It has been a while since we discussed GLP-1s and semaglutides outside of the quarterly financial disclosures. It was a bit of an ongoing thread (see archives) culminating in this edition about Novo Nordisk allowing their patent to lapse, allegedly due to non payment, in Canada last summer. The predictions then were that the July 2025 lapse would open the door to generic entry in 2026 and that is exactly what happened.

In April 2026, Health Canada approved Dr. Reddy’s generic semaglutide injection and by the end of June it had approved three generic semaglutide products, including the country’s first generic semaglutide approved specifically for weight management.

India was among the first major markets to open to generic semaglutide in March 2026 after Novo’s patent expiry, with Health Canada’s April 2026 approval making it the first G7 country on the list, followed by Brazil in May 2026 and now South Africa in July 2026. So if we’re counting, that makes three BRICS and one ‘middle power’ since Davos. Make of that geopolitical coincidence what you will.

Much of the GLP-1 story in 2026 has understandably focused on Lilly’s extraordinary rise: Q2 sales of Mounjaro reached $9.94 billion USD and Zepbound $4.93 billion USD, together accounting for almost 65% of Lilly’s quarterly revenue and widening its lead over Novo Nordisk. But the other really big story here and the one that I predict will dominate 2026 is the rise in generic GLP-1s and semaglutide products.

In July 2026, South Africa’s SAHPRA approved Indian manufacturer Sun Pharma’s generic semaglutide injection, its second such market after India, following expiry of Novo’s South African patent in March. The approval is specifically for adults with inadequately controlled Type 2 diabetes. SAHPRA are currently evaluating another twelve generic semaglutide applications. Novo’s response came almost immediately. Two days after the Sun Pharma news it announced Extensior, a cheaper, ‘authorised copy’ of Ozempic manufactured by Novo itself and rolled out in partnership with Acino. Unlike a generic, it uses the same active ingredient, manufacturing process and delivery method as Ozempic, under another name. But it would appear to me that this is likely an attempt to compete with an emerging generics market. Novo had already reduced some Wegovy prices in the country.

We are therefore getting something close to a live experiment in GLP-1 competition to watch over the coming months: originator versus ‘authorised copy’ versus generics, potentially followed by many more entrants, alongside Lilly. What happens to prices, prescribing, access and market share in South Africa over the coming year will be fascinating and potentially instructive for other markets approaching their own semaglutide patent cliffs. Does the price fall dramatically? Does the eligible patient population expand? Do payers change their willingness to pay/reimburse? And looking forward, when does the biomanufacturing ecosystem around South African manufacturers become an opportunity in future situations of this kind?

Another relevant story here is that an online distributor of unlicensed semaglutide products in the UK was shut down earlier this year in Northamptonshire by the MHRA after the separate discovery of an illegal manufacturing network in the country the previous year. A trade that is reportedly becoming more common.

Looking to Q2: Three different post-pandemic business models may now be emerging. Moderna’s Q2 revenue did not decline: it actually rose modestly to $145 million and beat expectations, helped by international COVID vaccine sales and partnership payments, while the company is trying to build a broader mRNA business across seasonal respiratory vaccines and oncology. BioNTech is taking a different route, cutting spending as COVID vaccine demand falls while continuing its increasingly pronounced move towards oncology. Novavax represents a third model: shifting away from dependence on direct vaccine sales and towards licensing its protein-based vaccine platform and Matrix-M adjuvant, with its Sanofi partnership central to its route towards profitability. These are three different approaches to answer the same post-pandemic question: what does a commercially sustainable epidemic-response platform actually look like when there isn’t a pandemic? None has definitively answered it yet.

Always-on diagnostic, therapeutic and vaccine readiness asks companies and manufacturers to maintain capabilities whose greatest public value lies precisely in our hope that they will not be urgently needed. That counterfactual-driven reality often sits at odds with a shareholder-driven system in which capital and R&D migrate towards opportunities with more predictable returns. The arguments for advance commitments, advance-purchase mechanisms and other forms of permanent preparedness financing are therefore not simply that they worked during COVID. It is that without mechanisms for valuing readiness between crises, we are effectively relying on commercial markets to maintain these for free.

There is a separate tension emerging around manufacturing geography. AstraZeneca has committed $50 billion to U.S. research, development and manufacturing, while Lilly announced another $4.5 billion across two Indiana sites in May, taking its capital commitments in the state since 2020 above $21 billion. These investments sit within a much broader wave of pharmaceutical reshoring as companies respond to U.S. tariff policy and supply-chain risk. More on all of this in the FiRs below.

