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.

EU negotiator Americo Zampetti warns that ideological polarization over pathogen access threatens to derail the WHO Pandemic Agreement.
EU negotiator Americo Zampetti warns that ideological polarisation over pathogen access threatens to derail the WHO Pandemic Agreement.

EU negotiator Americo Zampetti warns that ideological polarisation over pathogen access threatens to derail the WHO Pandemic Agreement.

On the eve of the eighth round of talks on an annex to the Pandemic Agreement, the European Union’s (EU) chief negotiator has warned that “ideology” is blocking consensus.

Negotiators meet at the Intergovernmental Working Group (IGWG) at the World Health Organization (WHO) headquarters in Geneva from 14-18 September to thrash out the pathogen access and benefit sharing (PABS) system. 

But little progress has been made over the past year on PABS – or during the four years of talks on the Pandemic Agreement that preceded these talks.

The deadlock is between two camps represented by the EU on the one hand, and an alliance of the African region and Group of Equity countries on the other.

“We are in a world which is very polarised across this particular issue,” Americo Zampetti, Minister Counsellor for Global Health at the EU Delegation to the United Nations, told a recent European Parliament subcommittee briefing this week (7 September).

“The whole agreement, let’s say the mother agreement, is kept hostage by this annex which is very, for lack of a better word, ideologically driven,” Zampetti added.

European Parliament public health lawmakers debate the deadlock surrounding WHO Pandemic Agreement pathogen-sharing negotiations on 7 September.
Members of the European Parliament debate the deadlock surrounding WHO Pandemic Agreement pathogen-sharing negotiations on 7 September.

Other negotiation observers, including Knowledge Ecology International (KEI) and global health academics, have also urged parties to find a more pragmatic solution to the standoff.

Member states must finalise the PABS annex before the Pandemic Agreement, adopted by the World Health Assembly in May 2025, can be opened for member state ratification.

Groundbreaking clauses included in the Pandemic Agreement – including that manufacturers donate a minimum of 10% of medical countermeasures during pandemics and public health emergencies of international concern (PHEIC), and reserve a further 10% for the WHO at cost – cannot be implemented unless the PABS talks succeed. 

Meanwhile, the world’s fastest Ebola outbreak is unfolding in the Democratic Republic of Congo, mpox has re-emerged, and rapid climate change is heightening the risk of epidemics and pandemics.

Two camps

The PABS system will regulate how information about dangerous pathogens should be shared (access), and how the medical products developed from this information (the benefits) are shared.

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.

This model aims to prevent a repeat of COVID-19 era inequities, where Global South countries rapidly shared pathogen samples but were last in line to receive vaccines and therapeutics. 

By maintaining sovereign data control and requiring binding PABS contracts upfront, developing countries want to ensure that commitments, such as real-time vaccine allocations and technology transfers, are legally secured.

In December 2025, over 80 developing nations – led by the Africa Group and the 33-country Group for Equity – also submitted standard draft contracts to bind pathogen access directly to enforceable benefit-sharing obligations at the IGWG negotiations.

‘Transactional approach’

These nations want manufacturers to pay a subscription to be part of a PABS system,  alongside mandatory technology transfers and non-exclusive licences for pandemic-related vaccines, treatments and diagnostics.

“This transactional approach seems to us very unsuited to get to good results,” said Zampetti. “We need to have common sense prevail.”

Conversely, the European Union advocates a “hybrid model” featuring multi-tiered pathways and open databases. Under this framework, pharmaceutical manufacturers sign private contracts with the WHO, committing at least 10% of real-time production for vaccines, therapeutics and diagnostics during emergencies.

EU negotiators also want to exclude intellectual property rules from the annex, while developing countries insist that benefit-sharing must cover downstream scientific derivatives to prevent commercial developers from circumventing obligations.

While EU officials portray their proposal as the pragmatic option, developing countries argue that non-exclusive pathways risk undermining mandatory benefit-sharing. 

Under open-access systems, provider states lose legal leverage as soon as raw genetic data is downloaded, allowing commercial developers to create products without guaranteeing fair access.

Despite the friction, both competing models share a common technical foundation, based on a WHO Coordinated Laboratory Network for physical samples, WHO-recognised sequence databases, and Unique Persistent Identifiers to ensure end-to-end traceability of pathogen resources.

NGO offers way forward

Knowledge Ecology International director Jamie Love addressing an open session on the Pandemic Agreement.

