Kenya’s President William Ruto (left) applauds Kenyan Cabinet Secretary Musalia Mudavadi and US Secretary of State Marco Rubio after signing the first ever MOU in terms of the America First Global Health Strategy.

Country controversies, secret terms, opaque procurement, and massive unspent congressional funds have characterised the first year of the America First Global Health Strategy.

“Services are weaker than they were a year ago, HIV testing is down, treatment of children living with HIV is down, and community-based prevention is gutted,” said Emily Bass, expert consultant for Physicians for Human Rights (PHR), about the change in US policy.

Introducing the new strategy a year ago (18 September 2025), United States Secretary of State Marco Rubio pitched it as an antidote to “inefficient and wasteful” past global health programmes.

Since then, 35 countries have signed bilateral memorandums of understanding (MOUs) with the US in terms of this strategy. Two of these, Kenya and the Democratic Republic of Congo (DRC), face legal challenges from civil society groups over the terms.

Three – Ghana, Zimbabwe and Namibia – have refused the terms offered by the US, the main sticking point being US demands for sensitive health data. Zambia is struggling to find a way to secure US aid without having to sell the family silver. Several countries, including the DRC and Guinea, signed health MOUs alongside deals to sell minerals to the US.

The Trump administration has also refused any further aid to South Africa, the country with the largest HIV population in the world, primarily over its measures to address apartheid-era racial injustice and its case against Israel at the International Court of Justice.

‘Safer, stronger, more prosperous’?

The stated aim of the MOUs, which replace US Agency for International Development (USAID) and President’s Emergency Plan for AIDS Relief (PEPFAR) grants, is to “make America safer, stronger, and more prosperous”.

The five-year MOUs also aim to rapidly transfer responsibility for key health services to countries themselves, with domestic “co-financing” commitments progressively increasing every year.

The MOUs also demand that countries invest heavily in disease surveillance networks in order to supply the US with pathogen information within a week of any outbreak. 

The aim is not only to “keep America safe” but to give US firms exclusive access to pathogen information to enable them to make vaccines, medicines and diagnostics to combat these. This is a direct challenge to the pathogen access and benefit-sharing (PABS) system currently being negotiated at the World Health Organization (WHO), of which the US is no longer a member.

Onerous co-financing 

DRC Health Minister Dr Roger Kamba, US Chargé d’Affaires Ian McCary and DRC Prime Minister Judith Tuluka Suminwa at the signing of an MOU in terms of the America First Global Health Strategy

A recent analysis of 18 MOUs by Public Citizen and Partners In Health found US funding would be cut to the countries by over $2 billion by 2030, a 59% reduction in comparison to 2024 funding. 

The organisations had to resort to Freedom of Information Act (FOIA) requests and lawsuits against the Trump administration to extract some of the secretive MOUs.

Countries facing the steepest cuts are Rwanda (97% reduction), Liberia (84%), Burundi (78%), Madagascar (77%), and Sierra Leone (71%).

Five years will be insufficient for 11 of the countries to raise domestic funds to cover the gap left by the cuts, yet the US forbids countries from “including funding from other donors or multilateral organisations” to bolster their commitments, according to the analysis.

Public Citizen/ Partners in Health analysis of 18 MOUs shows a 59% cut in funds over five years.

“Malawi would have to mobilise new funding equal to 56% of the country’s total health expenditure to meet its annualised co-financing commitment,” the analysis notes.

By 2030, seven of the poorest African countries will have fewer health workers, thanks to reduced US and partner government investment. These are Burundi, Cameroon, Eswatini, Kenya, Lesotho, Madagascar and Malawi.

Some of the 18 MOUs also stipulate financial punishment if countries fail to meet their co-financing commitments. Uganda and Côte d’Ivoire face a $2 reduction in US aid for every $1 they fail to pay. Ethiopia, Kenya, Mozambique, Cameroon, and Malawi will lose $1 for every $1 domestic shortfall.

Money in the House

Sheila Davis, CEO of Partners in Health (PIH)

Perversely, as the Trump administration slashes health aid packages for some of the world’s poorest countries, over $3.6 billion in funds allocated for this very purpose by the US Congress have not been disbursed.

“September 30 marks the expiration of $1.35 billion of appropriated funding for TB, malaria, HIV and maternal and child health. While this money has already been approved by Congress, it will not reach the patients it was meant for unless the State Department releases it in the next 12 days,” Sheila Davis, CEO of Partners in Health (PIH), told reporters on Thursday.

Her colleague, Dr Vincent Lin, described the date, the end of the US fiscal year, as a ”funding cliff”, noting that over 100 PEPFAR programmes under the Centers for Disease Control and Prevention (CDC) covering the HIV treatment of eight million people are also set to expire.

Meanwhile, PEPFAR is $2.3 billion underspent this year due to the US State Department delaying payments, jeopardising the HIV treatment of 20 million people.

“The executive branch agencies, especially the Office of Management and Budget (OMB), USAID’s Legacy Unit, and the State Department, have been withholding and underspending global health funds at an unprecedented level,” said Lin.

“If that money is continuously withheld, that would cause tens of thousands of preventable deaths from infectious diseases, including TB, malaria, and HIV, and among moms and babies from illness in childbirth and delivery, further furthering this backsliding that we’ve already seen over the last two years,” he added.

In late August, 170 Members of Congress wrote to Rubio and OMB head Russell Vought demanding that they release the over $3 billion in “unobligated” global health funding, warning that their refusal to spend the funds as directed by Congress “defy the law and threaten lives”.

White House OMB Director Russell Vought

Opaque procurement

A year ago, Rubio described US foreign assistance programs as “deeply broken”, claiming that 60% of US health funding was “spent on technical assistance, program management, and other forms of overhead”.

This has been disputed by the Center for Global Development, which reviewed PEPFAR’s 2024 spending and found that 63% of funds “directly enables lifesaving treatment programs”. And what the US State Department characterised as “low-priority site-level technical assistance” – only 18% of funding – covered essential elements including data for tracking treatment adherence, health worker training, and community outreach.

However, procurement for the new MOUs is characterised by little transparency or official guidelines.

PIH monitoring of how the 35 MOUs are being implemented has uncovered “potentially $3- $5 billion” going out to implementers this month by “sole source or non-competitive mechanisms”, said Lin.

“We’re also tracing a new innovation fund for US companies that’s set to dole out $800 million this year to handpicked entities without a competitive process, and the [State Department’s] Annual Program Statement, a semi-competitive mechanism that will push out several billion dollars in funding without clear guidelines or alignment to federal procurement law,” he added. 

Extract from the US State Department’s Annual Programme Statement call.

“It is shocking, to say the least, that federal procurement is not being utilised for huge volumes of US dollars,” Lin noted.

“We’ve heard through the grapevine a handful of junior staff are reviewing hundreds of submissions.”

Awards via the Innovation Fund include $150 million to US company Zipline, and undisclosed amounts to Gilead for HIV drug lenacapavir and SC Johnson for a mosquito repellent.

Congress has indicated that the Innovation Fund is set to scale up to at least $800 million, “which is a huge portion of overall global health spending, but there’s minimal information at all about what’s happening”, said Lin.

Distorting country priorities

Twenty-five years ago, African leaders committed to allocating at least 15% of their domestic budgets to health – but only four of the continent’s 55 nations have come close.

It is gratifying to imagine a dictator like Paul Biya, the draconian 94-year-old president of Cameroon who has ruled his country for 44 years, being forced to divert some of the money he spends on frequent Swiss shopping trips to his citizens’ health.

Under Cameroon’s MOU with the US, the Biya government has committed to increasing its health spending by $450 million over five years to unlock $400 million in US aid.

Shortly after signing the MOU, Cameroon proposed a health budget of over $684 million for 2026, an increase of around 30% on the previous year. 

But by July, it had only released 19% of its immunisation budget. MP Essomba Bengono told local media outlet SBBC that about 430,000 Cameroonian children had not received their vaccines because the country has been unable to meet its financial commitments.

While it is unclear why the immunisation budget has not been released, the danger with the new bilaterals is that rulers like Biya may make promises to the US, then shift money around to meet these terms with little regard for their countries’ health priorities.

Even more sensitive leaders may be forced to distort their budgets to meet the US needs rather than their own – for example, meeting the US demand for pathogen information requires an army of data capturers who will take funds away from health worker posts.

No provision for community-based care

Luyengo Clinic in Eswatini. PEPFAR funded 80% of the clinic’s cost, and the HIV treatment of 3,000 clients has been in jeopardy.

Before Trump, PEPFAR grants were allocated via country operational plans developed by governments in partnership with civil society organisations. Even in countries where civil society organisations have little room, such as Uganda and Burundi, governments were forced to include them.

The current MOUs are purely government-to-government with no provision for civil society, and community-based services are all but abolished. This means that those who know best how to reach at-risk populations no longer have a seat at the table. 

It also almost certainly means service delivery will be weaker – particularly for “key populations” most at risk of HIV, such as sex workers and men who have sex with men.

Of course, the Trump aid shock provided the impetus for the “Accra Reset”, aimed at fostering African sovereignty and resilience. Achieving this is a long way off, but starting this journey has been long overdrew.

Finally, as the Ebola outbreak has shown, bilateral agreements are no match for outbreaks, epidemics and pandemics. Imagine trying to coordinate 35+ agreements in the face of a fast-spreading pathogen

Image Credits: Public Citizen/ Partners in Health, UNAIDS.

An analysis of early digital campaigns in the race for the next WHO Director-General, reveals a sharp contrast between consolidated sovereign-technical networks and broad multilateral policy forums.
An analysis of early digital campaigns in the race for the next WHO Director-General reveals a sharp contrast between consolidated sovereign-technical networks and broad policy forums.

The race to lead the World Health Organization (WHO) is intensifying. Early digital campaign data reveals an active contest to capture the pivotal African vote and outreach to established United States, European Union and corporate networks. While the full field of contenders is still taking shape ahead of the nomination deadline, digital engagement metrics already highlight geographical and institutional fault lines.

Ahead of the 24 September deadline for candidates to enter the race for WHO Director-General, early digital campaign footprints offer initial visibility into the contenders’ strategic priorities, reach, and professional networks.

While online interactions – such as ‘likes’ or comments – do not constitute formal endorsements, analysing them provides a crucial window into early campaign dynamics. Mapped systematically, this data – consisting of nearly 7,500 direct interactions – reveals the distinct geopolitical and institutional networks each candidate taps into.