And finally, the Bundibugyo Ebola outbreak in the Democratic Republic of the Congo has deteriorated considerably. By 7 August it had surpassed 4000 confirmed infections, with 4053 cases and 1850 deaths reported across five provinces, making it the largest Ebola outbreak ever recorded in the DRC and the second-largest globally after the 2014 – 2016 West African epidemic. A WHO-supported treatment trial is underway in the DRC, while the University of Oxford’s ChAdOx1 BDBV vaccine, manufactured by the Serum Institute of India, became the first vaccine specifically targeting Bundibugyo ebolavirus to enter a Phase I clinical trial; its first volunteer was vaccinated on 24 July. Moderna’s CEPI-backed mRNA-1469 candidate followed: the first participant in its separate Phase I trial in Canada was dosed on 3 August. There remains no approved vaccine specifically for Bundibugyo ebolavirus. At the very moment Q2’s financials remind us how difficult it is to sustain infectious-disease R&D commercially between emergencies, Bundibugyo is showing us why maintaining capability matters.

I hope you’re having a beautiful summer.

Until next time,

Christiana

Q2 2026 Pharma Financials Are Here

Q2 2026 disclosures are now in from most of the major pharma and biotech companies. The numbers themselves show an industry in the middle of a transfer of value. AbbVie’s Skyrizi and Rinvoq for inflammatory diseases, J&J’s Tremfya for psoriasis and other inflammatory diseases, Bayer’s Nubeqa for prostate cancer and Kerendia for chronic kidney disease associated with Type 2 diabetes and BMS’s Camzyos for obstructive hypertrophic cardiomyopathy and Reblozyl for anaemia associated with certain blood disorders are growing against sharp erosion in Humira, Xarelto, Eylea, Entresto and Revlimid.

GLP-1s remain the extraordinary growth story, led once again this quarter by Lilly’s Mounjaro for Type 2 diabetes and Zepbound for obesity, even as the generic-semiglutide developments discussed above tell us that the next phase of that market has already begun. Vaccines did worse than at the end of 2025 this quarter, but there was a bit of a bump in Q4 as a result of RSV and being rolled out in maternal health. Meanwhile, the specialist COVID-era companies are beginning to look like three quite different post-pandemic businesses. Q2 is a useful snapshot of where pharmaceutical capital, R&D and manufacturing capacity are moving next. The order of these entries is a little imperfect but I have used the best general order I could put together.

1. Eli Lilly - 48% UP

No company came close to Lilly this quarter. Worldwide revenue rose 48% to $23 billion USD, driven principally by a 60% increase in volume. Lilly’s Mounjaro for Type 2 diabetes jumped 91% to $9.9 billion USD, while Zepbound for obesity brought in $4.9 billion USD, up 46%. Together, the two products accounted for almost 65% of Lilly’s quarterly revenue.

Q2 was also the first commercial quarter for Lilly’s Foundayo (orforglipron), its oral GLP-1 for obesity, adding another route of administration to a franchise already dominating the company’s growth. Lilly raised its full-year revenue guidance to $85 –87 billion USD. Lilly is taking branded share at extraordinary speed even as generic semaglutide is beginning to emerge in other markets.

2. Sanofi - 17.8% Growth

Sanofi’s second-quarter sales rose 17.8% to $13.4 billion USD, prompting the company to lift its full-year growth forecast to around 10%. Sanofi and Regeneron’s Dupixent for inflammatory diseases did much of the heavy lifting, with sales jumping 37.6% and surpassing $6 billion USD in a quarter for the first time.

Vaccine sales fell 4.7% to about $1.3 billion USD, with combined flu and COVID-19 vaccine revenue plunging 61.7%. Recently acquired Heplisav-B for hepatitis B prevention contributed $131.4 million USD, while AstraZeneca-partnered Beyfortus for RSV prevention in infants grew 54.2% to $125.6 million USD.

Sanofi expects vaccine sales to reduce for the full year, including a low- to mid-teens decline in Q3 as respiratory-vaccine revenue shifts into Q4. Net income fell 91.3% following approximately $1.2 billion USD in impairment charges.

3. AbbVie - 10.2% Growth

AbbVie’s immunology franchise continues to absorb the Humira decline. Humira (adalimumab) is off-patent with many available biosimilars. Worldwide net revenue rose 10.2% to $16.99 billion USD. AbbVie’s Skyrizi for inflammatory diseases grew 24.4% to $5.5 billion USD and Rinvoq for inflammatory diseases grew 24.5% to $2.5 billion USD; together they now account for roughly 47% of company revenue. Humira, meanwhile, fell another 35.9% to $756 million USD.

Neuroscience grew 20.3% to $3.2 billion USD, supported by Vraylar, Botox Therapeutic and Vyalev. AbbVie also announced a definitive agreement to acquire Apogee Therapeutics.

This may be the clearest patent-cliff success story in the quarter: AbbVie has not stopped Humira erosion; it has built two new blockbusters quickly enough to make that erosion progressively less central to the company’s financial story.

4. Gilead Sciences - 10% Growth

Gilead reported $7.8 billion USD in total revenue, with its base business growing approximately 10%. HIV sales rose 12% to $5.7 billion USD, while the prevention franchise passed $1 billion USD in quarterly sales for the first time.

