The current Ebola outbreak is the biggest the world has ever seen, yet the draft Political Declaration on Pandemics lacks a practical plan to protect the world from future pandemics.

United Nations member states are almost certain to break the silence on the final draft of the Political Declaration on Pandemic Prevention, Preparedness and Response (PPPR) that was sent to them recently– but likely for all the wrong reasons.

Armenia and Rwanda, the co-facilitators of the declaration negotiations, put the “final” text of the declaration for the High-Level Meeting (HLM) on PPPR in September under the silence procedure on 28 July.

The silence procedure means that member states have a certain period during which to object – or break the silence – otherwise the text is regarded as agreed on.

Health Policy Watch can exclusively share the UN HLM on PPPR Political Declaration Final Text for Silence Procedure. However, it is unlikely to be adopted unchanged.

The text identifies all key problems haunting the world’s pandemic preparedness, but its key weakness is its failure to provide concrete steps to address these.

Ideological red flags

Yet, as recent UN negotiations have shown, the red flags for member states are unlikely to be the lack of a sound implementation plan but rather ideological objections. 

For example, the text identifies climate change as one of the issues straining developing countries’ pandemic prevention, preparedness and response. But at the recent HLM on Road Safety last month, the United States was the lone vote against that political declaration – in part because it mentioned climate change.

The PPPR declaration also recognises that women and girls are among the groups disproportionately affected by pandemics, and calls for “gender equality” to be mainstreamed “into all policies and programmes”.

It also calls for “universal access to sexual and reproductive health care services” by 2030, and the reaffirmation of “commitments to ensure universal access to sexual and reproductive health and rights (SRHR) in accordance with the Programme of Action of the International Conference on Population and Development (ICPD) and the Beijing Platform for Action”.

The ICPD, adopted by 179 member states in 1994, calls for the “universal access to a full range of reproductive health services, including family planning”.

Meanwhile, the Beijing Platform, adopted a year later by 189 member states, establishes that all people have “the right to attain the highest standard of sexual and reproductive health” and that their right to make reproduction decisions should be “free of discrimination, coercion and violence”.

However, SRHR has become highly contested in the UN, with several countries claiming that, by linking sexual and reproductive health to rights, the UN and the World Health Organization (WHO) are trying to promote universal access to abortion.

In recent years, conservative countries – several countries in the Middle East and Africa, the Trump administration’s US, Russia and Pakistan – have objected to the term “sexual and reproductive health and rights” during UN and WHO sessions.

The positive aspects of the text

“The final draft contains positive language on foundational elements that – fully acted upon – would lead to a stronger pandemic readiness system,” according to a group called The Friends of the HLM on PPPR.

The co-convenors of this group are The Elders, FOUR PAWS, The Independent Panel for Pandemic Preparedness and Response and Resilience Action Network International (rani). 

The positive aspects identified by The Friends include that it welcomes the adoption of the Pandemic Agreement and amendments to the International Health Regulations (2005) and calls for the timely conclusion of the pathogen access and benefit-sharing (PABS) negotiations. It also promotes geographically diversified research, development and manufacturing of health tools, and calls for “the need for financing preparedness”.

The group also approves of “recognising a One Health approach to prevent spillover of pathogens from animals to humans” and “the importance of data, tools and assessments that facilitate action-oriented plans, and science and evidence-based monitoring”.

And the real problems…

Helen Clark, co-chair of The Independent Panel and a member of The Elders.

But Helen Clark, on behalf of The Friends’ co-convenors, notes: “At a time when the Ebola Bundibugyo emergency is now the second largest Ebola outbreak in history, we need measurable commitments which put effective multi-sectoral plans into action, serious money on the table, and ensure real accountability.

“The ultimate test of this declaration is simple: will its implementation make the world measurably safer? Member States have an opportunity now to ensure that it does,” adds Clark, who is co-chair of The Independent Panel and a member of The Elders.

The Friends identify four key gaps in the draft and urge “an infusion of urgency and ambition”. 

The first weakness is the lack of “concrete commitments or timelines” to fill the financing gap, including the $15 billion needed annually to prepare for pandemics.

“The complexity and slowness of disbursing funds for the current Ebola emergency and the question marks around funding for successful tests, treatments, and vaccines underscores the dire need for reliable and rapidly disbursed surge financing,” The Friends note, recommending “a financing tracker to ensure transparency and identify areas where gaps persist”.  

Weakness Two lies in the failure to “strengthen the capacities of veterinary, animal, and environmental health services” given that more than 70% of emerging infectious diseases in humans are zoonotic,– including the recent mpox, Andes hantavirus and Ebola Bundibugyo outbreaks.

The third weakness is its failure to recognise current gaps in monitoring, “including monitoring of equitable access to medical countermeasures, operational readiness, financing, and the social dimensions of resilience”.

Finally, The Friends highlight that the Secretary General gets almost five years to report back on the implementation of the political declaration.

“This is too late to follow up on commitments from this meeting, and will take momentum from an already neglected agenda,” they note, proposing a report within three years instead.

The HLM is set for 25 September, the last Friday of the UN General Assembly. The date has been criticised by the Independent Panel and others, as many delegations leave New York on that day and may not attend.

Many hope that high-level political engagement at the HLM will give fresh impetus to the PABS talks, the final piece of the Pandemic Agreement, which have made little progress for months.

Inequality fuels pandemics

Meanwhile, a recent study published in the New England Journal of Medicine warns that the “dominant model of pandemic preparedness has focused on technical capacities: stronger laboratories and surveillance, more effective vaccines and medicines, faster emergency response”.

Yet, argue the authors, including Nobel Prize-winning economist Joseph Stiglitz,  some of the most “prepared” countries have mounted the most ineffectual responses in real time.

“Among the officials and experts charged with stopping pandemics, the current understanding of what drives pandemic risk for the world is proving to be insufficient. The missing element, we believe, is inequality,” say Stiglitz and co-authors Matthew Kavanagh, Monica Geingos,  Winnie Byanyima and Michael Marmot, for the Global Council on Inequality, AIDS, and Pandemics.

“The co-occurrence of increasing pandemic frequency and increasing inequality is not coincidental – it reflects a self-reinforcing cycle: inequality makes outbreaks more likely to become pandemics, then drives their severity and duration, while pandemics deepen inequality, making future outbreaks harder to control and fueling the next cycle,” they argue.

They argue for an “inequality-informed response” to prepare for pandemics, proposing four approaches.

The first involves addressing the social determinants that drive outbreaks to become pandemics, for example, ensuring social protection including expanded unemployment insurance and paid sick leave “so people can follow public health guidance without impossible trade-offs”.

The second activity involves “strengthening visibility, governance, and trust” by establishing multisectoral governance bodies that include government officials, community organisations, and scientific leadership.
The third involves reforming the international financial architecture to enable “sovereign debt-suspension mechanism for distressed nations during pandemic emergencies”, International Monetary Fund special drawing rights during pandemics and
expanded pandemic lending facilities.
The fourth measure involves equitable access to pandemic science and technologies, including “open licensing for publicly funded biomedical research with pandemic relevance” and expanded regional manufacturing capacity for “cutting-edge medicines and vaccines for today’s major diseases”.

 

Image Credits: X/Tedros Adhanom Ghebreyesus.

Will member states still value the work of the WHO when they have embraced AI?

A finance ministry official can now draft in an afternoon what used to take a WHO mission, a consultant and a wait of weeks. That single fact, multiplied across almost everything WHO produces, is the real story behind this year’s budget cuts — and almost nobody in Geneva is telling it yet.

Picture a health ministry official in a mid-income country. Two years ago, adapting a WHO clinical guideline into a national protocol meant WHO staff time, a consultant, or waiting for the next country mission.

Today she opens a general-purpose AI assistant, points it at WHO’s own – largely open-access – guidance library, and has a serviceable first draft before lunch. Nobody announced this. No governing body voted on it. It simply became true, quietly, over the past two years, and it is already reshaping what happens when member states next debate how much to pay Geneva.

That is the story beneath WHO’s budget cuts, and WHO has not yet told it in public.

New rulebook – and the harder question underneath it

Last month, at the AI for Good Global Summit in Geneva, WHO joined the International Telecommunication Union and the World Intellectual Property Organization to launch a joint framework on AI in health innovation timed almost exactly to a moment when generative-AI patents published over the previous two years overtook the total from the entire preceding decade. 

It extends a six-year pattern of WHO writing, with real skill, the rules by which the world should govern AI. What none of that writing addresses is what AI does to the value of what WHO itself is paid to produce.

Bolting an AI layer onto business as usual – a copilot here, a chatbot there – will not answer that. What is arriving is a change in what WHO’s outputs are worth, who can produce them, and what member states believe they are buying when they pay their dues. The window for choosing WHO’s place in that shift is the term of the next Director-General, not some comfortable decade beyond.

Two shocks, one organisation

Two shocks are landing on WHO at once, and so far only one has been reckoned with in public.

The first is financial. In February 2025, the Executive Board cut the proposed base budget for 2026–27 from $ 5.3 billion to $ 4.9 billion. By May, the Assembly had approved US$ 4.267 billion – a 9% cut on 2024–25, 22% below the original ambition. 

In the same vote, member states approved a second consecutive 20% rise in assessed contributions – the fixed dues every government owes – continuing a path toward those dues covering half of WHO’s base budget by 2030–31. 

