airline ticket cost since April 2018 by Executive Order 430-17, and Jamaica’s US$20 Tourism Enhancement Fee, charged on every incoming airline passenger and bundled into airfares under the Tourism Enhancement Act, are textbook examples of the convenience maxim (Punta Cana International Airport, n.d.; Tourism Enhancement Fund, n.d.).

4. Economy: take out as little as possible beyond what enters the treasury. The critical test, and the one Venice’s 2024 pilot largely failed, was its implementation cost — reported at approximately €3 million (≈US$3.55 million), covering the communication campaign, information panels, ticket-checking staff, and the dedicated booking website — set against revenue of roughly €2.4 million (≈US$2.8 million), so the program ran at a net loss in its first year (InTrieste 2024). Digital collection systems that minimize marginal cost per transaction are essential. Edinburgh, Bali, and Bonaire have designed for this; Venice had not.

How the World Is Doing It: A Regional Sample

Africa

Source: Picture taken by author, Khama Rhino Sanctuary, Botswana, 2016.

As Table 1 illustrates, country experiences in Africa offer two lessons. First, long-overdue fee revisions can sharply increase revenue. For example, Botswana's 2022 revision exceeded its first-year forecast. Second, a well-designed levy can be paired with devolved revenue rights to local conservancies, as Namibia demonstrates, or set as a flat ad-valorem charge whose proceeds are ring-fenced for tourism infrastructure and conservation, as Rwanda's accommodation tax shows. Namibia's logic is clear: the externality is borne locally, the corrective revenue is retained locally, and monitoring is done by those who live with the resource. Wildlife populations on conservancy land in Namibia have grown faster than on state-managed land alone. Kenya and Tanzania stand in contrast: overlapping and fragmented levies that raise revenue without certainty, transparency, or visitor trust.

Botswana’s protected-area fee revision of April 2022 — the first revision in over twenty years — generated US$7.8 million in its first full year, 4.3 times the US$1.8 million originally forecast (BIOFIN 2024). The reform was developed through an evidence-based, participatory process led by the Biodiversity Finance Initiative (BIOFIN) of the United Nations Development Program, in collaboration with the Government of Botswana. Fees were differentiated by visitor category (local citizen, members of the Southern African Development Community (SADC) countries, international visitors) and by activity, with rates benchmarked against comparable parks in the region and informed by willingness-to-pay studies conducted in Botswana and elsewhere. Revenue from protected areas currently flows to central finances and supports general national development priorities — including health services, education, and aid to underprivileged communities — though BIOFIN and Botswana’s Department of Wildlife and National Parks have advocated for greater revenue retention to fund park management directly. The Botswana case demonstrates that an evidence-based design, rigorous benchmarking, and stakeholder consultation can produce a fee structure that vastly exceeds revenue projections without depressing visitation — a good application of Adam Smith’s certainty maxim.

Namibia's Ministry of Environment, Forestry and Tourism (MEFT) raised premium-park entrance fees for international visitors in April 2026, the first such revision since 2021 (MEFT 2026). Premium parks now charge international visitors N$280 per day (~US$17), up from N$150 (~US$9) — an 87% increase. The revised structure is tiered along two dimensions: by nationality, with Namibian residents paying a token rate, SADC citizens an intermediate rate, and international visitors the full rate; and by park category, with premium parks (Etosha and other flagships) commanding higher fees than standard reserves. Entrance and conservation levies are bundled into a single charge. Revenue is statutorily earmarked for park management and conservation under MEFT regulations, and Namibia's broader community-based natural resource management (CBNRM) system — covering 86 communal conservancies that benefit some 244,000 residents — has long demonstrated how tourism revenue can be linked to conservation outcomes and local livelihoods (MEFT/NACSO 2023; NACSO 2025; WWF 2023). Where Botswana's revenue flows centrally, Namibia's CBNRM model channels a meaningful share of tourism receipts directly to the communities that bear the costs of living alongside wildlife — a structural feature that distinguishes it from most other African tourism-revenue regimes.

Kenya levies a 2% tourism turnover charge on accommodation and services across the country, layered atop park-fee increases at major destinations (Tourism Fund Kenya 2024). The result is a multi-layered, partially overlapping levy structure that creates administrative complexity and reduces certainty for both operators and visitors.

Tanzania’s case is more pointed: along the northern safari circuit, a tourist may encounter as many as nine separate levy points (Tourism Development Levy, value-added tax, hotel levy, conservation fees, concession fees, vehicle fees, and others) between leaving Arusha and entering Serengeti (Tanzania Revenue Authority 2025). Kenya and Tanzania thus stand as cautionary examples of what happens when a tax system grows by adding taxes and fees rather than by design: each levy may be individually justifiable, but the cumulative effect deviates from Adam Smith’s economy and certainty maxims simultaneously.

Rwanda’s 3% accommodation tax, effective February 2025, demonstrates the opposite: a single flat ad-valorem rate on hotel room cost, with revenue statutorily earmarked for tourism infrastructure, maintenance, and conservation under the Second National Strategy for Transformation (NST2). Rwanda’s tourism sector generated US$647 million in revenue in 2024, a 4.3% increase over 2023, with gorilla tourism alone contributing approximately US$200 million — a 27% year-on-year increase (RDB 2025). The accommodation tax is one instrument among several that the Rwanda Development Board expects will help close the gap toward the country’s US$1.1 billion annual tourism revenue target for 2029 (RDB 2025). The contrast with Kenya and Tanzania is instructive: Rwanda’s design is simple, predictable, and tied to a clearly stated public purpose — exactly the conditions under which a tourism levy can succeed without distorting visitor decisions or burdening operators.

The lesson from the African experience is consistent with what is observed across regions: simplicity, certainty, and visibility of the earmark matter more for both revenue performance and political legitimacy than the size of the levy itself.

Asia-Pacific

As shown in Table 2, the Asia-Pacific cases offer four design choices: Japan and Bhutan demonstrate how levies embedded in tickets or per-night charges scale revenue; Kyoto’s five-tier rate shows tiering pushed to its logical extreme, with the top rate fifty times the bottom rate; the Maldives illustrates a hypothecated environmental levy tiered by accommodation type; and New Zealand stands as the cautionary case where a tripled levy was used to substitute existing conservation funding rather than supplement it.

Japan’s departure tax collected a record ¥52.5 billion (≈US$340 million) in fiscal 2024 (Japan Times 2025). Kyoto’s five-tier levy, effective 1 March 2026, peaks at ¥10,000 (≈US$64) per person per night for rooms costing over ¥100,000 (≈US$640) — luxury properties where the incremental charge represents roughly 10% of the room rate. For budget travelers in rooms under ¥6,000 (≈US$38) the charge is ¥200 (≈US$1.30) — proportionality and certainty achieved simultaneously (Kyoto City 2026; Japan Travel 2025).

Bali offers a partial-success story. Its Foreign Tourism Levy collected IDR 318 billion (≈US$19.2 million) in 2024, exceeding the conservatively budgeted target of IDR 250 billion (≈US$15.1 million). But of 6.33 million foreign arrivals, only about 2.12 million — roughly 34% — actually paid, leaving the levy short of its potential IDR 945 billion (≈US$57 million) (TTG Asia 2025; Bali Times 2025). This result was far less than expected and the shortfall attributed to an imperfect collection system rather than tourist resistance.

New Zealand's case is cautionary. The International Visitor Conservation and Tourism Levy (IVL) tripled from NZ$35 (~US$21) to NZ$100 (~US$60) on 1 October 2024. The tripling of the IVL to NZ$100 (≈US$60) was undermined by a deliberate Treasury "funding switch": of the roughly NZ$229 million (≈US$137 million) projected annually from the higher levy, only about NZ$90 million (≈US$54 million) goes to new conservation and tourism spending, while up to NZ$139 million (≈US$83 million) a year flows back to the general budget in the form of substitution — IVL revenue replacing previously committed funding rather than adding to it (Ministry of Business, Innovation and Employment, New Zealand n.d.; NZ Herald 2025). Hence, a levy ostensibly raised for conservation and tourism ends up funding general expenditure, with no net increase in the resources directed to the externality the levy was designed to address.

The Maldives, by contrast, doubled its Green Tax to US$12 per person per night at resorts from 1 January 2025 (and to US$6 at guesthouses with 50 or fewer rooms), under the 14th amendment to the Maldives Tourism Act. Funds are directed toward marine conservation, coral-reef preservation, and waste-management infrastructure, with collection administered by the Maldives Inland Revenue Authority on a clear monthly schedule — a model of certainty in design (MIRA 2025; Travel Trade Maldives 2024).

The Caribbean: A Region in Transition

Source: Picture taken by author, Map of the Caribbean in the XVI-XIX centuries, 2003

The Caribbean Tourism Organization’s Caribbean Tourism Performance Review 2024 has documented that the region surpassed pre-pandemic visitor levels for the second consecutive year, while urging that destinations must “double down on strategic investments, innovative partnerships, and sustainable practices that protect our people, our culture and our environment” (CTO 2025a). The CTO established a new position--Deputy Director, Sustainable Tourism, and signed a non-binding Memorandum of Understanding with the consulting firm ICF in late 2025, running through 2029, to advance sustainable tourism development, climate adaptation, and resilience-building across the region (CTO 2025 c d).

As highlighted in Table 3, the Caribbean cases reviewed here span a full design spectrum. At one end, Barbados and Bonaire offer well-structured, clearly targeted arrangements with ring-fenced earmarks for marine and island sustainability. At the other, Jamaica, the Dominican Republic, and the Bahamas generate substantial revenue but route it through general budget mechanisms with only loose conservation earmarks. Aruba sits between these poles: a unitary fee with a single ring-fenced purpose, modest in scope but clean in design. The evidence collectively suggests that a dedicated, additive, and legally ring-fenced cruise passenger levy is the instrument best suited to the cruise externality — provided it is not used, as New Zealand’s IVL was, to substitute rather than supplement existing conservation funding.

Barbados has pioneered a two-track approach that links tourist levy design to sovereign debt management. Its tiered Room Rate Levy — from BDS$5.00 (≈US$2.50) per night at “B” Class properties to BDS$11.00 at “A” Class hotels and BDS$20.00 (≈US$10) at Luxury properties — directly funds tourism development (Government of Barbados 2019). The more innovative instrument is the 2022 debt-for-nature swap: a US$150 million blue loan co-guaranteed by the Inter-American Development Bank (US$100 million) and The Nature Conservancy (US$50 million) refinanced expensive sovereign debt at an average 7.2% cost down to a 4.9% all-in cost, with 100% of the resulting interest savings — projected at approximately US$50 million over 15 years — channeled into the Barbados Environmental Sustainability Fund (IDB 2022; The Nature Conservancy 2022). The operation simultaneously committed Barbados to protect 30% of its Exclusive Economic Zone and gave the island the Caribbean’s most transparent link between visitor revenue, fiscal management, and ecological outcome. In December 2024, Barbados completed a further transaction — the world’s first debt-for-climate-resilience operation — repurposing US$592.7 million in higher-cost domestic bonds at a lower 3.5% rate, with guarantees from the IDB and the European Investment Bank. The transaction is projected to generate approximately US$125 million in fiscal savings (US$220 million in interest savings over ten years), to be channeled into the South Coast Water Reclamation Project for water management, agricultural irrigation, and aquifer recharge (IDB 2024; Central Bank of Barbados 2025).

Bonaire’s two-part system is a clear application of Adam Smith’s toll principle. The US$75 Visitor Entry Tax, introduced in July 2022 and paid online before arrival, funds general island sustainability, education, and infrastructure. The separate US$40 Nature Fee, mandatory for all water users and managed by STINAPA, goes directly to the Bonaire National Marine Park, financing reef restoration, ranger enforcement, and pollution cleanup (STINAPA n.d.; Pew Charitable Trusts 2025). In 2025, Bonaire collected approximately US$14.5 million from the entry tax and US$3.4 million from the Nature Fee (Pew Charitable Trusts 2026). The reef that those funds protect is among the healthiest in the Caribbean — a causal relationship, not a coincidence.

Jamaica’s layered tourism tax architecture — a US$20 Tourism Enhancement Fee (US$2 for cruise passengers), a Guest Accommodation Room Tax, departure taxes, airport improvement fees, an airline passenger levy, and various passenger fees and charges — generated J$53.6 billion (US$345.8 million) in aggregate direct revenue to the Consolidated Fund in fiscal year 2023/24, with the TEF component alone accounting for US$59.2 million (Jamaica Information Service 2024). The funds support airports, roads, and cultural infrastructure but lack the ring-fenced conservation mandate of Barbados or Bonaire. In February 2026, the government announced that the General Consumption Tax rate on tourism activities would rise from 10% to 15% effective 1 April 2027, with implementation deliberately delayed to give the sector time to recover from Hurricane Melissa. The increase is projected to yield approximately J$11.4 billion (≈US$72 million) in additional annual revenue, though critics warn of competitiveness risks against regional rivals (Jamaica Observer 2026; PwC Jamaica 2026).

The Dominican Republic collects US$10 per arrival through a Tourist Card embedded in the airline ticket — in force since April 2018 under Presidential Decree 430-17 and General Norm 08-2018 — plus a US$20 departure tax (IATA 2022). The instrument generates significant revenue but carries no statutory environmental earmark.

Aruba’s US$20 sustainability fee, applied once per calendar year to all air arrivals from July 2024, is collected through the mandatory Embarkation and Disembarkation card system (Aruba Tourism Authority 2024). Proceeds are channeled entirely into upgrading the island’s wastewater system via the new Aruba Wastewater Sustainable Solutions structure, designed to eliminate ecological damage to coastal lagoons (AWSS 2025). The fee design is certain (fixed at US$20, applied once annually), convenient (collected at check-in), and economical (digital collection minimizes marginal administration cost). The earmark is additive: the wastewater project would not otherwise have a dedicated funding stream.

The Bahamas’s 2024 overhaul of its cruise tax scheme is the region’s most complex reform. The departure tax for cruise passengers leaving from Nassau, Freeport, or Bimini rose from US$18 to US$23 (US$25 from private islands not visiting another Bahamian port), supplemented by a US$5 tourism sustainability levy and a US$2 tourism enhancement levy, with funds directed to the Tourism Development Fund for conservation and community economic development (Bahamas Customs Department 2025). The three-tier structure is analytically sound — each levy is tied to a distinct externality — but the multiplicity creates administrative complexity.

Sint Maarten’s still-pending stayover-and-arrival levy, formally opposed by the Sint Maarten Hospitality and Trade Association and currently under review (SHTA 2025), illustrates the political economy of adopting such measures: even where the fiscal and conservation case is strong, organized industry resistance can stall implementation indefinitely.

Across the Caribbean, cruise passengers represent the single largest category of visitor impact without commensurate fiscal contribution. The CTO’s 2025 Caribbean Weekend summit, convened aboard Royal Caribbean’s Icon of the Seas, directly addressed this with calls for master planning to ensure destinations can manage sustainable tourism development as cruise arrivals approach 36 million in 2025 (CTO 2025a).

Europe

The European cases in Table 4 illustrate the full spread in earmark design, from Edinburgh's five-star pre-published spending plan to Venice's loss-making 2024 pilot, and make clear that what separates the high-performing schemes from the underperforming ones is governance design and effective implementation, not levy size. Europe offers a fuller spectrum of design choices than any other region: percentage-of-room versus flat-rate models, ring-fenced versus general-revenue earmarks, single-tier versus multi-level (regional and municipal) structures, and increases tied either to specific public investments or to broader political bargains over housing and overcrowding.

Greece’s fee scheme is the continent’s highest-revenue success. According to Greece’s Independent Authority for Public Revenue, the Resilience Fee for the climate crisis was estimated to generate €588.47 million (≈US$671 million) in 2025, up 59.5% from €368.92 million (≈US$421 million) in 2024. The levy replaced the earlier Accommodation Tax in 2024, which had collected €124.65 million in 2018, €133.57 million in 2019, €41.9 million in 2020 (pandemic year), €68.9 million in 2021, €136.77 million in 2022, and €147.82 million in 2023 (roughly US$142–169 million in pre-pandemic years). The 2024 reform raised charges per overnight stay and extended the fee to short-term rentals, with a further proportional increase in 2025 for the April–October peak season across hotels, other accommodations, and platform-based rentals (Tornos News 2026). The fund is statutorily ring-fenced for natural-disaster preparedness and climate adaptation under Law 5073/2023, addressing the wildfire and flooding events of 2023 that motivated its creation. A separate cruise-passenger levy of €1–€20 (≈US$1–US$23) per port call, peaking at Mykonos and Santorini, took effect on 21 July 2025 under Law 5162/2024 (Article 27), applying the polluter-pays principle to the highest-impact visitor segment (Hellenic Republic 2024; GTP Headlines 2025).

Edinburgh’s scheme, to be launched in mid-2026, is exceptionally transparent by international comparison: the city published a detailed three-year £90 million (≈US$122 million) spending program before the levy launched, specifying every project across three investment streams — City Operations and Infrastructure; Culture, Heritage and Events; and Destination and Visitor Management (City of Edinburgh Council 2025a b c, 2026a b). That transparency is the political-economy condition for sustainability: residents and the tourism sector can both see exactly where their levy revenue is going before they are asked to pay it.

Amsterdam’s 12.5% accommodation rate is the highest in the European Union — a deliberate demand-management instrument as much as a revenue tool. From January 2024 the Dutch capital replaced its previous 7% rate plus €3 (≈US$3.50) per-person fee with a single 12.5% charge on the accommodation cost (excluding VAT), and added a separate cruise passenger levy that has now risen to €15 (≈US$17.70) per passenger per day in 2026 (City of Amsterdam n.d). Total tourist tax revenue is projected at approximately €262 million (≈US$309 million) annually under the new structure — but unlike Greece, Edinburgh, or Bonaire, the revenue flows to Amsterdam’s general municipal budget without a statutory environmental or housing earmark. Industry critics, including the Dutch hotel sector, have argued that the absence of ring-fencing weakens the political legitimacy of the high rates.

Barcelona introduced a structurally different design: a two-level (regional plus municipal) tax in which the doubling of the base rate from April 2026 was paired, by law, with a 25% statutory earmark for affordable housing policy (Catalan News 2026; Idealista 2026; Barcelona City Council 2026). The Tax on Stays in Tourist Establishments (IEET), levied by the Generalitat de Catalunya, now ranges from €2 to €7 (≈US$2.35 to US$8.25) per person per night by accommodation tier. Barcelona City Council adds a municipal surcharge that rose from €4 to €5 (≈US$4.70 to US$5.90) in April 2026 and is scheduled to increase by €1 (≈US$1.20) each year until reaching €8 (≈US$9.45) in 2029. A guest at a five-star hotel in Barcelona, who paid €7.50 (≈US$8.85) per night in early 2026, will pay €15 (≈US$17.70) by 2029. Catalonia’s tourist-tax revenue rose from approximately €90 million (≈US$106 million) in 2024 to a projected €200 million (≈US$236 million) in 2025. The housing earmark — explicitly motivated by displacement of long-term residents into short-term tourist rentals — is an ambitious example of using a tourist levy to address a secondary externality of tourism (housing affordability) rather than its primary one (environmental impact).

Paris demonstrates the political economy of event-driven design. The city tripled its taxe de séjour effective January 2024 to finance Île-de-France Mobilités — the regional transport authority — for the 2024 Summer Olympics and beyond. Rates now range from €0.65 (≈US$0.77) per night for basic campsites to €15.60 (≈US$18.40) per night for “palace”-category luxury hotels, including a 200% Île-de-France regional surcharge dedicated to transport infrastructure (France 24 2023; Trippz 2025). The increase is projected to generate up to €423 million (≈US$499 million) annually — well above the €200 million (≈US$236 million) the Grand Paris transport authority estimated. The Paris case shows how a major event can serve as a political opportunity to lock in a permanent rate increase, but it also raises the durability question: when the Olympics are over and the transport investments are sunk, will the tripled levy continue to find a public-purpose justification, or will it drift toward general-revenue substitution as in New Zealand?

Venice illustrates the opposite end of the spectrum. The 2024 day-tripper pilot collected only €2.19 million (≈US$2.58 million) against an implementation cost of approximately €3 million (≈US$3.54 million), with no measurable deterrent effect on day-tripper volumes and no fines actually issued. The 2025 reform doubled chargeable days to 54, deployed roughly 140 inspectors per day, scanned over 445,000 QR codes, issued some 2,500 fines of €50–€300 (≈US$59–US$354), and lifted revenue to €5.42 million (≈US$6.40 million) from 723,497 paying visitors during April–July (The Traveler 2025; InTrieste 2024). Even on these tightened terms, however, the scheme’s effectiveness as a demand-management instrument — its main purpose — remains contested. The Venice case underscores that a levy whose collection cost approaches its revenue is not a public good; it is a fiscal experiment whose costs are borne disproportionately by the visitors who comply and the residents whose city is patrolled.

Pacific Small Islands and Hawaii

Across the Pacific, tourism levies have evolved from incidental revenue tools into the principal instruments through which small island jurisdictions finance the conservation of the natural assets that draw their visitors. The three cases summarized in Table 5 illustrate the breadth of design in these jurisdictions: Palau, a sovereign Small Island Developing State (SIDS) that has built one of the world’s most precise statutory allocations on a single US$100 fee; Fiji, a Melanesian SIDS that has assembled a multi-instrument levy architecture financing climate-adaptation projects since 2017; and Hawaii, a U.S. state with full federal fiscal backing that has nonetheless adopted Pacific small-island-style mechanisms.

The structural challenge is the same whether the polity is a sovereign SIDS or a U.S. state. Tourism contributes about 40% of Palau’s GDP and comparable shares of Fiji’s and Hawaii’s, and all three economies face fragile coastal ecosystems, escalating climate risk, narrow tax bases relative to their conservation needs, and tourism volumes that consistently outstrip domestic capacity to manage their environmental footprint. The Maui wildfires of August 2023 — which killed 102 people and destroyed Lahaina — made the political case in Hawaii exactly as Tropical Cyclone Winston (2016) and the wildfires and floods of 2023 made it in Fiji: dedicated, ring-fenced revenue is the only durable answer to climate-related disaster risk in tourism-dependent jurisdictions. For Pacific SIDS in particular, tourist levies are not optional — they are often the only viable conservation finance mechanism, given debt burdens that frequently exceed 60% of GDP, narrow economic bases, and limited fiscal space for environmental investment (Inamdar and Edwards 2026).

Palau’s Pristine Paradise Environmental Fee, in force since January 2018 under Republic of Palau Public Law 10-2, is a model of earmarking clarity that no other jurisdiction has matched (Republic of Palau 2017). The US$100 fee — embedded in every international airline ticket — flows through a five-purpose statutory allocation: US$10 to the Fisheries Protection Trust Fund, US$12.50 to local state governments for environmental management, US$22.50 to the National Treasury, US$25 to Palau International Airport, and US$30 to the Protected Areas Network Fund and the Palau National Marine Sanctuary — a sanctuary covering approximately 500,238 km² (80% of Palau’s Exclusive Economic Zone), one of the world’s largest protected ocean areas. Palau projected approximately US$7 million in revenue from the fee in fiscal 2025 (Pew Charitable Trusts 2026). The instrument reflects Adam Smith’s maxims in its design: certain (a fixed amount), convenient (collected automatically through the airline), economical (no domestic tax-collection apparatus required), and equitable (visitors pay in proportion to the externality their visit generates).

Fiji’s Environment and Climate Adaptation Levy (ECAL) illustrates a second Pacific design: not a single flat fee or percentage rate, but a multi-instrument levy architecture (Fiji Climate Change Portal 2018). Originally introduced in 2015 as the Environmental Levy at 6%, ECAL was renamed and raised to 10% in the 2017/2018 budget, then reduced to 5% from August 2020 in response to COVID-induced tourism revenue losses. The current package combines a 5% turnover levy on prescribed services (resorts, tour operators, restaurants, and other tourism-facing businesses with annual turnover above FJ$3 million, ≈US$1.37m), a 10% surcharge on luxury-vehicle imports, a 10% income surcharge on individuals earning over FJ$270,000 (≈US$123,000), a FJ$0.20 (≈US$0.09) plastic-bag levy, and an airport departure tax introduced at FJ$140 (≈US$64) in January 2024 and raised to FJ$170 (≈US$77) from August 2024 (HLB Fiji n.d.; Republic of Fiji Ministry of Finance 2023, 2024).

Since the 2017–2018 financial year, ECAL has generated approximately FJ$270.2 million (≈US$120m), of which FJ$255.9 million (≈US$117m) has financed 102 climate-adaptation and environmental-conservation projects — including coastal-community relocation, cyclone rehabilitation, meteorological services, rural development, and reef restoration (Marine Ecology Consulting n.d.). The Climate Relocation of Communities Trust Fund, established by Act of Parliament in 2019 and financed in part from ECAL proceeds, is designed to leverage bilateral and multilateral donor funding to relocate the low-lying coastal communities most exposed to sea-level rise (Government of Fiji 2019). The Fiji case demonstrates the practical advantage of a multi-instrument design: when one component must be temporarily eased — as ECAL was halved during COVID — the architecture as a whole continues to generate revenue through the other components, preserving funding continuity for ongoing climate-adaptation commitments.