Gilead’s Yeztugo (lenacapavir) for HIV prevention, the twice-yearly injectable’s quarterly sales reached $232 million USD.

However, in terms of earnings, acquisition-related R&D charges of approximately $11.2 billion USD associated with transactions including Arcellx, Tubulis and Ouro Medicines produced a large quarterly loss.

5. Novo Nordisk - 7% Growth

Novo’s turnaround remains gradual rather than dramatic. Adjusted sales rose 7% at constant exchange rates to DKK 78.5 billion, with adjusted operating profit up 11% to DKK 33.4 billion (>$5 billion USD).

Novo’s Wegovy for obesity, including its newer oral formulation, continues to gain prescriptions in the United States. But the competitive environment looks quite different from the one Novo dominated only a few years ago: Lilly is taking branded share at remarkable speed while generic semaglutide is simultaneously beginning to enter India, Canada, Brazil and South Africa.

That makes Novo particularly interesting to watch over the coming quarters. It is now competing in three directions at once: against Lilly at the innovative branded end, against new formulations and next-generation molecules and very soon, increasingly against lower-cost semaglutide too.

6. Bristol Myers Squibb - 6% Growth

BMS beat expectations comfortably, with revenue rising approximately 6% to $12.97 billion USD. Its Growth Portfolio now contributes around 59% of company sales and grew approximately 14–15% to $7.6 billion USD. BMS’s Camzyos for obstructive hypertrophic cardiomyopathy grew 59% to $416 million USD, Breyanzi for certain blood cancers rose 41%, and Reblozyl for anaemia associated with certain haematological disorders grew 29%. Eliquis also remained unexpectedly resilient, growing more than 20% to approximately $4.5 billion USD.

BMS raised full-year revenue guidance to $49–50 billion USD, from $46–47.5 billion USD previously.

7. Roche - 6% Growth (H1)

Roche reports half-year rather than Q2 results. First-half sales reached CHF 30.4 billion, representing 6% growth at constant exchange rates. The current strength of the Swiss franc is particularly visible here as those same sales were down 2% when reported in CHF.

Pharmaceutical sales rose 6% at constant exchange rates to CHF 23.6 billion, led by Roche’s Xolair for allergic and inflammatory conditions, Hemlibra for haemophilia A, Ocrevus for multiple sclerosis, Phesgo for HER2-positive breast cancer and Vabysmo for retinal diseases. Those five products generated CHF 11.0 billion collectively, up 12% at constant exchange rates. Diagnostics grew 3% to CHF 6.7 billion.

8. Johnson & Johnson - 5.7% Growth

J&J took in $25.3 billion USD for the quarter, a 5.7% increase. J&J’s Darzalex for multiple myeloma grew 17.6% to $4.2 billion USD, while Tremfya for psoriasis and other inflammatory diseases surged 71% to $2.1 billion USD.

It raised its 2026 sales and earnings guidance and remains on track to surpass $100 billion USD in annual sales for the first time.

9. Merck & Co. - 5% Growth

Merck’s worldwide sales rose 5% to $16.6 billion USD, or 4% excluding foreign exchange. Merck’s Keytruda franchise for cancer generated approximately $8.4 billion USD, up 5%, including $463 million USD from the newer subcutaneous Keytruda Qlex formulation.

The newer portfolio is beginning to matter. Merck’s Winrevair for pulmonary arterial hypertension grew 75% to $588 million USD, while Welireg for certain cancers grew 67% to $271 million USD.

Gardasil, the HPV vaccine, reached approximately $1.2 billion USD. The vaccine’s longer-term trajectory remains under pressure from Chinese competition than that it actually declined during Q2.

A $5.7 billion USD charge associated with the Terns Pharmaceuticals acquisition pushed Merck to a loss despite the underlying commercial growth.

10. GSK - 5% Growth

GSK’s Q2 sales rose 5% at constant currency to $11.3 billion USD, slightly exceeding expectations.

HIV product sales climbed 10% to $2.8 billion USD, with the long-acting injectable portfolio rising 35%. The direction here is worth watching alongside Gilead. Long-acting HIV treatment and prevention are becoming increasingly consequential commercial markets as well as major global-health implementation areas.

Vaccines grew 8% to $3 billion USD. GSK’s Shingrix for shingles prevention rose 3% to $1.2 billion USD, while its meningitis portfolio grew 21% to $619 million USD, helped by outbreak-driven demand.

GSK also announced their three-year cost-savings programme intended partly to support R&D and improve margins as HIV drug dolutegravir begins losing patent exclusivity in 2028.

11. AstraZeneca - 5% Growth

AstraZeneca’s Q2 revenue climbed 5% at constant currency to $15.4 billion USD, narrowly missing sales estimates. The particularly relevant development for this edition sits outside the quarterly product table: AstraZeneca has committed $50 billion USD to U.S. research, development and manufacturing through 2030. Together with similar large commitments elsewhere in the industry, this is part of the pharmaceutical reshoring story.