Why governments would vote to send Geneva more fixed money in the very years an AI assistant is learning to produce what those dues used to buy is a question this piece returns to.

The response has been a formal prioritization and realignment exercise, still running. WHO’s global workforce stood at 9,473 in July 2024 and 9,457 in December 2024, a 15-year peak by WHO’s own account. A WHO report obtained by Health Policy Watch projected roughly 2,371 separations against that base, implying a mid-2026 total near 7,086, this author’s arithmetic, not a published figure. The latest actual snapshot (31 December 2025) put headcount at 8,569 – already 888 below December 2024.

Figure 1. WHO’s total headcount, July 2024–December 2025 (verified), with the author’s illustrative scenarios to 2030 (dotted, not WHO data). Sources: WHO EB156/48; WHO HR Update Tables Dec 2025; Health Policy Watch.

Geneva headquarters, WHO’s largest office, is on track to shrink 28% by mid-2026, Africa and Europe close behind at 25% and 24%. Even after those cuts, WHO faces a $141 million gap in 2025 salary costs, and a projected $1.05 billion funding gap for 2026–27, down from $ 1.7 billion estimated in May 2025.

This is an unusually well-documented contraction, which is exactly why it is useful: it gives a checkable baseline against which the second, technological shock can be measured rather than guessed at.

Two workforces, one falling cost base

WHO’s people split into two legal populations. Established staff – 8,569 as of 31 December 2025 – are one. Affiliates – consultants, Special Service Agreement (SSA) holders, and Agreements-for-Performance-of-Work (APW) holders – are the second, and this group is contracting fastest: 9,937 cumulative engagements in 2025, down from 12,965 the year before. Comparing matching windows, SSA holders fell 21.4% year-on-year, consultants 22% in headcount and 25.5% in full-time-equivalent (FTE) terms, APW holders 31.8% in headcount and 34.2% in FTE terms.

Figure 2. WHO’s affiliate workforce fell in both comparable year-on-year windows measured. Sources: WHO EB156/48; HR Update Tables Dec 2025.

This cannot be pinned on AI alone. Affiliate contracts are the fastest lever any organisation has for cutting cost. What can fairly be said is the contraction is real, twice-measured, and concentrated in exactly the deliverable-based, language- and data-centric work this piece flags as most exposed to automation.

Senior management has been reshaped rather than thinned. Between 2017 and 2025, P6 posts fell 42% while D1 and D2 posts rose 29% and 31%; net across senior grades, a 9% reduction – even as entry-to-mid P1–P3 posts faced a projected 30% cut. Whether AI accelerates or repeats that pattern through 2030 is genuinely open.

Figure 3. Senior management posts (P6, D1, D2, ungraded), all major offices, July 2017 vs December 2025. Source: HR Update Tables Dec 2025, Figure 6.

The cost base is precisely known. As of the January–July 2024 half-year, staff costs were $814 million – 47% of total expenditure, up from 36% a year earlier. For 2026–27, a staffing paper reviewed by Health Policy Watch put projected total staff-related costs at $2.26 billion, of which $1.19 billion (52%) is contractual services or consultants.

Figure 4. Projected composition of WHO’s total staff-related costs, 2026–27 biennium. Source: Health Policy Watch reporting on WHO’s PBAC white paper.

Not all WHO work is the same

Here the story turns from documented fact to informed argument. WHO does at least five distinguishable kinds of work, unevenly exposed to automation. 

The ranking below is my own qualitative framework – low, medium or high, no percentage attached, because none is measured – anchored in two much-cited studies finding writers, translators, analysts and clerical occupations among the most exposed to large language models. Document production, translation, data processing and analysis are precisely what a large share of WHO’s staff and consultant time buys.

Figure 5. Illustrative automation-exposure ranking across five categories of WHO work — low/medium/high only, no percentage claimed.

A claim making the rounds in Geneva – that AI will “replace 80–90% of WHO jobs” – is both true and false, and the gap is the point. That figure is this author’s own working assumption, set above the published research’s central estimates. 

AI is plausibly on track to automate most tasks filling professional staff and consultant time today. It is nowhere near replacing the functions that justify WHO’s existence. The danger is that member states, watching the first happen in plain sight, quietly stop paying for the second.

Call the mechanism task hollowing: each role loses most of its routine content, headcount needed per output falls, and the humans who remain concentrate in judgement and accountability — consistent with the ILO’s own conclusion that transformation, not disappearance, is generative AI’s most likely impact. 

The affiliate contraction and the P6-to-D1/D2 reshaping above are both consistent with this happening inside WHO now, though neither can be pinned on AI specifically rather than budget pressure alone.

The shift is audible in donor language. At last month’s summit, the Global Fund’s John Fairhurst told a panel that countries want efficiency, more impact per dollar, and AI is the pathway they are reaching for. That is a financier approvingly describing exactly the substitution mechanism this piece warns about.

Three phases, and the trap inside the savings

Three phases seem likely to 2030 – my scenario, not a WHO projection: an assistive phase through 2026–27, where staff use AI individually with little structural headcount change; an agentic phase, roughly 2027–29, where agents own whole workflows and affiliate and admin posts contract further; and a substitution phase from around 2029, where member states run their own AI health-intelligence capacity and WHO’s value as output producer approaches zero.

The variable that actually decides WHO’s financing is not how busy its staff are, but how much member states value what only WHO can provide. Countries will not stop funding WHO because its staff stop working. They will stop to the extent an AI assistant hands them, for a fraction of the cost, the report they used to rely on WHO to produce. The question shifts from “does WHO work hard?” to “what can only WHO do?”

But there is a trap inside the savings this implies. Applying illustrative cut rates to the two verified cost figures above – from a cautious 25%/10% to an aggressive 55%/30% – yields plausible annual savings by 2030 of roughly $202 million to $488 million: bookends built on two real numbers, not a forecast. 

But every franc WHO saves by automating production is a franc it has just demonstrated a member state could save at home. Savings are necessary. They are not a strategy.

The member state question

Every financing conversation about WHO has so far assumed the only variable was generosity. AI changes the question itself: it is no longer only about willingness to pay, but whether the thing being paid for still needs to be bought from Geneva at all.

The timing of WHO’s own financing reform makes this uncomfortable. In 2020–21, assessed contributions covered just 16% of WHO’s base budget; in 2022 the Assembly agreed to raise that to 50% by 2030–31, and member states have since approved two consecutive 20% increases. Governments have voted twice to send WHO more fixed dues in exactly the years an AI assistant is becoming capable of producing much of what those dues used to buy.

Figure 6. WHO’s assessed-contribution share of the base budget, 2020–21 to the 2030–31 target agreed at WHA75. Sources: WHO funding pages.

WHO’s own investment case claims every dollar invested delivers a return of at least $35 – logic that depends on WHO being the necessary producer of the goods being valued. 

To the extent a ministry can generate the report itself, that return has to be recalculated, not because WHO got worse, but because the alternative got cheap. Before the next dues vote, member states will quietly ask: what does WHO supply that we could not now generate ourselves? Where the honest answer is “not much,” that dollar is at risk.

There is a genuine counter-argument, and it is WHO’s strongest card. A world of 194 finance ministries each generating their own AI-assisted guidance, with no shared quality bar, is a world of fragmented, occasionally wrong health advice – exactly what a global normative body exists to prevent. 

The risk is not speculative. Alain Labrique, WHO’s director of data, digital health, analytics and AI, warned at the summit that imported models are typically trained on data unrepresentative of the people they are meant to serve. This is echoed by Harvard researchers who note roughly 90% of global genomic data belongs to people of European descent.

The honest answer is not that WHO should out-produce the AI – it will lose that race on cost – but that WHO should become the body that certifies whether the AI got it right, anchored in convening authority no single ministry can replicate. 

As HealthAI’s Ricardo Baptista Leite put it in Geneva: “Innovation moves at the speed of trust.” Trust is the one input WHO can still supply more cheaply than anyone, which makes it strange how slowly Geneva has moved to industrialise exactly that.

Writing the rules for the world

WHO has, to its credit, been an early and prolific author of AI governance for the world. Set that against what the same institution was doing with AI inside its own walls, and the contrast is hard to miss. The HR process document governing the current restructuring describes a wholly manual sequence of spreadsheets and hand-built organigrams, with no visible role for the AI tools whose ethics WHO was simultaneously instructing the world how to govern.

The UN system tells a version of the same story. Secretary-General Antonio Guterres launched the UN80 reform initiative in March 2025 but independent analysis in December 2025 found no formal mechanism yet existed to advance AI proposals system-wide. It took until January 2026 for the UN to announce its first system-wide staff AI-literacy partnership – roughly three years after ChatGPT’s public release.

Figure 7. From ChatGPT’s public release to the UN system’s first staff-wide AI tooling partnership — roughly 38 months.

This is not an outside critic’s complaint. Anders Nordström, WHO’s former acting Director-General, made close to the same argument in Think Global Health last month, reclaiming trust requires WHO to become excellent at what it alone can do. “Modernization must begin internally,” he concluded.

None of this is entirely unreasonable. Rules built for a different era are not obviously wrong to apply cautiously to a technology prone to fabricating plausible text. But caution and speed are not opposite ends of one axis: banking supervisors and hospital systems deployed internal AI copilots under equally strict rules well inside the three-year window it took the UN system to reach the starting line.