Currently, this dynamic is most visible in the digital campaigns of Dr Hans Henri Kluge (Regional Director for Europe) and Dr Hanan H. Balkhy (Regional Director for the Eastern Mediterranean).

Their head-to-head duel is flanked by the candidacy of Indonesian Health Minister Budi Gunadi Sadikin and former Qatari Public Health Minister Hanan Mohammed Al-Kuwari.

Al-Kuwari currently lacks a public social media presence, but Sadikin commands a massive domestic reach of approximately 280,000 followers on Instagram. Although he has yet to launch a dedicated personal campaign account on professional networks, his candidacy is already generating significant discussion and commentary among global policy analysts, health executives, and financial strategists.

Our analysis examines the contrasting leadership models and digital campaign themes established in the candidates’ initial announcements, and maps their core networks across state and diplomatic accounts. It also tracks their competing bids for the pivotal African regional vote, evaluates their strategic reach into US and European policy circles, and unpacks the distinct corporate, academic, and civil society networks reacting to their campaigns.

Here is what the data reveals.

Technical stewardship versus deliberative diplomacy

Screenshots from Dr Balkhy’s and Dr Kluge’s early digital campaigns. Postings and interactions highlight contrasting leadership styles and distinct global influence networks.
Screenshots from Dr Balkhy’s and Dr Kluge’s early digital campaigns. Postings and interactions highlight contrasting leadership styles and distinct global influence networks.

The narrative of Balkhy’s digital campaign strategy is based on clinical frontline credibility, state-sovereign legitimacy, and scientific stewardship. The tone in her post announcing her nomination is authoritative and defined by respect and gratitude towards Saudi Arabia’s leadership, notably King Salman and Crown Prince Mohammed bin Salman.

She systematically links her personal career as a paediatrician and infectious diseases specialist to the establishment of Saudi Arabia’s national infection control authorities and her hands-on management of the MERS-CoV crisis. This narrative of clinical stewardship is celebrated by regional colleagues and commentators as a historic moment for women to lead global health, mirroring wider praise across her network that frames her candidacy as an inspiration for women and girls in the Arab world.

Through her subsequent campaign updates across the African continent and South-East Asia, Balkhy has expanded this clinical core into a broader platform of international health diplomacy. During her engagements at the African regional committee in Addis Ababa and the South-East Asia regional committee in Timor-Leste, she framed her vision around mutual capacity building, ‘One Health’ collaboration, and strengthening local manufacturing and regulatory infrastructure.

Kluge leverages multilateral forums like the South-East Asia Regional Committee to project a platform of participative dialogue and institutional consensus building.
Kluge leverages multilateral forums like the South-East Asia Regional Committee to project a platform of participative dialogue and institutional consensus building.

Kluge’s campaign framing, on the other hand, relies on bottom-up messaging centred on administrative transparency and participative dialogue. His tone is inclusive, marked by active listening and deference towards member states – a strategy designed to allay concerns surrounding a European candidacy.

He links his career as a field-tested public health physician directly to decades of operational crisis management in conflict zones, spanning Somalia, Liberia, Siberia, Myanmar, and the Central African Republic. He pairs this background with his strategic stewardship of the WHO European region.

In his recent campaign updates and official manifesto, “Rebuilding WHO Together”, Kluge has formalised his platform around structural institutional reform, sustainable financing, and a networked “One WHO”. His campaign tour across Africa, framed as a personal “homecoming”, and his participation in the Dili Declaration on health workforce equity reinforce his emphasis on placing local health workers and primary health care at the heart of universal health coverage.

Sovereign bases: securing the home turf

Geographic data highlights regional strongholds while capturing competing candidate efforts to build diplomatic traction across Africa and US policy circles.
Geographic data highlights regional strongholds while capturing competing candidate efforts to build diplomatic traction across Africa and US policy circles.

Translating these narratives into future campaign momentum relies heavily on state-level alignment. A granular analysis of candidate interaction reveals how each nominee’s sovereign network mirrors the distinct administrative and political architecture of their nominating regions.

State-level interactions with Kluge’s posts are anchored by continuous, repeat interactions from key European officials, led by the Belgian diplomatic corps. This digital base is highlighted by Karel Tousseyn, Belgium’s Ambassador to Finland, who repeatedly reacts across several campaign posts, alongside active engagement from Belgian Ambassador to India Didier Vanderhasselt.

Beyond his nominating state, a wider European footprint is consistently visible across his campaign updates. The most frequent cabinet-level engager on Kluge’s platform is Latvian Health Minister Hosam Abu Meri, who continuously responds to major announcements. Reactions also came from Monegasque Minister for Social Affairs and Health Christophe Robino, Irish Minister of State for Mental Health Mary Butler, and Swedish Global Health Ambassador Karin Tegmark Wisell. Notably, programmatic updates also drew direct engagement from the official WHO Bangladesh country office page.

Social data reveals sharp dividing lines, contrasting Balkhy’s sovereign-multilateral base against Kluge’s engagement with pharma, EU policy, and research networks.
Social data reveals sharp dividing lines, contrasting Balkhy’s sovereign-multilateral base against Kluge’s engagement with pharma, EU policy, and research networks.

Mirroring this network, online interactions with Balkhy’s campaign updates reveal a consolidated, sovereign-technical base dominated by Saudi government and regulatory authorities who demonstrate sustained, repeat engagement across multiple posts.

This platform footprint is anchored by senior Ministry of Health leadership, including Chief of Staff Fahad Alkhowaiter, Assistant Deputy Minister Abdulaziz Alrabiah, and Risk Management Director Najla Almutairi. Continuous interactions also came from Saudi Food and Drug Authority (SFDA) leads Adel A. Alharf and Khaloud Alzahrani.

This sovereign core is reinforced across the Eastern Mediterranean by regional public health leads and ministerial figures who maintain steady engagement across her international tour updates. Continuous digital interaction is driven by Egyptian Ministry of Health and Population Associate Minister for International Relations Hatem Amer, Omani Ministry of Health Head of AMR Abdullah Alqayoudhi, and former Sudanese Health Minister Akram Ali Eltom. Together, they reflect strong regional networks across the region, complemented by interactions from the official WHO Lebanon country office page.

Competing for the pivotal African regional vote

Balkhy leverages key regional events in Addis Ababa to pivot her sovereign base toward building strategic, continent-wide health security partnerships across Africa.
Balkhy leverages key regional events in Addis Ababa to pivot her sovereign base toward building strategic, continent-wide health security partnerships across Africa.

With their respective home bases digitally engaged, both candidates turned their focus outward to contest one of the election’s most critical voting blocks representing 47 sovereign member states. Both regional directors targeted the WHO’s African region (AFRO) around its regional committee meeting at the end of August, seeking traction across a bloc that frequently votes in unison and that is an indispensable force in the Director-General election.

Surrounding his campaign travels across the African continent, Kluge’s collaborative, bottom-up model was reflected in his online engagement. Digital momentum for his campaign was driven by regional representatives, technical experts, and advocates across AFRO who demonstrated sustained engagement. This footprint was anchored by repeated interactions with Africa CDC Senior Country Representative for Ethiopia and Mauritius Aniekeme Uwah, WHO Regional Office for Africa Programme Support Specialist Pascal Mulindwa, West African Health Organization (WAHO) Healthcare Services Director Virgil Lokossou, Africa CDC Youth Division Program Coordinator Simon Ernest, and acting Africa CDC Deputy Director General Tajudeen Raji.

In a parallel strategic move, Balkhy’s major campaign update marked a pivot toward the African continent. This triggered immediate digital momentum among operational, technical, and institutional figures on the ground. Repeat interactions were led by Institut Pasteur de Dakar CEO and former WHO Assistant Director-General Ibrahima Socé Fall, UNICEF Human Resources Manager Stanley Kilel, International Planned Parenthood Federation (IPPF) Regional Director for Africa Claudia Shilumani, and Africa CDC One Health-AMR Technical Officer Fowzia Mohamed, alongside former Africa CDC Acting Director Ahmed Ogwell Ouma.

This platform footprint was further reinforced by continental leadership, including Ethiopian Public Health Institute (EPHI) Deputy Director General Getachew Tollera, African Union Interafrican Bureau for Animal Resources (AU-IBAR) Director Huyam Salih, and Sudanese International Health Director General at the Federal Ministry of Health Alaa Altayeb Mudathir. This indicates that Balkhy generated substantial momentum among key institutional and technical accounts in the African region.

US health security and the EU executive machinery

Candidate networks highlight strategic geopolitical reach, connecting Balkhy to Washington biosecurity circles and Kluge to EU executive bodies.
Candidate networks highlight strategic geopolitical reach, connecting Balkhy to Washington biosecurity circles and Kluge to EU executive bodies.

Notably, Balkhy also maintains digital links to US security and public health institutions, marked by sustained reactions from key figures across her campaign updates. High-ranking US government advisers and biosecurity experts – including former presidential adviser Larry Kerr and former US Ambassador Jimmy Kolker – sustained regular engagement across her platform.

Online reactions to her campaign posts extend across core US health security bodies. Key accounts interacting with her updates include former CDC leader Scott McNabb, CDC Senior Global Health Adviser Lynn Filpi, Health and Human Services Senior Global Health Officer Angela Monahan, and former US global health security executive Summer Galloway. This network hints at her potential to serve as a diplomatic bridge for the US following Washington’s withdrawal from the WHO.

Kluge, meanwhile, maintains deep administrative ties to the heart of the European Union, reflected in ongoing engagement across the EU’s health executive machinery. Senior officials from the European Commission Directorate-General for Health and Food Safety (DG SANTE) – including Head of Unit Florina Telea, Team Leader Ines Elise Prainsack-Ward, and Policy Officer Irini Kessissoglou – alongside European Health Emergency Preparedness and Response Authority (DG HERA) leads Giorgos Rossides and Margarida Alho, feature as interaction partners across his updates.

This footprint is further reinforced by European Health and Digital Executive Agency (HaDEA) Deputy Head of Unit Nadia Elhaggagi and Team Leader Debora Fumagalli. This administrative footprint demonstrates that Kluge’s platform actively connects with the day-to-day regulatory and health security machinery of the EU – despite the Commission declining to endorse Kluge so far.

Corporate connects: big pharma versus biotech R&D

Kluge’s corporate footprint centres on strategy and pharma, while Balkhy connects predominantly to hospital systems and specialized biotech R&D.
Kluge’s corporate footprint centres on consulting and pharma, while Balkhy connects predominantly to hospital systems and specialized biotech R&D.