12. Viatris - 5% Growth

Viatris reported $3.76 billion USD in quarterly revenue, up approximately 5% reported and 3.5% operationally. Greater China was the strongest geography, with operational sales growth of approximately 16%, supported by cardiovascular medicines and e-commerce expansion.

The company whose model depends heavily on global established-product and generic supply and manufacturing reliability raised its full-year revenue while flagging $100–150 million USD of possible second-half revenue risk arising from manufacturing disruption at its Indore and Nashik sites in India.

13. Abbott - 4.8% Growth

Abbott reported approximately $12.6 billion USD in quarterly sales, with underlying sales growth of 4.8%. Reported growth was substantially higher because of the March 2026 Exact Sciences acquisition.

Abbott’s FreeStyle Libre for continuous glucose monitoring in diabetes passed $2 billion USD in quarterly revenue for the first time, although growth moderated without additional major reimbursement expansions. The growth in obesity and diabetes therapeutics is occurring within a much broader expansion of the metabolic-health market, including diagnostics and monitoring.

14. Merck KGaA - 4.1% Organic Growth

Merck KGaA reported Q2 net sales of approximately €5.43 billion, up 4.1% organically.

Life Science and Electronics were the principal growth engines, with semiconductor-material demand benefiting from investment associated with advanced computing and AI. Healthcare was weaker: reported growth benefited from the SpringWorks acquisition while organic Healthcare sales declined, including continued erosion of Mavenclad. Merck KGaA also remains on track with its proposed $11.3 billion USD acquisition of Bio-Techne, substantially expanding its exposure to life-science research tools.

15. Pfizer - 3% Growth

Pfizer’s revenue rose approximately 3% to $15.03 billion USD, ahead of consensus expectations. Excluding COVID products, the underlying portfolio performed considerably more strongly.

Pfizer and BMS’s Eliquis for prevention of stroke and systemic embolism in certain patients grew strongly, while Pfizer and Astellas’s Padcev for bladder cancer also continued to expand. Pfizer raised full-year revenue guidance to $60.5 – 62.5 billion USD but reduced its COVID-product expectations as demand for Paxlovid continued to soften.

The important distinction between Pfizer and the three ‘specialist’ COVID-era vaccine companies is diversification: Pfizer entered the pandemic with an enormous established pharmaceutical portfolio to which it could return as COVID revenue disappeared.

16. Bayer - 2.2% Growth

Bayer’s group sales rose 2.2% at constant currency to approximately €10.87 billion. Pharmaceuticals were broadly flat at approximately €4.46 billion.

The story here is another patent-cliff transition. Bayer’s Nubeqa for prostate cancer grew more than 60%, while Kerendia for chronic kidney disease associated with Type 2 diabetes grew more than 80%. Meanwhile, Xarelto fell approximately 42% and Eylea approximately 33% as biosimilar competition continued.

Bayer describes 2026 as the final year of the pharmaceutical division’s ‘resilience phase’ before an anticipated return to growth. Whether the newer portfolio can replace the extraordinary scale of those older franchises is therefore becoming measurable quarter by quarter.

17. Novartis - 1% Growth

Novartis’s Q2 sales grew 1% at constant currency to $14.4 billion USD, providing the company with its ‘return-to-growth’ quarter following sales contraction in Q1.

Novartis’s Kisqali for HR-positive/HER2-negative breast cancer leapt 43% from the year-ago period to $1.7 billion USD.

Conversely, sales of Entresto for heart failure halved to $1.2 billion USD as generic competition accelerated. Novartis is working through what it has called the largest patent expiry in its history. The company reaffirmed full-year guidance for low-single-digit net sales growth.

18. Moderna - 2% Growth

A seasonally quiet quarter for Moderna. Revenue rose approximately 2% to $145 million USD, beating expectations, while the net loss reduced to approximately $782 million USD.

That modest increase matters because it corrects the feeling that all three ‘specialist’ COVID-era companies posted collapsing Q2 revenues. Moderna did not - its current challenge is to demonstrate that the scientific and manufacturing platform built around COVID can support a sustainable commercial business between emergencies.

Moderna is pursuing that through respiratory vaccines, oncology and continued work on epidemic pathogens, including the CEPI-backed Bundibugyo Ebola vaccine.

19. BioNTech - 59.4% Decrease

BioNTech’s revenue fell to approximately €106 million from €261 million a year earlier. COVID-19 vaccine demand continues to normalise, although the year-on-year comparison also reflects existing vaccine-stock dynamics and the timing of milestone payments.

BioNTech cut its full-year revenue guidance to €1.6 – 1.9 billion and continues to redirect its centre of gravity towards oncology.

The transition is now substantial enough that describing oncology simply as ‘diversification’ becomes an understatement to what BioNTech is attempting to do, i.e. turn a company globally identified with a pandemic vaccine into a long-term oncology platform.