Four futures

Two independent choices – how fast AI is adopted, and whether WHO repositions from producer to steward – generate four outcomes: a discussion framework, not a model with predictive weights.

Figure 8. Four futures for WHO, built on two independent choices.

Only one quadrant is durable: fast adoption paired with a genuine shift to steward. Fast adoption without repositioning gives credibility without capability. Slow adoption while staying a producer is managed decline. 

Slow adoption with continued cost-cutting is the sharpest trap – implosion by efficiency, where every saving proves to member states they could have made it themselves, funding falls further, capable staff leave, and WHO shrinks into a smaller producer of outputs that matter less each year.

The inheritance, and what has to happen now

A new Director-General takes office in 2027, inheriting a financing contraction already locked in at $4.267 billion, and a technological displacement that is only just beginning. 

Stabilisation is the wrong objective: rebuilding the old equilibrium means rebuilding an institution optimised for a world in which technical outputs were expensive to produce – a world that is ending. The next Director-General will be remembered either as the leader who managed WHO’s decline with dignity, or who repositioned it for the AI era. There is no third option.

For incoming leadership: name the producer-to-steward shift on day one; write the rules for AI in health before regulators and private platforms fill the vacuum; decentralise deliberately rather than by budget accident; extend the current restructuring machinery to affiliates, currently outside its protections; and re-contract with member states around value, not volume. 

Nordström’s own reform agenda reaches a similar place from a different direction – sharper mandate, single-term leadership, open recruitment of regional directors, a functioning board of trustees, financing primarily through assessed contributions. Independent reform voices and this piece’s automation argument converge from separate directions on the same conclusion: the institution that survives is smaller, more disciplined, and clearer about what only it can do.

For WHO management: reposition the value proposition before the savings, not after; treat AI adoption as core infrastructure, not a side-project; manage the transition as workforce transformation, not attrition; govern the affiliate workforce deliberately, since it has no continuing contract and no comparable safety net; and publish WHO’s own analysis of AI’s workforce impact before an outside body, or this piece, becomes the only source anyone can cite.

For member states: fund the transformation, not just the contraction; be explicit about what you are buying – norms, trust and equity, on their own terms; protect the global-public-good core; and use the 2027 transition to mandate the producer-to-steward shift, then measure the next Director-General against it.

For staff: the next shock is structural, not cyclical – plan a career on the assumption that routine task-content does not come back, and the transformed job rewards judgement over throughput; demand transformation governance, not just consultation on cuts; and insist savings are reinvested, not banked.

Warning that does not stop at WHO’s door

The pattern is not WHO-specific. On 1 December 2025, Guterres presented the UN Secretariat’s revised 2026 budget: a $577 million (15.1%) cut, and a reduction of 2,681 posts – 18.8% of the Secretariat’s regular-budget staffing table.

Every knowledge-intensive public institution that defines its value by the outputs it produces is exposed as those outputs become nearly free to generate. The institutions that last will be the ones whose value rests on what AI cannot supply: legitimacy, convening power, trust, accountability, and stewardship of public goods no single actor can be trusted to hold alone.

WHO will not be destroyed by artificial intelligence. It can only be destroyed by failing to understand what artificial intelligence makes it for. The task facing this generation of leadership, staff and member states is to make sure that when the cost of producing health knowledge falls to nearly nothing, the world still understands why it needs a World Health Organization — and chooses, deliberately, to keep funding one.

That ministry official, drafting her national protocol in an afternoon, is not the enemy of that outcome. She is the earliest, clearest evidence of the question WHO now has to answer: not whether it works hard enough, but what, in a world where a laptop can draft almost anything, only WHO can still be trusted to do.

A note on the numbers: Verifiable figures above — headcounts, budgets, contribution shares, contract counts — come from WHO’s own governing-body documents, published HR tables, or named reporting. Everything forward-looking — the 2030 scenario lines, the three-phase trajectory, the savings ranges, the four-futures framework, the automation-exposure rankings — is this author’s own analytical synthesis, built on those verified figures but not a WHO forecast. Where automation is described as consistent with the affiliate contraction or senior-grade reshaping, that is interpretation, not proven causation — budget pressure alone could produce the same numbers.

K. Rifat Hossain is Health Policy Watch’s Director of Development. He worked for the WHO for nearly two decades at headquarters in Geneva, the Regional Office for the Western Pacific and the WHO Country Office in Poland, working on health data and intelligence, refugee and migration health, and digital and AI systems for health. He has also worked for the ILO and the UN Economic Commission for Europe.

 

Image Credits: AI generated by picai.

Thousands of Zimbabweans passing through the Musina repatriation centre are desperate to find safety after fleeing anti-migrant unrest in South Africa.

HARARE, Zimbabwe – For the past two decades, 49-year-old Renious Gumbi from Mberengwa in Zimbabwe lived in South Africa, where he worked as a bricklayer.

Gumbi, who was living with HIV, received free antiretroviral (ARV) treatment from his local clinic in South Africa as, according to that country’s Constitution, “everyone has the right to have access to healthcare services”.

But worsening economic conditions and growing unemployment in South Africa have led to the formation of anti-immigrant groups such as Operation Dubula and March and March, which have blamed non-citizens for service delivery problems – although these have been caused largely by systemic corruption.

Over several months, anti-immigrant groups have blockaded many clinics and hospitals, refusing to allow non-citizens to enter.

As a result, Gumbi was unable to get ARVs since June and became seriously ill. In desperation, his wife, Senzeni, arranged for him to return to Zimbabwe using cross-border transporters known as malayitshas.

Gumbi was at last given ARVs at the Zimbabwean border with South Africa, but it was too late. He died soon after returning to the country of his birth.

“It was cruel for South African leaders to leave anti-migrant activists blocking my husband from getting his ARV treatment drugs,” Senzeni told Health Policy Watch.

“It is also heartless for the Zimbabwean government not to have a plan for its people living with HIV in South Africa when the same regime benefits from the money many Zimbabweans based in South Africa formally send to help their loved ones back home.”

Harder to get ARVs 

Access to ARV  treatment in Zimbabwe has grown more difficult since talks between the United States and Zimbabwe on future US aid for HIV and other health services broke down in February, jeopardising the HIV treatment of some 1.2 million people reliant on US aid.

A recent study also projects that approximately 75,000 Zimbabweans will contract HIV within a year if there is a complete withdrawal of the US President’s Emergency Plan for AIDS Relief (PEPFAR).

While South Africa has also been badly affected by the US decision to phase out all HIV and other health support, it was not reliant on the US to pay for antiretroviral treatment.

It is hard to estimate how many Zimbabweans are in South Africa as thousands have entered the country illegally through poorly policed borders. However, between two and three million Zimbabweans are estimated to be living in the country following the near-collapse of the Zimbabwean economy from the early 2000s. 

This has contributed to strain on the country’s health services, already damaged by systemic government corruption.

Despite the guarantees in South Africa’s Constitution, Dr Sibongiseni Dhlomo, chairperson of the country’s Parliamentary Health Portfolio Committee, told Parliament last year that non-South Africans should only be entitled to emergency health services, not comprehensive healthcare, as the country does not have “unlimited resources”. 

However, this would require changes to various laws and the Constitution. Meanwhile, in 2025 the South African High Court ruled that Operation Dudula could not bar people without South African identity documents from health facilities.

But March and March gave undocumented migrants until 30 June to leave South Africa, and have resorted to threats, violence and ongoing blockages of health facilities.

On 30 June, thousands of people were forced to leave their homes amid anti-migrant protests and violence in South Africa, seeking refuge in parks, churches, and consulates.

Amidst the chaos, many Zimbabweans fleeing from the flaring xenophobic tensions in South Africa have heart-rending stories.

Gilbert Muzokomba, aged 58, has lived in South Africa since 1999, and was also prevented from accessing his ARVs from a clinic in Gauteng province’s East Rand.

Five years into this 27-year-stay in South Africa, Muzokomba married a South African. In 2009, he and his wife tested positive for HIV and started ARV medication.

However, his wife died in 2020, and recently Muzokomba found himself under pressure to leave South Africa from his neighbours.

After defaulting on treatment for a very long time, he decided to head back to Zimbabwe in the hope of quickly resuming ARVs. But there was no guidance for new arrivals about how and where to get ARVs, he said.

“I left South Africa voluntarily after seeing that I might end up dying without access to my HIV treatment drugs, having been repeatedly barred from accessing the treatment by anti-immigrant groups. I had already defaulted, and my health is deteriorating fast,” Muzokomba told Health Policy Watch.

He was placed on a waiting list for a register for local HIV patients accessing free ARVs, but the process has taken longer than expected, costing him his health.

Delayed treatment

Meanwhile, 23-year-old Nelisiwe Mugodhi was born with HIV in South Africa, but also fled from xenophobic violence several days after she also defaulted on her treatment after being barred from a clinic in Khayelitsha, a large slum settlement in Cape Town.

Mugodhi claimed that her parents succumbed to AIDS a few years ago and, as their only child, she was able to soldier on thanks to Good Samaritans in South Africa.

But when xenophobia tensions broke out this year, Mugodhi fled to a place she barely knew.

Mugodhi said she was eventually placed on ARV treatment back home, but it took a long time and her condition had deteriorated for days, rendering her sick from bouts of diarrhoea, headaches, swollen feet and incessant coughing.