In a brief issued this week, KEI director Jamie Love writes that a “quid pro quo [approach], linking access to the pathogen samples and digital sequences to equity provisions, has known flaws”.

These flaws include that researchers won’t always need PABS to get access to pathogens or their genomic sequences. And when they don’t, “companies will have little or no incentive to be legally bound to the concessionary sharing of production”.

Love also points out that many countries have already signed agreements to share pathogens outside of PABS, a reference to the terms of bilateral agreements that the United States is pursuing with countries that exchange US support for health programmes for rapid access to pathogen information from outbreaks – with no strings attached.

Love also highlights that attaching too many conditions to access to pathogen information will slow down the response.

Finally, he argues: “With the rise of AI, proving that a specific, locally identified pathogen sequence contributed deterministically to an AI-generated candidate immunogen or small molecule remains technically intractable”.

Instead, KEI argues that countries should ensure 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).

Danger of bilateral agreements 

Kenyan Cabinet Secretary Musalia Mudavadi and US Secretary of State Marco Rubio sign the first bilateral agreement in terms of the America First Global Health Policy, in which the US offers health aid in exchange for access to pathogen information.

Meanwhile, academics writing in a recent commentary in The Lancet warn that the delay in reaching agreement is enabling the bilateral agreements to “bypass multilateral systems operationally but also reduce reliance on collectively negotiated multilateral frameworks, such as the Pandemic Agreement”.

This could weaken the collective bargaining power of low-income and middle-income countries, they warn.

“For PABS to remain politically viable, WHO member states might need to show greater flexibility, responsiveness, and willingness to negotiate workable compromises capable of addressing longstanding concerns surrounding equity, manufacturing capacity, technology transfer, and reciprocal benefit sharing,” they argue.

Zampetti also warned against applying principles from the 1992 UN Convention on Biological Diversity (CBD) to pathogen sharing.

The 1992 Convention established national sovereignty over genetic resources, requiring commercial operators to share benefits with provider states. Developing countries insist that CBD-style reciprocity is essential to prevent rich states from monopolising resulting treatments.

However, Zampetti contends that treating lethal pathogens as sovereign assets under these rules creates rigid barriers that hinder emergency response.

“This is a template which is very much unsuited for pathogens,” he said. “Pathogens are not something that you want to conserve.”

The World Health Assembly extended the negotiation timeline to next year’s WHA in May, but progress has been incredibly slow.

“We just need to try to bring it to a conclusion on something that is reasonable,” said Zampetti.

Image Credits: European Union/HPW.

9/11 Lower manhattan Children's health
Smoke continues to rise from Ground Zero following the attack on the World Trade Center in lower Manhattan.

A new CDC research center aims to better understand the possible health effects of those 21 years or younger at the time of their 9/11 exposure.

For the past two decades, the World Trade Center (WTC) health program has pioneered research exploring the health effects of people exposed to the toxic dust and trauma of the 9/11 attacks. Most of this research has focused on people exposed as adults: first responders, emergency personnel, and community members.

Yet some 40,000 children were living in lower Manhattan when hijackers brought down the WTC Twin Towers. The resulting environmental fallout from pulverized buildings that blanketed the area would later be linked to a host of acute and chronic health conditions. Despite this, no systemic study has attempted to fully understand and track the health consequences in the youngest survivors. 

That has left a glaring gap in how exposure to the toxic dust and environmental contaminants affected babies in utero, infants, children, and young adults – a disparity that the Centers for Disease Control and Prevention (CDC) is seeking to close through an Early Life Exposure Research Center.

CDC described the center as “an important first step in addressing this need.” Earlier this year, researchers from the center wrote in an American Journal of Industrial Medicine commentary that ‘[c]ommemorating 25 years since the September 11, 2001, terrorist attacks in New York City allows us to recognize the successful collaboration of community, labor, academia, and government in creating a unique program to monitor and treat environmental health effects in a population of responders and civilian survivors,” but that this September offers an opportunity to “recognize and remedy a gap” in understanding exposure in the youngest survivors. 

The youth research cohort is the result of a December 2022 Congressional mandate to the CDC to track emerging health concerns for those under 21 years old during the attacks.

The news of a research center dedicated to the youngest exposed to 9/11 contaminants comes after a year of turmoil for the CDC, with widespread reductions in workforce across federal agencies.

In February, Department of Government Efficiency (DOGE)-related efforts led to a 20% reduction in WTC program staff, prompting outcry from New York lawmakers, and concerns that certifications to allow treatment of new conditions and cancers would be delayed. 