20. Novavax - 76% Decrease

Novavax revenue fell 76% to $57 million USD.

Q2 2025 included approximately $202 million USD in one-off revenue associated with the Nuvaxovid FDA approval milestone and a Takeda contract amendment, making the year-on-year comparison unusually severe. Underlying product sales actually increased to approximately $19 million USD, supported by demand related to the Matrix-M adjuvant.

Novavax raised full-year adjusted revenue guidance to $235–275 million USD.

More important than the headline decline is the emerging business model. Novavax is increasingly moving away from dependence on direct vaccine sales towards licensing its protein-vaccine technology and Matrix-M adjuvant platform, with the Sanofi partnership central to that strategy.

What did Q2 tell us?

There were a lot of patent-cliffs, replacement, readjustment and continued adaptation.

Humira is being replaced by Skyrizi and Rinvoq. Xarelto and Eylea are being offset by Nubeqa and Kerendia. Entresto is falling while Novartis scales Kisqali and its newer portfolio. Merck is already constructing the post-Keytruda company before Keytruda itself reaches its cliff. GSK is preparing years in advance for dolutegravir. And Novo and Lilly are competing for dominance of a metabolic-disease market whose foundational GLP-1 molecule is simultaneously beginning its transition towards generic competition elsewhere.

The infectious-disease focussed companies tell a similar story. COVID created an enormous but temporary commercial market and funded platforms, manufacturing infrastructure and scientific capacity that must now find sustainable economic roles. Three different post-pandemic business models appear to be emerging: Moderna is trying to broaden mRNA across respiratory disease and oncology while retaining epidemic-response capability; BioNTech is increasingly building its future around oncology; and Novavax is moving towards a technology-licensing and adjuvant-platform model. They emerged from the same extraordinary market event but are answering the question of what comes after it in their own way.

Pharmaceutical markets are extremely effective at reallocating capital towards the next identifiable source of demand - this Q2 demonstrates that fairly well. The commercial success of the next generation of medicines and the public financing of preparedness are two sides of the same question: what do we want pharmaceutical markets to optimise for, and who pays for the capabilities we need them to maintain when ordinary market incentives disappear.

(Source: EliLilly; Linksbridge; AbbVie; Gilead; NovoNordisk; BMS; Roche; JohnsonJohnson; Merck; GSK; AstraZeneca; Viatris; Abbott; Pfizer; Bayer; Novartis; Moderna; BioNTech; Novavax)

Greetings. I write to you at the end of this week feeling refreshed with a clear and relatively uncluttered mind. I started last weekend bright and early with a long walk through fields, forests and villages; then down to the lake. Living in that region of the countryside at the time, I walked part of this route regularly in 2020 during the early lockdowns. The sights and smells are familiar and close to my heart. Simultaneously, I started C.S. Lewis’ The Screwtape Letters on audiobook. It is the first time in a while that I managed to finish a book in a weekend and it is one I highly recommend. I have come to enjoy analysing and discussing books I have read with ChatGPT. Although it often misquotes, over-interprets and hallucinates - leading to minor disagreements.

Having resolved to stay off the Economist app that morning, I broke my resolution heading to the city for an afternoon coffee with a friend. Watching most of The Economist Editor-in-Chief, Zanny Minton Beddoes, interview with Elon Musk; I found plenty that might be relevant to unpack. He speaks about AI, the world he envisions and stumbles through questions on some of his other pet interests. He also talks about “prosperity for all” and an “age of abundance.” I was raised in the same peaceful, leafy Pretoria neighbourhood as Musk. (Evidently, not at the same time.) I have heard and been exposed to many opinions in my time that more or less align with his worldview and as such I am under no illusions as to what his ideal vision of the future is. I decided not to discuss the salient points of this interview today. But here are some relevant resources. USAID shutdown has led to hundreds of thousands of deaths; One Year Later: The Effect of US ‘Chainsaw’ on Global Health; If you’ve heard that London is dystopian and dangerous – read this. It just isn’t.

On a different note, finding myself outside the Global Health Campus last week, I was mindful of several significant stories that were unfolding across some the organisations housed within the building. By Friday, the Global Fund Board meeting had concluded against the backdrop of an eighth replenishment that fell short of its target, with sustainability, transition and country ownership taking on renewed urgency in an increasingly constrained financing environment. A few days later, Unitaid announced Dr Luis Pizarro as its next Executive Director, succeeding Dr Philippe Duneton after nearly a decade at the helm. Then, just this week, Gavi welcomed the restoration of frozen US funding, albeit accompanied by new conditions surrounding the future use of thimerosal-containing vaccines. A reminder of how scientific, political and geopolitical considerations are becoming ever more closely intertwined.

Together, these developments typify something of the present moment: global health institutions remain committed to progress while operating within a markedly different financial and geopolitical landscape from the one that shaped much of the past decades. Additionally, ahead of the next WHO Director-General election, WHO has introduced a new requirement for Regional Directors seeking the post to take leave while campaigning. This is procedural but seeks to strengthen transparency and establish a clearer separation between institutional responsibilities and electoral activity. All of these reflections prompted the question that I explore further in the Fortnight in Resources below: Where Does Global Health Governance Go From Here?.