Beyond geography, clear economic and academic dividing lines draw a sharp boundary between the two campaign ecosystems. In times of increased public-private partnerships to leverage the funding gap in global health, these networks might prove to be highly effective.

Kluge’s platform maintains high visibility within the established European industrial healthcare sector. His digital interactions feature top-level corporate figures, anchored by engagements with Bayer AG Board Member Stefan Oelrich, European Federation of Pharmaceutical Industries and Associations (EFPIA) Director General Nathalie Moll, and Vaccines Europe Executive Director Sibilia Quilici.

His commercial reach extends across multinational pharma through engagement from Astellas Pharma Vice President Matt Slabbert, Johnson & Johnson EMEA Government Affairs Lead Anouk De Vroey, and MSD Italia Managing Director Nicoletta Luppi. Together, these connections reflect an extensive European industrial footprint.

In contrast, Balkhy’s economic connections are concentrated in specialised research and development networks and clinical transformation leads. Alongside Saudi healthcare executives – such as King Abdullah Bin Abdulaziz University Hospital CEO Nesreen Alwallan – her platform engages clinical and scientific pioneers in antimicrobial resistance (AMR) and biosecurity.

Repeat interactions come from Swiss biotech firm BioVersys AG Chief Executive Marc Gitzinger, alongside engagements from Roche Pharma Global Head of Infectious Diseases Michael Lobritz, Roche Diagnostics Policy Director Jilian Sacks, Sanofi Head of Vaccines Tine Rikke Jorgensen, AstraZeneca Saudi Arabia Country President Hatem Werdany, and Eli Lilly Government Affairs Lead Fahad Alsafri Alharbi.

Academic pedigree and civil society anchors

The candidates’ digital campaign footprints reveal a distinct strategic split. Kluge draws heavily from health policy, economics, and civil society architects, whereas Balkhy mobilises a coalition of clinical researchers, epidemiologists, and AMR patient advocates.

Kluge’s continuous digital interaction is driven by London School of Economics Professor of Health Policy Elias Mossialos and Associate Professor Rocco Friebel, alongside Bocconi University Health Economics Professor Aleksandra Torbica.

His platform also draws engagement from former Médecins Sans Frontières International President Joanne Liu, alongside civil society representatives including European Public Health Alliance (EPHA) Director General Milka Sokolović, Movendi International President Kristina Sperkova, former EURORDIS-Rare Diseases Europe CEO Yann Le Cam, and US Sepsis Alliance Chief Medical Officer Cindy Hou.

Closely mirroring her clinical background in epidemiology and infectious diseases, Balkhy draws continuous engagement from leading researchers, including Institut Pasteur de Dakar CEO Ibrahima Socé Fall, Boston University Center on Emerging Infectious Diseases Founding Director Nahid Bhadelia, and Mohammed Bin Rashid University Professor Abiola Senok.

This footprint is further reinforced by patient advocacy leaders, such as WHO Taskforce of AMR Survivors Chair Vanessa Carter, International Centre for Antimicrobial Resistance Solutions (ICARS) Head of Human Health Danilo Lo-Fo-Wong, and Harvard Medical School Director Emeritus John G. Meara.

Inspirational advocates and policy lightning rods

WHO headquarters in Geneva. Kluge’s open-door campaign has drawn critical feedback on past reorganizations.
WHO headquarters in Geneva. Kluge’s open-door campaign has drawn critical feedback on past reorganizations.

Meanwhile, public commentary under their official nomination posts reveals that Kluge and Balkhy operate in entirely different narrative landscapes.

The community response to Balkhy’s announcement is remarkably cohesive, combining themes of scientific authority, regional progress, and the historic symbolic impact of female Arab leadership. Her clinical and strategic credentials are heavily emphasised; for instance, former Afghan Health Minister and WHO Executive Board Member Wahid Majrooh praises her “courage and humble leadership” during complex regional geopolitical crises.

Her role as a pioneer is widely celebrated. WHO policy adviser Alissar Rady declared that it is “time for women to lead health,” while patient advocate Vanessa Carter described Balkhy as an exceptional role model for women in global health. Additionally, commentators link her candidacy directly to Saudi Arabia’s expanding contributions to the WHO.

Meanwhile, Kluge’s platform provides an active forum for both institutional celebration and systemic critique. Supporters praise his communicative warmth and crisis-tested, human-centric diplomacy. Some commentators commend his leadership during humanitarian emergencies in Myanmar, while others express gratitude for his supportive role in establishing Kazakhstan’s primary healthcare demonstration platform.

On the other hand, his open-door approach acts as a lightning rod for internal structural grievances. The most sensitive critiques come from within the WHO’s own technical ranks. WHO international classification committees expert Patricia Welch Saleeby delivers a blunt indictment of past reorganisations, warning against the use of external management consulting firms. WHO Health Emergencies Response Officer Banza Freddy Mutoka flags the diplomatic hurdles Kluge will face in convincing Eastern Mediterranean (EMRO) and African member states to align behind his European-backed reform vision.

Doctors, diplomats, and disruptors

The prospective candidates for WHO Director-General (left to right): Dr Hanan Balkhy (WHO EMRO Director), Dr Hans Kluge (WHO EURO Director), Budi Gunadi Sadikin (Minister of Health, Indonesia), and Dr Hanan Al-Kuwari (former Minister of Public Health, Qatar).
The prospective candidates for WHO Director-General (left to right): Dr Hanan Balkhy (WHO EMRO Director), Dr Hans Kluge (WHO EURO Director), Budi Gunadi Sadikin (Minister of Health, Indonesia), and Dr Hanan Al-Kuwari (former Minister of Public Health, Qatar).

With only days remaining before the official nomination window closes, early digital campaigns show that the next Director-General must navigate a highly visible web of online influence, public policy critique, and multi-regional networks. Ultimately, the divergence between the active platforms of Balkhy and Kluge highlights a critical strategic contrast in how the prospective candidates envision leading the WHO through its next era:

  • Balkhy’s campaign relies on a foundation of clinical authority and biosecurity expertise, targeting scientific excellence and frontline epidemic containment. Backed by a highly disciplined GCC sovereign core and key ties within Washington’s health security circles, her model offers the organization institutional stability and sovereign financial backing.
  • Kluge’s campaign, positioned at the intersection of European public administration, multinational industrial partners, and progressive civil society, relies on diplomatic agility and open-door dialogue. Yet, because his platform functions as a public policy forum, his candidacy is directly bound to the friction of systemic WHO reform, internal staff grievances, and post-colonial African demands for structural financial autonomy.

Meanwhile, Qatari candidate Hanan Mohamed Al-Kuwari has remained largely absent from social media channels, whereas Indonesian Health Minister Budi Gunadi Sadikin has featured prominently in high-level policy commentary.

Digital engagement surrounding the announcement of Sadikin’s candidacy on Health Policy Watch was notably robust, drawing significant analysis from global health executives, financial strategists, and policy experts intrigued by his non-traditional, finance-driven background.

As the candidates prepare for the next leg of the campaign, the geographical focus shifts toward remaining regional forums. What is already clear, however, is that the winner of this election will inherit a highly fragmented agency operating under unprecedented fiscal and institutional strain—and their capacity to convert early digital engagement into real-world sovereign trust will determine their success in shaping the future of global health.

Editorial note: how we analysed the data

To analyse the dynamics of the early digital campaigns, Health Policy Watch conducted a comprehensive social media listening study of the candidates’ digital footprints on LinkedIn. The analysis mapped the campaigns of Kluge, Balkhy, and the broader candidate field by extracting interactions across official campaign updates, nomination announcements, and policy manifestos collected through 16 September.

In total, we evaluated nearly 7,500 direct interactions (reactions, likes, and comments) – representing a network of more than 5,200 unique professional accounts. Dual engagements – where individual accounts interacted with campaign posts across multiple competing candidates – were systematically excluded to isolate primary candidate-specific networks (leaving 5,098 primary candidate accounts). The evaluation relies strictly on publicly accessible engagement from accounts disclosing self-reported affiliations, excluding private communications and non-public diplomatic negotiations.

While social media listening offers a unique lens into the professional ecosystems surrounding the Director-General election, several analytical boundaries apply. The dataset relies on LinkedIn as the primary professional platform for global health governance. Consequently, it captures digitally active, English-speaking policy elites, but may under-represent contacts whose main reach relies on domestic consumer networks or traditional, non-digital diplomatic channels.

See related story:

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

Image Credits: Felix Sassmannshausen/HPW, Felix Sassmannshausen, Hans Kluge via LinkedIn, Hanan Balkhy via LinkedIn, Wikipedia .

Grain shipment in Sudan
World Food Programme officials oversee the deliveru of grain in Sudan.

The Trump administration dismantled aid and attacked the global system as wasteful. Now a Trump pick looks set to lead one of the world’s biggest humanitarian agencies. This story was originally published by The New Humanitarian.

Image Credits: WFP/Abubakar Garelnabei, Wikipedia.

Medicare drugs Pharmaceuticals

A new modelling study suggests that US Medicare “Most-Favored-Nation” policies on drug prices would cut Medicare spending on brand name drugs, but potentially incentivize companies to increase prices or delay new drug launches elsewhere.

Efforts to control the cost of United States government spending on drugs culminated in a “most-favored-nation” policy,  a Trump administration initiative that ties what Medicare pays for medicines to prices charged in other high-income countries.

But a new analysis from researchers at Harvard University, the London School of Economics, and the University of Zurich, outlines that while the policy would decrease costs in the US, prices could soar elsewhere.

For about 75% of the medicines analyzed, the resulting Medicare savings would amount to almost four times the annual profits from the medicine’s sales in the country used to benchmark the price. 

“To avoid losing that much revenue, manufacturers would have a strong incentive to raise prices outside the US or delay launches,” The Lancet wrote in a statement.

Already, the policies have helped a pharmaceutical company secure higher drug prices in Japan in March 2026. Astellas Pharma, a Tokyo-based drug company, argued that domestic drug costs could influence US pricing under the most-favored nation policy, leading Japanese officials to award the drugmaker a higher price than typical. 

The study authors also pointed to market withdrawal of a cholesterol drug in Denmark, and US-UK pharmaceutical trade agreements as disruptions to access and pricing as a result of the policy.

“Referenced countries, from Germany to Japan to Australia, are facing substantial pressure from the US administration and industry to raise prices and spending on medicines,” said Dr Thomas Hwang, the lead study author and professor at Brigham and Women’s Hospital and Harvard Medical School. “But this is colliding with the reality that other countries have limited budget room to give.”