Hawai’i’s “Green Fee,” signed into law as Act 96 (Senate Bill 1396) on 27 May 2025, is the first state-level instrument of its kind in the United States. Effective January 2026, the law raises the Transient Accommodations Tax (TAT) by 0.75 percentage points — from 10.25% to 11% — and applies a parallel 11% TAT to cruise-ship gross fares for the duration each ship is docked at any Hawaiian port; each county may add a 3% surcharge on cruise fares, bringing the total cruise tax to as much as 14%. On 31 December 2025, however, the U.S. Court of Appeals for the Ninth Circuit issued an injunction temporarily halting enforcement of the cruise-ship provision pending appeal, while the lodging TAT increase took effect as scheduled (Honolulu Civil Beat 2026). The bill is projected to generate approximately US$100 million annually, channeled through two newly established special funds: the Climate Mitigation and Resiliency Special Fund and the Economic Development and Revitalization Special Fund. Revenue is split equally across three statutory purposes: protecting and restoring natural resources; increasing the resilience of structures and infrastructure to climate-related disasters, including wildfire and flood mitigation; and improving the visitor experience while mitigating the environmental footprint of tourism (Office of the Governor of Hawaii 2025; National Caucus of Environmental Legislators 2025).

The three Pacific cases illustrate design options rather than a single template. Palau demonstrates statutory detail: a flat fee with a fixed five-way split, embedded at the point of ticket purchase, with the conservation share legally protected against fiscal substitution. Fiji shows a multi-instrument architecture: complementary levies on services, imports, high incomes, and plastic, with revenue financing project pipelines in climate adaptation and community relocation. Hawaii demonstrates broad-based instrument design: a percentage layered onto an existing tax architecture, capturing both accommodation and cruise externalities, with revenue flowing through purpose-built special funds rather than line-item allocation. None of the three approaches is universally superior; what unites them is the recognition that visitors should contribute to the cost of the public goods their visits consume, and that without dedicated, statutorily protected revenue streams, no tourism-dependent Pacific economy can finance the conservation outcomes its visitors implicitly assume.

The Hawaii case challenges the assumption that tourism levies are mainly a tool for fiscally constrained jurisdictions. Hawaii is not a SIDS — it is a U.S. state with full access to federal disaster, infrastructure, and conservation funding through agencies including the Federal Emergency Management Agency (FEMA), the National Oceanic and Atmospheric Administration (NOAA), and the Department of the Interior. That a jurisdiction with this level of federal backing still adopted a dedicated tourism levy to close its climate-resilience financing gap should give pause to commentators who see such instruments only as a substitute for stronger public finances. Pacific small island jurisdictions adopt tourism levies not because they lack alternatives, but because no other instrument directly links those who pay to those who cause the damage.

North America, Mesoamerica, and Central America: National Parks, Maya Ruins, and the Fee Architecture of the Western Hemisphere

Source: Picture taken by author, Grand Canyon National Park, Arizona, 2018.

Five Western Hemisphere countries — the United States, Canada, Mexico, Guatemala, and Costa Rica — manage some of the world's most visited natural and cultural heritage sites. Table 6 shows that their tourist-fee systems span the full range of design choices. Four characteristics make this the most directly comparable regional peer group for the Galápagos. All five charge park entry fees rather than accommodation levies. Three (Mexico, Guatemala, Costa Rica) administer their fees across multiple levels of government, as Ecuador does in the Galápagos. Two (the United States and Costa Rica) — like the Galápagos — use U.S. dollars. And all five attract long-haul international visitors willing to pay to access these sites. No other regional grouping in the paper meets all four conditions.

The United States and Guatemala sit at opposite ends of the revenue-design spectrum, and the contrast is instructive. The U.S. national park system received a record 331.9 million visits in 2024 (National Park Service 2025) and from January 2026 introduced the most significant fee reform in National Park Service history: for the first time, entry pricing is differentiated by residency. Non-U.S. residents pay $250 for the annual America the Beautiful pass — more than triple the $80 resident rate — and at 11 of the busiest parks, including Yellowstone, Yosemite, Zion, Grand Canyon, Bryce Canyon, Rocky Mountain, Acadia, Glacier, Grand Teton, Sequoia and Kings Canyon, and Everglades, international visitors pay an additional $100 per person surcharge on top of standard vehicle fees (Department of the Interior 2025; National Park Service 2026 a b c d).

Guatemala’s Tikal National Park — inscribed as a UNESCO mixed World Heritage Site in 1979 for both its extraordinary Mayan archaeological record and its surrounding 57,600-hectare tropical forest, embedded within the much larger Maya Biosphere Reserve of more than 2.1 million hectares — charges foreign visitors Guatemalan quetzal (GTQ) 150, approximately USD $19 per day (UNESCO World Heritage Centre n.d.; Tikal National Park n.d.; Ministerio de Cultura y Deportes de Guatemala n.d.). Visitors from North America and Europe who have already spent $1,500–3,000 reaching Flores, Guatemala, pay less than the cost of a dinner at the airport to enter one of the New World’s most significant archaeological sites. The demand evidence is unambiguous: Tikal could double or triple its fee without measurable impact on visitor numbers. The conservation consequences of chronic underpricing are visible — an outdated Master Plan, insufficient ranger coverage, documented looting within the reserve, and ongoing deforestation pressure on the surrounding Maya Biosphere Reserve (UNESCO World Heritage Centre n.d.; IUCN World Heritage Outlook n.d.).

Canada and Mexico occupy the middle ground between these poles, but each illustrates a specific governance failure. Parks Canada manages 48 national parks and national park reserves and recorded more than 15 million visits in 2024–25, with Banff alone receiving 4.23 million visitors (Daily Passport 2026; Parks Canada 2026a b). The Discovery Pass at CAD $83.50 (about US$61) is one of the world’s best-value annual park passes (Parks Canada 2026a; Off Track Travel 2026). But Canada has deployed free summer access periods, for example, the Canada Strong Pass, running from June 19 to September 7 in both 2025 and 2026, as a conservation revenue exchange for domestic tourism stimulus goals (Parks Canada 2026 a b; Daily Passport 2026). This is the Canadian variant of New Zealand’s substitution problem: when government fiscal priorities temporarily override revenue-from-use principles, the conservation earmark is weakened. Unlike the United States, Canada also does not differentiate fees by nationality, leaving significant international visitor willingness-to-pay uncaptured at parks like Banff that attract substantial Asian tourism.

Mexico’s limitation is structural rather than cyclical. The country manages 193 federally designated archaeological zones through the National Institute of Anthropology and History (INAH), supplemented by state-level fees, natural protected area charges through the National Commission of Natural Protected Areas (CONANP) which administers 232 federally protected natural areas, and local ejido levies. The result is a multi-layer structure where visitors to sites like Tulum face two, three, or four separate ticket purchases at a single gate (Absolute Adventure Mexico 2026).

At Chichén Itzá, which attracted 2.2 million visitors in 2024, the total foreign entry charge in 2026 is MXN 697 (≈US$40), split between a federal INAH fee of MXN 105 and a state fee of MXN 592 (Absolute Adventure Mexico 2026; Yucatán Magazine 2025; INAH n.d.). The body responsible for site conservation receives roughly 15% of the total charge; the state government receives roughly 85%. Neither publishes an annual earmark report, and the revenue split reflects intergovernmental convenience rather than the externality the levy is meant to address.

The state-level VISITAX — a Quintana Roo arrival levy set at 2.5 × UMA, equivalent to MXN 283 (≈US$17.75) per foreign visitor in 2025 and unchanged for 2026 — was intended to fund beach protection, archaeological-site infrastructure, and tourism marketing. It illustrates a different failure mode: collection rather than allocation. An announced increase to 3.25 × UMA effective February 2024 was reversed, with the rate ultimately remaining at 2.5 × UMA and rising only with the annual UMA reset (Travelkore 2025; Open Jaw 2024). Unlike the airline-embedded fees that achieve near-universal compliance elsewhere, VISITAX must be paid separately through the official portal or at airport kiosks. Compliance has lagged accordingly: roughly four in ten visitors did not pay in the months following implementation, and reported annual collections through 2023 were on the order of MXN 103 million (≈US$6 million) — a small fraction of both the original MXN 600 million (≈US$29 million) projection and the revenue level Quintana Roo’s foreign visitor flows would theoretically support (Travelkore/PAX 2024; Mexico News Daily 2021).

Mexico thus offers two cautionary lessons: a major site fee captured by intergovernmental fiscal politics, and a state arrival fee whose architecture is sound but whose collection mechanism is structurally weak.

Costa Rica's US$29 departure tax — introduced in the 1970s as a directly collected fee, bundled into airline tickets since December 2014 — is the regional benchmark most often cited by neighboring countries (Tico Times 2014). The departure tax itself flows mainly to the general fund, airport infrastructure, security, and tourism marketing. Site-level park entry fees are layered on top — US$20 at Manuel Antonio, US$15 at Arenal, higher at Corcovado — and these are statutorily earmarked to the National Parks Fund under separate legislation (SINAC n.d. a, n.d. b; Costa Rica Guide n.d.). The Certification for Sustainable Tourism (CST) sits above the two-track structure as a global eco-tourism brand the country actively monetizes. The departure tax, however, is not fully earmarked, and Costa Rica has yet to publish an annual reconciliation tracking each colón from the gate to the conservation outcome — the same gap that limits Mexico's scheme. The result is a working architecture: weaker governance discipline than Bonaire or Edinburgh, but materially better than Tikal or Chichén Itzá.

The Tikal case also has a transnational dimension that neither Mexico nor Guatemala has yet exploited. The Maya Forest extends across Guatemala, Mexico, and Belize, covering over 2 million hectares in the Maya Biosphere Reserve alone — a single ecological system managed by three countries under incompatible fee regimes and governance architectures (UNESCO World Heritage Centre n.d.). A coordinated Maya Forest levy framework — analogous to the Caribbean cruise levy discussions the CTO convened in 2025 — would allow entry fees at Tikal, Palenque, Calakmul, and Belize’s Caracol to collectively fund transboundary conservation at a scale no individual country can sustain on USD $19 tickets.

The Galápagos Experience

The Galápagos is one of the most ecologically sensitive mass-tourism destination in the world. Visitor numbers have more than doubled over the past 20 years and are on course to reach one million annually by 2041 (IGTOA 2023; UNESCO World Heritage Committee 2023; Hunt et al. 2023). Land-based tourism now accounts for approximately 70% of arrivals, at a fraction of the revenue-per-visitor of ship-based tourism (Hunt et al. 2023; IUCN 2020).

At the same time, man-made waste and pollution have become a major threat to the unique fauna and flora of the Galápagos, both inland and within the Galápagos Marine Reserve. Addressing the water and sanitation services challenge facing the Galapagos is crucial to safeguarding public health and animal health, preserving biodiversity, and maintaining the overall health of the land and maritime ecosystems (Marquez 2025c). The islands’ solid waste grew 66% between 2010 and 2019, reaching 28.6 tons per day, and has continued rising since (Veolia 2019; Galapagos Conservation Trust 2021).

The archipelago’s native wildlife — which includes species found nowhere else in the world — is especially vulnerable to plastic pollution, which alters natural habitats and causes injury or death when animals become entangled in accumulated debris (Marquez 2019a). Giant tortoises on Santa Cruz are ingesting face masks, glass, and plastic bags (Ramón-Gómez et al. 2024). Industrial fishing fleets lurk just outside the 198,000 km² marine reserve — an area that includes the 60,000 km² Hermandad Reserve, established in January 2022 to protect the migratory corridor between the Galápagos and Cocos Island (Charles Darwin Foundation 2022; Castrejón and Defeo 2024). These are not separate crises; they are a single compounding challenge.

The Galápagos’ existing conservation finance architecture pairs an annual operating instrument with a permanent endowment vehicle, summarized in Table 7. The foreign-visitor entry fee was doubled to US$200 effective August 2024, the first increase in 26 years (Galapagos Conservation Trust 2024; CNN 2024), and is projected to generate approximately US$40 million annually under a statutorily fixed four-way distribution among the National Park Directorate, the four municipal governments, the Governing Council, and the Biosafety and Quarantine Agency (Globetrender 2024).

The Galápagos Life Fund, capitalized in May 2023 through the world’s largest debt-for-nature conversion in history, exchanged approximately US$1.628 billion of sovereign bonds for a US$656 million “Galápagos Marine Loan” backed by the U.S Development Finance Corporation political-risk insurance and an IDB guarantee (Republic of Ecuador, Ministry of Economy and Finance 2023; DFC 2023; IDB 2023), channeling roughly US$450 million to conservation over 18 years and seeding a permanent endowment projected to reach approximately US$227 million by 2041 (Reuters 2023; Pew Bertarelli Ocean Legacy 2024). Together, the two instruments fund the 138,000 km² Galápagos Marine Reserve and the 60,000 km² Hermandad Reserve created in January 2022 (Charles Darwin Foundation 2022).

Global Lessons and Relevance for the Galápagos’ Conservation Efforts

Source: Picture taken by author, Galapagos Islands. Ecuador, 2025.

The global review presented in this post, drawing on cases from Africa, Asia-Pacific, the Caribbean, Europe, the Pacific, and the Western Hemisphere, yields a set of lessons for the Galápagos summarized in Table 8 and discussed below. The evidence highlights what has worked, where the architecture remains incomplete, and what the global record suggests about the instruments available to close those gaps.

Lesson 1: Levy Design Must Match the Externality

The most effective tourist taxes are not general revenue instruments — they are fiscal responses to specific externalities. Bonaire’s dual-fee system illustrates this most clearly, with its Visitor Entry Tax and separate Nature Fee directed to distinct purposes. Palau’s Pristine Paradise Fee and Edinburgh’s pre-launch spending plan reflect the same principle. In every case, the earmark is the instrument.

Relevance for the Galápagos: The current US$200 entry fee distributes revenue across four recipients — the National Park Directorate (40%), municipalities (30%), the Governing Council (20%), and the Biosafety and Quarantine Agency (10%). This allocation funds broad categories but does not match individual revenue streams to the specific externalities that justify them. The fastest-growing costs — solid waste (28.6 tons per day and growing), water and sewage, and biosecurity enforcement — receive no dedicated levy. A Bonaire-style disaggregation, with each instrument tied to the externality it internalizes, is one option that could produce both better ecological outcomes and stronger political legitimacy.

Lesson 2: Tiered Rates Satisfy Equity Without Sacrificing Revenue

Every high-performing levy system surveyed uses tiering rather than flat rates — Greece by hotel category, Edinburgh by accommodation cost, Kyoto by room price, Barbados by lodging class. Tiering simultaneously satisfies Adam Smith’s equality maxim — proportionality to benefit received — and maximizes revenue extraction from high-willingness-to-pay visitors without pricing out budget travelers.

Relevance for the Galápagos: The current flat US$200 foreign entry fee treats a budget backpacker and a luxury liveaboard passenger identically. An accommodation levy tiered by vessel type and lodging category — modeled on Edinburgh and Kyoto — would charge high-end liveaboard cruises and luxury ecolodges a meaningfully higher rate while keeping the base entry fee accessible. A tiered accommodation levy of this kind could expand park revenue from a single, well-designed instrument, scaled to the segment of visitors most able to pay.

Lesson 3: Additionality Must Be Legally Guaranteed, Not Politically Promised

The single most instructive cautionary tale is New Zealand’s tripling of its International Visitor Levy in 2024, where Treasury used the additional revenue to substitute existing conservation funding rather than supplement it. Barbados is the counterexample: 100% of the interest savings from its 2022 debt-for-nature swap were contractually channeled to a dedicated sustainability fund, with independent oversight. The difference is not the size of the levy — it is whether additionality is a legal obligation or a political aspiration.

Relevance for the Galápagos: The Galápagos Life Fund’s governance model already embeds the additionality principle at the marine conservation level. The risk lies in the expansion instruments. Any new accommodation levy, biosecurity surcharge, or cruise passenger fee would benefit from a statutory earmark and an independent audit mechanism. The GLF board’s multi-stakeholder model offers one available template that could be extended to govern new instruments, helping ensure that any new revenue stream supplements rather than displaces existing commitments.

Lesson 4: Digital Collection Minimizes Cost and Maximizes Compliance

Venice’s 2024 pilot failed Adam Smith’s economy maxim: implementation cost exceeded revenue raised. The contrast with Bali’s LoveBali app, Bonaire’s pre-arrival payment system, Japan’s airline-ticket-embedded departure tax, and New Zealand’s NZeTA is clear. Digital collection at a natural payment moment — booking, check-in, or ticket purchase — maximizes both convenience and compliance while minimizing administrative overhead.

Relevance for the Galápagos: The US$200 entry fee is currently collected at the airport — a reasonably efficient point. The opportunity is to extend digital pre-payment to any new instruments the islands choose to introduce. A biosecurity surcharge, accommodation levy, or cruise passenger fee paid at the booking stage and embedded in operator invoices would reduce collection cost to near zero and close the compliance gap that undermines cash-at-entry systems. The LoveBali and Bonaire models are directly replicable at Galápagos visitor-flow scale.

Lesson 5: The Cruise Externality Requires Its Own Instrument

Cruise passengers represent the sharpest mismatch between visitor impact and fiscal contribution in virtually every destination surveyed. Amsterdam, the Bahamas, and Bonaire have each responded with cruise-specific levies addressing the port congestion, marine pollution, and grey-water discharge costs that accommodation-based levies do not capture. Likewise, the CTO’s 2025 summit called for master planning as Caribbean cruise arrivals approach 36 million annually (CTO 2025a).

Relevance for the Galápagos: Ship-based tourism generates significantly higher revenue per visitor than land-based tourism, yet the rapid growth in land-based arrivals means cruise passengers are proportionally undercontributing to the waste, marine, and biosecurity costs they impose. A dedicated cruise passenger levy of $20–30 per passenger per day — ring-fenced to seabed monitoring and grey-water management — is one option directly matched to this externality.

Lesson 6: Debt-for-Nature Architecture Can Be Layered with Levy Instruments

The Barbados experience reveals that debt-for-nature swaps and tourist levies are complementary, not alternative, instruments: a tiered accommodation levy and a debt-for-nature swap operate under a single sustainability framework. The IMF has endorsed this layered approach as part of the domestic revenue mobilization strategy for biodiversity-dependent economies (IMF 2024).

Relevance for the Galápagos: The Galápagos Life Fund (GLF) already replicates the debt-for-nature architecture that made Barbados a global model. The missing layer is the tiered accommodation levy that funds land-based externalities — the gap Barbados closes with its Room Rate Levy. Adding that instrument to the existing GLF structure would give the Galápagos the two-track model that is now the international gold standard: long-term endowment finance for marine conservation, plus annual levy revenue for the waste, water, and biosecurity costs that are growing fastest.

Lesson 7: Community Benefit-Sharing Determines Political Sustainability

Tourist levies that direct revenue exclusively to conservation or central government budgets, with no visible benefit to host communities, generate sustained political opposition that eventually undermines the instrument. Namibia’s 83 community conservancies, benefiting over 190,000 people directly, set the global benchmark. Edinburgh’s housing component, Aruba’s resident-facing wastewater investment, and Palau’s statutory municipal allocation reflect the same principle through different mechanisms.

Relevance for the Galápagos: The 30% municipal allocation in the current entry fee distribution is a structural recognition of the community benefit principle, but it is not matched by a dedicated Community Resilience Fund of the kind discussed in the enhanced framework. The artisanal fishing community — under pressure from both the marine reserve boundaries and the shift toward land-based tourism — represents the single most acute community equity challenge. A 10% set-aside from any new accommodation levy, managed by a community-governed fund on the Namibia model, is one option that could address this directly and help build the political coalition that makes the broader levy architecture durable.

Lesson 8: Transparent Governance Is Not a Constraint — It Is the Revenue

The World Bank’s finding that protected area investment generates a six- to 28-fold economic return (World Bank 2021) and the IMF’s identification of nature loss as a financial stability risk (IMF 2024) rest on the same premise: the return is realized only if the money reaches the asset it is meant to protect. Every high-performing levy system reviewed here — Edinburgh, Bonaire, Barbados, Palau, Botswana — publishes annual accounts. Greece’s 82.5% revenue overperformance was verifiable precisely because the earmarking was transparent. Amsterdam’s two-star earmark quality rating reflects the opposite: levy revenue recycled into destination marketing, unrelated to the externalities the levy ostensibly addresses.

Relevance for the Galápagos: The Galápagos Life Fund (GLF)’s multi-stakeholder governance board is already the strongest accountability structure in the islands’ conservation architecture. The entry fee distribution mechanism is less transparent: there is no public annual account of how the 30% municipal allocation is spent, what the 20% Governing Council share finances, or whether the 10% biosecurity allocation is adequate for the enforcement task. Extending the GLF’s governance model — independent board, annual published accounts, performance against ecological benchmarks — to other levy instruments is one option for strengthening the conditions under which international institutions, partner governments, and visitors themselves continue to regard the Galápagos as worth the premium.

Lesson 9: Tourist Levies Must Be Designed Within Ecuador’s Fiscal Policy Constraints

The economic case for expanding the Galápagos levy architecture cannot be made in isolation from Ecuador’s fiscal context. As a fully dollarized economy since 2000, Ecuador has no monetary policy flexibility and relies entirely on fiscal policy to manage economic fluctuations (FocusEconomics 2025; World Bank 2025). It operates under a 2024–2028 IMF Extended Fund Facility requiring fiscal consolidation, against a backdrop of structurally declining oil revenues — accelerated by the 2024 referendum-mandated suspension of Yasuní drilling that reduced production capacity by 12% (U.S. Department of State 2025; CurrencyTransfer 2025). The Noboa administration, reelected in April 2025, has committed to investment-led growth and legal certainty for international partners.

Relevance for the Galápagos: Three implications follow. First, dollarization means the Galápagos cannot rely on currency depreciation to maintain price competitiveness if levies are increased — any new instrument would need to be calibrated to the inelastic demand segment rather than the price-sensitive mass-market segment. Second, ring-fenced tourist levies that do not enter the central government budget are compatible with IMF consolidation requirements, since they do not expand the deficit. The GLF — where conservation grants flow directly from a foundation rather than from the general budget — is precisely this kind of off-budget instrument. Third, the strategic pivot away from oil dependency toward biodiversity-based revenues, endorsed by the World Bank Country Partnership Framework (World Bank 2025), positions the Galápagos levy architecture as a national economic diversification instrument, not merely a park management tool.

Lesson 10: Galápagos Visitors Are in the Most Price-Inelastic Segment of Tourism Demand

The peer-reviewed literature on tourism demand at ecotourism and heritage destinations offers a consistent finding: at established UNESCO Heritage sites with unique or irreplaceable assets, demand is significantly inelastic with respect to moderate fee increases. Studies in Andalusia, across UNESCO sustainable destinations, and at Chinese national parks all confirm this pattern (Blanco et al. 2021; Galián and Ordóñez 2022; Springer Nature 2025; NIH/PMC 2021).

The Galápagos occupies the most inelastic segment of this distribution. Visitors have already paid US$1,500–5,000 in long-haul airfares and specialist packages, making the entry fee a minor share of total trip cost. The destination has no comparable substitute as no other place offers the density of endemic species. And Galápagos visitors self-select for high environmental motivation, a population that contingent valuation studies consistently associate with elevated willingness to pay.

Relevance for the Galápagos: The August 2024 entry fee doubling from US$100 to US$200 is the clearest available test, and visitor numbers have continued to grow. This is revealed-preference evidence that confirms what the academic literature predicts. A further increase in the liveaboard premium from US$200 to US$250–300, a US$30–50 biosecurity surcharge, and a US$20–30 cruise passenger levy would collectively raise the average per-visitor fiscal contribution by 25–40% without approaching the willingness-to-pay ceiling. The appropriate revenue ceiling for the Galápagos is therefore not set by demand. It is set by governance capacity — the ability to absorb, administer, and account for additional revenue transparently. That is the binding constraint the GLF framework was built to address.

Lesson 11: Compared to Peer UNESCO Heritage Sites, the Galápagos Entry Fee Remains Underpriced

The US$200 Galápagos entry fee is the highest flat entry fee charged by any UNESCO natural site globally, and on that metric alone it appears bold. What matters for conservation finance, however, is not the entry fee in isolation but the total fiscal contribution per visitor day — and on that metric the Galápagos remains below its peer destinations. Machu Picchu, Angkor Wat, Komodo, Bhutan, and Palau all extract a higher total per-visit conservation contribution through some combination of entry fees, mandatory ancillary charges, and per-night surcharges. At Komodo, Machu Picchu, and Angkor Wat in particular, a significant portion of the visitor’s total contribution flows through mandatory ancillary charges, from ranger fees, guide levies, to activity surcharges, that are disaggregated by externality and more precisely targeted to conservation costs than a flat entry fee. The Galápagos charges US$200 at the gate and almost nothing thereafter.