Meanwhile, negotiations continued earlier this month on the Pathogen Access and Benefit-Sharing (PABS) annex. At the seventh meeting of the Intergovernmental Working Group (IGWG), Member States streamlined the draft text while continuing discussions on contracts, laboratory networks, sequence information and the benefits arising from pathogen sharing. The Africa Group has advocated for a federated model that would place participating laboratories and databases within a common WHO-governed framework, with clearer obligations linking pathogen sharing to equitable benefit-sharing. The European Union has proposed a hybrid model that builds on existing laboratory networks and contractual arrangements, favouring greater operational flexibility. Both approaches seek to strengthen preparedness while ensuring fairer access to the vaccines, diagnostics and therapeutics that follow, but they differ in where authority should sit and how benefit-sharing commitments should be implemented. With negotiations set to resume in September, there is a growing sense that the annex will ultimately determine how much of the Pandemic Agreement’s promise is ultimately realised in practice.

The DRC’s Bundibugyo outbreak continues to worsen. There are currently 3360 confirmed cases and 1487 deaths as of 27 July, on the verge of becoming the second-largest Ebola outbreak ever recorded. Uganda, however, has just closed its own chapter of it. On 28 July, Uganda’s Ministry of Health declared the country Ebola-free, ending a 74-day response: 20 cases, all traced to one imported case from DRC, no community spread. See the INSP dashboard. A friend working in the field reminded me of a former episode from Uganda’s Sudan virus disease outbreak last year; and the balance ministries strike between public health and economic reassurance in light of travel restrictions and other disruptions.

As we know too well from six years ago, how states handle outbreaks is rarely only about epidemiology. It is also diplomacy, tourism, trade and public confidence. Uganda’s two outbreaks in two years; and the different contexts in which they unfolded; illustrate how difficult those judgements can be. In a different way, they also serve as a useful reminder that the positions countries bring to global negotiating tables such as the IGWG are almost never formed in abstraction. They are shaped by history, experience, national context, political realities and calculations of practical consequences of decisions long after international meetings conclude.

Perhaps that is one of the reasons I enjoy these moments of fresh air and stepping away from the constant stream of news, if only briefly. It creates the space to see and make connections that are more easily made with space and breadth. Simultaneously, I feel grateful to have taken in so much culture and varied insights lately - beyond the headlines. This fortnight, more than anything else, I really found myself reflecting on change and transition: in institutions, financing, leadership and the international order itself. Whether these changes ultimately strengthen or weaken global health governance remains to be seen, but they are undoubtedly reshaping our environment.

Thank you for reading, Friend.

Wishing you a wonderful weekend.

Christiana

Some reading:

• Nature: Africa’s vaccine ambitions must move beyond fill-and-finish

• Lancet: Beyond vaccines: closing the critical gap in diagnostics and therapeutics for outbreak response

Where Does Global Health Governance Go From Here?

The Global health governance ecosystem is sometimes discussed as though it is one that exists in isolation from global politics. But it has always been a product of the international order within which it operates. For much of the past three decades, that order was characterised, albeit imperfectly, by expanding globalisation, growing confidence in multilateral cooperation and steadily increasing investment in global health. Many of the institutions, financing mechanisms and partnerships that define contemporary global health were built during that period.

Today, a geopolitical realignment is taking place. Development assistance is under pressure. Governments are balancing public health against defence, industrial strategy, energy security and domestic fiscal constraints. National resilience has become as prominent a political objective as international solidarity.

Thus, the question is not simply where global health governance goes from here but how it evolves when the assumptions upon which it was built no longer fully apply.

The Year 2000: The three assumptions that were true then

The age of positive expectation.

The turn of the millennium marked a defining moment for global health. The adoption of the Millennium Development Goals (MDGs) in September 2000, when 189 UN member states signed onto the Millennium Declaration, placed health firmly within the center of the international development agenda. Child mortality, maternal health, HIV/AIDS, tuberculosis and malaria became global political priorities, supported by an unprecedented expansion in development assistance for health, which roughly tripled over the following decade, from around $10.8 billion USD in 2001 to $28.1 billion USD by 2012. During this period, institutions such as the Global Fund, Gavi, Unitaid and many others emerged or expanded rapidly. Gavi launched at Davos in January 2000 around a $750 million USD pledge from the Gates Foundation, with the Global Fund following in 2002. Philanthropic organisations, most notably the Gates Foundation itself, became increasingly influential actors alongside governments and multilateral agencies. The growing influence of institutions such as the World Bank, particularly moving into the 2010s, also reflected the broader shift towards viewing health not only as a development outcome, but increasingly as an investment in economic resilience, human capital and long-term growth.