Attempts to cut Medicare drug spending 

Medicare drug spending
President Trump with members of his cabinet at a press conference announcing new Medicare drug pricing policies.

“People living in the United States have long paid more for medicines than virtually anywhere else in the world,” said study author Dr Aaron Kesselheim, also a researcher at Harvard’s Brigham and Women’s Hospital.

To understand how these policies would impact pricing in the US and elsewhere, the researchers analysed 195 patented medicines that together account for $87.9 billion of Medicare’s annual spending through its two programs: GLOBE, which covers medicines given in hospitals and clinics, and GUARD, which covers those in pharmacies. Both are most-favored nation (MFN) pricing models under the Trump Administration’s executive order to combat Medicare drug pricing.

The researchers estimated savings by comparing how much Medicare is currently spending to prices in 19 countries referenced in the MFN executive order. They then modelled two scenarios: expanding MFN to include all Medicare beneficiaries instead of the current 25%, and excluding manufacturers with confidential deals. 

Medicare drug spending
A graphic from KFF.org showing how the national share of Medicare’s spending on drugs has increased dramatically in the past decade, outpacing any peer nation.

Without any exemptions, the researchers estimate Medicare could save $5.2 billion (16%) under GLOBE and $6.4 billion (18%) under GUARD during its initial phase. Expanding the rules to cover all Medicare beneficiaries could raise these savings to $21 billion and $25.5 billion. 

Under these payment models, the lowest price used as an international benchmark was found to be 71% lower than what Medicare pays, with South Korea, Norway, and Australia as the most common countries referenced by Medicare to set pricing.

“The most-favored-nation pricing models were meant to address this gap,” said Kesselheim in reference to how much more the US pays for drugs. “[B]ut their scope is limited by various exemptions and will likely face legal challenges,” said Kesselheim. These exemptions- where companies strike side deals with Medicare, are likely to undercut government savings from MFN. 

The study estimates that reported confidential deals between manufacturers and the Trump administration could cut the policy’s overall Medicare savings: for the initial group of 17 manufacturers with announced agreements, the study’s projected savings would be cut by 71%.

“The Trump administration’s most-favoured-nation pricing models have the potential to deliver real savings to the US federal government and taxpayers. But if manufacturers can evade participation in these models by striking side deals, most of those savings might not be realised,” said Hwang.

Concerns for global pharmaceutical market

The MFN policy ties what Medicare pays to prices charged in other high-income countries, leading the researchers to argue that the policy could unintentionally drive prices up outside of the US. 

That’s because for the 138 medicines analyzed in the study, the estimated Medicare savings are nearly four times larger than that medicine’s total annual sales in the country used as the price benchmark.

“For most of these medicines, keeping prices low in other countries would cost manufacturers more in lost Medicare revenue than they earn from selling there, creating a strong incentive to raise prices or block them from being visible to Medicare for referencing,” the Lancet said in a press statement. 

“Manufacturers could try to do that by developing different formulations, converting existing discounts into confidential rebates, or delaying launches.”

Dr Kerstin Vokinger of ETH and University of Zurich noted that “policies in the US may impact access to medicines globally. Policymakers should ensure that availability of important medicines is not delayed as a result,” the study author said.

Confidential deals may wipe out Medicare savings

Medicare covers around 68 million older and disabled Americans- and the program was historically barred from negotiating medicine prices directly with manufacturers until the Biden-era 2022 Inflation Reduction Act authorised it to negotiate prices for a small number of costly medicines. 

The Trump administration’s MFN policy goes further, aligning what Medicare pays for brand-name medicines with prices in comparable high-income countries, after adjusting for purchasing power. Under the GLOBE and GUARD pricing models, a randomly selected 25% of Medicare beneficiaries would be covered over a five-year period.

Yet even with the 16-18% savings reduction through MFN, the cost gap in what the US pays versus other countries persists, the authors write. 

Confidential deals between manufacturers and Medicare also jeopardize savings, they write. These deals are excluded from MFN rules, meaning actual savings are likely lower–roughly 4-6% instead.

The authors did acknowledge study limitations, including reliance on public databases, which may not reflect other countries’ confidential discounts. They also relied on historical data, which may not capture newly approved medicines–and could not predict how manufacturers or insurers will ultimately respond to the MFN rules. 

Image Credits: WHO, PBS News, KFF .

While transmission eases in the original Ituri province hotspot, Ebola Bundibugyo virus continues to spread in many parts of the Democratic Republic of Congo.

The Ebola Bundibugyo virus outbreak is showing early signs of containment in the Ituri province in the northeastern part of the Democratic Republic of Congo (DRC), where it first surfaced in April. 

But in North Kivu province, to the south, cases are still rising fast, with weekly cases nearly doubling over the past two weeks, from about 100 to 200. 

Elsewhere, there are mixed signals, which make it difficult to define a single trend, said WHO Director-General Dr Tedros Adhanom Ghebreyesus and other senior WHO staff at a Geneva press conference on Wednesday. 

To date,  more than 7,200 cases have been reported, and over 3,500 deaths across seven DRC provinces.

“Although there are signs of reduced transmission in Ituri … in the past week alone, around 300 new cases and 160 deaths were reported, accounting for nearly half the national total,” Tedros said.   

WHO declared the outbreak a Public Health Emergency of International Concern in May. 

With regard to trends elsewhere, “the area is so vast that it’s hard to speak of a single epidemic,” Tedros noted, referring to DRC’s span, a country the size of western Europe. “It’s many outbreaks in many places. We must get the response right in every one of them. 

“There are major cities such as Kisangani, home to 1.5 million people, and remote villages,” he continued. “There are conflict-affected areas, mining zones, and sparsely populated lands near the border with South Sudan in a region of very high population mobility. 

“In many areas, roads are barely passable and reaching people by small aircraft is often hard. And while most Congolese people support the response, a small minority have attacked aid workers and health facilities.”

Urges approval of UN draft declaration on pandemics  

WHO Director General Dr Tedros Adhanom Ghebreyesus

Tedros urged WHO and UN member states to approve a draft resolution on Pandemic Prevention, Preparedness and Response, due to be considered at a High-Level Meeting of the UN General Assembly on 25 September, saying that the declaration could help move the world from the kind of ‘ad hoc’ actions that have been a feature of the Ebola response to more coherent measures.  

“The world remains insufficiently prepared,” the WHO head declared. “In the draft declaration, countries are committing to expand research and geographically diversified production, so vaccines, diagnostics, and treatments can be available, affordable, and accessible within the first 100 days of a pandemic threat.

“The draft declaration also calls for a one-health approach, inclusive community engagement, action against misinformation, stronger implementation of the [WHO] International Health Regulations,” Tedros added, referring to the rules that require countries to inform WHO promptly about any outbreak posing an epidemic risk, and coordinate its response.”

And it calls for timely completion of the Pathogen Access and Benefit-sharing (PABS) annex to the WHO pandemic agreement, “which member states are negotiating here in Geneva as we speak,” he said. “It’s essential that countries finalize negotiations so the Pandemic Agreement can begin the ratification process and enter into force.”

See related story here: 

‘Critical’ to Complete Pandemic Agreement by UN Meeting in 2026

Humanitarian crisis shadows outbreak challenges 

Kigonzi camp for internally displaced persons in Bunia, DRC on 2 June, one of the original virus hotspots.

The deep humanitarian crisis facing DRC continues to confound response to the Ebola outbreak in multiple dimensions, the WHO officials underlined.  The crisis is the result of years of fighting between the powerful, Rwanda-backed M-23 militia and government forces, leading to mass displacement and loss of livelihoods.  The conflict’s resurgence in late 2024 and January 2025 made things even worse. The M-23 forces took over large chunks of eastern Congo, including the regional capital of Goma, forcing a new wave of displacement from homes and farms.  

“Nearly a million people in Ituri alone are living in refugee camps, and then, together with that, there is hunger,” Tedros said. 

Amidst the rise in hunger and threats of insurgent forces, people are less likely to turn to health clinics, leading to more maternal and newborn deaths, as well as illness and death from other treatable conditions, like HIV, the WHO DG pointed out. 

The conflict has also led to simmering resentment in DRC, which has seen a massive response to the Ebola outbreak, while deeper, underlying problems are left to fester. 

Against that landscape, local communities have sometimes resented the visibly massive deployment of health workers, seeing it as a reflection of cynical self-interest by Western donors fearful of the virus’s international spread, rather than an effort to save local lives. Those attitudes are changing in light of the deadly toll the virus has taken, but ever so slowly.

Tedros observed: “Ebola is seen as a more serious, but lesser evil still” in comparison to issues like the loss of livelihoods.”  

Humanitarian groups have asked donors for some $1.1 billion to address the deeper roots of the DRC’s crisis, noted Chikwe Ihekweazu, Executive Director of WHO Health Emergencies Programme. 

That is along with a request for some $1.3 billion from donors for the Ebola response. Ihekweazu declined to say how much of those funds had actually been raised. 

Vaccine and therapeutic trials

DRC Minister of Health Dr Samuel-Roger Kamba, launches a vaccination campaign against Ebola virus disease in Kisangani, Tshopo Province.

Along with improved case reporting and contact tracing, at least in Ituri province, the past several weeks has seen the initial rollout of the ERVEBO Ebola vaccine among health workers. 

The vaccine, approved for the Zaire Ebola virus strain, is being administered in the context of observational trials to see if it also offers protection against Bundibugyo, for which no vaccine yet exists, said WHO’s Meg Doherty, director of the Department of Science for Health, at the press briefing.

“Already, in Kisangani more than 3,000 or so persons have been vaccinated,” Doherty said, adding that soon, Médecins Sans Frontières (MSF) is planning to launch a much larger study, involving some 20,000 frontline health workers. This study “will look at the vaccine’s impact on Bundibugyo disease, morbidity, mortality.”

Kisangani is the capital of DRC’s Tshopo province, just to the west of the hotspots in Ituri province. 

In parallel, a laboratory study of blood samples drawn from people who received the ERVEBO vaccine should also get underway in the coming two or three weeks, she said, led by the University of Antwerp and the DRC’s Institut National de Recherche Biomédicale (INRB). The study will attempt to determine if the antibodies generated against the Zaire Ebola strain can also provide cross-protection against the Bundibugyo virus strain. 