Relevance for the Galápagos: Three observations follow. First, there is peer-group precedent for the Galápagos to consider charging more, not necessarily through a higher flat fee, but through the disaggregated architecture every comparable site uses. Second, the UNESCO comparison supports the case for disaggregation specifically: Komodo’s ancillary charges demonstrate that visitors accept fees clearly linked to the service received. A Galápagos biosecurity surcharge, trail maintenance fee, or marine park levy would fit within the range of charges that visitors to peer UNESCO sites already routinely pay. Third, the Komodo overcrowding crisis — which prompted Indonesia’s Ministry of Forestry to impose a 1,000-visitors-per-day cap effective April 2026 after visitation exceeded the site’s established carrying capacity is a direct warning. Komodo raised fees incrementally but without a coherent demand-management architecture. The Galápagos, facing a similar trajectory, could use tiered pricing not only to raise revenue from high-willingness-to-pay visitors but to actively manage visitor flows and prevent disproportionate ecological costs.

Lesson 12: The Western Hemisphere Park-Fee Models Validate Residency Tiering, Earmark Discipline, and Two-Track Architecture

The five-country Western Hemisphere comparison surveyed here— the United States, Canada, Mexico, Guatemala, and Costa Rica — yields four operational lessons that sharpen three of the preceding lessons and add a fourth.

First, residency-based tiering is now established international practice. The U.S. January 2026 reform — a roughly 3:1 resident-to-non-resident ratio, combined with a US$100 surcharge at eleven of the most-visited parks — is the most significant validation of differentiated pricing in National Park Service history. Ecuador could apply similar logic within the Galápagos fee structure: a formal Ecuadorian national rate alongside the foreign visitor rate, and a liveaboard premium tier above the standard entry, would mirror what the U.S. system has operationalized at scale. This is a separate axis of differentiation alongside the accommodation-class tiering described in Lesson 2.

Second, the Chichén Itzá revenue split defines the governance floor. Only 15% of the foreign visitor fee flows to the federal conservation body, INAH, while 85% flows to the state of Yucatán’s CULTUR board. When the body responsible for conservation receives a small share while general state revenues capture the rest, the instrument has been captured by fiscal convenience. The Galápagos’ 40/30/20/10 distribution is more equitable, but Mexico’s cautionary example illustrates the value of legally fixing those percentages, publishing annual accounts, and ensuring that no future budget negotiation can quietly erode the park directorate’s share. VISITAX adds a second cautionary lesson: even a well-targeted levy can fail if its collection mechanism leaves compliance to visitor goodwill. The Galápagos entry fee, collected as a precondition of entering the National Park, is precisely the kind of mechanism Quintana Roo lacks. These cases reinforce Lessons 4 and 8.

Third, Tikal defines the floor the Galápagos has already cleared. Charging ~US$19 for entry to one of the hemisphere’s most significant World Heritage sites produces the predictable consequences: a Master Plan dating to 2003 that the administration has tried unsuccessfully to update for three years running, illegal looting documented as a critical threat, deforestation pressure from the surrounding Petén, and inadequate ranger capacity. The Galápagos sits at the opposite pole. Its challenge is not to avoid Tikal’s underpricing error but to ensure its high-revenue model is matched by the governance architecture that converts revenue into conservation outcomes as shown in the Barbados, Bonaire, and Edinburgh cases. Together with the Bhutan and Palau ceiling in Lesson 11, Tikal anchors the lower bound of the pricing range within which the Galápagos has substantial room to move.

Fourth, the Costa Rica two-track model points to a missing layer in the Galápagos architecture. Costa Rica combines a single low-cost air-departure fee with site-level entrance fees set independently by SINAC for each of its 29 national parks, with daily visitor caps and online pre-booking at the most ecologically sensitive sites. The Galápagos has the flat US$200 entry but no equivalent layer of differentiated site, trail, or activity fees. Adding such a layer, a higher entry premium for the most ecologically sensitive sites such as Bartolomé or Genovesa, a separate marine-activity surcharge, and a guided-trail levy where ranger costs are highest, are options that would replicate the disaggregation Costa Rica has operationalized at national-system scale, and would directly address the externality-matching observation set out in Lesson 1.

Taken together, these four sub-lessons confirm and extend the eleven that precede them. Residency tiering is one possible axis of differentiation that complements the accommodation-class tiering described in Lesson 2. Chichén Itzá and VISITAX serve as cautionary mirrors of Lessons 4 and 8. Tikal anchors the lower bound of the pricing range described in Lesson 11. And Costa Rica’s two-track architecture offers one of the more operationally specific demonstrations of the externality-matching principle set out in Lesson 1 — a model the Galápagos may wish to consider as a reference point rather than a template to copy.

Options for Strengthening Galápagos Conservation Finance

The twelve lessons above point toward a coherent set of options for the Galápagos. The eight structural lessons describe what good levy architecture looks like in practice: externality-matched, tiered, digitally collected, additive, cruise-disaggregated, layered with the GLF, community-sharing, and transparently governed. Three contextual lessons identify the conditions under which an expanded levy framework would be feasible. A twelfth, regional-comparative lesson confirms that the operational instruments such as residency tiering, earmark discipline, and two-track site-level pricing are already in use at peer destinations across the Western Hemisphere, and can be adapted to Galápagos conditions.

Ecuador’s fiscal context is itself part of an argument for considering an expanded levy agenda rather than against it. Dollarization, declining oil revenues, IMF fiscal consolidation requirements, and the World Bank’s endorsement of biodiversity-based revenue diversification all point in a similar direction: off-budget, ring-fenced, tourism-funded conservation instruments are the kind of fiscal tool the country’s circumstances make attractive, and the GLF plus an expanded levy framework offers an existing template (World Bank 2025; FocusEconomics 2025; IMF 2024).

The demand-elasticity evidence suggests that price-side concerns may be less binding than commonly assumed. Galápagos visitors sit in the most price-inelastic segment of global tourism demand: they have self-selected for an unique ecological experience, have already committed to high total trip costs, and the revealed-preference evidence from the 2024 fee doubling is consistent with the academic finding that demand at such destinations does not fall in response to moderate fee increases. A further 25–40 percent increase in the average per-visitor contribution through tiered liveaboard premiums, biosecurity surcharges, and cruise passenger levies appears unlikely to reduce visitor numbers, and would not approach the willingness-to-pay ceiling for the destination’s core high-spending segment (Blanco et al. 2021; NIH/PMC 2021).

The peer comparisons place the Galápagos within a clear range of plausible options. The US$200 entry fee is already the world’s highest flat natural-site fee, but Bhutan, Palau, Komodo, and Machu Picchu each extract a higher total per-visit conservation contribution through a combination of entry fees, ancillary charges, and ranger or guide levies. The Western Hemisphere comparison adds further range: U.S. residency tiering, Costa Rica’s two-track site-level pricing, and the Mexican and Guatemalan cautionary cases collectively show that the instruments under consideration are not theoretical — they are in use, at scale, at peer destinations sharing comparable institutional and political conditions. Peer-group precedent therefore exists for the Galápagos to consider charging more, not through a higher flat fee but through the disaggregated, activity-linked architecture that every comparable site uses.

The Galápagos chose boldness in 2024 by doubling its entry fee. The available evidence suggests that the next phase may turn less on boldness than on operational design: whether and how to layer Costa Rica’s site-level disaggregation, the U.S. residency differential, and Bonaire’s externality matching onto the existing $200 entry plus GLF foundation.

Adam Smith’s four maxims offer one framework against which these options can be assessed. Whatever combination of instruments is ultimately considered, the question for policymakers is whether each would be applied equitably, certainly, conveniently, and economically (Smith 1776), and whether it would carry governance features, such as statutory ring-fences, additionality guarantees, independent audit, and community benefit-sharing, that distinguish a conservation instrument from a general tax.

The cumulative proposition is that the Galápagos already has one of the world’s most innovative conservation finance instruments in the Galápagos Life Fund, but it does not yet have the complementary levy architecture that comparable high-performing destinations have built around their flagship instruments. The US$200 entry fee is akin to Adam Smith’s toll — but a flat one, applied without tiering, without disaggregation by externality, and without the digital pre-collection that minimizes cost and maximizes compliance. The GLF is a Barbados-style debt conversion — but without the tiered accommodation levy that Barbados pairs with it to fund the land-based costs the endowment does not reach.

Whether to expand the levy architecture, and in what combination, is ultimately a decision for the Government of Ecuador, the Galápagos Governing Council, the Park Directorate, and the GLF Board. What this review offers is a structured account of the available options, the comparative experience that informs them, and the Adam Smith criteria — equity, certainty, convenience, and economy — by which their merits can be weighed.

Source: Picture taken by author, Galapagos Islands. Ecuador, 2019.

Conclusion: The Principle and the Practice

The economic case for tourist taxes is not new. It rests on the oldest principle in public finance: those who benefit from a public good should contribute to its maintenance, in proportion to what they use.

Adam Smith's tollgate keeper, charging each carriage in proportion to the wear it imposes on the road (Smith 1776, V.i.d.6), is, in 2026, akin to the QR code scanner on the jetty at Puerto Ayora on Santa Cruz Island in the Galápagos archipelago, verifying that the visitor has paid their levy before walking the trails that their predecessors helped to protect. It is also the ED card terminal at Aruba’s airport, the LoveBali app, and the STINAPA dive tag pinned to a wetsuit in Bonaire. The technology changes. The principle does not.

What the global cases collectively contribute is a demonstration of range. They show that locations can embed conservation finance directly into sovereign debt architecture, and that a dual-fee system including — can sustain conservation outside the government budget. They show that high-volume, fragmented levy systems can generate significant revenue while raising harder questions about earmarking discipline, and that a single-purpose, infrastructure-linked sustainability fee, collected efficiently and spent additively, is one operational expression of Adam Smith's design maxims. They show that residency tiering and site-level disaggregation can be operated at national-system scale with effective administration, and that the absence of either earmark discipline or pricing adequacy produces predictable failures — revenue that does not reach conservation in the first case, and a fee too low to fund it in the second.

The implication is not that the Galápagos must adopt any particular instrument from this record, but that it has a wide set of references to draw on, each illustrating a specific design feature (earmarking, tiering, digital collection, additionality, community benefit-sharing, transparent governance) that policymakers can weigh in any combination suited to the local conditions.

If a well-designed, properly earmarked, multi-tier tourist levy can be made to work in the Galápagos, with transparent governance, additionality guarantees, and genuine community benefit-sharing, the comparative record suggests it can work in other places. However, if the Galápagos continues to rely on a flat entry fee and a marine conservation fund while land-based tourism grows faster than the waste, water, and biosecurity infrastructure that supports it, the experience will offer an equally instructive lesson: that revenue mobilization without governance design produces taxation rather than conservation finance.

The choice between those options is, in Adam Smith’s terms, a question of whether any toll that is applied is done equitably, certainly, conveniently, and economically (Smith 1776), and whether the revenue, like the carriage on the well-maintained highway, is directed to help conserve to the road it came from. That is the framework this review offers.

The decision rests with Ecuador’s policymakers in consultation with its citizens.

Source: Picture taken by author, Galapagos Islands. Ecuador, 2025.

DISCLAIMER: The views expressed in this post are those of the author, and they do not represent the views of the Charles Darwin Foundation, its Board and Governing Members, or its management.

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Veolia. 2019. Galápagos Waste Characterization Study. As cited in Orcatec, Waste Management Blueprint Galapagos Islands, 2021. https://www.orcatec.ec/images/orcatec/01-inicio/202106_Waste%20Management%20Blueprint%20Galapagos_Final.pdf.

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“I am like the man who carried a brick with him to show the world what his house was like.”

— Bertolt Brecht (1898–1956), epigraph in Mario Benedetti (1920–2009), “La casa y el ladrillo” (1977)

“La memoria no es lo que recordamos, sino lo que nos recuerda. La memoria es un presente que nunca acaba de pasar.”

“Memory is not what we remember, but what remembers us. Memory is a present that never quite comes to an end.”

— Octavio Paz (1914–1998), 1990 Mexican Nobel Prize Laurate in Literature, “¿Águila o sol?” (1997)

Introduction

I grew up in Cuenca, Ecuador, my native city built of mortar, brick, and stone. Founded in 1557, it was designed in accordance with the strict urban planning regulations issued thirty years earlier by Emperador Carlos V, ruler of Spain, Germany, the Netherlands, and much of Italy and the Americas. The city became part of a vast empire on which, as people said, the sun never set, as daylight always touched some corner of its domains (Parker 2019). Cuenca still observes the formal orthogonal town plan that it has respected for 400 years, and centuries of history are captured in walls, courtyards, and cobblestone streets (UNESCO World Heritage Centre, 1999). Its handmade bricks, shaped from local clay using long-standing techniques, remain part of the city’s architecture and identity (Aguirre Ullauri et al., 2022). In 1999, Cuenca was inscribed as a UNESCO World Heritage Site (UNESCO World Heritage Centre, 1999).

Source: Photo taken by author, Cuenca (Ecuador) September 2025.

The city is surrounded by mountains on all sides and is shaped geographically by four rivers that flow through it — the Tomebamba, Yanuncay, Tarqui, and Machángara — all of which originate in the páramo of Parque Nacional Cajas to the west.

Source: Photos taken by author, Cuenca (Ecuador) September 2025.

As a child, along with my brothers and sisters, we walked those stone-paved streets the way children do, without thinking, as if the city itself were simply our playground. We crossed the bridges connecting barrios across a green valley carved by the four rivers, and wandered through streets, parks, plazas, colonial houses, and churches, built by generations of Cuencanos who were nudged by ambitious dreams that what they created and left behind would endure, becoming part of the city’s legacy for their children and their children’s children.

I discovered Cuenca on foot, and later on my red bicycle, riding alongside my sister Magdalena between our home in El Vergel, then a new, evolving neighborhood, and our school in the old quarters near the Catedral de la Inmaculada Concepción, whose construction began in 1885 and was largely completed in the mid-1970s.

Decades have passed since my family left Cuenca, moving from place to place as part of my father’s work—learning about and experiencing the wider world, as he used to say. Yet those early memories remain vivid: the Calle Larga; the Luis Cordero Street, where my maternal grandparents lived, and where we too lived for a time; the Gran Colombia Street, between Juan Montalvo Street and Tarqui Street, where my paternal grandparents made their home, nearby to the Iglesia de Santo Domingo, where my abuelo Miguel attended the daily 5:00 AM Mass; La Escalinata in El Barranco; and the Tomebamba River, cutting through visible layers of history.

Source: Photos taken by author, Cuenca (Ecuador) September 2025.

But what I remember most are the walks with my parents to the Iglesia del Santo Cenáculo, a Jesuit church near my paternal grandparents’ home and close to the primary school I first attended after our return from Medellín, Colombia, where my father as young physician was completing a medical specialty at the Hospital San Vicente de Paul, a major teaching and referral medical center. Built between 1894 and 1912, El Cenáculo was a place of quiet devotion. Stone and brick there carried a simple message: we have endured and will continue to endure.

Source: Photos taken by author, Cuenca (Ecuador) September 2025.

My father, Miguel A. Marquez—our Viejo—a pathologist and oncologist, grew up influenced by the intellectual, artistic, and bohemian spirit that traditionally has characterized Cuenca, and instilled in us a deep belief and understanding of the rationality underlying the convergence and complementarity of science and spirituality. Like many Cuencanos who leave to explore the world, we carried those early fragments of place and meaning with us. That sense of carrying something forward returned, unexpectedly, years later in the suburbs of Bethesda, Maryland, a place my family came to embrace as our second home following my father’s work posting in Washington, D.C.

Source: Photo taken by author, Cuenca (Ecuador) September 2025.

A House, a Garden, a Beginning

The home of the Hope Connections for Cancer Support, a nonprofit organization that provides free programs of emotional support, education, and wellness for people with cancer and their families, has a history of its own (Marquez 2026). Built in 1928 for Gilbert Hovey Grosvenor, the long-time editor of the National Geographic Magazine from 1899 to 1954, and president of the National Geographic Society from 1920 to 1954, and his wife, Elsie May Bell Grosvenor, daughter of Alexander Graham Bell, the inventor of the telephone and a pioneer in the science of communication, it has had several distinct lives: as a private residence, a conservation space, and now a place for healing (Kyles 2022; National Geographic Society n.d.; Encyclopedia Britannica 2026). Its purpose has changed, but its continuity has not, evolving from a place shaped by the advancement of human connection and knowledge to one devoted to restoring connection in the face of illness and death.

Source: Photo taken by author, Hope Connections for Cancer Support, Bethesda, Maryland, USA, April 2026.

My wife and I serve on the Development Committee of the organization. The unveiling of the Healing Garden marked an important milestone, one shaped by sustained effort and shared commitment. The idea is simple: a quiet space organized around a curved brick pathway, where names are inscribed not as endings, but as continuities. My family will also have a brick there:

Source: Photo taken by author, Hope Connections for Cancer Support, Bethesda, Maryland, USA, April 2026.

And as the event began on that early spring afternoon of April 16, 2026, we received news that reframed the moment entirely: our third grandson, Gabriel, had just been born. While we were there to honor my father’s memory, a new life had begun, adding another Marquesito to our family and revealing, with clarity, the deep interconnectedness of the cycle of life and the ceaseless progression of the human spirit from one generation to the next.

In that instant, the boundaries between the past and a new beginning seemed to dissolve, blending “the real and the fantastic” into a profound sense of continuity. That moment, indeed, seemed to illustrate what Gabriel García Márquez, the 1982 Colombian Nobel Laureate in Literature, reminded us: life is not only what one lives, but what one remembers and how one tells it (García Márquez 2002).

What We Carry

The accumulated scientific evidence is clear: tobacco, a legal product, kills (American Cancer Society 2024; U.S. Department of Health and Human Services 2004). My father died of lung cancer—a largely preventable disease attributable to lifelong tobacco use and addiction. I spent part of my professional life working on that problem, advocating for and supporting countries in the design and implementation of policies to reduce tobacco demand, consumption, and associated health risks through taxation to raise prices and reduce affordability, regulation, and education to change the social acceptability of tobacco use (Marquez, 2025; Marquez & Moreno-Dodson, 2017).

Source of Image: Shutterstock id 2455595409

But standing there on that beautiful early spring afternoon of April 16, 2026, holding that brick, none of it felt like policy. It felt as if my father's spirit was there — perhaps in one of the late-afternoon bats that appeared, reminding us of his late-night working habits that had earned him the nickname "El Masho Marquez”.

That moment evoked the words of the Peruvian poet César Vallejo, who reminds us: “Cuando alguien se va, alguien queda. El punto por donde pasó un hombre ya no está solo. Únicamente está solo, de soledad humana, el lugar por donde ningún hombre ha pasado” (Vallejo 1939/2007)—that when someone leaves, someone remains, and the places touched by human presence are never truly empty. Loss, then, is never abstract; it endures quietly and persistently in our lives. And yet memory does more than register absence—it builds continuity.

Also, like a southern echo, there came to mind the words of Pablo Neruda, the 1971 Chilean Nobel Laureate in Literature, reminding us that ordinary things like stone, wood, and earth carry human experience and give it form (Neruda 1954). The same is true of bricks, like those that will shape Hope Connections for Cancer Support Healing Garden, not as markers of closure, but as part of a pathway of memory where loved ones are remembered and honored.

People will walk through the Healing Garden without knowing the names beneath their feet, and yet they will be sustained by them. This is the space Hope Connections for Cancer Support was made to occupy. Medicine may diagnose and treat disease, but community is what sustains people!

What We Leave Behind

In Cuenca, we learned early that the city we inhabited was built by people we will never meet. They shaped clay, fired it, and set it in place as red bricks with the expectation that it would last. What they built, we inherited. What we build now, others will inherit.

One day, my grandson Gabriel—along with his brothers Javier and Leo—may walk the Hope Connections for Cancer Support Healing Garden path in Bethesda. They may pause, read the Marquez name, and come to understand something of the man who came before them, whose life, values, and presence are carried in their genes and live on in them as part of their spirit.

That is what a brick can do. It does not simply mark what has passed. It holds it quietly within the present, where memory endures. And in doing so, it reminds us that what we leave behind does not disappear, but it endures in our memory and continues to live among us.

To conclude, perhaps it is appropriate to draw from the Ecuadorian writer Jorge Icaza, whose novel Huasipungo (1934) gave Spanish-language literature one of its most enduring Kichwa-rooted concepts. The word combines huasi (house) and pungo (door) — the threshold of ancestral ground. A commemorative brick in a healing garden is like a small huasipungo: a doorway between the house and the land, where a name is held, and where a people’s memory lives (Icaza, 1934).

How You Can Help Hope Connections for Cancer Support

If this message resonates with you, there are meaningful ways to contribute:

• Make a donation to support free programs and services

• Become a sustaining donor and help ensure continuity of care

• Volunteer your time or expertise

• Share this message to expand awareness and reach

Learn more and support Hope Connections:
https://hopeconnectionsforcancer.org

The Impact of Your Support

Contributions make possible the offering of evidence-based programs:

• Support groups that reduce isolation.

• Mind-body programs that build resilience.

• Educational sessions that empower patients and caregivers.

• Outreach efforts that expand access to underserved communities.

Every act of support helps transform the cancer experience—from isolation to connection.

In the end, the message is simple, but it carries profound meaning: No one should face cancer alone.

Follow Hope Connections for Cancer Support

• Instagram:
  https://www.instagram.com/hopeconnections4cancer

• Facebook:
  https://www.facebook.com/hopeconnectionsforcancer

• LinkedIn:
  https://www.linkedin.com/company/hopeconnectionsforcancersupport

• X (formerly Twitter):
  https://x.com/hopeconn4cancer

References

Aguirre Ullauri, M. del C., Romero Bastidas, M., Ramírez Bustamante, J., & Castillo Carchipulla, E. 2022. The handmade brick of Cuenca (Ecuador): An initial characterization within the heritage framework. Conservar Património, 41, 68–94. https://doi.org/10.14568/cp26915

American Cancer Society. 2024. Lung cancer risk factors. Atlanta, GA. https://www.cancer.org/cancer/types/lung-cancer/causes-risks-prevention/risk-factors.html

Benedetti, M. 1977. La casa y el ladrillo. Madrid: Visor Libros. https://www.visor-libros.com/products/la-casa-y-el-ladrillo-1976-1977

Encyclopedia Britannica. 2026. Gilbert Hovey Grosvenor. In Encyclopedia Britannica. Retrieved April 21, 2026, from https://www.britannica.com/biography/Gilbert-Hovey-Grosvenor

García Márquez, G. 2002. Vivir para contarla. Barcelona: Mondadori. https://openlibrary.org/books/OL3735659M/Vivir_para_contarla

Icaza, J. 1934. Huasipungo. Quito: Imprenta Nacional. https://www.solidaridadobrera.org/ateneo_nacho/libros/Jorge%20Icaza%20-%20Huasipungo.pdf

Marquez, P. V., & Moreno-Dodson, B. (Eds.). 2017. Tobacco tax reform at the crossroads of health and development. Washington, DC: World Bank Group. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/491661505803109617

Marquez, P. V. 2025. Global tobacco taxation: A decade of stalled progress and missed opportunities for improving public health. https://pmarquez.substack.com/p/global-tobacco-taxation-a-decade

Marquez, P. V. 2026. “No one should face cancer alone": Why community support matters — The Hope Connections for Cancer Care experience. Substack post, March 17, 2026. https://pmarquez.substack.com/p/no-one-should-face-cancer-alone-why

Kyles, A. 2022. Hope Connections moves to new home at Grosvenor Mansion in Bethesda. Bethesda Magazine, October 5, 2022. https://bethesdamagazine.com/2022/10/05/hope-connections-moves-to-new-home-at-grosvenor-mansion-in-bethesda/

National Geographic Society. n.d. Our Story. Washington, DC.
https://www.nationalgeographic.org/society/our-story/

Neruda, P. 1954. Odas Elementales. Buenos Aires: Editorial Losada. https://www.worldcat.org/title/odas-elementales/oclc/4784758

Paz, O. 1997. ¿Águila o sol? In Obras completas (Vol. 11). México, D.F.: Fondo de Cultura Económica. (Original work published 1951) https://www.fondodeculturaeconomica.com/Ficha/9789681639051/F

Parker, G. 2019. Emperor: A New Life of Charles V. New Haven: Yale University Press.
https://yalebooks.yale.edu/book/9780300241020/emperor/

UNESCO World Heritage Centre. 1999. Historic Centre of Santa Ana de los Ríos de Cuenca (Inscription No. 863). Paris: UNESCO World Heritage List. https://whc.unesco.org/en/list/863/

U.S. Department of Health and Human Services. 2004. The health consequences of smoking: A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. https://www.ncbi.nlm.nih.gov/books/NBK44695/

Vallejo, C. 1939/2007. “No vive ya nadie en la casa.” In Poemas humanos. Lima [Madrid, 1939]: Ediciones Laberintos, Centro Peruano de Estudios Culturales.
https://ia800705.us.archive.org/24/items/PoemasHumanos/Poemas-Humanos.pdf

“One day or one night—between my days and my nights, what difference could there be?”