Decades of research to support survivor and first responder health

A worker stands at Ground Zero Wednesday, Oct. 3, 2001, in New York City.

The 9/11 attacks released unprecedented quantities of complex mixtures of chemicals into the environment. The years of advocacy by affected communities and academics resulted in the passage of the James Zadroga 9/11 Health and Compensation Act–the basis for the WTC Health Program. 

The program was created in 2011 by the CDC’s National Institute for Occupational Safety and Health to provide medical monitoring and treatment of certain WTC-related respiratory diseases, cancers, and mental health conditions. It also funds research into health conditions associated with exposure to dust, debris, and smoke from the 9/11 attacks in New York, Shanksville, and the Pentagon.

In the 25 years since the devastating attacks, more than 1,500 scientific publications have documented the health effects among 9/11-exposed populations, the CDC said.

Among the health effects explored were conditions of the lungs and respiratory tract, cancers, and mental health disorders. This research provided the foundational work for determining which kinds of conditions were linked to 9/11 exposure.

Yet, the authors write that “only a small percentage of those publications have focused on individuals potentially exposed at a young age.” The research that does focus on children found higher rates of asthma and respiratory symptoms among children exposed to the 9/11 dust cloud in Manhattan.

Other studies focused on the negative cardiometabolic and behavioral effects, cancer development, and exposure to toxic forever chemicals. 

But experts and advocates argue that this research only paints a partial picture of the poor health effects children exposed to the disaster may suffer.

“We need to understand the cognitive and neurodevelopmental impacts,” said Dr Joan Reibman, a pulmonologist and professor at NYU Grossman School of Medicine, and an author on the paper arguing for more research. “We need to understand cancer incidence and the characteristics of cancer in this group.”  

Reibman also pointed out that most of the past studies have focused on male populations, leaving a “significant gap in our understanding of the impact on reproductive health.” 

Attention turns to the youngest people exposed

indoor air quality
Children are especially vulnerable to environmental exposures, leading advocates and academics to push for research to fully understand the extent of 9/11-related health effects.

Researchers have long noted that children react differently to chemical exposures than adults. That’s because they experience larger exposures relative to their body size–and their bodies are less able to eliminate chemicals, the CDC said. Children can also have higher exposure to hazards because of crawling, putting their hands in their mouths, and faster breathing rates, said Reibman, whose research focuses on the health effects of WTC chemicals. 

Reibman also notes that though these survivors have a longer lifespan, gives more time for disease to develop, few have been tracked in formal studies.

“Both the WTC Health Program and the [New York City] WTC Health Registry were open to those exposed at a young age, including those exposed in utero,” she said, pointing to the respective CDC and New York programs.

However, Reibman explained that relatively few individuals meet these criteria. Only about 2,400 survivors are enrolled in the CDC program, while 3,200 are enrolled in the NYC program. This prompted a “concerted effort,” Reibman said, to enroll more people into the programs, ultimately leading to a 2022 amendment of the Public Health Service Act to expand the cohort size to include those within 1.5 miles of the WTC sites.

Challenges in studying 9/11 exposures 25 years later

The 9/11 Memorial at the site of the World Trade Centers in New York.

Reibman and others acknowledged the difficulties in piecing together a study large enough to link certain exposures to health outcomes. The WTC Youth Research Coordinating Center “will have to overcome significant barriers to recruitment, which will require the involvement of community groups and novel recruitment techniques,” she said. 

Also needed are an interdisciplinary team of biostatisticians, epidemiologists, and disease specialists to determine the impact of exposures on disease.

Captain Matt Karwowski (Commissioned Corps of the US Public Health Service), chief of the research and evaluation branch at the WTC Health Program, told Health Policy Watch that enrollment would begin after the coordinating center is fully established.

Image Credits: US Coast Guard/Brandon Brewer, US National Archives/ Paul Morse, Courtesy of the George W. Bush Presidential Library, Kelly Sikkema, DHS/Benjamin Applebaum.

August 2026 saw record breaking temperatures to become the joint warmest month alongside July 2023.

Record heat in August this year has made it the joint warmest month alongside July 2023. It was also the first month since November 2025 when global temperatures were 1.65°C higher than the pre-industrial level baseline, shooting the Paris Agreement target of limiting global warming to 1.5°C yet again.

In its latest update, Copernicus, the European Union’s (EU) Earth Observation programme, has also confirmed that this summer was the warmest summer on record for Western Europe.