This period also coincided with an era of growing economic globalisation and relative geopolitical stability.

Scientific collaboration expanded across borders, supply chains became increasingly interlinked and there was broad confidence that collective action through multilateral institutions offered the most effective means of addressing global health challenges. By the time the Sustainable Development Goals (SDGs) were adopted in 2015, with SDG 3 reframing health around a broader, universal ambition anchored by target 3.8’s commitment to universal health coverage, the global health ecosystem had become even broader, more sophisticated and better financed than at the turn of the century; with development assistance for health eventually reaching an all-time high of roughly $80 billion USD in 2021 at the height of the COVID-19 pandemic response. Although important inequalities persisted, there was a widespread expectation that this trajectory of gradual expansion and deeper international cooperation would continue.

In the years following COVID-19 there was a widespread sense that global health had entered a new phase. The pandemic had exposed weaknesses in health systems and preparedness, elevated public health on political agendas and prompted renewed commitments to international cooperation. Six years on, however, three assumptions that seemed reasonable at the time appear increasingly uncertain.

First Assumption: Financing

1. The first was that the global health sector; and by extension, financing, would continue its long-term trajectory of expansion. While funding has never been linear, there was a feeling in the aftermath of COVID-19 that the pandemic had demonstrated the societal costs of underinvestment so clearly that preparedness, R&D and health systems strengthening would command somewhat sustained political support. Instead, many governments have reduced both internal healthcare spending and development assistance as fiscal pressures have mounted and competing domestic priorities have intensified. This is not simply a consequence of changing attitudes towards health. It reflects a broader recalibration of government spending in an environment shaped by inflation, debt, defence commitments and slower economic growth. WHO warned that abrupt reductions in external financing are already disrupting essential services in many low- and even middle-income countries, including immunisation, disease surveillance and emergency preparedness, while urging countries to transition towards domestic financing models.

Second Assumption: Multilateralism

2. A second assumption was that multilateral institutions would remain the undisputed center of global health governance. WHO, among other organisations, continues to play an indispensable role in norm-setting, technical guidance and coordination. At the same time, the governance landscape has become more diffuse. Regional organisations have expanded their influence, development finance institutions have become increasingly prominent health actors, philanthropic organisations continue to shape and influence research priorities, and public-private partnerships remain central to product development and implementation. COVID-19 brought the world of global public health into the limelight in a new way. And the public sentiments that developed at the time have only persisted and, in some instances, been encouraged. What one did not expect was that the centrality of power, its legitimacy and even science as a whole would become so widely questioned and scrutinised so as to have been so functionally undermined and arguably even unseated from its authoritative role by both position and public consensus. Rather than replacing multilateralism, these developments as a whole have produced a more complex ecosystem in which authority and influence are distributed across a wider range of institutions and actors.

Third Assumption: Relevance

3. The third assumption was that the political prominence and relevance that health gained during and in the aftermath of COVID-19 would endure as a standalone strategic priority in its own right. In practice, health has retained a seat at the table, but rarely the head of it. Davos this year had a notably absent health agenda and far less SDG focus than previous years. Governments are now navigating a geopolitical environment characterised by strategic competition, conflict, supply chain vulnerabilities and renewed emphasis on economic and technological sovereignty; and health has been folded into that environment rather than exempted from it. Decisions about vaccine manufacturing, supply chains, biotechnological development and critical health infrastructure are no longer viewed solely through a public health lens, but also as questions of strategic capability and national resilience - sometimes seemingly to health's advantage, as in the growing interest in regional manufacturing as a strategic asset, but sometimes to its detriment, when public health considerations are simply outweighed by competing economic or security priorities. Or when development plans fail to fully appreciate the cross-sectoral benefits of addressing the social determinants of health. Health has become one input among several into decisions that it once had a stronger independent claim to influence.

The result is an interesting paradox. As global health institutions have continued to develop new governance mechanisms and strengthen international frameworks, the political consensus and financing needed to sustain them have become more uncertain. Pandemic preparedness illustrates this well through the Pandemic Agreement, the Pandemic Fund and continued reforms to the International Health Regulations. The Global Preparedness Monitoring Board (GPMB) argued that while the global architecture has advanced, sustained political commitment and financing remain insufficient to meet future pandemic risks. Capacity has, in some respects, advanced further than political consensus. Incidentally, the GPMB is expected to conclude its work in 2026 following the publication of its final report.

Perhaps the defining characteristic of contemporary global health governance is not the creation of new institutions, but the increasing complexity of the ecosystem itself. Over the past two decades, global health has expanded well beyond governments and multilateral agencies to include regional organisations, development finance institutions, philanthropic foundations, research partnerships, civil society and an increasingly influential private sector. This diversification has undoubtedly strengthened innovation, financing and technical expertise. At the same time, it may have contributed to blurring traditional lines of authority and accountability; making governance less about the authority of a single institution and increasingly about the interactions between many. Success now depends less on creating additional architecture than on ensuring that an already sophisticated ecosystem functions efficiently and coherently. In many respects, the challenge facing global health governance today is not one of institutional absence but of institutional alignment: enabling a large network of actors, each with different mandates generally speaking, different incentives and constituencies, to work collectively towards shared goals.