—Jorge Luis Borges (1899–1986), Argentine poet, essayist, and author of short stories, “La Escritura del Dios,” in El Aleph (“The Writing of the God,” in The Aleph and Other Stories) (2011)

Introduction

As reflected in a previous post, I came to understand the complexity and human drama of coma and related disorders of consciousness through an unforeseen event that profoundly affected my family (Marquez 2019; Marquez 2026; Weitzel and Bavishi 2024). These events are among the most uncertain and clinically challenging in medicine, often emerging suddenly and unpredictably, whether after a spontaneous subarachnoid hemorrhage, as in my own family’s experience, or following a traffic injury or another acute brain lesion.

It was with that perspective in mind that I attended the World Coma Day 2026 event at Johns Hopkins Hospital, titled “Dignity in Silence: Systems of Humanism for Patients with Disorders of Consciousness,” organized by the Neurosciences Critical Care Unit (NCCU) under the leadership of the distinguished Colombian colleague, José Ignacio Suárez, a neurologist, neurointensivist, and leading specialist in neurocritical care, and his team (World Coma Day 2026; Johns Hopkins Medicine n.d.a. 2026; Cho and Suarez 2025).

In this post, I reflect on each of the themes discussed during the event—from patient narratives and music therapy, to consent as an evolving patient right, to improvements in prognostic communication. Together, they point toward a broader vision of care: one that seeks not only to preserve life, but also to restore it by more fully recognizing the person within the patient, supporting families, and bringing greater humility and humanity to clinical judgment and decision-making. In this sense, the themes discussed offer a compelling window into how the care of persons with disorders of consciousness is being redefined, not only through scientific and clinical advances, but also through a renewed commitment to person-centered care.

This shift has taken on added urgency in light of emerging evidence that, in some patients with severe brain injury, awareness may persist even when the body can no longer reliably express it (Bodien et al. 2024; Owen et al. 2006). Advances in neurophysiology, neuroimaging, and computational analysis are increasingly making it possible to detect these concealed signs of consciousness, challenging long-held assumptions and reshaping how clinicians approach diagnosis, prognosis, and the ethical responsibilities of care (Schiff 2007; Monti et al. 2010).

Key Themes from the Event "Dignity in Silence”

1. Restoring Personhood Through Patient Narratives

A powerful theme discussed at the onset of the event was the importance of patient narratives in restoring personhood to individuals whose ability to speak, respond, or interact with the world may be profoundly altered. This matters because patients with disorders of consciousness are especially vulnerable to being reduced, however unintentionally, to their neurological status, imaging findings, or prognostic category. Yet the person does not disappear when responsiveness is lost. The patient remains someone with a biography, relationships, preferences, memories, and full humanity. Recognizing that reality is not incidental to good care, but central to it.

A compelling illustration of this came through Elizabeth Tracey’s presentation on TIMS—This Is My Story—a simple yet innovative instrument developed at Johns Hopkins Hospital to help restore identity and humanity within critical care (World Coma Day 2026; Tracey 2026). Developed during the COVID-19 pandemic, when medical teams were caring for gravely ill patients while often knowing little about them as people, TIMS consists of a brief audio narrative, typically about 1.5 minutes long, that provides a snapshot of the patient as a person. The recording, made by the patient or a loved one, if they record on the patient's behalf, is reviewed, securely uploaded, and linked within the patient’s electronic medical record, making it accessible to the care team during rounds and clinical discussions. It features responses to four guiding questions: how the patient wishes to be addressed; what brings them joy; what the medical team should know to care for them best; and what brings them peace. In this way, clinicians can hear, in the patient’s or family’s own voice, who that person is beyond the illness (Tracey et al. 2021; Tracey et al. 2024; Tracey et al. 2025).

The TIMS interview uses a structured yet flexible approach that begins with simple questions to build comfort, progresses to richer descriptions of the patient’s life and relationships, and culminates in open-ended reflections, including what loved ones would say if they were present with the patient, their hopes and fears, and what they believe the medical team should know to provide the best possible care (Tracey et al. 2021; Tracey et al. 2024; Tracey et al. 2025).

The questions are not about diagnosis, prognosis, or laboratory values. They are questions about identity, dignity, values, and meaning. TIMS offers a powerful reminder that humanized care does not always require more technology or more elaborate protocols; sometimes, it begins with asking better questions.

This narrative is not merely an “add-on” expression of compassion, as it can function as a clinically meaningful way of knowing the patient more fully. By preserving continuity between the person “before” and the person “now,” it provides orientation, moral grounding, and emotional connection for both families and care teams. Evaluation studies of the TIMS intervention show that its use is associated with greater clinician empathy and improved communication with families, as well as a stronger sense of connection within the care process (Tracey et al. 2024). A follow-up study found that most patients and loved ones regarded the TIMS recording process as easy, meaningful, and thought-provoking, although some found it uncomfortable and a minority questioned its relevance to their care (Tracey et al. 2025).

Perhaps most revealing are the responses from patients and families themselves: “I see you are trying to make me into a human”; “I am so glad to be able to help in my grandmother’s care”; or “No one has ever asked me these kinds of questions before.” These comments capture with clarity what modern hospital care can sometimes obscure: that severe illness, especially in emergency and intensive care units, can depersonalize patients at the very moment when their humanity most needs to be protected. TIMS pushes back against that tendency by restoring voice, biography, and relational presence to the clinical encounter.

At the event, this idea was not presented in abstract ethical terms alone. It was embedded in a broader argument: that patients in coma or related states should not be approached solely as “cases,” but as persons whose humanity remains present even when outward expression is limited or absent. The development of a dedicated TIMS application further suggests that preserving personhood need not remain an individual act of compassion; it can be intentionally designed into care delivery as a scalable, low-cost, high-value intervention.

The presentation concluded by extending this logic beyond patients, emphasizing that humanizing care also requires protecting the humanity of clinicians and other service providers themselves. Without adequate support, clinicians working under conditions of sustained uncertainty, high-stakes decision-making, and repeated exposure to suffering may become emotionally depleted and, over time, morally frayed, a condition closely related to moral distress and moral injury in clinical practice (Epstein and Hamric 2009; Dzeng and Curtis 2018; Greenberg et al. 2020).

As suggested in the discussion, interventions that restore personhood to patients—such as TIMS may also help mitigate this erosion by reconnecting clinicians with the values, meaning, and relational dimensions that initially drew them to medicine (Tracey et al. 2024; Tracey et al. 2025). In that sense, one of the most important frontiers in critical care may lie not only in technological sophistication, but in the deliberate recovery of personhood for patients, families, and clinicians alike.

Source: Salvador Dalí, The Persistence of Memory, 1931, oil on canvas., Photo of painting taken by author at The Museum of Modern Art, New York City, February 28, 2026.

Source: Wifredo Lam, Le Corps et l’âme / The Body and the Soul / El cuerpo y el alma, 1966, oil on canvas, private collection. Photo taken by author at Wilfredo Lam Retrospective “When I Don’t Sleep, I Dream”, The Museum of Modern Art, New York City, February 28, 2026.

2. Music Therapy and Human Connection Beyond Words

Another important theme discussed at the event was the role of music therapy and other sensory–relational interventions in the care of patients with disorders of consciousness.

As suggested in a recent review, music therapy holds promise as a treatment for patients with severe acute brain injury and disorders of consciousness admitted to critical care units (Devlin et al. 2025). It leverages the intrinsic properties of music to engage patients and their families and may promote recovery through neurological, psychological, and physiological mechanisms (Devlin et al. 2025).

Music occupies a unique place in human experience: it is emotional, relational, embodied, and deeply tied to memory and identity (Levitin 2006; Sacks 2007). For that reason, it may reach dimensions of awareness and responsiveness that are not always accessible through conventional clinical interaction, engaging distributed neural networks involved in emotion, autobiographical memory, and self-related processing (Janata 2009; Koelsch 2014). This helps explain why music has drawn increasing attention in neurorehabilitation and disorders-of-consciousness care, where emerging evidence suggests it may facilitate behavioral responsiveness, emotional engagement, and possibly diagnostic insight in patients with impaired consciousness (Devlin et al. 2025).

This theme was explored in a presentation by Kerry Devlin on “Music Therapy as a Humanizing and Diagnostic Tool in Disorders of Consciousness” (World Coma Day 2026; Devlin 2026). Drawing on her clinical work within the neurocritical care context at Johns Hopkins Medicine, Devlin argues that music therapy can serve both a humanizing function and a clinically informative role in patients with acute brain injury and disorders of consciousness, particularly when interventions are individualized and grounded in patients’ autobiographical and relational contexts (Devlin 2026).

At present, this contribution is best understood as part of an emerging clinical and conceptual framework rather than a fully standardized evidence base. Importantly, it does not romanticize music as a pathway to recovery. Rather, it situates music therapy as a noninvasive, context-sensitive intervention that may sustain connection, support families, and contribute meaningfully to care in settings defined by uncertainty and limited communication (Devlin 2026; Froutan et al. 2020).

Evidence from broader clinical contexts indicates that music-based interventions can reduce anxiety, agitation, and physiologic stress responses, including heart rate and blood pressure, while also supporting pain management (Bradt et al. 2016; Hole et al. 2015). For patients with coma or of patients with disorders of consciousness, the implications are particularly significant. As emphasized in Devlin’s work, music may function as salient, personally meaningful sensory stimulation capable of eliciting neural responses detectable through EEG or neuroimaging, subtle behavioral changes, and autonomic modulation (O’Kelly et al. 2013; Särkämö et al. 2008; Devlin 2026).

Autobiographical or preferred music appears especially effective in activating preserved neural networks and emotional circuits, suggesting that music may access aspects of the patient’s internal world that remain otherwise difficult to detect (O’Kelly et al. 2013; Särkämö et al. 2008). Thus, music therapy may contribute not only to patient comfort but also to the clinical assessment of awareness and responsiveness, an area of central importance in neurocritical care practice (Giacino et al. 2018).

Beyond passive listening, an important extension of this work lies in the integration of rhythm, movement, and embodied interaction, as seen in dance-based therapies. Interventions such as tango-based rehabilitation demonstrate how structured musical movement can simultaneously engage motor, cognitive, and emotional networks, supporting recovery in neurological conditions such as Parkinson’s disease (Hackney and Earhart 2009, 2010; McKee and Hackney 2013; Docu et al. 2022).

Indeed, as highlighted in a recent The New York Times article, structured tango therapy is increasingly being used as a clinically meaningful rehabilitation approach for people with Parkinson’s disease, employing rhythm, partnered movement, and improvisation to strengthen gait, balance, coordination, and cognitive engagement that help address both motor and non-motor deficits central to the condition (Rabin 2026). Similarly, a Washington Post article describes how a choir of stroke and brain injury survivors at a rehabilitation hospital uses structured singing as a therapeutic tool to improve speech, memory, coordination, and emotional resilience, illustrating how active, social music-making can support neurological recovery and restore a sense of identity and community after injury (Golden 2026).

While these studies are not specific to patients with disorders of consciousness, they are conceptually important. They illustrate how rhythm, synchronization, and interpersonal attunement can activate distributed neural systems and support functional recovery. Even in the absence of overt movement, the neural architecture of rhythm and entrainment may remain partially preserved, offering pathways for engagement beyond conventional clinical interaction (Thaut and Hoemberg 2014).

Music therapy also shapes the relational environment of care. Families often experience these interventions as moments that reconnect them with the person they know, evoking memory, identity, and emotional presence. These dimensions are especially important in caring for patients with disorders of consciousness, where uncertainty is profound and communication is limited. As emphasized in the broader literature, care in these settings must attend not only to neurologic status but also to the experiences of families navigating profound uncertainty, prolonged grief, and surrogate responsibility (Fins 2015; Laureys and Schiff 2012).

In this respect, music therapy, especially as conceptualized in Devlin’s work, points toward a deeper understanding of care: one in which clinical practice includes intentional efforts to remain in contact with the person, even when that contact must occur beyond words.

Source: Édouard Vuillard (1868-1940), At the Piano, 1884. Photo taken by author at Thielska Galleriet, Stockholm, April 3, 2026.

3. Consent as an Evolving Process: Autonomy, Surrogacy, and Ethical Accompaniment

A third major theme discussed at the event concerned the ethical complexity of caring for persons who cannot speak for themselves, particularly in relation to consent, autonomy, and surrogate decision-making.

These challenges are most evident in patients with disorders of consciousness. In this context, the question of consent takes on a different character. These are not simply cases of routine decisional incapacity. Rather, they involve conditions in which agency may be absent, partial, fluctuating, or hidden, and in which families are often asked to make consequential decisions in the midst of uncertainty, grief, and hope (Fins 2013; Laureys et al. 2010; Peterson et al. 2020; Owen et al. 2006; Giacino et al. 2018).

In such circumstances, the ethical challenge extends beyond determining who may authorize care; it lies in how decisions are made responsibly when the patient’s voice is not readily accessible. This has led to a growing emphasis on relational and interpretive models of decision-making, in which surrogates are understood not merely as legal proxies, but as moral agents tasked with representing the patient’s values and identity (Buchanan and Brock 2012; Sulmasy and Snyder 2010; Snyder 2012; Wendler and Rid 2011; Kon 2010).

Adam Schiavi’s presentation on “Gaining Consent in Patients with Disordered Consciousness,” delivered at the event, brought these ethical tensions into sharp focus (World Coma Day 2026; Schiavi 2026). It underscores a central insight, well supported in the literature, that respect for autonomy does not vanish when consciousness is impaired; rather, it becomes more difficult to discern and more demanding to uphold in practice (Fins 2013; Owen et al. 2006).

The literature and discussion presented during the session further support the view that, in this context, consent should not be understood merely as a one-time legal transaction or procedural formality. Rather, it is better understood as an ongoing relational process. Surrogates are not simply procedural substitutes; they become moral interpreters of what the patient might have wanted, valued, feared, or accepted. Ideally, such decisions should be guided first by the patient’s own previously expressed wishes and values and, where these are not known, by a best-interest standard grounded in respect for the person (Buchanan and Brock 2012; Suppes and Fins 2013; Rissman and Paquette 2020; Beauchamp and Childress 2019).

Yet in practice, as stressed in the presentation, this is extraordinarily difficult. Surrogates do not make decisions in a vacuum. They do so within relationships shaped by love, hope, fear, grief, memory, and moral responsibility (Wendler and Rid 2011; Vig et al. 2007). Nor can clinicians assume that neurological assessment alone resolves the ethical question of what ought to be done. Advances in neuroimaging and electrophysiology have shown that some patients diagnosed as unresponsive may retain covert awareness, further complicating ethical decision-making (Owen et al. 2006; Monti et al. 2010; Claassen et al. 2019).

Good care therefore requires not only technical expertise, but ethical attentiveness: the capacity to support families, clarify values, interpret uncertainty honestly, and engage in shared decision-making without collapsing uncertainty into false certainty (Kon 2010; Curtis and White 2008; Curtis 2004).

This relational understanding of consent has important implications across the continuum of care, from research participation and experimental therapies, to rehabilitation pathways and even routine bedside decisions. It also requires clinicians to remain attentive to the possibility of residual or recovering agency: to notice subtle signs of preference, discomfort, distress, or engagement, even when these do not amount to full decisional capacity (Giacino et al. 2018; Peterson et al. 2020).

One of the strongest messages emerging from this presentation was that consent in this setting is not merely about forms or procedural authorization. It is about taking seriously the personhood, values, and moral standing of the patient even when these must be interpreted through others who know and love them.

Source: Edvard Munch, The Sick Child, 1927. Photo taken by the author at the Munch Museum in Oslo, April 7, 2026.

4. Prognostication and Communication in Neurocritical Care

Perhaps no theme is more consequential or more difficult than how clinicians communicate prognosis in the face of profound neurological uncertainty.

Families facing coma or related disorders of consciousness often ask the most difficult of questions: Will he or she wake up? Will he or she recover? What kind of life will be possible? (Walker 2022; Edlow et al. 2021; Tinti et al. 2024). These are deeply human questions, but medicine cannot always answer them with the certainty families seek.

This challenge was addressed by Miriam Quinlan and Susanne Muehlschlegel in a panel entitled “Identifying Bias in Prognostic Conversations in Severe Acute Brain Injury and Disorders of Consciousness” (World Coma Day 2026; Muehlschlegel and Quinlan 2026). Their observations were important because prognostic communication is not simply a matter of delivering information. It is a relational and ethical act, shaped by uncertainty, variability, and the risk of bias in how outcomes are framed for families (White and Curtis 2008; Bernat 2006).

During the discussion, I raised an additional point that adds a further layer of complexity. The rapid development and widespread adoption of digital technologies are reshaping the clinical encounter itself. The traditional asymmetry of knowledge and authority that long characterized the provider–patient relationship is increasingly being redefined by the rise of a more medically literate and digitally connected public. Patients and families now often arrive having already consulted a wide array of sources, from Google and other search engines and AI-based platforms such as ChatGPT and Claude, to peer communities and health-related content shared through social media. While this can support greater engagement and more active participation in care, it can also generate confusion, misinformation, false reassurance, or unrealistic expectations. In this evolving context, prognostic communication requires not only technical competence, but also the ability to interpret, contextualize, and discuss information in ways that support trust among the actors involved (Tan and Goonawardene 2017).

The above shift does not eliminate the need for professional expertise, but it does require a more transparent and dialogical model of communication, one that openly addresses uncertainty, clarifies the benefits and risks trade-offs, and supports informed shared decision-making. Prognostication, in this sense, becomes not merely a clinical judgment but a communicative practice grounded in humility, clarity, and ethical responsibility (Elwyn et al. 2012; Kon 2010).

The lessons of the COVID-19 pandemic remain highly relevant (Marquez 2025). One of its clearest lessons was that, when uncertainty is high, trust depends less on claims of certainty than on honesty, transparency, and the ability to help people understand benefits and risks, options, and possible courses of action (Marquez 2026; Westphal and Ramos 2020; Rosenbaum 2020). In this context, prognostic communication in disorders of consciousness is not simply about conveying probabilities or securing consent. It is about ethical accompaniment: walking with patients and families through uncertainty while preserving the dignity, values, and moral standing of the person at the center of care (Fins 2015; Back et al. 2009).

This framing is strongly supported by Muehlschlegel’s published work, which emphasizes both the scientific limitations and the human stakes of neuroprognostication. Her recent review underscores the variability and uncertainty that continue to characterize the field, while also arguing for more patient-centered approaches to communication and shared decision-making (Muehlschlegel and Quinlan 2026; Muehlschlegel 2024; Muehlschlegel et al. 2024; Muehlschlegel et al. 2022).

This is especially important because prognostic error remains a persistent concern in disorders of consciousness. Advances in clinical assessment—including repeated bedside examinations and structured tools such as the Coma Recovery Scale–Revised (CRS-R), a structured and validated assessment tool that has significantly improved the detection of minimally conscious states and reduced rates of misdiagnosis in disorders of consciousness (Giacino et al. 2018; Schnakers et al. 2009), have shown that some patients who appear behaviorally unresponsive may nonetheless retain covert or “hidden” consciousness. In parallel, developments in neuroimaging, electrophysiology, and computational analysis, including functional MRI, high-density EEG, brain–computer interfaces, and AI-assisted diagnostics, are making it increasingly possible to detect these concealed signs of awareness and to refine prognostic assessment (Owen et al. 2006; Monti et al. 2010; Claassen et al. 2019).

At the same time, contemporary research and recent guidelines emphasize the need for caution. Clinicians are advised to avoid overconfidence and not to anchor prognostic judgments on any single indicator, recognizing both the heterogeneity of recovery trajectories and the limits of current knowledge (Muehlschlegel et al. 2024; Bodien et al. 2024).

This does not mean that prognosis is impossible, nor that every case should be approached with unrealistic optimism. It means, rather, that good prognostic communication requires both scientific rigor and moral humility. At its best, prognostic communication is not about predicting the future with utmost precision, but about helping families navigate uncertainty with clarity, compassion, and trust so they can better understand the likely trajectory ahead, and as I raised during the discussion, the potential benefits, limitations, and risks of proposed interventions, and how these may be weighed in the context of shared decision-making.

Hence, prognostic communication is not merely a technical act of forecasting; it is a profoundly human responsibility. It calls for honesty without arrogance, hope without illusion, and clinical judgment exercised with humility, care, and respect for the patient and family before us. This responsibility unfolds within a broader reality in which patient safety remains a central concern in health care—one shaped by the complexity and interdependence of medical practice, as well as the inevitability of errors and adverse events (Walton and Kerridge 2014). Acknowledging these conditions does not diminish the authority of the physician and the clinical teams. Rather, openness about uncertainty, evolving knowledge, and the possibility of harm can help build a more honest and trusting relationship with patients and society that is grounded in transparency, humility, and a shared recognition of human fallibility.

Source: Eduardo Kingman (Ecuadorian painter, 1913-1997), Mujer con la cabeza sobre la mesa (Woman with Head on Table), 1963.

Closing Reflection

As the presentations and discussions at the event drew to a close, a unifying message was delivered: the future of care for disorders of consciousness will be shaped not only by advances in science and technology, but by how well medicine sustains its commitment to the person at the center of care.

The event highlighted the importance of restoring personhood through patient narratives and relational engagement. Interventions such as narrative-based tools and music therapy illustrated how care can remain connected to the patient’s identity, memory, and lived experience, even when conventional communication is no longer possible (Tracey 2026; Devlin 2026). These approaches challenge reductionist models by reaffirming that the patient is not merely a clinical condition, but a person with relationships, values, and inherent dignity.

Building on this foundation, discussions on consent highlighted the ethical complexity of decision-making in disorders of consciousness. Consent, in this context, cannot be reduced to procedural authorization; it must be understood as an ongoing, relational process grounded in respect for the patient’s values and personhood, often interpreted through those who know them best (Schiavi 2026). This perspective underscores that ethical care requires not only determining what can be done, but how decisions are made in conditions of uncertainty.

The focus then shifted to prognostication and communication. A central message was that prognostic judgment is not simply a technical exercise in prediction, but a communicative practice shaped by uncertainty, variability, and the risk of bias. In an era where patients and families are increasingly informed and digitally connected, clinicians must be able to interpret, contextualize, and communicate information in ways that support trust and shared decision-making (Muehlschlegel and Quinlan 2026; Tan and Goonawardene 2017).

Advances in assessment and emerging neurotechnologies are reshaping this clinical field, adding both complexity and new possibilities for knowledge and practice. Developments in neuroimaging, electrophysiology, and computational analysis are making it increasingly possible to detect covert consciousness, refine prognosis, and guide more individualized care (Owen et al. 2006; Monti et al. 2010; Claassen et al. 2019). These innovations hold significant promise, not only in improving diagnostic accuracy, but also in reducing premature therapeutic pessimism and expanding the boundaries of what clinicians are able to perceive and understand.

Yet a central lesson from the event is that technological progress alone is not sufficient. Prognostic uncertainty remains substantial, and the risk of bias, whether in interpretation, communication, or decision-making, continues to shape outcomes in ways that are not always visible (Muehlschlegel and Quinlan 2026). Good care therefore depends as much on humility, judgment, and communication as it does on technical capability.

The event also underscored that humanizing care must extend beyond patients to include those who provide it. Clinicians and their teams working under conditions of sustained uncertainty and emotional strain require support to avoid moral distress and to remain connected to the values that define their profession. Interventions that restore personhood to patients may also help sustain empathy, meaning, and moral resilience within clinical practice (Devlin et al. 2025; Tracey et al. 2024).

Taken together, the insights offered at the event point toward a broader vision of care: one that integrates scientific rigor with ethical attentiveness, technological innovation with human connection, and clinical expertise with humility in the face of uncertainty. In the end, the most meaningful advances in this field may lie not only in improving our ability to detect, measure, or predict, but in strengthening our capacity to recognize, accompany, and care for the person, especially when that person’s voice is difficult to hear.

To conclude, it should be clear, that medicine’s enduring task remains unchanged. It is not only to preserve life while avoiding harm, but also to uphold the dignity and inherent worth of the person even under the most fragile and uncertain conditions that characterize coma and disorders of consciousness, and to accompany patients and their families along a care continuum aimed at restoring connection, meaning, and reintegration into family and community life.

Source: Oswaldo Guayasamín (Ecuadorian painter), “Meditación”, from the series La Edad de la Ira, 1962–1989.