Scientists attribute this record heat to the combined effect of the burning of fossil fuels and the strong El Niño conditions.

“August 2026 was a remarkable month in the global climate record. It was both the warmest August and the warmest month ever recorded, with global temperatures reaching 1.65°C above pre-industrial levels, marking the return of global temperatures above 1.5°C,” said Samantha Burgess, Strategic Lead for Climate at European Centre for Medium-Range Weather Forecasts (ECMWF).

“Combined with record global sea surface temperatures and the warmest summer on record for Western Europe, these observations show how climate change is driving extremes across both the atmosphere and the oceans. The impacts of these conditions are increasingly being felt by communities, economies and ecosystems across the world,” Burgess said.

See related story:

El Niño Forecast to Be Strongest on Record, Threatening Extreme Weather Through 2027

August 2026 – a record-breaking month

Global-average surface air temperature (°C) for 2023 (orange), 2024 (yellow), and 2026 (dark red). All other years between 1940 and 2025 are shown with grey lines. Data source: ERA5.

Average sea temperature also reached record highs in August over the extra-polar ocean, the water belts adjacent to the Arctic and Antarctic regions.

August 2026 was 1.65°C above the estimated pre-industrial 1850-1900 average, marking the first month above 1.5°C since November 2025. Global leaders hoped to limit global warming to 1.5°C, but this has now been breached more than once.

The period from June to August 2026 was also the joint-warmest period on record globally, on par with record-breaking temperatures in 2024.

Western Europe sees warmest summer on record

(Left) Anomalies and extremes in surface air temperature in June–August 2026. (Right) Average June–August surface air temperature anomalies for western Europe. Anomalies are relative to the June–August average for the 1991-2020 period.
Data source: ERA5

The average temperature over European land in August 2026 was 20.26°C, which is 1.10°C above the 1991-2020 average for the month. This makes it the fourth-warmest August on record.

Overall, summer 2026 (June to August) was the third warmest on record for Europe, behind 2024 and 2022. Heat has killed over 200,000 people over the past four years alone in Europe, according to the World Health Organization (WHO).

Western Europe in particular experienced its warmest summer on record, surpassing the long-standing 2003 record. The 2026 season was marked by a succession of exceptionally early, persistent and intense heatwaves across the region.

“Climate is sometimes seen as a partisan issue: as territory in the culture wars. That is palpably false. And we’ve just seen why: Europe’s summer has been hot as hell. This is the price of global fossil fuel addiction hitting home,” said Simon Stiell, UN Climate Change Executive Secretary, in an address to the European Parliament Committee.

“Understandably, Europe wants affordability, economic stability, energy security, and policy-making autonomy. Clean energy is the surest path to deliver, cheaply and safely,” he said.

Much of the region and large parts of central and eastern Europe also saw widespread dryness in August, in some cases persisting since May, with severe drought conditions reported in France, the UK, Hungary, Romania and Serbia.

In contrast, some regions like western Iberia, the Alpine region, northeastern Europe, eastern Türkiye and adjacent regions saw wetter-than-average conditions that caused local flooding in several areas.

Extreme weather was a global phenomenon

Anomalies and extremes in sea surface temperature for August 2026. Data source: ERA5

In August 2026, Arctic sea ice extent ranked 12th lowest for the month, with particularly low sea ice cover north of Franz Josef Land and Severnaya Zemlya, in the Russian Arctic sector.

Antarctic sea ice extent ranked fourth lowest for August, with below-average sea ice cover most pronounced in the Amundsen Sea and Indian Ocean sector.

Much of the southern USA and northern Mexico, parts of Canada, the Maghreb, part of the Horn of Africa, Siberia, large parts of Central Asia, China, South America, South Africa, and northern Australia were drier than average.

Wetter-than-average regions in August 2026 included the eastern USA and Canada, Alaska, parts of western and eastern Russia, the northern part of the Indian subcontinent, Chile and southeastern Brazil, as well as easternmost Asia, including eastern China, Taiwan and Japan.

Image Credits: Craig Manners/Unsplash, C3S/ECMWF.

  

A person with suspected Ebola arrives at a treatment centre in DRC.

After a gruelling recent Ebola infection, Dr Patrick Oparpio, a gynaecologist based in Bunia in the Democratic Republic of Congo (DRC), has urged health authorities to offer psychological support for Ebola survivors and their families.