“Then, after that, we will be bringing in sequentially other vaccines that are specific for Bundibugyo and those are the ChAdOx1 and the Moderna vaccines that you’ve heard much about,” Doherty said. 

The ChAdOx1 vaccine candidate is being developed by the Oxford Vaccine Group in partnership with the Serum Institute of India, and is in Phase 1 trials. It utilises the same adenovirus platform that underpinned the Oxford/AstraZeneca COVID-19 vaccine, adapted to target a Bundibugyo virus protein. 

Moderna’s mRNA-1469 vaccine candidate uses mRNA technology deployed in the COVID pandemic to teach host cells to identify and target a Bundibugyo surface glycoprotein. Phase 1 trials of that vaccine were initiated in August in Canada, supported by funding from the Coalition for Epidemic Preparedness Innovations (CEPI).

In terms of deployment of the vaccine candidates in DRC field trials, Doherty did not provide a timeline.   

Image Credits: X/Tedros Adhanom Ghebreyesus, X/@DrTedros, DRC Health Ministry.

The proposed EU Kids Act aims to shield youth from algorithmic mental health risks by banning under-13 social media access.
The proposed EU Kids Act aims to shield youth from algorithmic mental health risks by banning under-13 social media access.

Social media will be banned for children under 13 across the European Union according to the newly proposed “EU Kids Act”, announced by European Commission President Ursula von der Leyen today (16 September) in Brussels. The sweeping digital health initiative mandates strict parental oversight for young teenagers aged 13 to under 15 across all 27 member states.

“It is not about our minors accessing social media. It is about when and how we allow social media to access minors,” said von der Leyen during her State of the Union address in the European Parliament.

A leaked Commission draft of the “EU Kids Act”, published online by the media group Euractiv, highlights how the proposed legislation would target escalating youth mental health crises linked to addictive platform architecture and excessive daily screen time. Recent Eurobarometer data indicates that European teenagers currently average 4.5 hours online on school days, triggering urgent public health concerns regarding sleep disruption, anxiety, and exposure to harmful algorithmic content.

If successful, the initiative would set a precedent as the first binding supranational agreement establishing unified digital health and age-restriction standards for minors.

Key measures in the EU Kids Act

Ursula von der Leyen announces the “EU Kids Act”.
Ursula von der Leyen announces the “EU Kids Act”.

The draft EU strategy specifically targets “Social Media+” platforms, video-sharing services, and conversational artificial intelligence companions that pose psychological risks to developing brains. Under the proposed framework, adolescents aged 13 to under 15 may only access guardian-supervised “mini-accounts” restricted to an explicit one-hour daily screen-time cap, default private settings, and limited contact lists.

Platform operators will be legally required to enforce safety-by-design standards by default including: eliminating infinite scrolling, push-notification triggers, and engagement-driven reward loops that exploit adolescent dopamine systems. The legislation also requires technology companies to scientifically demonstrate that their services are safe before deploying them to young users.

The European Commission proposal builds directly on recommendations from an EU expert panel, which urged Brussels to establish an EU-wide minimum digital age and shift the burden of proof onto technology companies.

The proposal comes after a major legal setback in France, where the Constitutional Council struck down a national social media ban for under-15s over constitutional rights concerns. It also follows a historic multi-billion dollar settlement in the United States between Meta and state attorneys general over claims that its platform features deliberately harm minors, and lead to their addiction.

Privacy safeguards and legal compromises

To address privacy concerns, the draft requires platforms to use an open-source EU age verification tool built on zero-knowledge cryptographic proofs, allowing users to verify their age threshold without disclosing their identity or exact birthdate. However, legal experts like Christiane Wendehorst from the University of Vienna warn that critical circumvention loopholes remain, as teenagers could easily bypass one-off checks by registering under the credentials of older siblings or friends.

While the EU Special Panel recommended a single access restriction below age 13 alongside more evolving autonomous use for older adolescents, the leaked Commission draft adopts a significantly stricter approach that extends mandatory parental oversight up to age 15. By opting for supervised “mini-accounts” rather than an outright ban, Brussels seeks to avoid the legal flaws of France’s national law, which was struck down for disproportionately restricting minors’ freedom of expression.

Furthermore, the Commission draft formalises the EU expert panel’s recommendation to shift the burden of proof regarding compliance onto platform operators, via administrative mechanisms. Platforms classified as “Very Large Online Platforms” under EU law must submit plans for public authority approval 30 days before rolling out any new service or feature, funded by an EU-wide supervisory fee on the operators.

Next steps in European lawmaking

The European Parliament and the Council of the EU act as co-legislators, negotiating the EU Kids Act's final binding rules.
The European Parliament and the Council of the EU act as co-legislators, negotiating the EU Kids Act’s final binding rules.

By pairing strict age-gated access with systemic design overhauls, European regulators also intend to set a standard for a binding international framework for child online health and safety, harmonizing rules across a now fragmented EU landscape.

“Europe has the power to act; it is we who decide our rules, not Big Tech,” said EU Commission President von der Leyen.

While the European Commission will formally table its proposal on Thursday, the ultimate fate of the “EU Kids Act” rests with the European Parliament and the EU Council, where parliamentarians and government ministers will have to negotiate over the final, binding rules. Within this legislative process, member states exercise decisive power through the Council, where qualified majority approval is required before any text can become binding law.

See related story:

Warning labels, Time restrictions? Experts Mull How to Curb Social Media Harms

Image Credits: Ron Lach via Pexels, EU/HPW.

The Global Fund has rolled out AI-powered TB screening, which reduces the time it takes to analyse chest X-rays from two days to just a few seconds.

Countries supported by the Global Fund put over a million more people on antiretroviral (ARV) treatment, sustained tuberculosis treatment and distributed 34 million more insecticide-treated mosquito nets in 2025 than the previous year.

In 2025, some 26.9 million people were on ARVs (compared to 25.6 million), 7.4 million people were treated for TB, and 196 million mosquito nets were distributed (up from 162 million), according to the Global Fund’s results report released on Wednesday.

This was despite enormous challenges caused by the slashing of global health aid after Donald Trump was sworn in as president of the United States in January 2025.

Executive director Peter Sands said that the fund “responded swiftly and flexibly to protect people and programmes hit hardest by funding cuts”, helping countries to “maximise the impact of the resources that were available”.

He cited the rollout of lenacapavir, the twice-yearly injection that prevents HIV, and expanded use of AI-enabled digital X-rays for TB screening as examples of more effective and innovative services.

However, Sands conceded that some countries “managed to weather the changes with remarkably little impact” while “others were much harder hit”, and that HIV prevention services “were hit hard by reductions in domestic and international funding”.

Dr Nkululeko Dube inspects the first batch of lenacapavir in his facility’s pharmacy in Eswatini.

Transition away from donor dependence

Sands said that the fund is “very closely engaged with countries” to achieve nationally financed health systems that are not dependent on external support.

The Global Fund is helping this transition by offering technical expertise, support to improve public financial management, co-financing incentives and pooled procurement.

When asked by Health Policy Watch whether the Global Fund was trying to assist in areas particularly targeted for defunding by the US, including “key populations” most at risk of HIV and South Africa, Sands affirmed support for both.

“We continue to focus our efforts on the people who are most at risk, and with HIV, that means key and vulnerable populations,” said Sands. “In South Africa, we have put particular effort on the rollout of lenacapavir, and see that as a crucial part of the broader strategy of reducing new infections in the country.”

“Key populations” vary from region to region, but usually include sex workers and men who have sex with men. The Trump administration has oriented its HIV support to preventing mother-to-child transmission.

Curbing malaria

Marcela and her baby under a mosquito net. Her home in Mozambique was destroyed by floods earlier this year, and two of her children contracted malaria while in a shelter.​ Climate change is increasing malaria.

Sands said that curbing malaria poses the most challenges, with the rise of people’s resistance to anti-malaria drugs and mosquitoes’ resistance to insecticide. 

The fund has expanded its distribution of mosquito nets treated with two insecticides, which are 45% more effective in the face of rising mosquito resistance. 

Compounding these challenges are conflicts in many of the countries most affected by malaria, and the impact of climate change. 

“The increasing frequency of extreme weather events often leads to upsurges in malaria,” said Sands.

“Demography is itself a challenge,” he added, explaining that many malaria-prevalent countries have “very rapidly growing populations”, which has resulted in reduced per capita health spending.

In the past year, there were 282 million malaria cases and 610,000 deaths, mainly among children under the age of five and pregnant women. 

“Malaria has a big mortality and morbidity impact on some of the very poorest communities in the world,” said Sands, and spending on the disease “is undoubtedly inadequate”.

“How do we get on the front foot and continue to drive progress on a disease that kills far too many young children, far too many pregnant women, and holds back economic and social development in so many of the poorest communities?”

Image Credits: Global Fund.

The campaign against female genital mutilation has been spearheaded by activists such as Rugiatu Neneh Turay-Koroma, head of Amazonian Initiative Movement (AIM) in Sierra Leone.

There have been documented decreases in female genital mutilation (FGM) rates in West Africa – declines not granted by governments, but fought for community by community by survivors, activists, and even former practitioners. 

In July 2025, that fight produced a landmark ruling: the ECOWAS Court of Justice found that Sierra Leone’s failure to protect girls from FGM met the legal threshold for torture.

We have just published a five-country report mapping the movements behind these victories. But we would be remiss not to point out that inside the decline, the practice is changing shape.

FGM is moving into clinics

Globally, UNFPA estimates that 230 million women and girls alive today have undergone some form of FGM.  UNICEF estimates that around 52 million of them, roughly one in four, were cut by health personnel.  

In Guinea, where prevalence remains near 95%, an estimated 15% of procedures are performed by health workers. In Nigeria, the figure is around 13%. 

Cutting also happens at younger ages. In The Gambia, the average age at which girls are cut has fallen from age four to just before age two, in the last three decades. Across the region, a trend is emerging: younger girls, clinical settings, sterile instruments, all giving the illusion of a legitimate, medically approved procedure.

The World Health Organisation (WHO) was alarmed enough to respond. Its 2025 guideline on preventing FGM recommends professional codes of conduct expressly prohibiting health workers from performing the practice, training to equip them as agents of prevention, and sensitive communication approaches to help them decline when families ask.

Those are the right tools. But they are supply-side, aimed at the hands that hold the instruments. They leave an important question unexplored. Why is there a demand side at all?

The percentage of women and girls aged 15-49 who have undergone some form of FGM in African countries where it is still practiced.