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Vig, Elizabeth K., Helene Starks, Janelle S. Taylor, Elizabeth K. Hopley, and Kelly Fryer-Edwards. 2007. “Surviving Surrogate Decision-Making: What Helps and Hampers the Experience of Making Medical Decisions for Others.”
Journal of General Internal Medicine 22 (9): 1274–1279.
https://doi.org/10.1007/s11606-007-0252-y

Walker, Cameron. 2022. “A Cure for Coma? Advances in Research and Care.” Johns Hopkins Magazine. https://hub.jhu.edu/magazine/2022/fall/coma-cure-research/

Walton, Merrilyn, and Ian Kerridge. 2014. “Do No Harm: Is It Time to Rethink the Hippocratic Oath?” Medical Education 48 (1): 17–27. https://doi.org/10.1111/medu.12275. PubMed: https://pubmed.ncbi.nlm.nih.gov/24330113/

Wendler, David, and Annette Rid. 2011. “Systematic Review: The Effect on Surrogates of Making Treatment Decisions for Others.” Annals of Internal Medicine 154 (5): 336–346.
https://doi.org/10.7326/0003-4819-154-5-201103010-0000

Westphal, Glauco Adrieno, and Juliano Ramos. 2020. “Shared Decision-Making in the Context of COVID-19.” Revista Brasileira de Terapia Intensiva 32 (2): 200–202. https://doi.org/10.5935/0103-507X.20200034

Weitzel, Levi, and Sheital Bavishi. 2024. “Disorders of Consciousness.”
Physical Medicine and Rehabilitation Clinics of North America 35 (3): 493–506.
https://doi.org/10.1016/j.pmr.2024.02.003

World Coma Day 2026. 2026. Dignity in Silence: Systems of Humanism for Patients with Disorders of Consciousness. Johns Hopkins Hospital / Neurocritical Care Society, March 24, 2026. Event page: https://secure.qgiv.com/event/worldcomaday2026/page/3767836/ (secure.qgiv.com)

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Source: Photo taken by author, March 2026, at the beginning of the Spring of 2026.

Pierre Teilhard de Chardin. The Phenomenon of Man (1959; pp. 35-36).

Introduction

Some years ago, when I first learned that my wife had been rushed into the emergency room of a local hospital, my mind froze. I found myself struggling to understand how such an event could have occurred without any manifested malaise or known symptom.

The transition triggered by a spontaneous subarachnoid brain hemorrhage was subtle in its onset, but fast in its progression.

As I have narrated before, her life was likely saved by the decision of my second son who was at home at the time to call 911 right away (Marquez 2019). In events such as this, time is critical—every minute can make the difference between life and death (Marquez 2025). The emergency rescue services dispatched an ambulance within minutes and took her to a nearby local hospital. Soon after, my first son, who had rushed to the hospital, called me. I was out on a long Sunday walk when he reached me to share the news and asked me to come to the emergency ward of the hospital right away, saying, “something bad happened to Mom.” When I arrived, my wife had been stabilized and was being prepared for transfer by a medical evacuation helicopter to a specialized tertiary hospital with the capacity to manage such complex cases.

In that moment, I felt torn, suspended, almost in a vacuum, between disbelief and reflection, trying to process what I was hearing and witnessing, while recognizing the need to reframe my thoughts and prepare to confront an unpredictable, fast evolving new reality. It took a few minutes, but contemplation eventually gave way to action. Together with my sons, I called my daughter, who was out of town, so she could arrange her return home that same night. We also began making plans to travel to Baltimore, where the specialized hospital is located, and to find a place to stay nearby.

That day marked the beginning of a journey that would progress over months, moving from crisis to uncertainty, from silence and waiting to small signs of return and recovery, sustained throughout by the unconditional presence of my three children and our extended family, and by a quiet, never-failing faith that “somebody up there likes her.” Indeed, as the days and nights passed, they reinforced a deep belief—one I inherited from my father in the convergence and inseparable connection between science and spirituality.

What has remained with me over the eight years since that experience is not only the memory of fear and a deep sense of uncertainty and vulnerability, but also a more profound realization, an almost existential awakening, of the fragility of life, and how suddenly it can slip into what medicine defines as a coma.

On March 22, the Neurocritical Care Society and the Curing Coma Campaign marks World Coma Day, a global effort to raise awareness about coma, its impact on patients and families, and the need for continued research, care, and support. A timely reminder that behind every case is a human story, and that recovery science matters (Neurocritical Care Society 2026).

Before attending this event at Johns Hopkins Hospital, at the invitation of the Neurosurgery Intensive Care Unit team where my wife was once admitted, I found myself transported back, reliving the experience as I reviewed the literature to better understand the nature of coma: its causes and implications from both biological and human perspectives, and what can be done to support a return toward consciousness and ultimately, to life itself.

Here, in this post, I offer some reflections to help shine a light on this year’s World Coma Day.

Source: Neurocritical Care Society 2026.

What Is Coma?

As described in detail in Figure 1, clinically, coma is defined as a state of profound unresponsiveness in which a patient is alive but unable to wake, respond to stimuli, or engage with the environment, and is characterized by the absence of sleep–wake cycles (Flanagan and Lin 2023). Coma is part of a broader category known as disorders of consciousness (DoC), which also includes the vegetative state and minimally conscious state (Giacino et al. 2018).

This clinical definition, while precise, does not fully capture the lived reality. Coma is not merely the absence of responsiveness, it is a disruption of the complex neural networks that sustain awareness, identity, and connection to others (Edlow et al. 2021).

Recent advances in neuroscience have further complicated our understanding. Evidence suggests that some patients diagnosed as unconscious may retain “covert consciousness” or brain activity indicating awareness that cannot be outwardly expressed (Claassen et al. 2019).

This challenges long-held assumptions and underscores the need for humility in clinical judgment.

Figure 1: Coma Definitions

Source: Adapted from Helbok et al. 2022.

Beyond Silence, Covert Consciousness

One of the most important developments in the field over the past decade has been the recognition that consciousness can be present but hidden.

Advanced neuroimaging and electrophysiological techniques and research conducted have demonstrated that some patients who appear entirely unresponsive may, in fact, show brain activation consistent with awareness, a condition often referred to as covert consciousness (Claassen et al. 2019).

At the same time, research findings suggest that misdiagnosis rates may reach up to 30–40%, highlighting the limits of bedside clinical assessment alone (Schnakers et al. 2009).

Uncertainty, therefore, remains a defining feature of coma. As Professor José Ignacio Suárez, a world-class specialist and respected Colombian colleague, who serves as the Chief of the Neurosciences Critical Care Unit at Johns Hopkins Hospital, has observed, such uncertainty affects not only clinicians but especially families seeking answers to the most fundamental question: “Is he or she going to wake up? And, if their loved one does wake up, what will their life look like?” (Walker 2022; Edlow et al. 2021; Tinti et al. 2024).

Source: Photo taken by Giovanni S Marquez, San José de Costa Rica, February 2026.

Causes: When the Brain Is Overwhelmed

Coma is not a disease, but a consequence, a final common pathway of severe brain dysfunction.

Figure 2 lists the most common coma causes. Global evidence indicates that intracerebral hemorrhage, traumatic brain injury, and spontaneous subarachnoid hemorrhage are the leading causes across clinical settings (Helbok et al. 2022).

Figure 2: Coma Etiologies

Source: Adapted from Helbok et al. 2022.

Recovery: A Trajectory, Not an Event

One of the most important, and hopeful, insights emerging from recent research is that recovery from coma is not binary (Edlow et al. 2021). That is, it is not a switch from “off” to “on.” It is a trajectory, often slow, nonlinear, and deeply individualized (Giacino et al. 2018; Egawa et al. 2024).

Some patients regain consciousness within days; others show signs of improvement months or even years later. Small behavioral changes, often subtle and easily overlooked, can signal meaningful neurological progress (Giacino et al. 2018).

At the same time, outcomes vary widely. Prognosis depends on factors such as the underlying cause of injury, neurological examination findings, and neuroimaging results, yet it remains inherently uncertain (Helbok et al. 2022).

Studies further show that individuals emerging from prolonged disorders of consciousness often continue to experience significant functional limitations even after one year, underscoring the need for sustained rehabilitation and long-term support (Egawa et al. 2024; Edlow et al. 2021).

Advances in Care: Expanding the Possibility of Recovery

Encouragingly, the field is evolving rapidly (Edlow et al. 2021; Provencio et al. 2020), as highlighted below:

1. Improved Diagnosis

Standardized tools such as the Coma Recovery Scale–Revised (CRS-R) remain the gold standard, while repeated and structured assessments are improving diagnostic accuracy (Giacino et al. 2018; Schnakers et al. 2009).

Emerging technologies are complementing bedside evaluation:

• Electroencephalography (EEG) and functional magnetic resonance imaging (fMRI): Measure brain activity through electrical signals and blood flow, respectively, to detect hidden signs of consciousness (Giacino et al. 2018; Claassen et al. 2019; Owen et al. 2006; Monti et al. 2010).

• Electromyography-based systems (EMG): Detect subtle muscle activity, helping identify hidden attempts to move or respond (Provencio et al. 2020).

• Multimodal diagnostic frameworks: Combine clinical examinations with multiple technologies to improve diagnosis and prognostication (Helbok et al. 2022; Giacino et al. 2018).

• Standardized behavioral assessment tools (e.g., Coma Recovery Scale–Revised):
  Use structured, repeated evaluations to track levels of consciousness and reduce misdiagnosis (Giacino et al. 2018).

These approaches are increasingly capable of detecting subtle or covert signs of consciousness that may not be evident clinically (Claassen et al. 2019; Edlow et al. 2021).

2. Neurotechnology and Artificial Intelligence

Recent research points toward a future in which AI-assisted monitoring can continuously assess brain function and predict transitions in consciousness states (Edlow et al. 2021).

Machine learning models are already demonstrating the ability to predict coma and delirium trajectories in intensive care unit (ICU) patients with increasing accuracy, offering the potential for earlier and more targeted interventions (Egawa et al. 2024).

3. Neurostimulation and Pharmacologic Therapies

Therapies such as the following are being explored to promote recovery:

• Transcranial stimulation: Non-invasive techniques (such as transcranial magnetic or electrical stimulation) that modulate brain activity through the scalp to enhance neural connectivity and promote recovery of consciousness (Thibaut et al. 2014; Lefaucheur et al. 2020).

• Deep brain stimulation: An invasive approach in which electrodes are implanted in specific brain regions to deliver targeted electrical impulses, with potential to improve arousal and responsiveness in selected patients (Schiff et al. 2007; Giacino et al. 2018).

• Pharmacologic agents (e.g., amantadine): Medications that stimulate brain function or neurotransmitter activity; amantadine has shown evidence of accelerating recovery in some patients with disorders of consciousness (Giacino et al. 2012; Whyte et al. 2005). Among these, amantadine, a dopaminergic and NMDA-receptor modulating agent that enhances arousal, attention, and neural signaling, remains the most widely used neurostimulant in clinical practice, with evidence of benefit in selected patients (Helbok et al. 2022; Giacino et al. 2018). Randomized clinical trial evidence has shown that, in patients with disorders of consciousness following traumatic brain injury, amantadine can accelerate the pace of functional recovery during the subacute phase. While not universally effective, it is currently the best-supported pharmacologic intervention and is recommended in clinical guidelines for carefully selected patients (Giacino et al. 2012; Giacino et al. 2018).

4. Early and Integrated Rehabilitation

Perhaps most importantly, there is growing recognition that recovery depends not only on acute care, but on continuity across the care pathway:

• ICU care, where timely stabilization, prevention of secondary brain injury, and adherence to neurocritical care protocols are essential to preserve brain function and create the conditions for potential recovery. Early decisions made in the ICU,, including sedation management, hemodynamic optimization (careful management of a patient’s blood circulation, especially blood pressure, blood flow, and oxygen delivery to ensure adequate perfusion of vital organs, particularly the brain), and avoidance of complications, can significantly influence long-term neurological outcomes (Giacino et al. 2018; Helbok et al. 2022).

• Early neurorehabilitation, initiated as soon as the patient is medically stable, has been shown to improve functional outcomes by promoting neuroplasticity, the brain’s ability to adapt, reorganize, and form new neural connections in response to injury, while preventing complications such as contractures (permanent shortening of muscles and joints) and deconditioning (loss of strength and functional capacity due to prolonged immobility), and facilitating the gradual recovery of consciousness and function (Turner-Stokes et al. 2015; World Health Organization 2017).

• Long-term community support, including outpatient rehabilitation, social services, and caregiver support systems, which are critical to sustaining recovery, improving quality of life, and addressing the long-term cognitive, emotional, and social consequences experienced by patients and their families (World Health Organization 2022; Provencio et al. 2020).

This aligns closely with broader health system principles: survival must be matched by investment in recovery, function, and quality of life (Edlow et al. 2021; Egawa et al. 2024).

Ethics and Decision-Making Under Uncertainty

Few areas of medicine present more profound ethical challenges.

• Prognosis is often uncertain

• Clinical assessments may be imperfect

• Decisions about life-sustaining treatment carry irreversible consequences

The high rates of misdiagnosis and the emerging evidence of covert consciousness raise a critical concern: That early decisions, made under uncertainty, may inadvertently limit the possibility of recovery (Schnakers et al. 2009; Claassen et al. 2019). Notably, clinical practice varies widely, including when to consider withdrawal of life-sustaining treatment, highlighting the absence of universally accepted standards (Helbok et al. 2022; Yakhkind et al. 2024).

This has led to increasing calls for:

• Repeated and standardized assessments, recognizing that recovery of consciousness can be delayed and fluctuating. Serial use of validated tools, such as the Coma Recovery Scale–Revised, helps reduce misdiagnosis and improves detection of subtle signs of awareness over time.

• Greater use of advanced diagnostics, including functional MRI, EEG, and other neurophysiological techniques, which can reveal covert consciousness and brain activity not evident on bedside examination alone.

• A more cautious and evidence-informed approach to prognostication, avoiding premature or overly deterministic predictions about outcomes, particularly in the early stages after brain injury, when uncertainty remains high and recovery trajectories are variable (Provencio et al. 2020; Suárez 2004).

Building Systems for Recovery: From Acute Care to Long-Term Outcomes

My personal experience, standing in the emergency room and later spending days and nights in a neurosciences critical care unit, confronting the sudden stillness of someone I love, remains a powerful reminder of the fragility of life.

But it also points to a broader challenge. As health systems improve their ability to save lives, they must also strengthen their capacity to restore lives. In many settings, this care is delivered within specialized neurosciences critical care units (NSUs) (Suárez 2004).

The NSUs were developed in response to the recognition that critically ill neurological and neurosurgical patients—across adolescent, adult, and geriatric populations—have distinct and complex needs requiring highly specialized intensive nursing and medical care (Suárez 2004). As such, NSUs are designed as dedicated environments where multidisciplinary teams are equipped to manage the dynamic interplay between systemic physiology and central nervous system function (Suárez 2004).

In turn, the emergence of NSUs has helped shape neurocritical care as a subspecialty, bringing together clinicians from diverse medical and surgical backgrounds. with a shared focus on improving both short- and long-term neurological outcomes (Suárez 2004; Helbok et al. 2022).

Yet strengthening these systems requires more than specialized units alone (Marquez and Chockalingam 2023). It calls for a broader, integrated approach across the continuum of care, within and outside medical facilities:

• Investment in neurorehabilitation systems to support functional recovery and long-term outcomes after severe brain injury (World Health Organization 2017; Turner-Stokes et al. 2015).

• Adequate financing of services and financial protection mechanisms are essential to ensure equitable access to care across the continuum—from emergency response and intensive care to rehabilitation and long-term support—while protecting patients and families from catastrophic health expenditures and the risk of impoverishment (World Bank Group and World Health Organization 2025; Wagstaff et al. 2018). This includes public financing, insurance coverage, and social protection measures that reduce out-of-pocket costs and financial hardship.

• Support for families and caregivers, who experience significant psychological, social, and economic burdens when caring for individuals with disorders of consciousness (Provencio et al. 2020; Helbok et al. 2022).

• Integration of mental health and psychosocial care into recovery pathways, recognizing the emotional and cognitive sequelae affecting both patients and caregivers (World Health Organization 2022; Marquez 2023; Giacino et al. 2018).

• Strengthening of multidisciplinary care models, including neurosciences critical care units and coordinated post-acute services, to ensure that expertise, technology, and human-centered care are aligned across the continuum of care (Suárez 2004; World Health Organization 2017; Helbok et al. 2022).

• Continued investment in research and innovation, including advances in neuroimaging, biomarkers, and therapeutic interventions aimed at improving diagnosis, prognostication, and recovery (Edlow et al. 2021; Egawa et al. 2024).

Global evidence shows significant variability in coma care across settings—highlighting the need for coordinated, evidence-based systems that extend from emergency response to acute care and long-term recovery, anchored in universal health coverage arrangements that ensure individuals and families can access needed services without suffering financial hardship (Helbok et al. 2022; Provencio et al. 2020; World Bank Group and World Health Organization 2025).

In many ways, therefore, disorders of consciousness sit at the intersection of medicine, neuroscience, ethics, and public health.

Source: Image id Shutterstock_1878018001 (1)

Source: Adapted from Forty Years of Neurocritical Care | Johns Hopkins Medicine

Source: The JHH Neurosciences Critical Care Unit (NCCU) Team, Adapted from Forty Years of Neurocritical Care | Johns Hopkins Medicine

Closing Reflection

As I attend today this World Coma Day event at Johns Hopkins Hospital, I do so not only as a public health practitioner, but as someone who has witnessed firsthand the fragile boundary between presence and absence.

Coma is not simply a medical condition. It is a threshold—between silence and awareness, between uncertainty and possibility. And increasingly, as discussed above, science is teaching us that even in that ‘dignified silence’, something may remain—waiting, perhaps, for the conditions that allow it to return.

In reflecting on this journey, both personal and collective, I am reminded of the timeless words of Pedro Calderón de la Barca (1635) in the classical Spanish play, La vida es sueño:

¿Qué es la vida? Un frenesí.
¿Qué es la vida? Una ilusión,
una sombra, una ficción,
y el mayor bien es pequeño:
que toda la vida es sueño,
y los sueños, sueños son.

(*What is life? A frenzy.
What is life? An illusion,
a shadow, a fiction;
and the greatest good is but small:
for all of life is a dream,
and dreams are but dreams.)

Perhaps nowhere does this reflection resonate more deeply than in the experience of coma, where life itself seems suspended between dream and reality, between absence and return.

And yet, within that fragile space, there remains not only uncertainty, but also the enduring possibility of recovery, connection, and life reclaimed.

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Source: Photo taken by Giovanni S Marquez, San José de Costa Rica, February 2026.

Support Johns Hopkins Neurosurgery Intensive Care Unit

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Hope Connections provides free support, education, and wellness programs that are offered both in person and virtually for people with cancer at all stages, as well as their families and caregivers. Through professionally facilitated support groups, mind-body wellness activities, educational sessions, and community outreach, the organization helps individuals navigate the cancer journey with connection, resilience, and hope.

For me, this engagement is not only about contributing time and experience; it is also deeply personal. It is a way to remember and honor my father, who died a decade ago around this time from tobacco-attributable lung cancer, a loss that, like millions of others around the world, was, in many ways, preventable. Unfortunately, in spite of decades of accumulated global evidence, tobacco—a legal product—continues to kill, exacting a heavy health and economic toll and underscoring the urgency of adopting and effectively implementing comprehensive public policies—from stronger regulation and sustained public education to inflation-adjusted tax increases that raise prices, reduce affordability, and ultimately curb consumption, reduce associated health risks, and prevent premature deaths (Marquez and Moreno-Dodson 2017; Drope, et al. 2025).

Source of Image: Shutterstock id 2455595409

As I reflect in this post, my father’s story, while deeply personal, also reflects a much broader global reality that highlights the scale and urgency of the cancer burden today.

A Growing Burden—Globally and Close to Home

Cancer is often described in numbers, but the numbers themselves tell a powerful human story.

Globally, there were an estimated 20 million new cancer cases and 9.7 million deaths in 2022, and the burden is projected to rise significantly in the coming decades (Bray et al. 2024; World Health Organization 2025). The most common cancers—lung, breast, colorectal, prostate, and stomach—account for a large share of this burden.

Figure 1 presents three distinct measures of cancer mortality. Total deaths simply reflect the number of people who died from cancer, and by this measure the total has doubled. Crude death rates, shown in yellow, adjust for population growth, reducing the apparent increase from more than 100% to roughly 20%. Age-adjusted death rates, shown in blue, further account for the fact that populations are older today; on this basis, the cancer death rate has actually declined by more than 20%.

Figure 1:

Source: Adapted from Ritchie, H (2026).

In the United States, cancer remains a leading cause of death, with approximately 2 million new cases and more than 600,000 deaths each year, despite steady declines in mortality over the past three decades (American Cancer Society 2025).

Closer to where I currently live, in Maryland:

• About 32,000 new cancer cases occur annually.

• The most common cancers include breast, prostate, lung, and colorectal cancers.

• Cancer incidence in Maryland is roughly 450 cases per 100,000 population, about the national average, while mortality remains substantial, reflecting ongoing challenges in early detection, timely access to diagnosis and treatment, and persistent health disparities (NCI/CDC State Cancer Profiles 2025; Johns Hopkins Medicine 2025).

These figures remind us that cancer is both a global challenge and a local reality—touching families and communities all around us.

Who Is Most Affected

While cancer does not differentiate between people, the disease and its impacts do not affect all populations equally.

• Older adults bear the greatest burden, reflecting cumulative exposure to risk factors and age-related vulnerability (Bray et al. 2024; National Cancer Institute 2025).

• Adolescents and young adults are experiencing rising rates of certain cancers, including early-onset colorectal cancer, a trend increasingly documented across multiple countries (Hughes et al. 2024; Siegel et al. 2023).

• Racial and ethnic disparities persist, with some populations, particularly minorities, experiencing higher mortality and poorer outcomes due to differences in access, stage at diagnosis, and structural inequities (Siegel et al. 2025; Centers for Disease Control and Prevention 2025).

• Individuals in lower-income settings often face delayed diagnosis and limited access to care, contributing to disproportionately higher mortality despite lower incidence in some cases (World Health Organization 2025; GBD Cancer Collaborators 2025).

These patterns reflect not only biology, but also differences in access, environment, and opportunity.

Prevention, Progress, and Persistent Gaps

A substantial proportion of cancers are preventable. As shown in Figure 2, tobacco use remains a leading modifiable risk factor in the United States and across the world, responsible for a significant share of lung cancer deaths worldwide. Other contributors include infections, alcohol use, obesity, and environmental exposures (Fink, et al. 2026).

Figure 2:

Source: Adapted from Zhang, et al. 2025.

At the same time, progress has been real:

• Cancer mortality in the United States has declined significantly since 1991, with death rates falling by about one-third, translating into millions of deaths averted due to reductions in smoking, early detection, and improved treatment (Siegel et al. 2025; American Cancer Society 2025).

• Advances in treatment have improved survival across many cancer types, including through precision medicine, immunotherapy, and targeted therapies, contributing to rising survival rates (National Cancer Institute 2025; Siegel et al. 2025).

And yet, important gaps remain:

• Too many cancers are diagnosed at late stages, such as cervical cancer, when treatment is less effective and outcomes are poorer (World Health Organization 2025).

• Access to treatment remains uneven, with disparities across income levels, geography, and population groups affecting outcomes (GBD Cancer Collaborators 2025; World Health Organization 2025).

• Financial burden continues to affect patients and families, with cancer care costs contributing to economic hardship, including lost income and out-of-pocket expenses (National Cancer Institute 2024; Yabroff et al. 2021).

Cancer, in this sense, reflects both scientific progress and persistent inequities.

The Experience Beyond the Diagnosis

What the data often cannot fully capture is what it means to live with cancer.

It is a lived experience that affects:

• Emotional wellbeing: often marked by anxiety, depression, and uncertainty.

• Family dynamics: as caregiving roles shift and responsibilities grow.

• Social relationships: with many individuals experiencing isolation or stigma.

• Financial stability: due to treatment costs, catastrophic out-of-pocket payments, and loss of income.

• A person’s sense of identity and future: as life plans are disrupted and priorities reshaped.

As both the evidence and lived experience remind us:

Cancer does not differentiate between people. But access to care—and to support—often does.

Where Community Makes the Difference

This is where community matters. Not as an add-on, but as an essential component of the care pathway.

Organizations like Hope Connections operate in the space between the medical facility and everyday life, addressing needs that are often invisible in traditional health systems but central to human wellbeing.

They provide:

• Supportive and palliative care: relieving symptoms and improving quality of life.

• Mental health services: addressing emotional distress and uncertainty.

• Caregiver support: helping families sustain care over time.

• Community-based programs: offering connection, education, and resilience.

Evidence shows that such support improves quality of life, reduces distress, and strengthens coping capacity (Bergerot et al. 2024; JMIR 2024).