This week, the DRC reported 6,843 Ebola cases and 3,310 deaths – a case fatality rate of over 48%  – mostly from Ituri province, where Bunia is situated, according to the Africa Centres for Disease Control and Prevention (Africa CDC).

“I was in a coma for four days, and spent eight days under intubation,” Oparpio told a webinar last week organised by the World Health Organization’s (WHO) Information Network for Epidemics, known as Epi-WIN.

“I was hospitalised for a very long time. When I was discharged from the hospital, I didn’t believe I was going to be able to go back to my regular life or get back to my professional life,” said Oparpio, whose fiancée was also infected but did not survive.

“After I recovered, I had to be taken care of by psychologists. I had to get some therapy. When I look around me, I see orphans. I see people who have lost loved ones who need that psychiatric support. That’s one of the things that the WHO needs to think about as well. I haven’t really seen that being addressed.”

Oparpio, who only went to an Ebola treatment centre several days after falling ill as he initially thought he had malaria, said Ebola survivors could help educate their communities.

“We can talk to those in vulnerable situations to help prevent the spread of the disease,” said Oparpio.

“We are probably better situated to fight against this disease as we’ve already experienced it. We know what it’s like, and we know what our community is thinking, and how to answer some of the questions that they have, and [address] some of the distrust that they have.”

“Some 218 health workers have been infected, but most in the early phase of the outbreak,” Dr Yap Boum told the Africa CDC media briefing on Thursday.

In the past week, an additional health zone, Kayna in North Kivu, reported Ebola cases for the first time. This means 61 health zones are affected in six out of the DRC’s 26 provinces. 

Ituri is the worst-affected province, accounting for 80% of cases. Twenty-eight of its 36 health zones have Ebola cases. However, the outbreak may be stabilising as Ituri reported fewer cases and deaths in the past week than previously.

However, cases continue to rise in Ituri’s neighbouring provinces of North Kivu and Haut-Uélé. North Kivu is the second worst affected province, with 16 of its 34 health zones affected.  However, no new cases have been reported from South Kivu province since 29 May. 

Image Credits: DRC Health Ministry.

A healthcare worker in Ghana prepares a vaccine for administration at a primary health clinic. Recent WHO prequalification of a multi-dose RSV vaccine aims to streamline delivery across low-resource settings.
A healthcare worker in Ghana prepares a vaccine for administration at a primary health clinic. Recent WHO prequalification of a multi-dose RSV vaccine aims to streamline delivery across low-resource settings.

A new three-dose vial presentation of the maternal RSV vaccine received prequalification from the World Health Organization (WHO) on Wednesday, unlocking large-scale distribution across lower-income countries. The decision enables global health alliances to introduce affordable immunisation during pregnancy, protecting newborns from severe respiratory disease.

Respiratory syncytial virus (RSV) remains the second leading cause of infant mortality globally after malaria, claiming over 100,000 lives annually among children under five, according to the WHO. More than 97% of these deaths occur in low- and middle-income countries with a particularly high burden in sub-Saharan Africa, where healthcare facilities often lack specialised respiratory care.

Pregnant women vaccinated in their third trimester with the multi-dose vial, marketed as Abrysvo by Pfizer, transfer protective antibodies across the placenta, shielding infants throughout their first six months of life.

The vaccine showed high efficacy in global clinical trials across high- and low-income settings, according to the European Medicines Agency (EMA). In pivotal Phase 3 clinical trials, it demonstrated 81.8% efficacy against severe RSV-associated lower respiratory disease in the infant’s first 90 days, maintaining 69.4% efficacy through six months.

Gavi, the Vaccine Alliance, welcomed the WHO’s decision on Wednesday and announced it would expand access for lower-income countries.

“The WHO prequalification of a multi-dose RSV maternal vaccine marks an important step towards ensuring that all children, regardless of where they are born, are protected at their very first breath,” said Emily Kobayashi, Director of Vaccine Programmes at Gavi.

Expanding RSV vaccine access in low-income settings

Building on Gavi’s board approval to establish a dedicated maternal programme for its 2026–2030 strategic period, the Vaccine Alliance said that eligible low-income countries can now apply for funding to integrate maternal immunisation into routine healthcare systems.

The RSV vaccine was developed with support from the Gates Foundation and reduces logistical barriers and cold-chain costs for developing health systems by packing multiple doses into a single vial. While monoclonal antibodies offer direct passive protection to newborns, maternal vaccination provides an alternative route by conferring immunity before birth, broadening global prevention options alongside existing antibody therapies.