“To be honest, I don’t know if I will ever recover. I was healthy and have never fallen sick when I had access to treatment while in South Africa before the latest xenophobic tensions,” Mugodhi told HPW.

Zimbabwe’s brave face

People fleeing South Africa were relieved to get the ARV triple therapy, Reydin, from Médecins Sans Frontières (MSF) at the Zimbabwean border.

It remains to be seen how the Zimbabwean government is going to cope with the influx of HIV positive migrants from South Africa.

For now, officials have put on a brave face. During a recent appearance in Parliament, Health Minister Douglas Mombeshora said health workers had been deployed at the country’s borders to screen returnees and identify those living with chronic conditions like HIV, diabetes and hypertension.

“We have put in place our health workers at the ports of entry to make sure that every returnee is being screened, from adults to children. So far, we have screened over 99,000 Zimbabweans,” Mombeshora said.

But the Minister also said: “We are not able to institute long-term treatment on their arrival because we need to first take baseline tests, like viral load and things like that, which cannot be done at the port of entry at the moment.” 

In late July, Médecins Sans Frontières (MSF) reported that it was running a clinic alongside the South African government’s repatriation centre in Musina, a town bordering Zimbabwe and South Africa.

MSF reported assisting people who have defaulted on ARVs and chronic medication, particularly to treat high blood pressure.

Media reports indicate that 34,000 people have returned to Malawi and 100,000 to Zimbabwe, illustrating the regional scale of displacement, according to MSF.

“More than 100,000 people fleeing or being displaced are the kind of numbers MSF see in hot conflict areas, not relatively stable democracies like South Africa,” says MSF’s Caroline Masunda. “With so many displaced people, we call on governments in the region to step up collaborative efforts to ensure continuity of care for patients”.

The temporary repatriation camp at Musina, the South African town on the border with Zimbabwe.

 Official figures show that by early July 2026, 21,000 Zimbabweans had been repatriated with government assistance, while a further 57,000 returned at their own expense.

Kensington Marufu, an HIV/AIDS activist and lawyer aged 36 who was born with HIV, says that the return of migrants from South Africa will worsen the country’s HIV crisis.

“Most of these returnees are definitely secretive about their health status, especially HIV,  which will cause problems here. They don’t know where to get help with their condition after being away from home for many years. I think these returning migrants will have a problem with adherence to treatment, which will negatively impact on their health,” Marufu told Health Policy Watch.

Marufu, who tested positive for HIV at the age of 10, is a renowned lawyer. His parents and only brother succumbed to AIDS some years ago.

Zimbabwean Pastor Reki Jimu, who has lived with HIV for decades and spearheads the fight against HIV in Zimbabwe, says he has the names of many Zimbabwean migrants now back in the country who have defaulted on treatment and are now faced with life-threatening complications.

“I know several returnees from South Africa who have defaulted on ARV treatment after getting disturbed by xenophobic tensions there. Many of these people are now hospitalised here because of missing out on opportunities to acquire their medication here,” Jimu told Health Policy Watch.

An estimated 1.3 million people are living with HIV in Zimbabwe, according to UNAIDS. But the return of the country’s migrants will swell this number and strain the country’s health system.

“I don’t know if I will survive here in Zimbabwe,” said Mugodhi.

Image Credits: Kate Stegeman/ MSF, Taduw Andre/ MSF, MSF.

The Cairo EMRO headquarters, maintaining regional operations as Director Hanan Balkhy takes leave to campaign in the Director-General election race.
The Cairo EMRO headquarters, maintaining regional operations as Director Hanan Balkhy takes leave to campaign in the Director-General election race.
Dr. Hanan Balkhy, WHO Regional Director for the Eastern Mediterranean (EMRO).
Balkhy, WHO Regional Director for the Eastern Mediterranean (EMRO).

Eastern Mediterranean Regional Director Dr Hanan Balkhy will take immediate leave effective Tuesday to formally launch her campaign in the WHO Director-General Election, according to an internal notice from DG Dr Tedros Adhanom Ghebreyesus seen by Health Policy Watch.

Balkhy becomes the first serving regional director required to take leave after Tedros issued newly tightened election guidelines in July to resolve campaign finance and ethical concerns.

Under the new directive, all internal candidates must exhaust their accrued annual leave before transitioning to special leave on half-pay, effectively levelling the playing field.

Previously, regional directors enjoyed a distinct structural advantage over other internal candidates such as Assistant Directors-General by retaining their full salaries, travel budgets, and administrative machinery while actively campaigning.

To comply with the newly enforced guidelines, internal candidates must ensure a complete separation between official WHO functions and campaign activities.

“The election of the Director-General must be conducted in a manner that safeguards the independence, impartiality and integrity of the organization,” Tedros stated in the internal notice.

Ensuring regional continuity

Dr Ismail was appointed officer-in-charge of EMRO.
Ismail was appointed officer-in-charge of EMRO.

To maintain regional operations during the leave period, Tedros has designated Dr Adham Ismail Abdel-Moneim as Officer-in-Charge of the Eastern Mediterranean Regional Office (EMRO).

Before assuming his current role as director of programme management in 2024, Abdel-Moneim served as the WHO Representative to Saudi Arabia, Yemen, and Iraq. Before these field assignments, he spent 13 years with the regional medicines team in Cairo.

In the circular note, Tedros expressed his gratitude to Ismail for assuming these responsibilities, stating he is confident that “WHO’s vital work will continue without interruption” and that the new officer-in-charge “will ensure continuity in the leadership and management of the Region”.

For Balkhy, her new status has significant consequences, as she must now withdraw from speaking in her official capacity at global forums such as the upcoming World Health Summit in Berlin in October.

The WHO code of conduct dictates that internal candidates must “clearly separate their WHO functions from their candidacy and avoid any overlap, or perception of overlap, between campaign activities and their work for WHO.”

Balkhy is, however, permitted to attend the Berlin summit as a private candidate on campaign leave. However, the code actively encourages candidates to utilise major international conferences to hold bilateral meetings and campaign activities strictly on the margins of the event.

Another procedural grey area persists regarding when a candidate is officially recognised. For instance, a nominating country can delay its formal request to allow their candidate to continue high-profile diplomatic travel.

Without strict enforcement during the pre-nomination phase, candidates may still utilise official platforms to build international support. This gap highlights the limits of voluntary ethical commitments before formal nominations are announced.

Narrowing field of prospective contenders

As the September deadline for official applications draws closer, the field is slowly taking shape, with the first candidates officially entering the Director-General election race.

However, several high-profile global health leaders have recently removed themselves from the succession race. The Pan American Health Organization’s regional director, Dr Jarbas Barbosa, ruled out a bid to focus on leading his region. WHO Chief Scientist Jeremy Farrar also told Politico he has “no intention” to run.

Want to Become the Next WHO Director-General? Get in Line 

Image Credits: WHO/EMRO, Hannan Balkhy, WHO.

HIV activists disrupt US AIDS Coordinator Jeff Graham at a US pre-conference session. Quantifying the effect of the Trump cuts is difficult
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VITAL SIGNS COLUMN: Eighteen months into the dismantling of the global AIDS response, how many have died? The honest answer is that nobody knows. Rio’s numbers are inferences, its assumptions and projections disputable. But 30 years and tens of billions of dollars into the HIV/AIDS pandemic, we should not still be guessing.

The week’s Vital Signs came from Rio de Janeiro, where the 26th International AIDS Conference convened last week under the banner “Rethink. Rebuild. Rise.” A stirring slogan that would surely awaken even the dead? Therein lies the question: 18 months after Washington started dismantling the architecture of the global HIV response, how many people are dying as a result?

Nobody knows, because no one has counted the dead. Every figure in circulation is a projection against a hypothetical world without aid cuts. Mourning the unknown dead dampened the vibrant Rio buzz that I have so enjoyed in the past.

A third kind of half-truth

The assassination of evidence by advocacy should worry a global health enterprise proud of its underlying scientific base. That base is now under assault from multiple directions, with “mal-information” – distinct from misinformation or disinformation – being the latest threat.

Mal-information concerns data analysis that could be taken out of context and manipulated to make misleading connections, which damage or advance particular causes. Nowadays, that is facilitated by generally reduced population numeracy, which undermines trust in public policy and institutions and fuels weird theories and conspiracies.

Coming to HIV/AIDS, the message from Rio is that foreign aid cuts cost lives. The arithmetic of this is somewhat awkward. Policymakers scanning the headlines of well-presented UNAIDS updates may not understand, or overlook, that these are centred on epidemiological modelling. And so we rely on estimations. 

However, as we learnt from disputed mortality projections when COVID-19 was advancing relentlessly, it is the assumptions underlying mathematical models that have a huge bearing on the numbers churned out. These, in turn, take on a life of their own to support or refute whatever case protagonists want to push.

Meanwhile, it is doubtful whether the Rio delegates had time to study the UNAIDS modelling methodology note, whose entrails require forensic drilling with advanced statistical tools.

This is what is revealed. As UNAIDS does not count AIDS deaths, it estimates them in worst-affected countries via a model fed by prevalence tests at antenatal clinics, household surveys and clinic treatment registers. The model already contains assumptions about how many people die when treatment is interrupted, and so it cannot independently prove that the aid cuts killed anyone.