Why families practice FGM

If you’ve never lived in a community where FGM is practised, you’re probably wondering why parents even cut their daughters. That question assumes that the practice survives because of ignorance or indifference. 

That’s a limited, and implicitly Eurocentric, reading. The practice actually survives on the core values most humans hold about parental love. Those values just operate in a different set of beliefs about what protects a girl and what she requires to thrive.

Cultural belonging is not abstract. It is the difference between being embraced by your own people and being considered a stranger.

In the Sahiyo mini-documentary, Behind the Wall, Gambian activist Absa Samba recalls the popular girls at her primary school announcing they would only befriend girls who were pure and clean – meaning, girls who had been cut. 

Unsure of her own status, she went home and asked her mother. She was delighted to be informed that she had undergone FGM. Now confident in her in-group superiority, the next day she joined the popular girls in shaming the uncut.

Their taunt of choice was solima, a Mandinka slur for the uninitiated. “If you’re a solima”, one Gambian woman told Reuters during the 2024 FGM repeal debate, “people will tell you you smell bad; no one will eat the food you cook; no one will be your friend; no one will want you as a wife”. 

The initiation rites that accompany FGM mark a girl as marriageable, respectable and claimed. In Sierra Leone, for example, membership in the powerful women-led Bondo society is virtually impossible for the uncut. An uncut girl learns early what exclusion costs, and families are desperate to prevent their wards from paying that price.  

In many West African communities where FGM is practised, cutting isn’t viewed as an infringement on bodily autonomy but as an act of responsible parenting, securing a daughter’s future in the world. 

Campaigns against it are readily framed by pro-FGM advocates as Western judgement and overreach under the guise of child protection.

FGM is still performed on the majority of girls in several African countries, particularly Somalia, Djibouti, Guinea, Egypt and Eritrea.

Why medicalisation?

Why are they asking doctors and nurses instead of the traditional practitioners, known as ngansingbas, exciseuses and soweis? Belonging explains the ask. 

So why is that demand moving into hospitals? The standard answer is evasion. The belief is that a clinical face makes the practice harder to detect and prosecute. There is truth in that reading, but as clinicians and advocates, we think it misses something, and the miss matters. 

In many practising communities, FGM is understood as a health measure in its own right.  An uncut girl is believed to face itching, infection and poor genital hygiene, and FGM is seen as a way of keeping her clean and disease-free.

The same framing extends to the belief that labial/clitoral excision or “pruning” curbs unbridled sexual desire, and with it, the sexual exploitation, early pregnancy, and sexually transmitted infections that desire is blamed for.

These are not fringe views. When The Gambia’s Supreme Court heard the challenge to the country’s FGM ban last December, the lead plaintiff, Imam Abdoulie Fatty, testified that the practice is part of cleanliness in Islam.

In a 2019 Egyptian study, mothers and even physicians suggested that clinical cutting was the responsible way to protect a girl from the dangers uncut genitalia are believed to carry. To societies holding these beliefs, FGM is not viewed as a violation. It is seen as a form of preventative care, a momentary discomfort endured for longer-term benefit, in the same vein as vaccination or deworming.

What if anti-FGM messaging (sort of) worked?

FGM cutting tools relinquished by soweis in Masimra Chiefdom in Sierra Leone.

It is into these communities, with an existing framework of FGM as healthcare, that decades of anti-FGM messaging were unleashed. It led with the dangers of the blade and the bush. The focus was on unsterile instruments, re-used razors, dirt floors and infection. Parents who love their daughters listened. They didn’t want their children cut with the same razor that had been used on ten other girls.

They didn’t ignore the harm-based messaging; they acted on it. By modifying their existing belief that cutting itself is protection into a new one: that it is only cutting as it is traditionally performed that endangers girls. 

Qualitative research in Nigeria found that parents chose health workers because they considered them more hygienic, skilled, and able to manage emergencies, while some providers presented medicalised cutting as a way to avert serious complications. 

Studies in Guinea and The Gambia likewise found health workers themselves describing medicalisation as safer than cutting by traditional practitioners. 

They heard ‘do it safely’

A former sowei in Sierra Leone receiving a certificate for handing over her cutting tools in Masimra Chiefdom.

We got the point but missed the mark. It is clear that somewhere in the decades of campaigning, the core of the matter got muddied. FGM’s cruelty is in the cutting of healthy tissue from a person who did not consent, with physical, sexual and psychological consequences that no sterile environment prevents. 

It is in the gender-based violence of denying women a say in what happens to their bodies and refusing them societal acceptance because they have not participated in a “cultural norm.” 

It is in the patriarchal control underpinning the entire system, so total that women and girls are socialised to barter pleasure for honour but are ultimately denied both. A clinic changes none of this. 

But to FGM-practising communities, updating what has already been marketed as a beneficial hygienic practice into a more sanitary environment is a logical conclusion. The clinic appears to remove infection risks. It shields the family’s privacy from what they perceive to be legal overreach, and it still fulfils the cultural obligation. 

Urbanisation, provider income, health workers drawn from practising communities, and the search for legal cover, also drive medicalisation. But it is a reading that the evidence permits, and more importantly, it is one with consequences for how we work.

What if medicalisation is less a story of communities evading our message than of communities internalising a message that we as anti-FGM advocates failed to phrase fully?

That reading may be uncomfortable for those of us who have spent years crafting these campaigns. But it is also strangely hopeful. If parents have shown they respond to messages about harm, then our task is to clarify what we’re cautioning against.

Torture: Name the brutality 

Health ministries, professional bodies and advocates should stop leading with the dangers of unsafe conditions and start leading with the damage of the cutting itself, in the terms the ECOWAS Court has now made available: FGM is a violation of a girl’s bodily integrity that meets the threshold for torture. 

That holds regardless of who holds the instrument, whether it is a sterilised stainless steel scalpel or a 600-franc razor, and whether the girl is sedated in a hospital bed in Conakry or pinned down on the mud floor of a hut in Kindia. 

Health professionals must frame FGM not as a misunderstood traditional practice that can be refined but as an act of brutality, akin to amputating a perfectly healthy limb. A request in such stark opposition to the Hippocratic Oath that no clinician can ethically perform it.

It’s the cutting, not the setting  

Communities need to understand that no venue sanitises FGM. This is a position on which the WHO and every serious medical authority is unequivocal. Clinicians and the WHO have warned that medicalised procedures may involve deeper or more extensive excision than traditional cutting. Trained hands with proper instruments, working on a child who is anaesthetised rather than struggling, can remove more healthy tissue than traditional cutters.

The evidence here is still thin, resting largely on clinical observation rather than comparative study, and this gap itself deserves research funding. But the outcome is not in doubt: the more healthy tissue removed, the worse the long-term sexual and reproductive consequences, and the less there is for reconstructive surgery to work with.

Medicalisation also carries a danger beyond the procedure room, one the WHO has warned of since 1997. The credibility of health systems normalises FGM. It entrenches the practice by appearing to legitimise it. 

Every clinician who cuts lends the white coat’s authority to the idea that FGM is a health service. For families who already conflate circumcision with care, that authority reads as confirmation. That is a threat to girls and the standing of the profession.

Professional misconduct

Medical and dental councils, nursing and midwifery boards and the bodies that license private clinics across West Africa should issue explicit, written directives to every professional on their registers. 

They should say that performing, assisting with, referring for or supervising any form of FGM, including re-infibulation, is professional misconduct, regardless of the family’s request or the setting. 

The consequences should be stated in advance and applied fully, such as suspension on first report, removal from the register on proof, loss of the facility’s operating licence where a clinic has permitted it, and automatic referral to the police where national law criminalises the practice. 

Regional bodies such as the West African Health Organisation and the West African College of Physicians should ask their member councils to adopt a common standard, so that a practitioner struck off in one country cannot simply re-register in the next. The message to the profession must be as unambiguous as the message we are asking the profession to deliver to families.

Equip health workers as messengers

Health workers are trusted by patients and can be trained to advocate against FGM.

In a trial across Kenya, Guinea and Somalia, patients of health workers trained in person-centred communication on FGM became significantly more opposed to the practice, and were more likely to say they would not cut their daughters, than patients of untrained colleagues.

This tells us that we might have found new messengers in a more effective medium. Think about it. The anti-FGM message arrived in FGM-practising communities on radio, on billboards, emblazoned across T-shirts at protest marches. However necessary its intent, it was perceived as uninvited and unsolicited. 

Doctors and nurses, approached for clinical cutting, hold a different position entirely. They do not knock on a family’s door. The family comes to them, request in hand. Often themselves respected members of FGM-practising communities, they are being invited into the very conversation campaigners have spent years trying to start. 

The WHO’s sensitive communication guidance recognises this opportunity when it asks health workers to decline the request for FGM and explain its risks. 

The instinct is right, but it courts a familiar trap. A catalogue of risks is easily misheard. These families are at the hospital precisely because they believe risk is best managed by clinicians. 

So equip health workers to speak less about risk, which can be mitigated, and more about harm, which parents have a duty to prevent. 

Train them to say that cutting causes the very problems it claims to prevent, from infections to sexual dysfunction to complications during childbirth; that their medical training cannot erase the physical and psychological trauma of FGM; and that an uncut girl is already clean, healthy and equipped to thrive. 

Use the authority of the white coat not simply to “do no harm” but to deter others from it.

Test the messaging

Road sign warning against FGM near Kapchorwa in Uganda.

Medicalisation didn’t emerge in a vacuum, and it won’t recede in one either. The WHO’s guidelines concede that the effect of health-sector interventions on medicalisation is an open research gap. 

Why don’t we widen the frame? We have barely studied how anti-FGM messages are actually metabolised inside communities, and what alternatives to cutting best satisfy the cultural belonging need. 

Those are not two gaps but one, and funders should resource them in tandem. This will only happen when they  stop pigeonholing FGM as a niche African practice that can be modernised and urbanised away, and start seeking to understand it with the same nuance and depth they give to other forms of gender-based violence. Because that is what it is.

The transnational movement to end FGM across West Africa has shown that rates can decline. Medicalisation shows us where the next front is. It was never about the bush or the blade but the violence.

Famia Nkansa is the communications lead for Purposeful, an Africa-rooted global hub for girls’ organising and activism.

Dr Bintu Mansaray is executive director of the Institute of Gender and Children’s Health Research in Sierra Leone.

Dr Frances Wurie is an obstetrician-gynaecologist at The Woman’s Place in Sierra Leone.