Ensuring seamless rollout is critical. Even in high-income regions like Europe, implementation of RSV prevention has faced hurdles due to delivery gaps and fragmented funding – a challenge global health officials hope Gavi’s centralized support will prevent in lower-income settings.

Monitoring safety and birth outcomes

Regulatory bodies, including the EMA, authorised Abrysvo after concluding that its protective benefits far outweigh potential risks. Post-authorization surveillance in the United States confirmed that preterm birth rates among vaccinated mothers showed no statistically significant increase and remained within expected background levels.

Routine post-marketing surveillance programmes in Europe and the United States continue to track real-world health outcomes to ensure standard safety monitoring across diverse populations.

See related story:

Immunising for Prosperity: Why Europe Must Treat RSV and Pneumococcal Jabs an Economic Imperative

Image Credits: USAID/Ghana via Flickr.

Outright supporters take part in a Pride march in New York City.

HIV services, mental health and harm reduction programmes have been severely affected by the huge funding cuts to organisations providing services for lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) people over the past 18 months.

Perversely, organisations in countries with the most repressive conditions for LGBTIQ people have been worst affected by cuts, according to a report released on Thursday by Outright, the international LGBTIQ human rights group.

“Organisations in countries with the harshest living conditions, the least impartial justice systems, the most widespread discrimination, and the deepest divisions between social groups were roughly two to three times more likely to have been affected by the cuts than those in countries at the other end of each measure,” according to the report.

In Ghana and Uganda, the cuts have coincided with draconian laws increasing punishment for same-sex activity – resulting in a spike in attacks on LGBTIQ people and a greater need for support services.

Budgets cut by 50-75% 

Of the 229 LGBTIQ organisations from 94 countries that responded to Outright, 203 lost funding after Donald Trump became president of the United States in January 2025.

The funding cuts have been fast and dramatic, with almost half of the affected organisations losing 50% of their budget, and three-quarters losing at least a quarter.

“The losses concentrate among small, community-rooted groups: 73% operate on annual budgets under $250,000, leaving no reserves to absorb a shortfall of this size.”

After Trump assumed power, the US cut funds for HIV programmes aimed at “key populations” most at risk of infection, including men who have sex with men (MSM) and trans women.

The US State Department also terminated the Global Equality Fund, the public-private partnership launched in 2011 that has distributed over $100 million to LGBTIQ organisations.

Life-saving services stopped

“Half of the affected organisations have cut health services, including mental healthcare. On HIV specifically, 45% have reduced or discontinued prevention, treatment, or care, and 50% named LGBTIQ people living with HIV among the constituencies most affected by the reductions they made,” according to the report.

“The cuts strike directly into lifesaving and dignity-affirming services: HIV testing, treatment adherence support, PrEP information, STI [sexually transmitted infection] prevention, mental health counselling, psychosocial support, harm reduction tools, reproductive health services, health referrals, and safe community-based care.”

The Global Black Gay Men Connect network has also documented significant disruptions to HIV services for key populations, with 77% of the key population organisations it surveyed reported interruptions to the supply of antiretrovirals, pre-exposure prophylaxis (PrEP) and condoms.

In many places, the health services were effective because they were “delivered by trusted organisations that understand the specific risks faced by LGBTIQ people and can help them navigate stigma, discrimination, criminalisation, and fear of exposure”, the report notes.

“The money was pulled out of the places where queer organisations were doing the work that no one else is doing,” Outright’s Alberto de Belaunde told a webinar to launch the report on Thursday.

“The places with the least capacity to absorb the loss are exactly where it is highest.”

Outright’s Alberto de Belaunde.

Deaths, retrenchments

For security reasons, several organisations cited in the report aren’t named, while the countries of a few are withheld. However, the report documents tragic stories from countries as far apart as Nepal and Zimbabwe.

“We are unable to refill medication for our constituents, which has led to defaulting and the death of two of the people who defaulted,” reported a Zimbabwean organisation that provided HIV services for MSM and trans women.

“Funding cuts hit us hard at the community level,” said Kenya’s Mamboleo Peer Empowerment Group. “We had to let go of 100 peer educators, caregivers, outreach workers, and paralegals, the people who were not just staff but trusted faces within the LGBTQ community. 

“These were the individuals who checked in on clients, supported them to stay on HIV treatment, responded to GBV [gender-based violence] cases, and ensured no one felt alone. With their absence, outreach activities stopped almost overnight. Safe spaces went quiet, food support was disrupted, and emergency shelter and evacuation assistance became difficult to sustain.”