Worse, when clinics stop reporting – for example, if funding and staffing shrink – the model reads the silence as falling treatment and over-estimates deaths. Or, when registers go stale, it under-estimates them. 

Furthermore, the published margin of error covers only the model’s own arithmetic, not mistakes in the country data collection process. The historical series must also be revised annually, shifting past figures and making trend comparisons unstable. 

Where countries do not produce data, UNAIDS makes estimates that reviewers cannot inspect. The share filled in by such statistical guesswork is rising, as surveillance and reporting systems fray under resource constraints.

While UNAIDS documents these challenges honestly, the obvious question is whether future global HIV policy can be formulated on this basis. Even stock market indices are easier to understand.

Reduced confidence

IAS President Beatriz Grinsztejn,  UNAIDS executive director Winnie Byanyima, Erika Castellanos of the Global Action for Trans Equality, Aouth Africa’s Deputy Health Minister Dr Joe Phaahla, PAHO regional director Jarbas Barbosa and Brazilian Secretary of Health Dr Mariângela Simao launching the UNAIDS report.

With this caveat, the UNAIDS special report for Rio models AIDS-related deaths at 570,000 in 2025 with a range (430,000 to 780,000) so wide as to greatly reduce confidence in the central estimate. The spread is wider still around the number of people living with HIV, put at 41 million within bounds of 35.3 and 47.5 million.

The same modelling offers a mirror image. If the United Nations HIV/AIDS Political Declaration’s targets were met in full, it says, 3.2 million infections and 1.3 million deaths would be averted by 2030. That projects what success would buy, not what failure will cost –  an important distinction lost at the conference.

Confusion comes from other projections that disagree, partly because they model different worlds. One gives 74,000 excess deaths across seven African countries by 2030, assuming a 90-day funding freeze followed by near-total collapse. Another gives 770,000 to 2.9 million across all low- and middle-income countries.

Thirteen months ago, UNAIDS itself feared four million deaths by 2029, on the assumption that American-supported services collapsed entirely. The spread reflects assumptions, not data.

No dose-response curve for aid

The principal villain portrayed as responsible for future projected deaths is the aid cuts. How justified is that?

Donor government funding for HIV/AIDS dropped 25% in a year – from $8.3 billion in 2024 to $6.2 billion in 2025, the lowest level since 2007.  

It was entirely American: US disbursements fell $2.09 billion against a global fall of $2.08 billion. Other donors had already cut earlier, and now their combined total held level.

That could potentially translate into raised AIDS mortality, but by how much is uncertain. There is no “dose-response curve” for foreign aid akin to that for a drug, or even for a public health intervention like clean air.

Meanwhile, the overall financing picture is complex. Foreign aid cuts for HIV have been partially offset by a 4% increase in domestic funding in 2025, with more than 55 countries now committing to raise their own contributions. Domestic resources, public and private, carry 59% of total HIV financing in low- and middle-income countries. Total resources therefore fell by only 6%, to $17.6 billion.

The models don’t tell us how many lives are thereby saved.

What was measured, not modelled?

Meanwhile, and remembering the pathology of HIV progression, it is not the magnitude of aid cuts that matters but where they fall. What we do know, because it has been measured rather than estimated, comes from the US programme’s own returns. 

Between 2024 and 2025, prevention spending fell 51%, testing by 17% and pre-exposure prophylaxis (PrEP) initiations by a third.

Direct service staff fell by 62,541, a quarter of that cadre. Some 77,000 fewer children received treatment through those programmes. Facilities that had treated ALMOST 442,000 people simply stopped reporting, their status now unknown.

That last figure is the modelling problem made flesh. Silence from a clinic is read by the model as treatment failing and converted into deaths – whether or not anybody died. How that is folded into a mortality calculation is not clear.

Meanwhile, the foreign aid picture is not static. Could US money be spluttering back? The US Congress appropriated $4.633 billion for bilateral HIV assistance this fiscal year, against the administration’s request of $2.9 billion. But the administration is delaying disbursements as far as possible.

The evidence sits in the gap between the two verbs. US HIV appropriations were flat across 2023, 2024 and 2025, yet disbursements fell 31% last year. Our AIDS mortality modelling is too simple to accommodate such shenanigans by factoring in actual aid flows.

A further twist is the America First Global Health Strategy, issued by the State Department last September, in which the US is seeking bilateral agreements with countries.

Ageing multilateralists like me should, in principle, be dismayed by such blatant subjugation of the collective global good to any country’s national interest.

But before automatically condemning the new US approach, is it not worth keeping an open mind on whether this is good or bad for long-term HIV control?

Time will tell. The 34 bilateral compacts signed since December 2025 commit some $24 billion to 2030, of which around $14 billion is from the US and close to $10 billion is required from recipients. 

Sovereignty-sensitive people will not like aid conditionalities. But this is not new, even in multilateral approaches where the World Bank is the master. And if this incentivises stronger national ownership and sustainability, it is a useful counter to the dependency that traditional aid has created.

Conditionality concerns

Guinea and the US sign a minerals MOU shortly before an MOU on health aid.

There are also concerns about sharing data and biomaterials, or about leveraging health assistance in business bargaining.  

A Kenyan court suspended implementation days after the country’s leadership signed an MOU with the US. Zambia and Zimbabwe backed away, the former having found its health agreement entangled with American access to copper and cobalt.

More serious for public health, the agreement texts examined so far are largely silent on “key populations”. These are people most at risk of HIV, including men who have sex with men, sex workers, transgender people, and people who inject drugs. 

Where preventive medication (PrEP) appears at all, it is as a commodity line item, with no commitment to reach the people most exposed.

Key populations are essential because this is where HIV/AIDS is increasingly concentrated, as we embark on the remaining journey toward an “AIDS-free world”. 

The critical question is whether the US will allow counterpart recipient funds to target key groups as part of jointly funded national programmes, even if American funding may not be used for them for ideological reasons.

Such twists and turns are difficult to include in current modelling, which does not reveal the weightings given to multiple factors at play. But new AI capabilities make that possible, whenever there is a resurgence of evidential rigour over convenient advocacy.

The harms donors are not causing

A protest against Uganda’s attempts to pass a ‘kill the gays’ law in 2012. In 2023, Uganda’s parliament tightened its anti-homosexuality laws, and this trend has been followed by several other African countries.

The consequences of donor leverage are one thing, but domestic policies have their own impacts. In 2026, 168 countries criminalised sex work, 152 the possession of small amounts of drugs, and 66 same-sex relations. 

For the first time since UNAIDS began tracking these trends, criminalisation of marginalised populations increased.

The Sahel led the way. Burkina Faso and Niger newly criminalised same-sex activity, and Senegal raised its penalties this year. Visits to Senegal’s treatment centres then fell by a quarter between January and February, as patients stayed away for fear of arrest.

This drives the condition underground. It would show up as falling rates in the data inputs of conventional models, which would then underestimate mortality. Meanwhile, no country can end AIDS while criminalising the people most at risk of it.

Aid cuts did not write those laws. That raises the question of whether foreign aid should be used to compensate for irresponsible domestic policies.

Nor did aid cuts set the price of the drug that could end HIV transmission. This was a lively topic in Rio. Two injections a year of Lenacapavir prevented every infection among women in its South African and Ugandan trial and cut infections by 96 % in a second trial. With 22 % of people living with HIV still not on treatment, this is game-changing.

But it carries a United States list price of $28,218 a year as a patented product, while analysts estimate it could be made generically for $25 to $40.

Pending generic availability, the manufacturer has offered no-profit supply through the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund across the 120 countries of its voluntary licence. This is enough for up to two million people over three years. 

Compared to the past, this is a lightning-speed transition from costly patented to more affordable generic medicines.

However, 17 middle-income countries, including Brazil, sit outside that licence and account for 19% of new HIV cases. This exposes an uncomfortable truth: solidarity in global health does not come free. Even among developing countries, the richer ones need to carry a bigger financial burden for the sake of the really poor.  Will they?

How this prevention breakthrough is integrated into mortality modelling is unclear and depends on the currently unknown rate of scale-up.

One detail is informative of the state of the world. Americans will benefit enormously and should thank South Africans for the trials that proved the drug. Yet Washington began a phased drawdown of its HIV programme in South Africa in June, citing the country’s failure to meet its policy demands.

A legacy worth leaving

Tracking HIV/AIDS through mathematical modelling using outdated assumptions is increasingly questionable. Especially in an era of rapid policy and pharmaceutical innovations, tightening resources, and geopolitical and social shifts that are not always benign. 

This is not a sound basis for the smart national and global strategies necessary to achieve the AIDS-free shared goal.

There is something indictable here. Thirty years into the pandemic, we still base many of our actions on inferences, deductions and sometimes, frankly, guesswork. Despite expending tens of billions of dollars, including creating two dedicated international bodies – UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria – and an extensive ecosystem of national bodies and numerous NGOs.

UNAIDS is meanwhile contemplating its own end. The UN80 review proposed closing it by the end of this year. UNAIDS has countered with a phased plan, and its board expects recommendations in October. 

Whatever is decided, it should consider its legacy. That legacy cannot be advocacy or therapeutic advances, because those are mostly the push of courageous people who have themselves endured HIV and those who work directly with them. 