But beyond the evidence, there is something even more fundamental: Community restores a sense of belonging, reminding us of our shared humanity and our responsibility to support others in need.

Source: Photo by author, early Spring of 2026.

Bridging Care and Humanity

Over the course of our professional lives, my wife and I have spent decades engaged in health systems, public health, and development work across low- and middle-income countries around the world.

Yet experiences like my father’s, and now my involvement with Hope Connections,have reinforced a simple truth: Medicine treats disease. Community supports healing.

As such, organizations like Hope Connections represent a form of social infrastructure for health: quiet, often underrecognized, yet indispensable. They help bridge the gap between clinical care and everyday life; between treatment and survivorship; and between illness and the human need for connection, understanding, and hope.

Why This Matters Now?

As the global cancer burden continues to grow, amid converging and syndemic crises in a convulsed post-pandemic world, the challenge ahead is not only to treat more patients, but to care for them comprehensively—and more humanely.

This requires investment not only in technologies and treatments, but also in:

• Supportive and palliative care.

• Mental health services.

• Caregiver support.

• Community-based organizations.

Let us be clear: this is needed because healing is not only about extending life, it is about sustaining dignity, resilience, and hope. Ultimately, it is about life itself.

A Personal Reflection—and a Call to Act

Cancer does not make distinctions between people. That is unflinching reality. But the presence or absence of support can make all the difference.

For us, being part of Hope Connections is a way to contribute to that support. It is also a way to honor my father’s memory by helping ensure that others do not have to face cancer alone.

Organizations like Hope Connections depend on the generosity of individuals and communities to sustain their work, offering free programs and services to those navigating one of life’s most difficult journeys: living with cancer.

How You Can Help

If this message resonates with you, there are meaningful ways to contribute:

• Make a donation to support free programs and services

• Become a sustaining donor and help ensure continuity of care

• Volunteer your time or expertise

• Share this message to expand awareness and reach

Learn more and support Hope Connections:
https://hopeconnectionsforcancer.org

The Impact of Your Support

Contributions make possible the offering of evidence-based programs:

• Support groups that reduce isolation.

• Mind-body programs that build resilience.

• Educational sessions that empower patients and caregivers.

• Outreach efforts that expand access to underserved communities.

Every act of support helps transform the cancer experience—from isolation to connection.

In the end, the message is simple, but it carries profound meaning: No one should face cancer alone.

Follow Hope Connections for Cancer Support

• Instagram:
  https://www.instagram.com/hopeconnections4cancer

• Facebook:
  https://www.facebook.com/hopeconnectionsforcancer

• LinkedIn:
  https://www.linkedin.com/company/hopeconnectionsforcancersupport

• X (formerly Twitter):
  https://x.com/hopeconn4cancer

References

• American Cancer Society. 2025. Cancer Facts & Figures 2025.
  https://www.cancer.org/research/cancer-facts-statistics.html

• Bergerot, C. D., et al. 2024. “Global Unmet Psychosocial Needs Among People with Cancer.” The Lancet EClinicalMedicine.
  https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00521-2/fulltext

• Bray, Freddie, et al. 2024. “Global Cancer Statistics 2022.” CA: A Cancer Journal for Clinicians. https://acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21834

• Centers for Disease Control and Prevention (CDC). 2025. “Health Equity in Cancer.” https://www.cdc.gov/cancer/health-equity/index.html

• Drope, J, Oo, S, Dorokhina, M, Guerrero-López, C, Rodriguez-Iglesias G, Mugosa, A, Bontu, A, Malik, S, Villacres, T, and Chaloupka, F. 2025. Cigarette Tax Scorecard (4th ed.). Baltimore: Economics for Health, Johns Hopkins University Bloomberg School of Public Health. https://www.economicsforhealth.org/research/cigarette-tax-scorecard-4th-edition/

• Fink, Hanna, et al. 2026. “Global and Regional Cancer Burden Attributable to Modifiable Risk Factors.” Nature Medicine. https://doi.org/10.1038/s41591-026-04219-7

• GBD 2023 Cancer Collaborators. 2025. “Global, Regional, and National Burden of Cancer, 1990–2023.” https://pmc.ncbi.nlm.nih.gov/articles/PMC12687902/

• Hughes, Natalie, et al. 2024. “Global Cancer Burden in Adolescents and Young Adults.” The Lancet Oncology.
  https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(24)00523-0/abstract

• International Agency for Research on Cancer (IARC). 2024. Global Cancer Observatory. https://gco.iarc.fr/

• International Agency for Research on Cancer (IARC). 2026. Cancer Burden Attributable to Risk Factors. https://www.iarc.who.int/

• Johns Hopkins Medicine. 2025. Cancer in Maryland.
  https://www.hopkinsmedicine.org/kimmel-cancer-center/community-outreach-engagement/cancer-maryland

• JMIR Cancer. 2024. “Digital Psychosocial Interventions for Cancer Patients.”
  https://cancer.jmir.org/2024/1/e46116/

• Marquez, Patricio V., and Blanca Moreno-Dodson. 2017. Tobacco Tax Reform at the Crossroads of Health and Development. World Bank.
  https://openknowledge.worldbank.org/handle/10986/28494

• National Cancer Institute (NCI). 2024. Economic Burden of Cancer.
  https://progressreport.cancer.gov/after/economic_burden

• National Cancer Institute (NCI). 2025. Cancer Statistics (SEER).
  https://seer.cancer.gov/statistics/

• NCI/CDC. 2025. State Cancer Profiles: Maryland.
  https://statecancerprofiles.cancer.gov/

• Ritchie, Hannah. 2026. “Global deaths from cancer have increased, but the world has made progress against it.” Data Insights, January 12, 2026. Our World In Data. https://ourworldindata.org/data-insights/global-deaths-from-cancer-have-increased-but-the-world-has-made-progress-against-it

• Siegel, Rebecca L., et al. 2023. “Colorectal Cancer Statistics, 2023.”
  https://acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21772

• Siegel, Rebecca L., et al. 2025. “Cancer Statistics, 2025.”
  https://pmc.ncbi.nlm.nih.gov/articles/PMC11745215/

• World Health Organization. 2025. Cancer Fact Sheet.
  https://www.who.int/news-room/fact-sheets/detail/cancer

• Yabroff, K. Robin, Angela B. Mariotto, Feifei Tangka, et al. 2021.
  “Annual Report to the Nation on the Status of Cancer, Part 2: Patient Economic Burden Associated With Cancer Care.” Journal of the National Cancer Institute 113 (12): 1670–1682.
  https://academic.oup.com/jnci/article/113/12/1670/6409890

• Zhang, Y, et al. 2025. Plasticisers chemical mixture, vitamin status, and mortality in US adults: a prospective population-based cohort. The Lancet Planetary Health. Advance online publication. DOI: 10.1016/j.lanplh.2025.101394. https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196%2825%2900272-4/fulltext

Isolated incident, part of the job

Yeah, well, tell that to the families.

Kids without daddies. Tell it to God.”

— Steve Earle, Coal Country, quoted in Jessie Singer, There Are No Accidents: The Deadly Rise of Injury and Disaster—Who Profits and Who Pays the Price (2022)

Source: Photo taken by author of his grandsons walking safely on the street, February 2026.

Introduction

This week, on March 10–11, 2026, I will attend several sessions at the World Bank Group’s annual transport conference, held under the theme “Transforming Transportation 2026: Powering Jobs and Growth” (World Bank Group 2026). In preparation for the event, I revisited some of my past work and wrote this post to share a perspective shaped by my experience at the institution working on road safety, health systems, and the broader links between transport, public health, and development policy (Bose and Marquez 2018; Marquez, Banjo and Chesheva 2009; Marquez and Bliss 2010; Marquez and Farrington 2013).

Transport systems are often discussed primarily in terms of infrastructure, logistics, and economic performance. Yet at their core they shape everyday life. For millions of people around the world, getting on a bus, walking to school, riding a motorcycle, or driving to work or to a medical appointment, is part of daily routines that connect them to jobs, education, markets, and essential services (OECD/ITF 2024).

Most trips occur without notice and end safely. But when roads are poorly designed, vehicles are unsafe, traffic rules weakly enforced, or emergency medical response delayed, an ordinary trip can suddenly become a tragedy, one that reverberates far beyond the roadside, affecting individuals, families and communities.

The human consequences of unsafe transport systems are not abstract. Recently, in my native Ecuador, a bus traveling on an inter-provincial route between Simiatug and Ambato, in the country’s central highlands, lost control and plunged about 150 meters down a ravine, killing 21 people and injuring at least 40, according to the country’s emergency services (Reuters 2025). In another crash in the southern province of Loja, near the border with Peru, a passenger bus collided with a car traveling in the opposite direction and overturned, reportedly leaving at least 16 people dead and 8 others injured, according to local media reports (Primicias 2024). Research on road traffic crashes in Ecuador shows that passengers and pedestrians face significantly higher risks of death—particularly during holiday periods and in incidents involving other vehicles—with fatality risks increasing in run-over, impact, crash, lane-departure, and vehicle-overturning incidents (Acosta-González, Cahueñas, and Pérez 2025).

Source: Photos of truck crash in Ecuador. Adapted from https://www.cbc.ca/news/world/ecuador-road-accident-1.4784577

What happened on the highways in Ecuador are not isolated tragedies. Similar crashes occur every day across the world, particularly in countries where rapid motorization has outpaced investments in safer transport infrastructure and effective road safety management systems (World Bank 2024a; WHO 2023; Marquez 2025b).

Understanding why such tragedies occur and how they can be prevented is essential if transport systems are to fulfill their broader role in supporting jobs and economic growth.

The Burden of Traffic Injuries

Traffic injuries represent one of the most serious and preventable public health challenge. Globally, road crashes claim approximately 1.19 million lives each year, while tens of millions more people suffer non-fatal injuries, many resulting in long-term disability (WHO 2023).

According to the World Health Organization (WHO), more than half of those killed on the world’s roads are vulnerable road users, including pedestrians, cyclists, and motorcyclists (WHO 2023).

Beyond fatalities, the burden of road crashes is reflected in the complex patterns of injuries sustained by survivors. Trauma registry analyses show that victims frequently suffer multiple injuries affecting the head, chest, abdomen, and extremities, often requiring intensive hospital care and prolonged rehabilitation (Chalya et al. 2012; Huang et al. 2016; Marquez 2025d).

Traumatic brain injuries, in particular, are among the leading causes of death and long-term disability following crashes, while fractures and internal injuries often require surgical intervention and extended hospital stays. For many survivors, recovery can take months or years, and some never regain their previous physical or economic independence (Chalya et al. 2012; Huang et al. 2016; Marquez 2025d).

These injury patterns reflect the high-energy forces involved in road collisions and underscore the substantial burden placed on health systems (Chalya et al. 2012; Huang et al. 2016; Marquez 2025d).

Beyond the immense human suffering, traffic injuries impose heavy economic burdens, including lost household income, expensive trauma care, vehicle repairs, and insurance payouts. In low- and middle-income countries (LMICs), fatalities and injuries account for 2–6 percent of GDP (World Bank 2024b). Also, a World Bank Group study suggests that reducing road traffic injuries in LMICs could increase GDP per capita by 7–22 percent over 24 years, underscoring the intersection of public health, road safety, and economic development (Bose and Marquez 2018).

These losses represent not only financial costs but also a significant erosion of human capital, the health and productive potential of individuals that underpins economic development (World Bank 2018; Holla, Schady, and Silva 2026).

Source: Image ID Shutterstock_1721662813 (1)

Source: Photo of bus collision in Ecuador. Adapted from https://www.bbc.com/news/world-latin-america-45186901

When “Accidents” Are Not Accidents

Despite the scale of the problem, road crashes are still widely described as “accidents” (Singer 2022; Baker et al 1992). The word suggests randomness or inevitability—events beyond human control. Yet decades of research in public health, engineering, and transport safety show that most traffic deaths are preventable, as they arise from identifiable traffic system failures (OECD/ITF 2023; OECD/ITF 2024).

Road crashes typically occur when multiple risks converge—unsafe road design, unsafe vehicles, excessive speed, alcohol or drug impairment, distracted driving, and inadequate enforcement of traffic laws. When these risks accumulate, the likelihood of a severe crash increase sharply (WHO 2017; WHO 2023).

Modern road safety policy increasingly reflects the Safe System approach—a framework that recognizes that human error is inevitable and that the human body has limited tolerance to crash forces. By acknowledging both the inevitability of human error and the physical limits of the human body, the approach emphasizes designing and managing the entire road transport system—including roads, vehicles, speeds, and post-crash care to prevent that inevitable human mistakes do not result in death or serious injury (WHO 2017; OECD/ITF 2023).

Countries that have implemented comprehensive road safety strategies—combining safer infrastructure, improved vehicle safety standards, speed management, consistent enforcement, and effective emergency medical response systems have achieved substantial reductions in fatalities, while others have faltered due to inaction or poor implementation (OECD/ITF 2023; Marquez 2025a; 2025b; 2025c; 2025g).

Recognizing that traffic deaths are preventable shifts the policy conversation. Instead of asking why crashes occur, policymakers must ask how transport systems can be redesigned so that human errors under unsafe environments do not result in fatal outcomes.

Source: Image ID Shutterstock_2530945387

Key Role for Emergency Medical Services

Even with safer roads and vehicles, crashes will still occur. When they do, survival often depends on the speed and effectiveness of emergency response (Marquez 2025a). Trauma medicine emphasizes the importance of the “golden hour,” the critical period following severe injury during which rapid medical treatment can significantly improve survival outcomes (Mock et al. 2012).

Trauma registry data show that patients transported by emergency medical services often arrive with high injury severity scores and signs of physiological shock, requiring advanced interventions such as airway management, blood transfusions, and surgical care (Huang et al. 2016).

Evidence indicates that coordinated emergency response networks and well-organized trauma systems can reduce mortality among severely injured patients by 15–25 percent (Mock et al. 2012).

Strengthening emergency medical services therefore represents a critical component of safer transport systems and more resilient health systems. Investments in emergency call centers, ambulance networks, trauma training, and hospital coordination can significantly improve survival outcomes following severe injuries (Marquez 2025a and 2025b).

Digital Innovation and Artificial Intelligence

Emerging technologies are beginning to reshape both transport systems and emergency response. Artificial intelligence and data analytics are enabling improved traffic management, more efficient public transport systems, and faster emergency response coordination.

As discussed in another post, these technologies can help predict ambulance demand, optimize dispatch decisions, and improve coordination between emergency responders and hospitals (Marquez and Bose 2025f).

Digital technologies are also increasingly used for real-time traffic monitoring, crash detection, and early notification systems that can automatically alert emergency responders when collisions occur.

When deployed responsibly, digital innovation and artificial intelligence tools have the potential to make transport systems safer, more efficient, and more responsive to the needs of the population.

Transport, Air Pollution, and Climate

Transport systems also play a major role in shaping environmental health and climate outcomes. Motorized vehicles are a major source of fine particulate matter (PM2.5) and nitrogen oxides, pollutants linked to cardiovascular disease, respiratory illness, lung cancer, and premature death (WHO 2021). In many rapidly growing cities, transport emissions represent one of the largest contributors to urban air pollution, exposing millions of people to harmful levels of airborne particles.

The health consequences are substantial. As documented in a The Lancet report, long-term exposure to air pollution is associated with increased risks of heart disease, stroke, chronic respiratory disease, and adverse pregnancy outcomes (Romanello et al., 2022). Transport systems therefore have direct implications for population health.

At the same time, the transport sector accounts for roughly one quarter of global energy-related carbon dioxide emissions, making it a central focus for climate mitigation efforts (International Energy Agency 2023). Road transport alone accounts for the majority of these emissions, driven by the global expansion of private motor vehicles and freight transport. The Lancet report provides evidence on the growing health hazards, exposures, and impacts associated with climate change (Romanello et al. 2022). Climate change is affecting human health both directly through increased exposure to extreme weather events and indirectly through disruptions to the physical, natural, and social systems that sustain wellbeing. It is also amplifying existing threats to food and water security, infrastructure, essential services, and livelihoods.

Addressing these challenges requires a combination of policy measures that are at the core of the transport systems agenda, including cleaner vehicle technologies, electrification of transport fleets, expanded public transport systems, and urban mobility strategies that reduce reliance on high-emission travel modes.

Cities that invest in public transit, walking infrastructure, and cycling networks not only reduce emissions but also improve air quality, enhance urban livability, and promote healthier lifestyles (Marquez 2013). As rising incomes in many developing countries lead to increased car ownership, traffic congestion, and growing levels of air and noise pollution, it may be time to draw greater attention to the benefits of walking and cycling as integral components of urban development and the planning of transport systems. Promoting pedestrian- and bicycle-friendly infrastructure can support not only sustainable mobility but also broader health promotion and disease prevention efforts.

Source: Photo taken by author of BICI CUENCA program that promotes riding bicycles in my native city streets, Cuenca, Ecuador, September 2025.

Source: Photo of “Muévete en Bici” program in Mexico City that support public cycling in the city. Adapted from https://www.eluniversal.com.mx/metropoli/muevete-en-bici-asi-disfrutan-ciclistas-paseo-dominical-en-cdmx/

From Mobility to Accessibility

A growing body of research suggests that transport policy should shift from focusing primarily on mobility (moving vehicles faster) to accessibility, which emphasizes people’s ability to reach jobs, services, and opportunities (World Bank Group 2025; OECD/ITF 2024).

Accessibility-focused transport systems prioritize reliable public transport, safe walking and cycling infrastructure, and integrated land-use planning that reduces travel distances.

These strategies will help ensure that transport investments contribute not only to economic growth but also to inclusive development and improved quality of life. Policies and investments that prioritize safe walking and cycling in cities, both in developing and rich countries alike, can reduce congestion and pollution while improving population health across all age groups. They also can foster collaboration across sectors, engage local communities, and expand access to jobs, education, and essential services, particularly for disadvantaged groups. The result is urban environments that are more efficient and sustainable, as well as healthier and more livable for all citizens.

Source: Pictures adapted from pxl_20250209_171113198 and mexico-city-bike-lanes

A Call to Design Transport Systems Around People

Transforming transport is no longer simply a mobility challenge; it is also a public health priority, an environmental necessity, and a development opportunity. Systems designed around safe and sustainable accessibility can simultaneously save lives, reduce emissions, expand economic opportunity, and enhance quality of life.

To this end, the World Bank’s transport program is now focusing on improving connectivity, safety, sustainability, and resilience while expanding access to jobs, markets, and services. Support is being provided to policies and investments that reduce unnecessary motorized travel, promote cleaner transport modes, improve infrastructure efficiency, and strengthen resilience to climate and economic shocks (World Bank Group 2025).

As discussions unfold at Transforming Transportation 2026, the challenge facing policymakers is not a lack of knowledge. Many solutions are already well established through research, policy experience, and country practice at the global level (OECD/ITF 2023; World Bank 2025).

The task ahead is to translate that knowledge into sustained action and ensure that transport systems are designed with people, not vehicles, at their center.

Ultimately, the true measure of a successful transport system is not how fast vehicles move, but how safely, cleanly, and reliably it connects people to jobs and economic opportunities.

Source: Image ID Shutterstock_2107119431

References

Acosta-González, Nicolás, Sheyla Cahueñas, and Carolina Pérez. 2025. “Risk Factors for Fatal Road Traffic Accidents in Ecuador.” Transportation Research Interdisciplinary Perspectives 32: 101515. https://doi.org/10.1016/j.trip.2025.101515.

Baker, Susan P., Brian O’Neill, Marvin J. Ginsburg, and Guohua Li. 1992. The Injury Fact Book. 2nd ed. New York: Oxford University Press. https://api.pageplace.de/preview/DT0400.9780199748709_A35477117/preview-9780199748709_A35477117.pdf

Bose, Dipan, Patricio V Marquez. 2018. The high toll of traffic injuries : unacceptable and preventable. Washington, D.C.: The World Bank. https://documentos.bancomundial.org/es/publication/documents-reports/documentdetail/374881515180592957

Chalya, Phillipo L., Joseph B. Mabula, Richard M. Dass, Mbelenge N., I. Ngayomela, A. Chandika, and J. M. Gilyoma. 2012. “Injury Characteristics and Outcome of Road Traffic Crash Victims at Bugando Medical Centre in Northwestern Tanzania.” Journal of Trauma Management & Outcomes 6 (1): 1. https://doi.org/10.1186/1752-2897-6-1.

Holla, Alaka, Norbert Schady, and Joana Silva, eds. 2026. Building Human Capital Where It Matters: Homes, Neighborhoods, and Workplaces. Washington, DC: World Bank. https://doi.org/10.1596/978-1-4648-2277-3.

Huang, Yu-Kang, Hsiang-Lin Lin, Yu-Chuan Chen, et al. 2016. “Injury Severity and Patterns of Road Traffic Crashes.” BMC Emergency Medicine 16: 41. https://doi.org/10.1186/s12873-016-0085-6.

International Energy Agency. 2023. “Transport.” Paris: IEA. https://www.iea.org/energy-system/transport.

Marquez, Patricio V. 2013. “Bikes, Cities and Health: A Good Combination.” World Bank Blogs, April 1, 2013. https://blogs.worldbank.org/en/transport/bikes-cities-and-health-a-good-combination

Marquez, Patricio V. 2025a. “Improving Road Safety: The Critical Role of Post-Crash Care in Saving Lives and Preventing Serious Disability”. Substack post (Global Public Health Issues) February 23, 2025. https://pmarquez.substack.com/p/improving-road-safety-the-critical

Marquez, Patricio V. 2025b. “After Marrakech Global Ministerial Conference on Road Safety: How Health Sector Interventions Can Contribute to Safer Roads?”. Substack post (Global Public Health Issues), February 23, 2025. https://pmarquez.substack.com/p/after-marrakech-global-ministerial

Marquez, Patricio V. 2025c. “Cellphones, Distracted Driving, and Unintended Consequences.” Substack post (Global Public Health Issues), February 23, 2025. https://substack.com/@pmarquez/p-157769156

Marquez, Patricio V. 2025d. “Injury Characteristics and Outcomes of Traffic Victims: Implications for Emergency Medical Care in Low- and Middle-Income Countries.” Substack post (Global Public Health Issues), August 15, 2025. https://substack.com/@pmarquez/p-171083348

Marquez, Patricio V, Dipan Bose. 2025f. “From Crisis to Innovation: How Artificial Intelligence Can Transform Emergency Medical Services and Save Lives.” Substack post (Global Public Health Issues), October 28, 2025.
https://pmarquez.substack.com/p/from-crisis-to-innovation-how-artificial

Marquez, Patricio V. 2025g. “Traffic Deaths Are Preventable: Why Vision Zero Faltered in U.S. Cities and What the World Can Learn.” Substack (Global Public Health Issues), December 5, 2025.
https://pmarquez.substack.com/p/traffic-deaths-are-preventable-why

Marquez, Patricio V; George A Banjo; Elena Y Chesheva. 2009. Confronting death on wheels: making roads safe in Europe and Central Asia - establishing multisectoral partnerships to address a silent epidemic. Washington, D.C.: World Bank. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/744131468257645475

Marquez, Patricio V., and Anthony G. Bliss. 2010. Dangerous Roads: Russia’s Safety Challenge. Europe and Central Asia Knowledge Brief No. 27. Washington, DC: World Bank.
https://openknowledge.worldbank.org/entities/publication/d9300104-8049-57ef-abcd-f47a51c1036e.

Marquez, Patricio V., and Jill L. Farrington. 2013. The Challenge of Non-Communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa: An Overview. Washington, DC: World Bank.
https://documents.worldbank.org/en/publication/documents-reports/documentdetail/844381468209068874.

Mock, Charles, Olufemi O. Abantanga, Thomas Juillard, et al. 2012. Strengthening Trauma Systems Globally: Improving Quality of Care. Geneva: World Health Organization.
https://www.who.int/publications/i/item/9789241503668.

OECD/International Transport Forum. 2023. Road Safety Annual Report 2023. Paris: ITF-OECD.
https://www.itf-oecd.org/road-safety-annual-report-2023

OECD/International Transport Forum. 2024. ITF Transport Outlook 2024. Paris: Organisation for Economic Co-operation and Development.
https://www.oecd.org/en/publications/serials/itf-transport-outlook_g1g834c5.html

Primicias. 2024. “Jefe de la Policía de Loja confirma 17 muertos y 10 heridos en fatal accidente de tránsito en la vía Loja-Catamayo.” Primicias, December 7, 2024.
https://www.primicias.ec/sucesos/muertos-heridos-accidente-transito-via-loja-catamayo-6diciembre-84933/.

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Introduction

A recent study published in Nature caught my attention as it urges researchers and policymakers to reconsider assumptions about economic inequality as a direct determinant of psychological health (Sommet et al., 2026).