Aid workers turn to sex work

Manisha Dhakal, a trans activist from the Blue Diamond Society in Nepal.

Manisha Dhakal, a trans activist from the Blue Diamond Society in Nepal, told the launch that her organisation lost 85% of its funding for an HIV service delivery programme that provided services in 21 districts at 24 service sites. 

Nepal’s HIV epidemic is concentrated in key populations, and the clinics were important to reach these groups. But Blue Diamond has been forced to close clinics and retrench staff.

“Some [Blue Diamond employees] have even been pushed towards the sex work profession because we don’t have a stable income,” said Dhakal.

An estimated 35,000 aid workers lost their jobs in Nepal after the US aid cuts, and for trans people there are few job opportunities other than sex work, according to AP.

Spike in distress calls

“Community need for emergency shelter and protection exploded in the wake of the Anti-Homosexuality Act and state-driven hostilities surrounding our general elections,” said John Grace, the coordinator of the Uganda Minority Shelters Consortium (UMSC). 

“UMSC logged a 283% spike in distress calls to our national crisis hotlines. But over 60 to 70% of the financial support sustaining our protection network vanished overnight,” said Grace.

The impact on UMSC’s work has been significant: “For every 10 emergency relocation and protection requests that we receive weekly from youth that are escaping mob violence or police raids or family rejection, we possess the resources to feed, to house, and protect only about three.”

A significant proportion of the young people UMSC helps are living with HIV, said Grace.

“The desperation is so severe that we have even documented some of the youth trading portions of their life-saving HIV medication on the informal market just for a single meal.”

John Grace, coordinator of the Uganda Minority Shelters Consortium.

An organisation in Malawi has closed its mobile clinics that offered HIV testing and referrals that were “critical in reaching MSM and transgender individuals who face stigma in public health facilities”.

Türkiye’s Kaos GL reported that the UN Refugee Agency (UNHCR) had withdrawn from a “collaborative project for LGBTI+ refugees in 2025, causing the organisation to “shut down the refugee rights program office, lay off staff members and reduce the program activities by 85%.” 

A queer-led organisation in Jordan reported that it has a limited stock of harm reduction tools and kits to minimise the negative health effects of drug use, “which increases the risk of contracting HIV and other STIs”.

No protection for intersex babies

There has always been virtually no funding for intersex people, who are born with reproductive or sexual anatomy, chromosomes, or hormones that do not fit the typical definitions of female or male.

“In many countries, intersex infants and children are subjected to medically unnecessary surgeries and other interventions on their sex characteristics, without their consent,” the report notes.

“The organisations working to end these practices are among the most under-resourced in the global LGBTIQ movement, and several report that funding cuts have forced them to suspend their work documenting cases of medical violence, educating health providers, and supporting intersex children’s families as they navigate medical bureaucracies.”

This means that there is no one “standing between a child and an unwanted, harmful surgery”, the report notes.

Minuscule funding

Neela Ghoshal, Outright’s director of law, policy, and research

Donor government funding for LGBTI communities has always been “minuscule”, amounting to four cents of every $100 in official development assistance in 2023–2024, according to De Belaunde.

“The US has not been the only funder to walk away from or reduce its support for LGBTIQ movements during this period,” said Neela Ghoshal, Outright’s director of law, policy, and research.

“Some other governments, corporations, and foundations have also pulled back. At the same time, organisations are working in a context of growing anti-gender organising, where the gains that we’ve achieved over the last several decades, which were already fragile, are increasingly at risk.”

To address the crisis, the Outright report appeals to potential donors to act immediately, outside standard grant cycles; provide multi-year, flexible funding; restore community-led health services; fund protection for LGBTIQ people, and “direct resources to those bearing the heaviest impacts”.

Image Credits: Outright International.

Saima Wazed sworn in as Director of WHO’s South East Asia Region in February 2024; six months later her mother, Sheikh Hasina was deposed as Prime Minister of Bangladesh.

Saima Wazed, WHO’s Regional Director (RD) for South-East Asia (SEARO) and daughter of ousted Bangladeshi Prime Minister Sheikh Hasina, resigned Wednesday, just a day after South-East Asian member states recommended her termination, WHO confirmed to Health Policy Watch. 

“The previous day, 8 September 2026, the Regional Committee had recommended that Wazed’s appointment as Regional Director be terminated. That recommendation had been due to be considered by the Executive Board,” said a WHO spokesperson in an email. 