As a Joint Programme of the biggest and most influential United Nations agencies, UNAIDS should leave behind something more systematic and tangible. How about a robust global system for measuring – not estimating – actual AIDS-related mortality?

 

Mukesh Kapila is professor emeritus of global health and humanitarian affairs at the University of Manchester, and a board member of Health Policy Watch. Vital Signs in Global Health is a regular column, and the opinions expressed are solely those of the author.  

Image Credits: Felipe Varanda/ IAS, Peter Tatchwell Foundation.

Scientists at Tanzania’s Ifakara Health Institute analyse malaria parasite samples to track genetic mutations associated with drug resistance, helping detect emerging threats before current treatments begin to fail.

KARAGWE, Tanzania – Maria Mwijage had barely reached the footpath home from the village well when mosquitoes began circling her legs. Overnight rain had filled roadside puddles and cattle hoof prints with stagnant water, turning them into breeding grounds.

She brushed the insects away, balanced the yellow jerry can on her head and continued towards her home in Nyachika village, in Tanzania’s northwestern Karagwe District.

For families here, the rains bring more than greener fields. They also mark the return of malaria.

“I usually know when it’s malaria before we even get to the hospital,” says Mwijage, 33, who has endured repeated bouts of the disease over the years.

She still remembers the night her 12-year-old son developed a high fever and began shivering uncontrollably.

“He was so weak. He kept crying through the night. None of us could sleep,” she recalls.

The following morning, she wrapped him in a blanket and hired a motorcycle taxi for the hour-long ride to Kayanga District Hospital. A rapid diagnostic test confirmed malaria, and health workers prescribed an artemisinin-based combination therapy (ACT), the treatment recommended across most of Africa.

Within days, he had recovered. For now, that remains the experience of most malaria patients across Tanzania. ACTs continue to cure uncomplicated malaria and health authorities are not recommending any changes to treatment. But scientists monitoring the malaria parasite say the organism itself is beginning to change.

A study published in Frontiers in Genetics has detected genetic mutations associated with partial resistance to artemisinin in northwestern Tanzania, raising concerns that the parasite could gradually become less responsive to one of the world’s most effective malaria medicines if its evolution is not closely monitored.

Mystery mutation

Researchers analysed 2,866 Plasmodium falciparum samples collected between 2021 and 2023 in seven districts of Kagera Region. Although the mutation remains uncommon, its wider distribution has caught scientists’ attention.

They found the K13 R561H mutation, recognised by the World Health Organization (WHO) as a marker of partial artemisinin resistance, remains concentrated in Karagwe and neighbouring Kyerwa District but has also appeared in Muleba and Bukoba Rural, suggesting it is spreading beyond its original hotspot.

“The medicines we use today are still effective,” says Dr Deus Ishengoma, a molecular biologist at the Ifakara Health Institute and one of the study’s authors.

“What this study shows is that the parasite is changing. We are seeing resistance-associated mutations in areas where they were previously uncommon, and that’s an early warning that we need to take seriously.”

Unlike routine malaria surveillance, which records infections and treatment outcomes, genomic surveillance looks inside the parasite’s DNA, allowing scientists to detect mutations years before patients begin failing treatment. That early warning can give countries time to strengthen surveillance while existing medicines are still working. Researchers point to Southeast Asia as a reminder of why that matters.

Felista Tarimo, a researcher at Tanzania’s Ifakara Health Institute, demonstrates mosquito collection as part of malaria surveillance activities. Photo by Ifakara Health Institute.

Crucial cooperation

More than a decade ago, scientists in western Cambodia detected similar mutations that initially caused parasites to clear more slowly after treatment. Patients still recovered, but resistance eventually spread to the partner medicines used alongside artemisinin, forcing several countries in the Greater Mekong Subregion to replace their first-line malaria treatments.

Africa is not facing that situation. ACTs continue to perform well across the continent, and the Tanzanian study found no evidence that patients are failing treatment. Instead, researchers see the findings as a signal to watch the parasite more closely.

Karagwe’s location adds to the concern. The district borders Rwanda and Uganda, where thousands of people cross every day to trade, visit relatives, farm and seek healthcare. Malaria parasites travel with infected people and mosquitoes, making drug resistance difficult to contain within national borders.

“Cross-border cooperation is essential because malaria does not stop at immigration checkpoints,” says regional malaria expert Zul Premji. “If one country detects resistance-associated mutations but neighbouring countries are not looking for the same markers, resistant parasites can spread unnoticed. Sharing surveillance data gives countries the best chance of detecting changes early and protecting the medicines we still have.”

Scientists say neighbouring countries around the Lake Victoria basin should not only exchange malaria case data but also compare genetic information and coordinate therapeutic efficacy studies so changes in parasite populations can be tracked consistently across the region.

Over the past two decades, governments and donors have invested heavily in mosquito nets, indoor spraying, rapid diagnostic tests and ACTs, helping reduce malaria deaths across much of sub-Saharan Africa.

Can We Win the Malaria Arms Race?

Far less money has gone into genomic surveillance—the specialised laboratories, sequencing technology and trained personnel needed to detect resistance before medicines begin to fail.

“Changing first-line malaria treatment is a major undertaking,” says Syabo Mwaisengela, a health economics and policy expert at Mzumbe University. “It means revising national treatment guidelines, retraining health workers, procuring new medicines and reorganising supply chains. Those changes are expensive. Detecting resistance early allows countries to respond before treatment failure becomes widespread.”

The researchers stress that Tanzania’s current malaria treatment policy remains appropriate. ACTs continue to cure uncomplicated malaria, and the study found no evidence that the medicines are losing their effectiveness.

Beyond the K13 mutation, scientists also detected genetic markers linked to resistance against older antimalarial drugs, including sulfadoxine-pyrimethamine, offering a broader picture of how Plasmodium falciparum is evolving across northwestern Tanzania.

For Mwijage, those scientific findings feel distant from everyday life. When her son became ill, she was not thinking about parasite genetics or molecular surveillance. She wanted the nearest hospital to have medicine that would make him well. It did. Scientists hope it stays that way.

They say identifying resistance-associated mutations while they remain uncommon gives Tanzania and its neighbours a chance to strengthen surveillance, expand laboratory capacity and coordinate monitoring across borders before one of Africa’s most effective malaria treatments comes under threat.

The inaccurate map of Africa shown during the US government information session.

RIO DE JANEIRO – The United States’ rapid dismantling of its HIV funding since January 2025 has caused the worst financial crisis for the sector in decades – but the US government’s willingness to host an information session on its new America First Global Health Strategy on the eve of the International AIDS Conference earned it some goodwill from delegates.

However, that goodwill rapidly evaporated when the US government displayed a wildly inaccurate map of Africa during a briefing by Jeff Graham, the acting US global AIDS co-ordinator. 

The US map locates Mozambique in the Horn of Africa, almost diametrically opposite to its actual position on the west coast of southern Africa. Nigeria appears in Niger, while West Africa’s Côte d’Ivoire was located in East Africa.

However, Graham did not notice the mistakes when he displayed the map during a session attended by Health Policy Watch.

The International AIDS Society (IAS) president-elect, Professor Kenneth Ngure of Jomo Kenyatta University in Kenya, responded, saying: “It is disheartening that a map mislabelling African countries was displayed. African countries must be taken seriously. The African continent continues to bear the greatest burden of the HIV pandemic, and our focus must now return to advancing the HIV response.”

Earlier, the US State Department told Reuters that it takes “full responsibility for ​the confusion and misrepresentation it ​caused for attendees, including ⁠our African partners”, claiming that a staff member had made last-minute changes to the presentation.

However, it did not offer any apology for not being able to locate the African countries with which it has signed Memorandums of Understanding (MOU), which outline the transition from US-supported to domestically financed HIV programmes.

 

Hygienists at the Rwampara Ebola Treatment Center (CTE) put on their personal protective equipment (PPE) in the isolation area before entering the centre, May 29, 2026.

BUNIA, Democratic Republic of Congo – Victorine Ngwobu Kasemi is the director of nursing at the Evangelical Medical Centre in Bunia, the epicentre of the Democratic Republic of Congo’s record-breaking Ebola epidemic. In recent weeks she’s had to watch colleagues succumb to the virus, and her children isolate themselves from her to keep safe.

“I’m afraid that at any moment I could die or infect my children, because this is a disease we can’t control, and no one knows where or when I might get contaminated,” said Kasemi.

Like hundreds of nurses working on the frontline, Kasemi faces the challenge of providing life-saving supportive care to patients without being infected. The most painful experience, she said, is watching helplessly as her colleagues succumb to the virus.

“There was a woman who came in with a miscarriage, and she had Ebola; two doctors and several nurses who treated this patient were infected,” she said. “One doctor, unfortunately, died from the toll it took. When a nurse was declared positive, she couldn’t bear it and fell into a depression until we lost her. We were unable to save her.”

These cascading infections illustrate a well-documented mode of transmission: Ebola, a severe viral hemorrhagic fever, spreads through direct contact with the blood, vomit, or other bodily fluids of an infected person, or via contaminated equipment – that puts healthcare workers at high risk. The average fatality rate is about 50%.

At home, medical staff have to carry the added burden of protecting their families.

“When I come home, my children ask me to stay on the balcony. They prepare my shower, I leave the balcony to go shower, and my clothes are immediately soaked in water,” Kasemi said. “That’s the life I’ve lived up until now.”