 

Image Credits: Thomas Triebel, UNFPA, UNFPA, Rugiatu Neneh Kamara/ Amazonian Initiative Movement , Rugiatu Neneh Kamara/ Amazonian Initiative Movement, IFPMA, Amnon Shavit / Wikimedia Commons.

Guyana, speaking for the Caribbean states of Bahamas, Barbados, Dominica and Belize.

Contracts, contracts, contracts. Virtually all the regional blocs that addressed the start of the eighth round of the pandemic agreement talks on Monday stressed that any pathogen access and benefit-sharing (PABS) system needs to include standard contracts with pharmaceutical manufacturers.

These would set out the terms of accessing dangerous pathogens, as well as how to share any “benefits” – vaccines, therapeutics and diagnostics – that were developed from this knowledge.

However, the powerful European Union (EU), which did not address the opening session, opposes such contracts and what its chief negotiator, Ambassador Americo Zampetti, has described as a “transactional approach” to the PABS negotiations.

The PABS annex is the last outstanding piece of Pandemic Agreement, adopted by the World Health Assembly in May 2025, holding up the agreement’s adoption.

The World Health Organization’s (WHO) African Region, Group of Equity, Eastern Mediterranean Region (EMRO), and South East Asia Region (SEARO) all spoke of the need for “legal certainty” that such contracts will ensure.

“Benefit sharing should be predictable, timely, and effective during a pandemic, without relying on ad hoc negotiations at a moment when certainty and solidarity are most needed,” said Guyana, speaking for the Caribbean states of Bahamas, Barbados, Dominica and Belize.

“Standardised PABS contracts should provide the legal foundation for the system. They should establish transparent, enforceable, and consistent obligations throughout the PABS chain, while ensuring that the use of PABS material and sequence information generates meaningful benefits for all countries, regardless of size or economic capacity.”

Pakistan’s Adeel Mumtaz Khokhar, speaking for EMRO.

Pakistan’s Adeel Mumtaz Khokhar, speaking for EMRO, reinforced this: “Replacing the link between access and benefit sharing with voluntary contributions or goodwill assistance cannot be the way forward. In this regard, legal certainty for both providers and users of PABS materials and DSI [data sequence information] can only be achieved through legally binding contracts.”

Nepal, representing SEARO, said that while state parties “are expected to make an obligation to share PABS materials and sequence information rapidly and timely, the system must ensure that this contribution is met with meaningful, equitable, and predictable benefit sharing, firmly anchored in legal certainty”.

It added that “to operationalise this, we support clear, predictable, and legally binding contractual arrangements”. 

Indonesia, speaking for an alliance of developing countries known as the Group of Equity, said that the obligations of both access-sharing and benefit-sharing should be clear.

“What comes back from the sharing of pathogens should be just as clear and agreed beforehand [as terms of access]. 

“We know this has sometimes been described as a transactional approach, but we would put it differently. There is nothing unusual about wanting to know what each side has committed to, and that is what makes the system fair and workable for all of us.”

Nepal, speaking for SEARO.

Algeria, speaking for the 47-member African region plus Egypt, Somalia and Sudan (part of EMRO), did not explicitly mention contracts but rather stressed the “legal certainty required by [the Pandemic Agreement’s] Article 12.5, paragraph B, on which providers, researchers, and manufacturers equally depend”. 

This paragraph specifies that the PABS system must establish clear “modalities, terms and conditions on access and benefit sharing that provide legal certainty.”

‘Federated’ or ‘hybrid’?

The Africa Group champions a “federated model”, where regional nodes retain sovereign control over the biological data of pathogens, and pharmaceutical manufacturers are required to sign binding benefit contracts with the WHO before they get access to the data.

Conversely, the European Union advocates a “hybrid model” featuring multi-tiered pathways and open databases to enable fast access to pathogen information. 

Arguing for the “federated” approach, Namibia told the opening of the Intergovernmental Working Group (IGWG) that Europe’s Genomic Data Infrastructure (GDI) project was based on countries retaining sovereignty over pathogen information.

Some €40 million has been invested in the GDI over the past four years, uniting 70 institutes across 24 European countries. 

“This is the design of a federated model, where the data is held at national level,” said Namibia’s Taime Sylvester. 

“Its aggregated and non-sensitive information is openly discoverable through a federated query system, with controlled access guaranteed to approved users in both public and the private sectors,” said Sylvester.

“We are not asking to build something new. We are asking that this meeting of IGWG8 begins from what already exists.” 

Algeria, speaking for the African region, Egypt, Somalia and Sudan.

Algeria repeated Africa’s proposal, describing it as a “federated model as the architecture for the [PABS] system as a whole: sovereign national nodes, common rules for all, a shared index, access on agreed terms, and obligations that travel with the material and the information”. 

“We did not conceive this architecture in isolation. Federated systems are today the operating choice of several public genomic and health data infrastructures. What we propose is therefore not a regional approach, but a common solution applicable to all parties on the same terms, in which international cooperation strengthens the sovereign rights of states.”

Downstream obligations

However, several non-state observers of the talks support a more pragmatic approach, involving more open access to pathogen information with strings attached to any commercial products developed as a result when they are ready for sale.

Championing this approach is Knowledge Ecology International (KEI), which proposes that manufacturers obtain contracts with the WHO, “not as a condition of having access to PABS materials and digital sequences, but as a condition of registering and selling products” to address pandemics or public health emergencies of international concern (PHEIC).

Supporting KEI’s position was Medicines Law and Policy’s Ellen ‘t Hoen, who asked the IGWG opening whether member states would engage with the proposal – with co-chair Ambassador Tovar Nunes Da Silva assuring her that they would.

CEPI proposes that developers should only meet the full PABS obligations “downstream upon reaching defined commercialisation thresholds or triggers”.

The Coalition for Epidemic Preparedness Innovations (CEPI) stressed that the success of PABS “depends on investment in de-risking R&D, so that authorised manufacturable products can reach people quickly”.

It proposed two “complementary mechanisms” to facilitate R&D: “an R&D safe harbour and an equivalency mechanism”.

The “safe harbour” would provide developers with a “low-friction pathway” to access pathogen materials without negotiating “the full PABS benefit-sharing package at the point of access”. 

Like KEI, CEPI proposes that developers should only meet full PABS obligations “downstream upon reaching defined commercialisation thresholds or triggers”. 

Meanwhile, “equivalency” would enable “qualifying commitments [to be] made through accredited R&D funders”, and these would count towards corresponding PABS benefit sharing obligations. 

“Where an accredited funder’s equitable access framework already meets agreed PABS standards, a developer’s compliance with that framework would be recognised as satisfying corresponding PABS obligations”. 

These two proposals would provide greater legal certainty and a more predictable pathway from upstream R&D to full PABS compliance, while reducing duplication, transaction burden, and compliance cost”, argues CEPI. 

Industry rejects ‘contractual requirements’

The International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) urged negotiators to “focus on practical, open, and workable mechanisms that strengthen preparedness and accelerate scientific collaboration between public and private researchers”.

It called for a PABS system that preserves “open, de-linked access, interoperability with existing databases and laboratory networks, and multiple pathways for accessing pathogens and sequence information”. 

“Contractual requirements, restrictive access conditions, or burdensome compliance measures introduced as a precondition for research risk creating delays precisely when speed matters most,” the IFPMA’s Grega Kumer told IGWG 8.

Warning of a shortage of funds for R&D, Kumer stressed: “PABS alone will not generate vaccines, therapeutics, or diagnostics. A system that introduces legal uncertainty, increases costs, duplicative obligations, or administrative burdens risks creating friction without addressing the underlying causes of access gaps.”

Top leadership present

Several countries sent their top diplomats to the opening of the Geneva talks, signalling their seriousness. This included new ambassadors to the UN in Geneva, Ireland’s Laurence Simms and South Africa’s Zaheer Laher, as well as the EU’s Zampetti.

France’s Ambassador Anne Claire Amprou, former chair of the Intergovernmental Negotiating Body (INB) that negotiated the Pandemic Agreement, was also present, as was her counterpart, Precious Matsoso, who is now part of the South African delegation.

Hygienists at the Rwampara Ebola Treatment Centre put on their personal protective equipment (PPE) in the isolation area before entering the centre.

The lethality of the Ebola outbreak in the Democratic Republic of Congo (DRC) is not just in its genome. Neither is it entirely explained by the country’s internal instability and defunded, broken health infrastructure. Have we allowed the virus to outsmart us by overlooking past lessons?

The signs around the DRC’s 17th Ebola outbreak indicate that it has reached the dimensions of a Shakespearean tragedy. If the Global Preparedness Monitoring Board, set up after the great West African epidemic of 2014-16, sends the Bard on a review mission, his back –to –office report may well conclude, as in Julius Caesar: “The fault, dear [Tedros], is not in our stars/ But in ourselves, that we are underlings.”

The limits to blaming

In a nutshell, that is what vexes this columnist: How much of Ebola getting out of control is because of DRC’s “stars” or self –induced troubles from its chaotic scramble for gold and guns with associated population movements, violence and broken health infrastructure?

And how much is it the failure of factors such as our global health structures, or the country’s dependence on donations, with decisions and directions from Geneva and Addis Ababa?

I interrogated publicly available data and found that a systematic analysis of the relative contributions of different factors is impossible. 

A study of the 2018–19 North Kivu epidemic indicated significant conflict–related disruptions of public health interventions. These are suggestive but largely modelling –based qualitative judgments. 

Meanwhile, other researchers found no significant short –term correlation between pathogen reproduction numbers and conflict counts, and only a modest correlation across the whole outbreak.

Every rookie epidemiologist knows that correlation does not prove causation. Meanwhile, the closest estimate of the fraction of an outbreak attributable to conflict is 12% for DRC cholera outbreaks. This is not comparable to Ebola but a smaller proportion than most commentators guess.

Frustrated by my ambiguous delving into a region the difficulties of which I know well from previous terrible times, I turned to the latest large language models set to their “highest level of effort”. Whatever the fear of AI wiping out humanity, it still could not give me a hallucination–free answer.  

There is inconclusive evidence to blame conflict and instability for the majority of the Ebola response underperformance in DRC. 

There is a stronger case for aid–defunded health systems bearing some responsibility, but combining these constraints is still not enough to explain a massive collective failure. Besides, other experiences show that we have done better in other places facing similar or worse challenges.

Flashing signals

WHO Director-General Dr Tedros Adhanom Ghebreyesus visiting the epicentre of the Bundibugyo outbreak in the DRC’s Ituri province.