For more than a decade, as highlighted in the study, influential research across social epidemiology, economics, sociology, and psychology has suggested that people living in more unequal societies tend to report lower subjective wellbeing and exhibit higher rates of mental health disorders such as depression and anxiety (Wilkinson and Pickett 2009; Oishi et al. 2011; Kondo et al. 2009; Pickett and Wilkinson 2015; Patel et al. 2018). The prevailing explanation has been that inequality heightens awareness of social hierarchies and fosters competitive social environments, intensifying status anxiety and weakening social cohesion—dynamics that ultimately undermine psychological wellbeing (Layte and Whelan 2014; Buttrick and Oishi 2017). Because of these interrelated mechanisms, reducing economic inequality has frequently been proposed as a powerful lever for improving population-level mental health (Marmot 2015; WHO Commission on Social Determinants of Health 2008).

Against this backdrop, Sommet and colleagues (2026) conducted for the Nature study a comprehensive meta-analysis of 168 multilevel studies involving more than 11 million individuals to examine whether income inequality is systematically associated with subjective wellbeing and mental health outcomes. Subjective wellbeing, in this context, refers to how individuals evaluate and experience their lives, including life satisfaction and the balance between positive and negative emotions (OECD 2013; OECD 2020).

Across countries, the authors found no consistent overall association between income inequality and subjective wellbeing once methodological biases and heterogeneous modeling approaches were addressed. Adverse effects were largely confined to low-income and economically unstable contexts (Sommet et al., 2026). In other words, the mere presence of large income differences within a society does not automatically translate into worse mental health outcomes.

Although these findings are striking at first reading, they do not diminish the broader importance of economic inequality. Rather, they suggest that inequality may operate less as an independent causal determinant and more as a contextual catalyst—shaping health outcomes through intermediary factors such as poverty, economic insecurity, institutional capacity, and social protection. Importantly, the authors acknowledge that alternative conceptualizations and measurements of inequality may still reveal effects under specific social and economic conditions.

In this post I summarize a broader literature review that I conducted to better understand this complex relationship.

Source: Picture taken by author of Wilfredo Lam’s Untitled painting, 1958, at Retrospective “When I Don’t Sleep, I Dream”, The Museum of Modern Art, New York, February 28, 2026.

Understanding Economic Inequality

Economic inequality is defined as the uneven distribution of income and wealth in a population. The Gini coefficient is a widely used indicator of income inequality that ranges from 0 (perfect equality) to 1 (perfect inequality); for example, Sweden has relatively low inequality (around 0.28), while the United States shows higher inequality (around 0.41) and Brazil exhibits even higher inequality (around 0.53) (World Bank 2024a). While income inequality refers to how unevenly income is distributed, wealth inequality captures disparities in asset ownership such as housing, savings, land, and financial investments.

Global disparities remain substantial, and that helps explain why inequality receives significant attention in public debate (OECD 2015a). The richest 10% of the global population receive 52% of total global income and own 76% of global wealth, while the poorest half earn just 8.5% of income and hold 2% of wealth (Alvaredo et al., 2022).

Branko Milanović’s work (2016) has showed that while globalization reduced inequality between countries, it increased inequality within many advanced economies. His “elephant curve” illustrates that technological change and globalization benefited emerging middle classes and top earners, while segments of lower-middle classes in advanced economies experienced stagnation.

Inequality measures primarily capture dispersion—the numerical distance between higher and lower incomes, but they do not tell us whether individuals can meet basic needs, feel economically secure, or perceive mobility pathways.

This distinction matters as the psychological implications are important. While income gaps may shape perceptions of fairness and social comparison, psychological distress appears more directly linked to economic stagnation, insecurity, and blocked mobility than to inequality per se (Rohde et al. 2016; Case and Deaton 2020). Dispersion alone does not automatically generate mental distress, deprivation and instability do (Adjaye-Gbewonyo et al. 2016).

Poverty and Economic Insecurity

Unlike inequality measures, which show dispersion, poverty directly captures whether individuals lack sufficient resources for survival and basic functioning (World Bank 2024b).

In June 2025, the World Bank updated the international extreme poverty line from USD 2.15 (2017 PPP) to USD 3.00 per day (2021 PPP) to reflect updated price data and cost-of-basic-needs estimates (World Bank 2025a; Baah et al. 2025). Under this revised threshold, approximately 808 million people—about 9.9% of the global population—were living in extreme poverty in 2025 (Baah et al., 2025; United Nations, 2025). Extreme poverty is heavily concentrated in Sub-Saharan Africa, where nearly half the population lives below the extreme poverty line and where roughly two-thirds of the world’s extreme poor reside. Fragile and conflict-affected states also account for a disproportionate share of global poverty (World Bank 2024; United Nations 2025). These numbers underscore that hundreds of millions of people remain unable to secure the most basic consumption needs necessary for physical and psychological wellbeing.

Beyond deprivation lies economic insecurity—exposure to shocks such as job loss, illness, income volatility, or inflation, combined with limited capacity to absorb them (OECD 2015b; World Bank 2022). It captures vulnerability and instability, not just income level. Even households above poverty thresholds can experience high insecurity if they lack savings, stable work, or social protection.

This matters for mental health and wellbeing. Ridley et al. (2020) show that poverty and economic shocks increase depression and anxiety risk, while mental illness reduces earnings and labor participation, creating a reinforcing cycle. Across OECD countries, for example, people in the lowest income groups are several times more likely to experience depressive symptoms than those in higher-income groups, highlighting the strong socioeconomic gradient in mental health outcomes (Vargas et al., 2025). Life satisfaction varies systematically by income security and employment status (OECD, 2024).

These gradients reflect material deprivation and economic instability rather than income dispersion alone. Individuals facing persistent financial strain experience higher levels of stress and insecurity, which increase cognitive load, bias decision-making toward short-term concerns, and reduce psychological resilience (Shah, Mullainathan, and Shafir 2012; Mani et al. 2013). At the same time, chronic exposure to economic uncertainty activates sustained stress responses that accumulate as physiological strain on the body and brain (McEwen and Stellar 1993).

Mental health outcomes, therefore, appear more closely associated with whether individuals can reliably secure essential goods and services—and whether they live under conditions of chronic economic uncertainty—than with the mere dispersion of incomes across society (OECD 2024; Vargas Lopes and Llena-Nozal 2025).

The Experience of Vulnerability

In her recent book, The Invisible Illness: A History, from Hysteria to Long Covid (2026), Emily Mendenhall adds an important dimension to understanding vulnerability beyond economic insecurity. She shows how health conditions that lack clear biological markers are often misunderstood, dismissed, or psychologized, resulting in stigma, disbelief, and fragmented care.

By tracing conditions from historical diagnoses like hysteria to contemporary long COVID, Mendenhall illustrates how chronic suffering is often intensified when institutions fail to provide recognition and coordinated support. The parallel with economic insecurity is striking. In both cases, distress is amplified when individuals face sustained uncertainty without reliable institutional buffering, whether in healthcare or economic policy (Mendenhall, 2026).

Mendenhall’s analysis reinforces the idea that vulnerability—whether medical or economic—cannot be reduced to simple averages or statistical gaps, and that structural support matters deeply for psychological wellbeing.

Source: Picture taken by author of Wilfredo Lam’s painting “La Rumeur de la terre (Rumblings of the Earth)”, 1950, at Retrospective “When I Don’t Sleep, I Dream”, The Museum of Modern Art, New York, February 28, 2026.

Employment: A Critical Transmission Channel

Employment is where economic conditions and mental wellbeing intersect. Jobs provides income, but also structure, identity, social connection, and a sense of purpose. Stable employment can buffer insecurity; unemployment and precarious work amplify it.

OECD research shows that mental health conditions are associated with higher unemployment and lower labor participation, costing economies up to 4% of GDP in medical care expenditures, lost productivity, and reduced employment (OECD, 2023). At the same time, unemployment itself increases psychological distress (Ridley et al., 2020).

The above dynamics are especially visible among Generation Z, generally defined as those born between 1997 and 2012 (Pew Research Center, 2019). Many members of this cohort are entering adulthood amid elevated inflation and labor market volatility. In several economies, youth face record highs on the ‘Misery Index.’ This index measures economic distress as the sum of the unemployment rate and the inflation rate, reflecting the idea that both joblessness and rising prices impose tangible costs on households and society (Okun 1970; Cato Institute 2009; Federal Reserve Bank of St. Louis, n.d.). High unemployment reduces opportunities; high inflation erodes purchasing power. Combined, these forces intensify economic insecurity.

For young adults at the start of their working lives, prolonged unemployment or unstable employment can have lasting effects. Early labor market instability leaves durable economic and psychological scars. Individuals entering the workforce during economic downturns face persistent reduction in wages and career progression that can last a decade or more (Kahn 2010; Oreopoulos, von Wachter, and Heisz 2012).

Research has also showed that there are long-term mental health scarring effects of exposure to youth unemployment and multiple exposure to unemployment during the life course (Strandh et al. 2014). These conditions are associated with heightened long-term vulnerability to anxiety and depressive symptoms (Strandh et al. 2014; Paul and Moser 2009).

More specifically, chronic economic insecurity imposes both cognitive and physiological burdens. Conditions of scarcity reduce the mental bandwidth available for processing information, planning ahead, regulating emotions, and making decisions, as individuals must constantly devote attention to meeting immediate needs. In turn, these constraints increase short-term decision bias and heighten stress reactivity, contributing to the cumulative physiological strain placed on the body and brain through prolonged exposure to chronic stress (Shah, Mullainathan, and Shafir 2012; Mani et al. 2013; McEwen and Stellar 1993).

The mental health consequences of instability therefore extend beyond financial limitations. They operate through disrupted expectations, constrained agency, and prolonged stress exposure (see related discussion on Marquez 2026).

Artificial Intelligence and Labor Market Disruption

Nowadays, the rapid development and adoption of artificial intelligence (AI) tools across industries add another layer of uncertainty. In a recent interview, Jamie Dimon, CEO of JPMorgan Chase, has acknowledged that AI may reduce employment in certain sectors while increasing productivity. He has urged proactive retraining and redeployment strategies to avoid large-scale displacement shocks (World Bank Group, 2025; Fortune, 2026).

The social implications are clear. The challenge that we face is not technological disruption per se, but how transitions are managed. If institutions fail to provide credible pathways for redeployment, insecurity increases—even if overall inequality measures remain stable. Hence, unmanaged technological disruption becomes another source of economic instability (Marquez 2026).

From this perspective, the emphasis placed by Ajay Banga, President of the World Bank Group, on job creation acquires particular importance. As he has emphasized, “The job is not done without jobs. Work is never just about wages, it is about dignity, stability, and the bridge between growth and belonging” (Martin 2025). Hence, employment should be understood as not merely an economic statistic, but as a source of psychological stability, human capital formation, and community belonging.

The Intergenerational Effects of Economic Insecurity on Health

The relationship between economic insecurity and physical and mental health unfolds not only within individuals but also across generations (Zhang et al. 2022; Chauhan and Potdar 2022). Economic hardship, social instability, and limited support systems shape the environments in which children are conceived, born, and raised. These conditions influence parental wellbeing and caregiving capacity, thereby affecting the early developmental foundations of human capital.

Maternal depression illustrates one of the clearest pathways through which adverse economic and social conditions influence child development (Chauhan and Potdar 2022). Often associated with poverty, gender inequality, exposure to violence, and weak social support networks, maternal depression reflects the psychological toll that economic and social stressors can impose on caregivers (World Bank 2012; Rahman et al. 2004; Walker et al. 2011; Stein et al. 2014; Black et al. 2017).

When mothers experience persistent psychological distress during pregnancy or early childhood, their capacity to provide consistent care, emotional responsiveness, and adequate nutrition may be affected, with consequences that may manifest across the life course, shaping children’s physical growth, cognitive development, emotional regulation, and educational attainment (Goeglein and Yatchmink 2020; Marquez and Dutta 2018).

Maternal depression has been linked to less responsive parenting, shorter durations of breastfeeding, and reduced attention to infant feeding and health practices (Stewart 2007). As a result, children of depressed mothers face higher risks of undernutrition and stunting—defined as impaired growth and development measured by low height-for-age (Wemakor and Akohene Mensah 2016; Lara et al. 2015; Marquez and Dutta 2018). While deficiencies of vitamin A and zinc are associated with increased child mortality, deficiencies of iodine and iron, together with stunting, can impair cognitive development and prevent children from reaching their full developmental potential. At the same time, childhood overweight is emerging as a growing concern. It generally arises from an energy imbalance between calories consumed and calories expended, shaped by the interaction of behavioral, environmental, and biological factors. Increasingly, childhood overweight contributes to the rising burden of adult obesity, diabetes, and other non-communicable diseases (Black et al. 2013). Many of these nutritional challenges originate during pregnancy and early childhood, a period when physical growth and brain development are particularly sensitive to environmental influences.

A large body of scientific evidence shows that adequate nutrition, care, and stimulation during pregnancy and the first years of life, often referred to as the “first 1,000 days”, are essential for healthy brain development and the acquisition of cognitive and socioemotional skills later in life (Black et al. 2013). When early childhood environments are compromised, the developmental consequences can be long-lasting.

Chronic stress during early life can disrupt brain development and alter stress-response systems, affecting cognitive development, emotional regulation, and later educational outcomes (Shonkoff et al. 2012; Goeglein and Yatchmink 2020). Empirical evidence illustrates the magnitude of these risks: children exposed to maternal depression before age five face a 17% higher likelihood of developmental vulnerability at school entry, with particularly strong impacts on social competence, physical health and well-being, and emotional maturity (Wall-Wieler, Roos, and Gotlib 2020).

The global scale of this challenge is considerable. Mental health conditions affect at least 10% of the world’s population, and approximately 20% of children and adolescents experience some form of mental disorder (WHO 2022). At the same time, an estimated 23% of the world’s 667 million children under age five are stunted, and nearly 45% of deaths among young children are linked to malnutrition (UNICEF, WHO, and World Bank 2023). Together, these statistics highlight the deep interconnections between economic insecurity, mental health, nutrition, and early childhood development.

Implications for Human Capital Development

Recent evidence from the World Bank’s 2026 report Building Human Capital Where It Matters: Homes, Neighborhoods, and Workplaces place these findings within a broader framework for development policy (Holla, Schady, and Silva 2026). The report emphasizes that human capital—the health, knowledge, and skills people accumulate throughout life—is shaped not only by schools and health systems but also by the environments in which people live and work, particularly the home, the neighborhood, and the workplace (Holla, Schady, and Silva 2026).

This perspective helps explain why maternal wellbeing and early childhood conditions play such a critical role in development outcomes. In the home, family resources and caregiving practices influence nutrition, early learning, and emotional development, factors that shape children’s physical growth, cognitive abilities, and socioemotional skills. These early-life conditions form the foundation of human capital and influence educational attainment, productivity, and earnings later in life.

The report further highlights that human capital formation is also shaped by neighborhood environments, including access to quality schools, health services, safe public spaces, and economic opportunities. Finally, workplaces serve as key arenas where skills are reinforced and expanded through experience, training, and on-the-job learning.

Viewed through this broader lens, poverty and economic insecurity, physical and mental health, and human capital development are deeply interconnected. Breaking intergenerational cycles of poverty, instability, and ill health therefore requires an integrated, cross-sectoral approach, one that strengthens families, communities, and labor markets simultaneously. Early disadvantages in nutrition, caregiving, and psychological wellbeing can accumulate across the life course, weakening the development of human capital and ultimately affecting productivity, labor market participation, and economic growth.

Conclusion: From Puzzlement to Clarity

When I first read the Nature meta-analysis questioning the link between inequality and mental distress, I felt somewhat puzzled, and it prompted me to look more closely at the broader literature to gain clarity. What emerged, consistent with the Nature meta-analysis findings, was not a dismissal of inequality as unimportant, but a clearer understanding of where the strongest evidence lies. Income gaps alone do not consistently predict psychological harm. What does, repeatedly and across contexts, is the lived experience of deprivation, instability, and economic insecurity—especially when reflected in unstable employment and limited opportunity for younger generations.

If we are serious about strengthening the physical and mental wellbeing of people and long-term economic resilience, our focus of attention and action must center in ensuring that people can meet basic needs, participate meaningfully in the labor market, and live with a realistic sense of stability and dignity.

It is precisely here that perhaps a compelling justification emerges for the jobs agenda now prioritized by the World Bank Group (2025b). In an era of rapid technological transition and persistent economic insecurity, World Bank President Ajay Banga’s emphasis on employment carries renewed urgency (Martin 2025a). Addressing poverty, generating and stabilizing employment, and strengthening institutional buffers are not peripheral to the mental health and wellbeing of a population, they are foundational to it.

Employment is not merely an economic statistic. It provides income, structure, social connection, dignity, and a sense of purpose. In doing so, it serves as a critical anchor of psychological stability and an essential channel through which individuals accumulate skills and build human capital.

Against the backdrop of technological disruption, demographic change, and ongoing economic uncertainty, economic opportunity and mental wellbeing should be understood as mutually reinforcing objectives. Policies that reduce poverty, support families, promote stable employment, and invest in health, early childhood development, and education do more than stimulate economic growth—they strengthen the human capital and social resilience upon which thriving societies ultimately depend.

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Source: Picture taken by author of Wilfredo Lam’s painting “Umbral (Threshold)”, 1950, at Retrospective “When I Don’t Sleep, I Dream”, The Museum of Modern Art, New York, February 28, 2026.

“We have said that life, by its very structure, having once been lifted to its stage of thought, cannot go on at all without requiring to ascend ever higher”

— Pierre Teilhard de Chardin, The Phenomenon of Man (1955)

Introduction

Nowadays, while browsing newspapers, magazines, or academic journals, whether in print or online, it is difficult to avoid the growing of attention devoted to artificial intelligence (AI), covering both potential benefits and dystopian warnings. This should not surprise us. It reflects a growing recognition that something fundamental is shifting, as familiar routines, ways of working, and social interactions are being reshaped by the introduction and use of AI and other digital technologies (Frey 2019; Kishtainy 2025; Marquez 2024a; Marquez 2024b).

A recent Bloomberg News article illustrates the scale of this disruption, describing an AI-powered tool capable of analyzing company data, regulatory filings, and market information to generate detailed financial assessments, tasks that once required skilled professionals several days to complete (Metz 2026). The rapid diffusion of such tools underscores mounting pressures on labor markets, where automation is no longer confined to routine work but increasingly involves analytical tasks. This raises concerns about job displacement, task reconfiguration, and the future demand for human expertise.

AI’s future remains deeply unsettled, with leading thinkers offering divergent visions that highlight both transformative potential and significant risks. Experts agree AI will reshape work, education, and society, not simply by automating tasks but by redefining how people interact, learn, and work, yet they differ on the pace and consequences of these changes and stress that outcomes will hinge on human governance, values, and collective choices and decisions rather than inevitable technological progress alone (The New York Times 2026).

In this post, I reflect on both the promise and the risks of AI for the mental health and wellbeing of individuals in societies already strained by economic uncertainty, social fragmentation, and rapid technological change. These reflections are informed in part by my participation in the public plenary “Wellbeing with AI: What’s Possible?”, convened on February 2, 2026, by the Johns Hopkins Bloomberg School of Public Health’s Department of Mental Health under the leadership of Professor Pamela Collins. The discussion featuring Tom Insel, Laura Reiley, and Holly Wilcox, and moderated by Johannes Thrul offered accumulated evidence, lived experience, and ethical reflection (JHBSPH 2026). My reflections also draw on recent economic and historical literature, as well as from public health and health systems analyses.

Source: Photo taken by author, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, February 2, 2026.

Understanding AI’s Expanding Role in Society

At its core, AI refers to computational systems capable of performing tasks traditionally associated with human intelligence, including learning from data, identifying patterns, making predictions, and generating recommendations (OECD 2019).

An AI system, as explained by the OECD’s AI Experts Group (AIGO), is a

machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. It uses machine and/or human-based inputs to perceive real and/or virtual environments; abstract such perceptions into models (in an automated manner e.g. with Machine Learning or manually); and use model inference to formulate options for information or action. AI systems are designed to operate with varying levels of autonomy (OECD 2019).

What distinguishes the current moment, however, is not the novelty of these capabilities, but the extraordinary speed, scale, and pervasiveness with which AI applications, alongside smartphones and digital media, are impacting everyday life, far faster than institutions, governance frameworks, and social norms are able to adapt (Frey 2019; Kishtainy 2025). This rapid diffusion has amplified both the promise of AI and the risks associated with unmanaged technological change.

Historically, AI resembles earlier general-purpose technologies whose benefits unfolded slowly and unevenly over time. Their early phases were often marked by labor displacement, rising inequality, and social stress, with productivity and welfare gains materializing only after sustained complementary investments in skills, institutions, and social protection. When societies fail to manage technological disruption, innovation can erode trust, weaken social cohesion, and undermine political stability (Frey 2019). These consequences are not merely economic in nature; they are fundamentally social and political.

Against this historical backdrop, the current AI revolution is unfolding on a global scale, extending well beyond high-income countries. AI and digital technologies are now mainstream, reshaping daily life, work, social interactions, and economic structures and workplaces across virtually all regions of the world.

AI use had expanded far beyond early adopters, with hundreds of millions of people using AI tools regularly and enterprises across most sectors integrating AI into core operational functions (Microsoft AI Economy Institute 2026; Adebayo 2026). More specifically, global AI adoption continued to climb in the second half of 2025, increasing by approximately 1.2 percentage points compared with earlier in the year, with an estimated 16.3 percent of the world’s population, roughly one in six people—using generative AI tools by late 2025 (Microsoft AI Economy Institute 2026).

Global adoption of AI is accelerating, but its diffusion remains highly uneven, shaped by persistent divides in digital infrastructure, skills, affordability, and institutional readiness within and across countries. A clear gap separates the Global North, high-income and upper-middle-income economies located primarily in North America, Europe, and parts of East Asia and Oceania characterized by advanced industrialization, robust digital infrastructure, high levels of technological capacity, and strong institutional and legal frameworks, from the Global South, which encompasses low- and middle-income countries across Africa, Latin America and the Caribbean, much of Asia, and the Middle East, where constraints remain more pronounced despite growing dynamism in digital uptake. As a result, AI use among the working-age population is estimated at 24.7 percent in high-income and upper-middle-income economies, compared with 14.1 percent in the Global South, where adoption is expanding at roughly half the pace, widening the global AI divide (Microsoft AI Economy Institute 2026).

Within this uneven landscape, countries that have invested early and consistently in digital infrastructure, human capital, and enabling regulatory systems continue to exhibit higher levels of AI uptake. At the same time, many emerging economies are expanding access through open-source models and mobile-based platforms, underscoring AI’s capacity to diffuse even where resources are constrained (Microsoft AI Economy Institute 2026).

Crucially, however, evidence suggests that impact depends less on access than on capability. As explained by Adebayo in an Inc post (2026), “AI power users” distinguish themselves not primarily through superior technical skill, but through how they approach work. Rather than dabbling, they experiment continuously iterating on prompts, building reusable workflows, and matching specific tools to clearly defined tasks. They tend to master one or two core AI platforms while rotating among several specialized applications as needed, and they break complex projects into discrete stages—such as research, outlining, drafting, and refinement—deploying AI strategically at each step. This way of working matters because its productivity effects compound: OpenAI data suggest that effective AI use can save 40–60 minutes per worker per day, gaining a day and a half of productivity each week, and implying that in organizations where most employees underutilize AI, thousands of productive hours are effectively lost each year (Adebayo 2026).

Together, these trends point to AI not merely as a neutral technological innovation, but as a one that is ushering a global socio-economic transformation—one whose benefits and risks will be shaped less by the availability of technology itself than by how societies invest in skills, governance, and inclusive digital ecosystems.

Beyond Economics: AI’s Impact on People’s Mental Health and Wellbeing

The combination of AI’s global reach, uneven diffusion, and highly differentiated impacts makes its social consequences difficult to assess through economic indicators alone. Public debate has understandably focused on productivity gains, automation, employment losses and displacement, and global competitiveness, with AI alternately portrayed as an engine of unprecedented progress or as a source of societal disruption and risk (Frey 2019; Acemoglu and Johnson 2023). Yet amid both optimism and unease, one of the most revealing ways to assess AI’s broader social impact is to examine how it affects people’s mental health and wellbeing—and how policy, equity, and governance choices shape those effects.

Unlike economic growth or efficiency gains metrics, mental health outcomes capture dimensions of human wellbeing that technology can support but never replace. These include human agency, the capacity to make meaningful choices and act with a sense of control over one’s life; security, protection from physical, economic, psychological, and social threats; identity, a sense of self, belonging, and meaning shaped by personal and cultural experience; and social connection—the trusting relationships that foster resilience and emotional wellbeing. Together they are core determinants of social stability, economic resilience, and political legitimacy. Ultimately, whether AI contributes to human development or compounds existing social harms will depend less on what machines can do than on how societies choose to design, regulate, and integrate AI within their institutions and systems to support human wellbeing (WHO 2023).