Unpaid wages, anger and infection risks 

At the Ebola Treatment Centre (CTE) in Ituri province, eastern DRC, Ebola response workers protest against delayed payment, July 13, 2026.

In mid-July, the severely underfunded frontline response was thrown deeper into chaos. Dozens of medical workers at Rwampara General Hospital in Ituri, a northeastern province on the border with Uganda where the first case was detected, on strike to protest unpaid wages.

Health workers from epidemiologists to health investigators and gravediggers leading the strike said they had not received pay since the epidemic began. The strike included everyone from epidemiologists and health investigators to gravediggers.

It has been a stop-cycle of strikes since protests began. Health staff walk out, receive new promises of payment, return to work, then resume strikes when the promised money doesn’t materialise.

Visits from top country officials have done little to quell the frustration. Prime Minister Judith Suminwa visited Ituri on July 24 to reassure health staff – they were back on strike within a day, still owed months of pay.

In a separate visit to Ituri, Health Minister Roger Kamba said that the government was in the process of verifying a list of people working on the epidemic response in order to sort out payments. He said the delay was due to unrelated names being added to it.

“We must make sure these payments reach the right people,” said Kamba. “We have the means to resolve this issue.”

Uncontained spread

Hygienists at the Rwampara Ebola Treatment Center (CTE) put on their personal protective equipment (PPE) in the isolation area before entering the center, May 29, 2026.

The DRC’s current outbreak – its 17th Ebola epidemic since 1976 – is spreading faster than any on record globally. It is already the third-largest ever in the DRC – and is on pace to become the largest in the history of the continent.

Africa Centre for Disease Control (Africa CDC) director Dr Jean Kaseya said at a press briefing on Thursday that the current outbreak has recorded seven times more cases than at the same stage of the 2014-2016 West Africa Ebola outbreak,

The critical threshold of 1,000 cases, which signals that an epidemic is spiralling out of control, was crossed in just 40 days, a pace the Africa CDC described as the “fastest-growing” epidemic ever recorded.  The 2,000-day threshold was crossed in only 20 days.

it took 235 days to reach 1000 cases during the 2018 North Kivu epidemic, which until recently, was at the time was the DRC’s worst outbreak on record.

The country has recorded 3,442 confirmed cases and 1,521 deaths – a case fatality rate of 44% – as of July 28, according to the DRC Ministry of Communications and Media. Nearly 800 patients remain in isolation or hospitals.

The toll includes 112 infected health workers – 35 of whom have died – across five provinces in eastern DRC: Haut-Uele, Ituri, North Kivu, South Kivu, and Tshopo.

Contact list far behind the curve

Test positity remains over 40%, indicating ongoing intense community transmission and gaps in active case search in the community, Africa CDC said Thursday.

As the response crumbles and contact tracers struggle to track the spread, the epidemic continues to break containment efforts, outpacing the response at every turn.

Over 80% of new cases in Ituri, the epicentre of the outbreak, are not linked to known cases, according to Africa CDC. Over 60% of deaths are linked to communities instead of treatment centres, showing authorities still have major ground to cover to catch up with the speed of the outbreak.

Struggles in contact tracing are compounded by the lack of medical countermeasures. Unlike previous epidemics in the DRC, caused by the Zaire strain for which vaccines exist, this one is caused by the Bundibugyo strain, which remains without a vaccine or approved treatment — making tracing one of the only tools responders have to get ahead of the virus.

The disease often begins abruptly with fever, extreme fatigue, muscle pain, headaches, and sore throat, before progressing to vomiting, diarrhoea, skin rash, and, in the most severe cases, internal and external bleeding, according to the World Health Organization (WHO).

The incubation period lasts 2 to 21 days, and an infected person becomes contagious only after symptoms appear. Close contact with a sick person, particularly during care or funeral rites, is the main route of transmission.

‘Heroes’ on the frontline

Medical staff prepare to enter the Centre Médical Évangélique to treat Ebola patients.

Dr Mubarack Kano, Medical Director of the Ituri Neuropsychopathology Centre in Bunia, said those risking it all to contain the virus are “heroes.”

Kano, who leads Ebola investigation in Bunia’s CNK Sayo health area, said this is especially true as they face backlash from community members who want to maintain traditional funeral customs like washing, dressing, and even kissing deceased victims that are still carrying massive viral loads.

“The workers responsible for breaking the chain of transmission by organising safe and dignified burials are the most exposed people, in a community that struggles to accept giving up customary funeral rites,” said Kano.

As medical workers and authorities refuse to hand over highly contagious bodies, it is only sowing deeper mistrust among some community members, who see it as part of a cover-up and even doubt the virus’s existence and see it as part of a resource grab.

Bahati Jhon, a father of eight, is a member of a safe and dignified burial (SDB) team in Rwampara.

“Since May 15, we’ve been doing this work. We face all kinds of risks. We’re sometimes physically attacked, threatened with death, chased,” Bahati Jhon, a father of eight and member of a safe and dignified burial (SDB) team in Rwampara, explained.

“During a burial the other day, someone in the community threw a stone at me, which unfortunately damaged one of my teeth, which I ultimately lost,” Jhon said.

It was not a one-off incident. In Rwampara, a centre was burned down on 21 May after authorities refused to return a body to its family. Elsewhere, burial teams were forced to abandon a coffin under pressure from angry residents.

Workers like Jhon keep taking on these risks, even as they go unpaid. “Since the epidemic began, we haven’t received a single franc. We don’t know what to do, as we can no longer provide for our families’ basic needs,” he said.

‘No one is coming to our aid’

Medical staff put on their personal protective equipment (PPE) before entering the Ebola Treatment Center (CTE) to care for patients at the Centre Médical Évangélique, July 9, 2026.

Despite efforts by relief teams to build trust and awareness, healthcare workers remain frequent targets of disinformation. In some cases, they’re being blamed for having invented the disease to enrich themselves.

“We are not here for the money. We face a critical situation,” Dr Kamara, a Rwampara health zone doctor, said. “There is a disease that is very real, and the goal of every healthcare worker is to treat, to save lives, and to limit the spread of the disease.”

An important part of the local response now centres on building local capacity to fight disinformation. The National Institute of Public Health is training local journalists, and MONUSCO has trained community leaders in Mambasa. DRC Authorities are also calling on community radio stations to step up awareness efforts.

The response is also being hamstrung by ongoing war. The armed conflicts in eastern DRC between Congolese forces and the Rwanda-backed AFC/M23 rebellion in North Kivu, South Kivu, and Ituri have displaced over a million people and blocked health workers’ access to affected areas, putting strain on an already fragile health system and exposing frontline workers to even more insecurity.

A patient inside one of the ETCs in Ituri, who declined to give his name, described the situation as becoming dire.

“We are shocked to see the absence of caregivers. What’s even more serious is that there are patients who arrived yesterday, and others even today, in critical condition. These patients are calling for help,” he said. “But no one is coming to our aid. We are here with no medication, no nurses.”

He said patients have had no food since last Monday morning.

Beyond the treatment centres, the war is fuelling another dark crisis for eastern DRC’s civilians. Panzi Hospital in South Kivu reported an 85% increase in newly registered survivors of sexual violence in the first half of 2026 compared to the previous year.

Sexual Violence Surges in Eastern DRC as Conflict and Ebola Overwhelm Health System

Who’s stepping up?

Continental overview of planned and disbursed funding for the Ebola outbreak and response shared by Africa CDC on Thursday.

The early weeks of the Ebola response were difficult and unbalanced, delaying the construction of Ebola treatment centres and proper patient care. Since then, funding has poured in, though not always fast enough to keep pace with the outbreak.

In June, Africa CDC and the WHO launched a joint response plan costing $518 million for the period June-November 2026.

Since then, the DRC government has already injected more than $50 million into the response. Paid in two instalments ($20 million then $30 million) by the public treasury, the funding pales in comparison to the overall national response plan budgeted at $319 million, and the continental Africa CDC/WHO plan of $518 million for June-November 2026.

In total, nations and international organisations have pledged around $1 billion to the response. Some 472$ million of that total has been distributed so far, according to Africa CDC. The agency estimates $1.4 billion will be required to fully quell the outbreak.

Among the main donors: the United States ($270 million), the United Kingdom (£20 million), the EU (€15 million), and the World Bank ($243 million). The WHO Foundation is running a campaign to raise $115 million, but so far has received less than half of that amount.

While international mobilisation remains visible, execution on the ground has struggled. Among the main donors: the United States ($270 million), the United Kingdom (£20 million), the EU (€15 million), and the World Bank ($243 million).

Questions and hope

US Support for Ebola Response is Unclear Amid Opaque Funds Disbursement and Non-Engagement with WHO

Some donor countries are channelling funds directly through NGOs, which are involved in awareness campaigns and the construction of treatment centres. But in some cases, including funds allocated by the United States, questions have also arisen around the opacity of fund recipients and how they have been used.

Criticisms have also arisen that the WHO-Africa CDC coordination effort may have diffused, rather than sharpened accountability over the management of the crisis.

John Katabuka, a doctor at the ETC of La Grâce General Referral Hospital in Bunia and deputy coordinator of the Bunia health zone, is looking at the future with caution, but not without hope.