Understanding why DRC’s Ebola outbreak continues to outpace control requires reverting to fundamentals, starting with the earliest signals.

These emanated when four health workers died over four days in April in Mongbwalu, a gold–rush town in Ituri. A short serial interval cluster is the classic sentinel signal for a viral haemorrhagic fever. This is not to be confused with malaria, typhoid and yellow fever  – all endemic in Ituri – but which predominantly kill patients and not their healthcare attendants. A cluster of staff deaths discriminates in a way that a cluster of community deaths does not, even if other common conditions are early mimics of Ebola.

Did complacent confidence in DRC’s extensive Ebola experience mean missing the oldest signal in filovirus epidemiology – the tell at outbreaks in Yambuku (1976), Kikwit (1995), and Gulu (2000)? 

When the alert reached Geneva on 5 May 2026, it did not immediately disturb anyone’s sleep. Why not? Reading signals is as much art as science, involving intuition honed by experience and not just following protocols. Did weaknesses in the emergency function in WHO Geneva and its regional and country offices in Brazzaville and Kinshasa, and the Pandemic and Epidemic Intelligence Hub in Berlin, forget this?

Or was this a case of crossed wires over too many switchboards? There is indication for this, with one analysis suggesting that the problem was not in signal availability  – including from ProMED, HealthMap and WHO’s own EIOS feeds – but in integrating concurrent multi–source signals into a unified decision product at the required speed.

 This enjoins humble circumspection before blaming donor aid cuts that halved global health assistance since 2021 and took a quarter off sub-Saharan Africa’s share in one year. 

Largest late detection

Although there is evidence that background disease surveillance was politically easier to abandon, the eastern DRC system limped along, to the credit of its underpaid and violence–threatened staff. They did produce the earliest signals missed on distant radars.

 It was not till 15 May that DRC declared the outbreak, and Africa Centres for Disease Control and Prevention followed three days later. With 246 suspected cases and 80 deaths, that was five times the size of the West African epidemic at its March 2014 announcement. 

Reported cases and deaths at the 16-week mark compared with previous Ebola outbreaks. The current epidemic dwarfs all others in recorded history, sitting at 6.5× more cases and 5.0× more deaths than the next-highest comparator at the same point.

Meanwhile, phylodynamic reconstruction suggests sustained transmission beginning around 22 February – and perhaps earlier still. This makes the current outbreak the largest late detection in the history of Ebola. It appears that the lesson on tardiness learnt from West Africa was unlearned.

With this outbreak passing 1,000 confirmed cases within 40 days of response activation, compared to the 2018 DRC outbreak taking 235 days to reach this milestone, fatal momentum was inevitable. 

Part of the confirmation delay was indeed due to reagents in Bunia’s laboratory being geared for the Ebola Zaire species. This was the Bundibugyo species produced false initial reassurance while infections multiplied undetected. Bundibugyo was first identified in 2007, but 19 years and three outbreaks later, there are no bedside tests, vaccines, or therapeutics because it historically killed the fewest people. 

And so it attracted the least funding, the unlearnt lesson being that closing preparedness gaps requires proactive investment in medical countermeasures because markets will not do that. This is further evident in current trials of oral prophylaxis restricted to those over the age of 12, pending a paediatric formulation, although children under five have twice the mortality of adults. 

Nevertheless, one lesson fully learnt was in Dr Tedros’s speedy declaration of a Public Health Emergency of International Concern (PHEIC) on 17 May, without awaiting his full advisory committee to opine. What is the subsequent impact?

Dashboard indications

Data through 10 September show 7,022 confirmed cases, 3,398 deaths, 823 in isolation, and 1,647 recoveries across seven provinces. The crude case fatality ratio (CFR) of 48.4%, up from 39% in July and 29% in June, does not signify a virus growing crueller. Sequencing of 626 genomes found increasing diversity but no fitness–altering mutations (as yet) from a lineage already distinct when it emerged.

The CFR is a proxy for system functioning and indicates how responses must be tailored to correct gaps. For example, North Kivu’s reported fatality ratio of around 66% contrasts with Ituri’s 45%, reflecting, in part, that Ituri finds the living and North Kivu mostly finds the dead.

A fixation with counting the dead does not help the living. Illuminating here are the US CDC’s five critical public health response indicators: case detection alerts, contact tracing, laboratory testing, isolation of infected persons, and safe and dignified burials. Their set targets are modelled toward progressive outbreak elimination. 

The latest operational scorecard is unsparing. Against a target of 20 contacts to be identified per case, the response managed 10.6. Against a target that 90%of new cases come from known contacts, the last available figure was 15-20%. Testing reached 72% of validated alerts against a 90% target. 

Fewer than half of affected health zones have a safe burial team. Contact follow-up has, however, crept to 85 % and is approaching the 95% needed.

In short, there are glimmers of progress with the outbreak’s uncontrolled expansion phase moderating towards end August to, perhaps, start plateauing. But it is still expanding geographically nearly seven months from its probable initial origins.

Seeking hope in effort

DRC healthworkers wearing PPE to protect themselves against Ebola.

None of this is a failure of effort. WHO has shipped over 330 tonnes of supplies, deployed more than 300 experts, and expanded laboratory capacity from one national reference facility to a network of 24. 

Nearly 1,400 treatment beds stand across 59 centres. I can vouch, as a former WHO director for emergency response, that this is among the fastest of WHO scale–ups, and certainly better than the embarrassing WHO show during the early days of the West African epidemic. Tedros’s own trips to the region were welcome morale boosters.

However hard the response runs now, it cannot make up for early shortcomings that saw a headquarters – demoralised by its own downsizing from aid cuts – sending disordered messages across rigid hierarchies and processes (a longstanding WHO problem), and despatching inexperienced initial staff to the field. 

An egregious illustration of this is that although a public health emergency of international concern (PHEIC) declaration requires operational delineation to be done, this does not appear to have happened between the Geneva–based emergencies programme and the African regional office in Brazzaville. However, commendably, the Kinshasa country office, which is perhaps its most emergency–burdened, was quickly bolstered. 

Meanwhile, the Bundibugyo virus made good use of unresolved answers to the oldest question in crisis health management. This is about whether emergency responses to existential threats of the nature of Ebola are best served by top-down command, and control arrangements or ground-level distribute–and–share partnerships. 

The self-evident metric for assessing the effectiveness of organisational approaches is achieving disease control quickly to minimise avoidable mortality and morbidity.

The conundrum of models

This was not an issue in WHO’s earliest years because of prevailing low levels of global development. But it increasingly torments the organization now. It is odd that an effective solution has eluded all Directors–General, largely because the evidence-proud but constitutionally constrained WHO has never evaluated different organisational models. 

This is for political reasons, which Africa brings to the fore because of the continent’s strident sovereignty movement demanding African solutions for African problems. 

That legitimate aspiration is somewhat hollowed by insufficient investment in necessary continental capacities. In any case, these take time to mature, and the popular delusion that great crises are opportunities to change and grow is patently dangerous when massive numbers of lives are at stake.

Nevertheless, who can dispute the excellent ideal of “One WHO” with its notion of one results framework, one budget, one harmonised workforce, and common administrative processes? 

The reality is more human, with reviews showing that where this works, it is because of cordial, cooperative personalities that override underlying mistrust and misaligned incentives and cultures. In other words, going beyond the bureaucratic matrix division of duties and responsibilities such as the post 2016 Emergency Response Framework.

Dr. Samuel Roger Kamba, Minister of Public Health, Hygiene and Social Welfare, visited the Ebola Treatment Center at the Bunia General Reference Hospital to inaugurate the new facilities built as part of efforts to strengthen patient care for those affected by the Ebola virus disease.

The key learning is that no organisation can sustain itself solely on the basis of personalities because these come and go. That applies particularly to the emergencies function where collective accountability under the “One WHO” approach could mean that there is none. That is the worry in the current case.

Meanwhile, my rough-and-ready review produces some organisational insights. Principally from three inquiries: WHO’s own 2015 Ebola Interim Assessment Panel, the UN’s 2016 High–level Panel, and the 2015 Harvard–LSHTM Independent Panel. 

They located West African response failures in the space between different WHO levels rather than exclusively in any one of them. A synthesis review concluded that post-2014 reforms did not achieve the necessary evolution in WHO and global health structure and governance that the West Africa debacle called for.

I think that is too harsh, as many capacity improvements have come about since then. But, as we shall see in the forthcoming Part II of this review, those may be drowning under the weight of complexities that the reforms have also introduced.

Regardless of these debates, current Ebola response directors would do well to consult previous learnings. WHO is no exception to the general lack of institutional memory among international bodies or free from the attitude to which every high–flier succumbs: to drive on regardless of the view in the rear-view mirror. And so, cycles of errors and oversights can repeat.

Legacies and inheritances

This should concern those seeking to be the next Director General. In less than a year, one of them inherits an outbreak that will, at best, have slowed down. Even that containment cannot be taken for granted as the virus appears to be getting closer to densely populated Kinshasa. 

Although Uganda – with relatively good health systems  – has succeeded in stemming domestic spread from imported cases and Rwanda remains firmly vigilant, fragile Central African Republic and South Sudan are most vulnerable as DRC cases creep closer to their borders. The next DG could, therefore, be faced not only with an urbanised DRC outbreak but a regional epidemic.

Reason enough for the current DG, four months into the ongoing response, to commission an independent real–time evaluation to suggest immediate improvements and enhancements.

Objective real-time scrutiny is an established good practice in major humanitarian operations. WHO already has its Intra –Action Review methodology, part of the IHR Monitoring and Evaluation Framework, developed and used during Covid.

This column has focused on WHO but the unfolding Ebola story is bigger than one agency. And so, a follow–on column will examine the wider regional and international response, including Africa CDC, the UN, operational partners and emerging issues of financing and co–ordination. 

Meanwhile, our global health leaders gather in New York on 25 September for the second High-Level Meeting on pandemic preparedness, under the banner of equity and solidarity. Shakespeare offers them advice via The Tragedy of King Lear: 

Poor naked wretches, wheresoe’er you are,
That bide the pelting of this pitiless storm…
O, I have ta’en
Too little care of this! Take physic, pomp;
Expose thyself to feel what wretches feel,
That thou mayst shake the superflux to them,
And show the heavens more just.

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: Anicet Kimonyo, X/Tedros Adhanom Ghebreyesus, X/Tedros Adhanom Ghebreyesus, DRC Department of Health.