The discussion of Wazed was held behind closed doors with no fanfare at the 79th Regional Committee meeting of SEARO member states, which ended today. 

Wazed’s resignation, first reported Wednesday night by Reuters, ends a tumultuous five-year term marked by fraud allegations, a year of leave, and, according to multiple people familiar with the matter, months of pressure from Dhaka on Director-General Tedros Adhanom Ghebreyesus to remove the RD that the new Bangladeshi government has prosecuted for fraud.

Speaking to the Indian Express after submitting her resignation letter, Wazed lashed back – denying all allegations and saying that she had quit “because of “harassment and intimidation” by the WHO Director General, Dr Tedros Adhanom Ghebreyesus. 

“Not allowing for an independent investigation… leaving me on Leave Without Pay as retaliation for requesting an investigation into his conduct… It was becoming mentally and financially impossible for me to cope with this kind of harassment and abuse from him,” she was quoted telling the Express. 

In response, WHO told Health Policy Watch, “this matter has been handled through the appropriate WHO processes in accordance with WHO’s regulatory framework, with due regard for fairness and due process, while safeguarding the interests of the Organization and its ability to fulfil its mandate.”

Dispute in shadow of overthrow of former Bangladeshi prime minister

Sheikh Hasina Wazed, former Prime Minister of Bangladesh in 2020, four years before being ousted.

Other sources close to the matter noted that the termination move came after months of pressure on WHO from the new Bangladeshi government to investigate and dismiss her.   

The sources, who requested anonymity, also contended had been paid at least part of her salary during the leave period. This could not be confirmed independently.

WHO had placed Wazed on leave in mid-2025, after Bangladesh’s Anti-Corruption Commission filed fraud and forgery charges against her in March.

The charges alleged that she misrepresented an honorary doctorate as an academic credential in her original WHO candidacy for the Regional Director’s position, and also had been engaged in improper land deals in Bangladesh.

The fraud charges were brought by the new government after Wazed’s mother, former Prime Minister Sheikh Hasina, fled the country to India on 5 August 2024 following massive student-led protests.

Wazed has denied the charges saying they were politically motivated. 

Separately, WHO had reportedly been investigating alleged irregularities in a travel claim made by Wazed for the reimbursement of some $901 related to a trip to China – something her lawyers have said was due to an administrative error. 

Action after months of pressure  

WHO Regional Director for South East Asia leads a regional member state briefing in Geneva, May 2025; in August she was placed on leave.

According to a diplomatic official involved in exchanges between Dhaka and WHO headquarters, who requested anonymity, representatives of Bangladesh’s interim government warned the WHO Director-General as early as 2025 that inaction on Wazed could prompt Bangladesh to reconsider its position within WHO’s South-East Asia Region, and consider a move into the Eastern Mediterranean Region. 

“The Regional Committee cannot afford another country leaving SEARO, noted one observer, citing Indonesia’s decision to affiliate with the West Pacific Region,” last year.  Currently there are ten WHO member states affiliated with the SEARO region, including: Bangladesh; Bhutan; Democratic People’s Republic of Korea; India; Maldives; Myanmar; Nepal; Sri Lanka; Thailand; and Timor-Leste. 

Tedros finally placed her on ‘leave’ in July. But the WHO statement at the time carefully sidestepped the term “administrative leave” that is typically used in cases involving investigative of wrongdoing, or potential disciplinary action, describing her only as “currently on leave”.

The choice of terms, officials told Health Policy Watch, was deliberate, intended to limit reputational damage both to Wazed and to the Organization.

Another WHO official familiar with the internal investigation, who also requested anonymity, said the investigation into the allegations against Wazed had effectively stalled for much of the period she was on leave.  

During that time, however, Wazed reportedly continued to reside in India, the host country of WHO’s South East Asia Regional Office, and a place where she could have immunity from the arrest warrant issued by Bangladesh. 

Her mother, Sheikh Hasina also has been in India since her government fell – reflecting the traditionally close ties she had maintained with Delhi.

Sheikh Hasina also faces criminal charges in Bangladesh, including over mass killings during the crackdown on protesters that preceded her ouster. Alleged abuses were documented in a UN Human Rights Office of the High Commissioner (OHCHR) report published after her overthrow. She denies wrongdoing.

Wazed’s resignation takes effect immediately; Typically, WHO would be  expected to open nominations for her successor in October.

Image Credits: WHO SEARO/LinkedIn, WHO.