“We need to monitor entry and exit points and rely on community-based surveillance to track every alert – contacts, suspected cases, and contacts of contacts,” he said, adding that disinformation and community resistance early in the epidemic caused delays in care and a cascading rise in deaths.

“We are not pessimistic. We believe treatment centres and their equipment can be brought up to standard, so that even expatriates who fall ill can trust the local ETC rather than being evacuated abroad.”

 This article is published in collaboration with Egab.

Image Credits: Anicet Kimonyo.

United Nations (UN) Secretary-General António Guterres warned countries that the temperature extremes will continue unless fossil fuel usage is halted.

As wildfires rage across continents, heatwaves claim thousands of lives and ocean temperatures shatter records, UN Secretary-General António Guterres warned on Friday that the climate crisis has entered “overdrive.”

“This is only a warm-up act,” he said. “El Niño is strengthening, adding fuel to a planet already on fire with scorching heat domes, apocalyptic wildfires and record hot seas.”

New forecasts from the World Meteorological Organization (WMO) show El Niño, the naturally occurring climate pattern that amplifies global temperatures and disrupts rainfall, is developing into a strong event at unprecedented speed.

The Niño 3.4 index, a key measure of Pacific warming, surged from 0.5°C in April to 1.6°C in June. Sea-surface temperatures in key monitoring regions are forecast to average nearly 3°C above normal between August and October.

The WMO projects the event will continue intensifying into November, meaning the extremes already battering communities worldwide are likely a prelude rather than a peak. Through October, nearly every land area on Earth is expected to be hotter than normal.

“Fossil fuels are fanning the flames of this crisis. Expansion must stop,” Guterres said. “More coal, oil and gas will lead to a more combustible future.”

“Unless we act, to protect people and tackle the root cause of the crisis, the dangers will become deadlier still,” he warned. “The warm-up act is over. We cannot afford to wait for the main event.”

Guterres called extreme heat “the silent killer,” warning that even that description may understate the crisis. Heat deaths are vastly undercounted worldwide, he said, with many fatalities never recorded as heat-related even when heat plays a decisive role.

“Behind all of the numbers are people,” he said. “Families trapped in unsafe homes. Workers forced to choose between their health and their income. Children unable to learn.”

El Niño continues to intensify

El Niño causes wetter than normal temperatures in some parts of the world and drier than normal in others.

El Niño and La Niña are naturally occurring phases that are characterised by above-average sea-surface temperatures in the central and eastern equatorial Pacific Ocean, and affect weather patterns globally.

The WMO had warned of a strong El Niño following a hot summer that left thousands dead in Europe alone, and now is hoping to give countries a heads-up to prepare.

“This El Niño, developing against the backdrop of unprecedented ocean heat and rising temperatures, provides governments and communities with a window of opportunity to anticipate risks and act before impacts unfold. The decisions we make today will shape the impacts we experience tomorrow,” said WMO Secretary-General Celeste Saulo.

Currently, though, countries continue to invest in fossil fuels, and pension funds also invest in such projects instead of clean technology. “The hope is that the public, who are being impacted by these extreme climate-related events, that the public will demand urgent and ambitious climate action, and action not only to protect them, but also action to address the root cause,” said a UN official as part of background comments made to the media.

Also read: As El Niño Intensifies – WMO Warns Policymakers to Brace for Escalating Impacts on Health Worldwide

Extreme heat and rainfall – a deadly combination

WMO forecasts above-average temperatures across most land areas globally. Africa, southern Europe, the Arabian Peninsula, the Indian subcontinent, eastern Asia, Central America, the Caribbean, Southern Africa, much of South America and New Zealand are expected to be worst-hit by extreme heat.

“Every city and country should have heat-health action plans, early warning systems and public health measures that reach every community in time,” Guterres said.

Wetter-than-normal conditions are expected across the Greater Horn of Africa, parts of Central Asia, Southern Europe, Western North America and Southeastern South America.

In contrast, drier-than-normal conditions are more likely over the Indian subcontinent; Southern and eastern Australia; Southern Central America and parts of the Caribbean; Northwestern South America; and Northern Europe.

“The impacts are accelerating, as we’re seeing in real time. Solutions are available, as we’ve seen over the course of the last two years since the Secretary General’s call to action was launched, but what is really missing is the political will to act at the speed and scale this moment demands,” the UN official speaking on background said.

Pointing to the recent geo-political tensions between the US and Iran, UN officials are also highlighted how clean energy can help countries be sovereign. Clean energy, supported especially by China, has helped Cuba and Pakistan rapidly deploy solar energy to tide against their serious energy crunch. This shift highlights how market forces and people’s needs can shape climate action even if political will lags.

Image Credits: UN Photo, WMO, WMO.

Dr Jason Mitchell, who heads FIJI’s HIV task team, and Mark Shaheel Lal, founder of Living Positive Fiji.

RIO DE JANEIRO – A graph showing the progression of HIV infections in Fiji resembles a cobra poised to strike. For years, the 330+ islands that make up Fiji had almost zero HIV cases, but the country’s 14-fold increase in infections over the past five years is represented by a near-vertical line rearing up over the country.

Around 12,000 people are believed to have HIV in a country of less than a million people spread over 100 or so habitable islands.

“What is driving this epidemic now is risky injecting drug use of people who currently inject methamphetamines,” said Dr Jason Mitchell, chair of Fiji’s National HIV Outbreak Cluster Response Task Force.

People share needles to inject the crystal meth, another exploding epidemic, and sometimes also deliberately share their blood after taking the drug to make it go further.

The Pacific islands – positioned between East Asia, the Americas, Australia and New Zealand – have long been a gateway for drug traffickers. But during COVID-19, the drugs were unable to move, and a domestic market for crystal meth was cultivated.

Map of Fiji

“In January 2025, we declared a national HIV outbreak, which was initially confined to the population of people who inject drugs. The epidemic is now spilling over into every other population group in the country,” Mitchell told a media briefing at the International AIDS Conference (AIDS 2026).

“UNAIDS estimates that we currently have 1.2% prevalence in people between the ages of 15 to 49, and that of course continues to increase. That’s roughly one in every 60 adults,” said Mitchell.

‘The prevalence in our antenatal population now exceeds 2% and, in 2025, one child was born with HIV every week, and we lost one child to HIV-related matters every month,” Mitchell added. 

“In a country of less than a million people, this is very significant, and perhaps for me it is the greatest crime and shame of all because this is all preventable.”

Last year, around 18% of mothers with HIV passed the virus on to their babies – the highest vertical transmission rate in the world.

Two in three of last year’s people diagnosed with HIV were aged between 20 and 34, and  94% are from the indigenous iTaukei population. Men initially outnumbered women by over 2:1, but the rates in women are increasing.

There has been a 45% increase in children aged 10 to 19 becoming infected with HIV, said Mitchell.

Communal culture drives HIV spread

Mitchell attributes the rapid spread among people who inject drugs to two things: the culture of communality in indigenous Fijians and a shortage of clean needles and syringes.

“We typically share everything,” explained Mitchell, giving the example of kava, a root used in traditional ceremonies that has an antidepressant effect. 

“The practice of consuming kava is you have one mixing bowl and one receptacle or glass that we all share. The practice of kava has spilt over into our consumption of alcohol. Anyone who has grown up in Fiji will have been introduced to this practice of one glass and one [bottle of] alcohol. You would never have your own glass.”

Similarly, with crystal meth, people pool resources to buy the drug, which they then share along with the needles and blood.

But Mark Shaheel Lal, founder of Living Positive Fiji and one of the few people to come out publicly with his HIV status, says that “a needle and syringe programme is something that really needs to be implemented, and it is not”. 

“We constantly run out of [antiretroviral] medication, which has just been introduced, and no one really knows about antiretrovirals themselves.”

Huge obstacles

An HIV awareness march in Fiji.

Mitchell concedes that Fiji is struggling: “Our 90-90-90 [global HIV] targets are 40-22-3.2,” he says. This means that, instead of 90% of people knowing their HIV status, only 40% do. Instead of 90% of those living with HIV being on treatment, only 22% are in  Fiji. Of those that are, only 3.2% have undetectable viral loads, instead of the 90% target.

Many HIV cases are being diagnosed through routine HIV testing when people donate blood.

The government has introduced pre-exposure prophylaxis (PrEP) and “we’re trying to strengthen our condom programming in a region that does not use condoms”, said Mitchell. 

However, he agrees with Lal that “what is missing from this response is the availability of a needle and syringe programme”.

“That is a central part of a harm reduction programme,” said Mitchell. “There’s a lot of will, especially from our politicians and government, but we need to introduce the systems first.”

However, Mitchell concedes that police crackdowns on pharmacies selling needles and syringes have exacerbated the situation. He also recognises that it will be hard to convince people that “the practices they have adopted from consuming kava and alcohol should not be used in the situation where you’re injecting drugs”. 

The country is also struggling with resources. Australia and New Zealand are assisting Fiji, both with resources and technical support, and India has made a significant donation of ARVs, but Mitchell says the islands need more.

Despite getting a small grant from the Global Fund, Fiji is heavily dependent on this – although it is due to transition off Global Fund money within three years.

“We need a full upscaled response,” said Mitchell, warning that the epidemic also poses a threat to other Pacific islands.

Image Credits: World Health Organization, Kerry Cullinan, Fiji Ministry of Health, Wikipedia.