Human Capital in the Times of AI

A central insight emerging from recent economic analysis is that AI does not substitute for human capital, it depends on it. In an article published by the International Monetary Fund (IMF), Pablo Peña identifies three human capacities that become more, not less, valuable as AI advances: curiosity, critical thinking, and self-regulation (Peña 2025). As Peña observed, these capacities are forms of human capital that grow when we are encouraged, repeatedly and deliberately, to be curious, think critically, and self-regulate. Together, they form a bridge between technological capability and human wellbeing.

Curiosity and the Limits of Prediction

AI systems excel at processing and combining existing data and information, but they cannot generate genuinely new knowledge rooted in lived experience. Peña illustrates this with a thought experiment: an AI trained on all available data before 1939 could not have created Yesterday by the Beatles, because the song emerged from human experiences that had not yet occurred (Peña 2025).

This insight extends well beyond song writing. In public health and social policy, AI can synthesize existing evidence, but it cannot independently design novel interventions, build trust with communities, or adapt creatively to uncertainty. Without sustained human curiosity and judgment, societies risk reaching a state of “peak data”, where data accumulation outpaces the capacity to interpret and apply it responsibly. Beyond this threshold, AI systems risk recycling past assumptions and amplifying bias unless matched by stronger governance and human-centered safeguards.

From a wellbeing perspective, curiosity is not merely an economic input; it is a psychological asset. It supports learning, growth, and meaning-making, which are key components of resilience. Over-reliance on AI for answers risks intellectual passivity and erosion of agency, both associated with poorer mental health outcomes.

Source of picture: Photo taken by the author of an exhibition at the Casa Fernando Pessoa, Lisbon, Portugal, September 2023.

Critical Thinking and Psychological Safety

Peña’s second pillar, critical thinking, is equally essential (Peña 2025). In areas such as mental health, ethics, and social policy, AI does not deliver objective truth; it recombines historical data, norms, and assumptions. Judgment therefore remains a human responsibility.

This matters because AI systems are vulnerable to bias, misinformation, and deliberate manipulation. As reliance on generative systems grows, so do incentives for data manipulation and persuasive but misleading outputs. For individuals seeking mental health support, these vulnerabilities are particularly acute. Critical thinking thus functions as a protective factor safeguarding psychological safety in an increasingly AI-mediated world.

Self-Regulation: The Weakest Link

Peña’s third insight, self-regulation, may be the most consequential for mental health (Peña 2025). As Peña notes, since Adam Smith, economists have recognized that human wellbeing depends not only on knowing what is good for us, but also on the capacity for self-regulation and self-control to act on that knowledge over time. AI can offer advice on sleep, exercise, therapy adherence, or substance use, but it cannot ensure follow-through. Outcomes depend on people’s ability to regulate behavior, emotions, and impulses.

As AI improves at telling us what we should do, the value of self-regulation increases rather than declines. This creates a paradox: better AI raises the stakes for human discipline. If AI design undermines self-regulation by fostering distraction, dependency, or passivity it may worsen wellbeing despite improving information.

Data as a Hidden Transaction

A critical structural dimension of AI’s wellbeing impact lies in the economics of data. In another IMF’s published article, Laura Veldkamp explains that data are not free: consumers pay for digital services not only with money, but with information about their behavior, preferences, and movements (Veldkamp 2025).

Crucially, this transaction is hidden. Data are bundled with digital goods and services, making it impossible for users to know what price they receive for their information. As Veldkamp argues, this bundling ensures that consumers systematically receive less than fair value. So, as Veldkamp suggests, revealing data’s true price can turn passive users into active suppliers who demand fair value.

For wellbeing, the implications are profound. Continuous data extraction can intensify surveillance, reduce autonomy, and create digital environments optimized for engagement rather than for promoting mental health and wellbeing. Such environments are associated with anxiety, depression, social comparison, and emotional manipulation, particularly among young people. The invisibility of this transaction also erodes trust, fostering feelings of powerlessness that undermine psychological wellbeing.

Youth Perspectives: Intuitive Resistance, Not Technophobia

Today’s adolescents are facing a convergence of complex social, digital, environmental, and economic pressures that are increasingly shaping their health, wellbeing, and life trajectories. The Second Lancet Commission on Adolescent Health and Wellbeing (Baird et al. 2025; Marquez 2025 d) concluded that adolescent lives are now shaped by powerful, mutually reinforcing megatrends. Since the 1990s, the proportion of young people living in conflict-affected settings has more than doubled, reaching an estimated 340 million adolescents worldwide. At the same time, this is the first truly global generation of digital natives—79 percent of 15–24-year-olds use the internet globally, with connectivity exceeding 95 percent in high-income countries—and the first cohort to live their entire lives in a world already altered by climate change, with global temperatures remaining at least 0.5°C above pre-industrial levels.

One of the most revealing insights in the current debate about social media and AI impact on human wellbeing comes from adolescents themselves. Research findings, for example, show that roughly 1 in 5 U.S. teens say they are on TikTok and YouTube almost constantly, and, at the same time, 64 percent of teens say they use AI chatbots, like ChatGPT and Character.ai, including about 3 in 10 who do so daily (Pew Research Center 2025 a).

While these sites remain a key part of their lives, with some using them “almost constantly”, teens express mixed feelings about social media’s impact. Recent survey and qualitative research findings from the Pew Research Center suggest that most teens credit social media with feeling more connected to friends, yet roughly 1 in 5 say social media sites hurt their mental health, and growing shares think they harm people their age (Pew Research Center 2025 b). Broader evidence from youth mental health research reinforces and deepens these concerns. Drawing on adolescents’ experiences with social media and digital platforms, growing exposure to algorithmically curated content has been associated with heightened anxiety, depressive symptoms, sleep disruption, and identity stress, with risks disproportionately affecting vulnerable youth and those already facing social or psychological adversity (Marquez 2024 c; Marquez 2025 a).

Previous related research from Common Sense Media (2024) shows that while a large majority of U.S. teens have used generative AI tools, their engagement is selective and purpose-driven, most often focused on homework assistance, creative tasks, and personal activities, reflecting a cautious and nuanced approach rather than indiscriminate use. However, findings from a follow-on nationally representative survey point to growing trust and wellbeing challenges in AI-mediated digital environments (Common Sense Media 2025). More than one-third of teens report having been misled by fake or AI-generated content, and many express deep skepticism toward major technology companies, doubting that youth mental health and responsible AI use are prioritized over profits. At the same time, teens are not passive recipients of these technologies: nearly three-quarters support stronger safeguards, including privacy protections, content warnings, and clear labeling of AI-generated material, underscoring the urgent need for a multi-stakeholder response that strengthens digital literacy, transparency, and trust while empowering young people to engage with AI critically rather than cynically.

Their concerns extend well beyond technical accuracy (Common Sense Media 2024). Young people frequently express unease about the erosion of creativity and originality, over-dependence on automated tools, declining confidence in their own cognitive and emotional capacities, privacy and data misuse, and the effects of AI-mediated interactions on relationships, identity formation, and authenticity (Common Sense Media 2024). Some explicitly describe discomfort with delegating thinking, judgment, or emotional expression to machines, particularly in domains closely tied to self-worth, moral reasoning, and personal meaning.

Importantly, the teens attitude reflects critical engagement rather than technophobia. Adolescents are not rejecting AI outright; many use it instrumentally while deliberately limiting reliance. This pattern aligns closely with economic and behavioral insights emphasizing the growing importance of human agency, critical thinking, and self-regulation in the AI age (Peña 2025).

From a mental health perspective, this intuitive resistance is instructive. Adolescence is a critical period for identity formation, emotional regulation, and the development of coping strategies. Technologies that shortcut effort, obscure agency, or blur boundaries between human and machine interaction may interfere with these developmental processes. In this sense, young people’s caution can be read not as resistance to innovation, but as an implicit demand that AI systems respect autonomy, support learning, and reinforce, rather than substitute for, the human capacities essential to long-term wellbeing.

Source of Image: Shutterstock_1549657265.

Brain Health, Brain Capital, and the AI Economy

In the current times of digital and AI transformation, the health of the human brain has emerged as a defining determinant of individual wellbeing, organizational performance, and long-term economic resilience (McKinsey & Company 2026 a). As defined in a recent report by McKinsey & Company and the World Economic Forum (2026 b), brain health refers to optimal brain functioning across the life course, supported by healthy development and the prevention or treatment of mental, neurological, and substance use disorders. Crucially, the report emphasizes that health alone is not sufficient: brain skills, including cognitive, interpersonal, self-leadership, and technological literacy capabilities, are equally essential for enabling individuals to adapt, relate, and contribute meaningfully. Together, brain health and brain skills constitute what the authors describe as brain capital.

As AI reshapes how work is organized and value is created, brain health is no longer just a health concern but a core economic and development priority (Kleinman, Lockwood Estrin, Usmani, Chisholm, Marquez, Evans, and Saxena 2016). The concept of the brain economy underscores this shift, emphasizing that modern prosperity depends on safeguarding and strengthening brain health alongside advancing digital and technological capabilities (McKinsey & Company 2026 a).

Brain health extends beyond the absence of mental or neurological disorders. It encompasses the capacity to think clearly, regulate emotions, manage stress, learn continuously, and sustain meaningful social connections across the life course. These capacities are increasingly strained by rapid technological change, post-pandemic stressors, population aging, and persistent inequities in access to effective mental health care, education, and other essential social services. Without deliberate investment, such pressures risk eroding the very human capabilities on which AI-enabled systems ultimately depend (McKinsey Health Institute and World Economic Forum 2026 b).

More specifically, the McKinsey Health Institute and World Economic Forum report (2026 b) warns that underinvestment in brain health carries substantial human and economic costs. The global burden of brain-health conditions is rising, driven by demographic aging, heightened stress, and growing uncertainty about the future. When societies overlook the brain’s central role in health and productivity, the consequences are felt in disrupted lives, lost potential, and heavy strain on families and caregivers (Marquez 2016; Marquez 2020 b). Evidence cited in this report suggests that scaling cost-effective interventions to prevent, treat, and support recovery from brain-health conditions could avert 267 million disability-adjusted life years (DALYs) globally by 2050, generating up to $6.2 trillion in cumulative GDP gains. Early investments yield especially high returns: high-quality early childhood programs have demonstrated 7–13 percent annual returns and benefit-to-cost ratios of up to 9:1, particularly in low- and middle-income countries (McKinsey Health Institute and the World Economic Forum 2026).

Beyond aggregate growth, investments in brain health contribute to better educational outcomes, more resilient workforces, stronger social cohesion, and greater capacity to adapt to technological and economic shocks (Marquez 2025 b; Marquez, Fleischer, and Mahoney 2024 e; Marquez 2024 f). Recognizing this, the joint analysis by the McKinsey Health Institute and the World Economic Forum (2026 b) calls for a coordinated, multi-sectoral approach to strengthening the brain economy—expanding access to quality brain-health care, integrating prevention and early intervention across health and social protection systems, and embedding brain-health considerations into education, social protection, workplace design and operations, and public policy (Marquez and Saxena 2016; Marquez 2022 a; Marquez 2023 a; Marquez 2025 c).

In parallel, advancing these reforms at national and global levels will require sustained mobilization of additional domestic resources—particularly through tax base expansion—to close financing gaps and strengthen the availability and quality of treatment and social support services. Innovative approaches such as pro-health taxes on tobacco, alcohol, and sugary drinks, alongside the elimination of wasteful subsidies and tax loopholes that disproportionately benefit the well-off can help expand fiscal space for mental health and psychosocial support services as integral parts of health service delivery platforms, and in the provision of education and other social programs (Marquez and Chockalingam 2023). As suggested elsewhere, rather than advocating for another siloed approach focused on individual health conditions, multi-sectoral funding must be leveraged to scale up mental health interventions while also promoting efforts to reduce duplication and inefficiencies (Marquez 2022 b).

Ultimately, investing in brain health strengthens human potential and human capital, which are fundamental to long-term economic growth and societal wealth creation. (Marquez 2025 c). In a world where machines increasingly enhance human effort, the capacity to think clearly, connect meaningfully, and exercise sound judgment becomes a critical source of comparative advantage. Leaders who prioritize brain health at organizational, national, and global levels will be better positioned to ensure that AI advances support human flourishing rather than erode it.

AI’s Promise in Mental Health Care

AI’s potential for expanding and improving the quality and effectiveness of mental health care as an integral part of health services delivery platforms is real.

A growing ecosystem of digital and AI-enabled tools is already being used to support the early identification of psychological distress—the experience of emotional and mental suffering that disrupts a person’s ability to cope, function, and feel well; assist with triage, personalize low-intensity interventions, and reduce administrative burdens that contribute to clinician burnout (Marquez 2024 d). These tools include digitized, validated screening instruments (e.g., PHQ-9, GAD-7, M3 Checklist) integrated into clinical and population-level platforms; AI-supported conversational agents such as Woebot Health and Wysa, which deliver evidence-informed cognitive and emotional support for mild to moderate symptoms; and passive sensing technologies that analyze smartphone or wearable data to detect early behavioral signals associated with stress and emotional suffering.

Evaluations conducted in academic and health-system settings, including those affiliated with the Johns Hopkins Bloomberg School of Public Health, suggest that when appropriately governed and clinically supervised, these tools can improve risk stratification, continuity of care, and efficiency, freeing clinician time while enabling earlier, more tailored responses to distress (Fitzpatrick et al. 2017; Inkster et al. 2018; Casu et al. 2024; WHO 2023; JHBSPH 2026).

At the system level, AI promises efficiencies that health ministries and insurers find appealing: faster screening, predictive analytics for demand planning, and automation of routine documentation. These gains matter, particularly in systems facing chronic staff shortages, funding limitations, and rising demand.

Yet, in spite of these technological developments, mental health is not a domain where speed, scale, or optimization alone equate to value. Care is relational, context-dependent, and ethically charged. Tools that perform well in logistics or pattern recognition can fail when applied to emotional nuance, crisis situations, or vulnerable populations. Evidence already points to risks including misinterpretation of affect, false reassurance, biased outputs, and opaque decision pathways that undermine accountability and trust (WHO 2023).

The Johns Hopkins panel underscored this tension. Panelists emphasized that while AI can enhance access to mental health services, responsibility for care, safety, and moral judgment cannot be delegated to algorithms. Human-in-the-loop oversight, clear escalation pathways, and enforceable ethical guardrails are not optional add-ons; they are prerequisites for responsible deployment and use (JHBSPH 2026).

Adopting AI for Mental Health Care Improvement: From Digital Therapist to Care Continuum Interface

Public debate often frames AI as a potential replacement for clinicians or other care givers. This is a false dichotomy. A more productive framing is to view AI as an interface within a continuum of care, not an endpoint of care.

In this role, AI and other digital platforms can support health promotion and disease prevention, early detection and triage, integrated physical and mental healthcare, recovery, and long-term wellbeing. As we saw during the COVID-19 pandemic, digital care options through teletherapy and mobile apps experienced an explosive growth, offering alternative service delivery models that can help overcome obstacles to care access, such as transportation barriers, stigma associated with visiting mental health clinics, personnel shortages, and high costs (Marquez 2023 a). These platforms, especially in mobile formats, can offer remote screening, diagnosis, monitoring, and treatment; facilitate remote training for non-specialist healthcare workers; and enhance online peer-to-peer support and self-care. Online symptom tracking apps are also available and can be used to prompt patients to share data daily which are analyzed with A) algorithms to identify patterns and alert providers in real time of any warning signs. (Marquez 2023 a).

Source: Photo taken by author, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, February 2, 2026.

Integrating Physical and Mental Health

The artificial separation of physical and mental health remains a major barrier to effective care (Marquez and Saxena 2016). Chronic illness frequently coexists with depression or anxiety, while untreated mental illness worsens physical outcomes and increases costs (WHO 2023). AI interfaces embedded in primary care or community platforms can help bridge this divide by guiding people toward coordinated pathways rather than fragmented referrals (Marquez 2023 a).

Off-Ramps and On-Ramps Across Levels of Care

AI can function either as an off-ramp from crisis or an on-ramp to care, depending on where an individual sits along the continuum of distress. At earlier stages, AI tools may support psychoeducation and guided reflection—providing clear, evidence-based information about mental health, emotions, behavior, and coping strategies, and prompting individuals to reflect on their experiences in ways that strengthen self-awareness, emotional regulation, and informed decision-making about their wellbeing. As needs intensify, it must trigger escalation to human professionals and emergency services when risk thresholds are crossed (JHBSPH 2026). Properly governed, AI becomes a ‘traffic controller—not a destination’.

Supporting Recovery and Self-Regulation

One of the most neglected phases in mental health care is the transition from symptom reduction to sustained wellbeing. Recovery involves rebuilding routines, relationships, identity, and purpose (Insel 2022). Between clinical encounters, AI tools can support adherence and goal-setting—complementing but not substituting human effort and action required to achieve recovery (Peña 2025).

System-Level Benefits and Safeguards

When deployed at scale, AI has the potential to enable earlier and more consistent delivery of mental health services, early identification of a problem, strengthening triage, continuity of care, workforce sustainability, and equity of access. Additionally, AI can inform system-level planning by improving demand forecasting, resource allocation, and administrative efficiency, thereby helping to mitigate clinician burnout. It can also assist planners in anticipating demand, allocating resources, and reducing administrative burden that contributes to burnout.

But these benefits depend on safeguards that are not optional. AI must remain decision-support, not decision-authority; escalation pathways to human care must be explicit; data privacy, consent, transparency, and accountability must be robust; and limitations and uncertainty must be clearly communicated (WHO 2023).

Without these guardrails, AI risks eroding trust and causing psychological harm, particularly among those seeking help at moments of vulnerability.

Treatment Versus Healing: Insel’s Systems Lens

Tom Insel’s distinction between treatment and healing offers a critical systems insight for understanding how care delivery, particularly in the context of AI, must extend beyond clinical intervention to support long-term recovery and wellbeing (Insel 2022).

As Insel explains, although effective treatments exist, outcomes often remain poor because care systems are fragmented and disconnected from the social conditions required for recovery. This gap underscores that healing depends fundamentally on people, place, and purpose, the human foundations that technology can support by improving coordination, access, and continuity of care, but can never replace.

People matter because healing is relational: trust, empathy, and sustained human connection with clinicians, caregivers, family, and peers are among the strongest predictors of recovery and wellbeing. Place matters because healing unfolds within lived environments—homes, communities, and care settings shaped by safety, dignity, culture, and the broader social determinants of health. Purpose matters because recovery is not merely symptom reduction but the restoration of meaning, agency, identity, and hope. Digital and AI-enabled tools can expand coverage and access, improve coordination, and personalize care, but they cannot substitute for human presence, supportive environments, or the sense of meaning that motivates healing.

Whether technology ultimately advances mental health and wellbeing depends on whether it is designed to strengthen human relationships, contribute to the improvement of living conditions, and support people in pursuing lives they value, rather than displacing these core human elements (Insel 2022; WHO 2023).

Closing the widening gap between rising mental health needs and persistently weak outcomes, therefore, requires moving beyond fragmented, episode-based service delivery toward coordinated, multisectoral systems that address social determinants of health, ensure continuity of care across settings, and support long-term recovery and wellbeing (Marquez, Fleischer, Mahoney 2024 e; Marquez 2024 f; Marquez 2025 c). Without such system-level integration, linking health, social protection, housing, education, and employment, digital and AI-enabled innovations risk optimizing access to services that remain structurally misaligned with the realities of people’s lives, rather than transforming outcomes in meaningful and sustainable ways.

Conclusion: The Human Measure of AI

AI is not a distant or sector-specific innovation. It is a general-purpose technology that is already reshaping how economies function, how institutions operate, and how people experience daily life. As this analysis has suggested, assessing AI’s social value solely through productivity, efficiency, or growth metrics misses its most consequential effects. Mental health and wellbeing provide a more sensitive and integrative lens, one that captures how technological change alters human agency, security, identity, and social connection.

Across the evidence reviewed, a consistent message emerges: AI does not diminish the importance of human capacities, it intensifies their relevance. Curiosity, critical thinking, and self-regulation become more valuable as AI systems expand, not less. When these capacities are supported, AI can enhance learning, judgment, and care. When they are weakened through hidden data extraction, over-automation, or poorly governed digital environments, wellbeing deteriorates, trust erodes, and social risk accumulates.

Mental health outcomes make these dynamics visible. Rising anxiety, burnout, and disengagement are not incidental side effects of technological progress; they are signals that human agency is being constrained, security undermined, identities destabilized, or social bonds weakened. Adolescents’ cautious engagement with AI underscores this reality, reflecting an intuitive understanding that technologies shaping cognition, creativity, and self-expression must reinforce rather than replacehuman development. In this sense, youth mental health functions as a leading indicator. The documented impacts of social media and algorithm-driven digital environments on adolescents’ wellbeing provide early warning signals of the broader risks that poorly governed AI systems may pose to societies at large, particularly when technological change outpaces institutional capacity, ethical safeguards, and social norms (JHBSPH 2026). Ultimately, AI’s success will not be measured by what machines can do, but by what societies choose to protect and prioritize.

This analysis also highlights that AI’s promise in mental health care is real but conditional. When embedded as an interface within a continuum of care—supporting prevention, early identification of problems, triage, integration of physical and mental health, and recovery—AI can improve access, continuity, and system efficiency. But when deployed without human oversight, ethical guardrails, or a clear continuum of care pathway, it risks causing harm precisely where vulnerability is greatest.

Overall, these findings converge on a central policy imperative: investing in brain health is no longer optional. In the AI era, cognitive, emotional, and social capacities constitute a foundational form of human capital and a decisive source of comparative advantage. Strengthening brain health through prevention, early intervention, supportive workplaces, and inclusive digital governance is essential to ensuring that AI advances translate into durable human and economic gains.

To conclude, it should be clear to all of us, as Kristalina Georgieva, Managing Director of the IMF, remarked at the World Government Summit in Dubai, United Arab Emirates, on February 3, 2026, that “AI will transform our economies. It will present immense opportunities and pose significant risks. And it falls to you, the world’s policymakers, to ensure that the opportunities are maximized for their countries and the risks controlled” (IMF 2026).

Ultimately, AI’s success will not be measured by what machines can do, but by what societies choose to protect and prioritize. Mental health offers a clear test of whether AI is being governed in ways that uphold dignity, resilience, and trust. When embedded within inclusive systems that invest in people and manage technological transition responsibly, AI can support forms of human development that benefit all. When it is not, AI risks becoming a lost opportunity for human advancement—one in which progress outpaces governance and the costs are paid in the wellbeing of individuals and societies as a whole.

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Introduction

The Economics for Health Cigarette Tax Scorecard (4th Edition) (Drope, et al. 2025) launched today, December 15, 2025, offers a clear assessment of global tobacco excise tax policy: most governments are still failing to use this powerful tool to reduce tobacco use, prevent disease, save lives, and strengthen domestic resource mobilization to improve public finances.

This stagnation is not random. As the Scorecard report suggests, it reflects a predictable pattern shaped by political hesitation, complex and ineffective tax structures, competing fiscal pressures, and persistent tobacco industry interference.

To move from diagnosis to action, the key question is no longer whether tobacco taxation works, but how to make it happen at scale and sustain it over time.

I. Why Tobacco Taxation Matters? Good for Public Health and Good for Public Revenues

Tobacco Taxes Discourage Tobacco Use

The public-health rationale for tobacco taxation is clear. Tobacco taxes increase prices and discourage tobacco use (Furman 2016). Research on the relationship between cigarette prices and smoking estimates price elasticities of demand—the percentage decrease in cigarette consumption resulting from a 1% increase in price. Different analyses suggest that the overall price elasticity of demand for adults ranges between 0.3 and 0.8, meaning that a 10% increase in cigarette prices leads to a 3% to 8% decline in consumption (Jha and Chaloupka 1999; Chaloupka and Warner 2000; Gallet and List 2003; IARC 2011; CBO 2012).

Given the addictive nature of tobacco products, assessing the impact of tax and price increases requires consideration of indicators beyond aggregate consumption volumes, including monitoring changes in smoking initiation, the frequency and success of quit attempts, and shifts in smoking prevalence within the population (Furman 2016). Longitudinal evidence from diverse country contexts consistently demonstrates that price plays a central role in influencing smoking behavior, and that excise taxes are a major determinant of retail cigarette prices (Furman 2016; Marquez and Moreno-Dodson 2017; Bloomberg Task Force on Fiscal Policy for Health 2019).

Reduction of Tobacco Use Lowers the Risk of Disease and Premature Death

The scientific evidence accumulated over the past five decades is clear: tobacco use kills. Indeed, tobacco use is one of the leading causes of preventable death worldwide. Figure 1, for instance, shows that tobacco use is estimated to be by far the dominant modifiable health risk factor, responsible for the largest proportion of deaths in the United States in 2025 (population attributable fraction 16·49%, 95% CI) (Zhang, et al. 2025).