What is emerging today?

Taken together, these shifts do not necessarily signal the decline of global health governance. Rather, they suggest that it is entering a different phase.

One notable trend is the growing importance of regional capability. The pandemic exposed the risks of concentrating manufacturing capacity, diagnostics and critical supply chains within a relatively small number of countries. In response, governments and regional organisations have invested in local manufacturing, regulatory cooperation and regional surveillance networks, not as alternatives to global cooperation, but as mechanisms for reducing vulnerability to future shocks and strengthening resilience closer to where health threats emerge.

Another trend is the closer integration of health with other policy domains. Decisions about investment, manufacturing and innovation are therefore shaped not only by public health considerations, but also by wider political and economic objectives.

Across the wider global health ecosystem, financing models, institutional relationships and patterns of leadership are all evolving in response to broader geopolitical and economic change. Regional organisations are assuming greater responsibility for coordination, regulation and implementation, while development finance institutions are playing an increasingly influential role in shaping health priorities alongside traditional health agencies. Philanthropic foundations, research partnerships and the private sector continue to influence innovation and delivery, while governments are placing greater emphasis on domestic capability, fiscal sustainability and strategic resilience. The result is not the retreat or dismantling of the global health governance structures that we know, but their evolution into a system that is more plural, but beyond that; more politically embedded and increasingly distributed across a wider range of actors than the one that emerged during the MDG era.

The Road Ahead

The question is therefore not whether global health governance should return to its pre-pandemic form. The international environment that shaped that model has changed, and governance will inevitably change with it. The more important question is whether the system can continue to fulfil its essential functions in a more fragmented and contested world. Effective governance has never depended solely on institutions. It depends on the ability to coordinate collective action, establish trusted norms, mobilise sustainable financing, generate and share evidence, and ensure that countries can respond to health threats that do not respect borders.

The challenge is not necessarily to preserve the institutions that shaped the previous era of global health, but to ensure that the system continues to perform the functions that effective governance requires. That means clarifying the respective roles of global, regional and national institutions; strengthening coordination without creating unnecessary duplication; building financing models that are resilient to political and economic cycles; and ensuring that scientific evidence continues to inform decision-making in an increasingly contested information environment. It also requires mobilising collective action, responding to shared threats and sustaining progress towards common goals under less favourable political and fiscal conditions than those that characterised much of the previous two decades.

These functions remain as important today as they were before COVID-19. If anything, they are becoming more important as climate challenges and geopolitical uncertainty increases. Preserving them will require adaptation and recognising that while the architecture of global health governance may continue to evolve, its underlying purpose remains unchanged.

Behind the scenes

Glorious summer mornings in July!

It’s July. June was one of those long months that nevertheless just seemed to fly by. It was a smouldering month, too. And I would not be original to address the reminder of the devastating effects of climate change. Hurtling, as a global community into what seems unfortunately to be a disaster. It made me think of another interpretation of Banksy’s recently erected statue, Man blinded by Flag, that I had an opportunity to see with a dear friend one Friday evening after an interesting talk at the British Academy on the role and relevance of International Law. Starting that week on the Italian coast, relaxing and celebrating the wedding of a coursemate from the UCL School of Pharmacy with a close friend, I headed back to London for what turned out to be one of the most professionally and intellectually substantive weeks I’ve had in a while.

At CEPI’s Global Vaccine Manufacturing Summit, held at the Royal Society of Arts, financing institutions, innovators, vaccine developers, regulators, manufacturers and philanthropies gathered to work through what it would actually take to make geographic diversification of vaccine manufacturing real rather than aspirational. The Summit kicked off with an evening reception before the full agenda the following day. The opening panel, moderated by Sir Peter Piot, set the policy priorities for the day. Trevor Mundel of Gates Foundation gave a keynote on AI’s potential to enable regional manufacturing, and WHO’s Hanan Balkhy pushed the equity conversation further, into reaching displaced populations and the growing push for regional health sovereignty. Across the day, the recurring threads were sustainable and regionally distributed manufacturing, innovative financing to keep facilities operational between outbreaks, regulatory readiness under the 100 Days Mission, and the role of AI in accelerating development. The ongoing Bundibugyo outbreak served as a reminder that none of this is abstract. The Summit also served as the platform for CEPI’s Vaccine Manufacturing Facility Network to sign a new charter deepening cooperation across its member institutions, which span Fiocruz in Brazil, Institut Pasteur de Dakar in Senegal, Samsung Biologics in South Korea, the Serum Institute of India, Bio Farma in Indonesia, and Aspen Pharma Group in South Africa. What I enjoyed most was the technical depth and substance provided by the presence of numerous innovators across product development. The innovation showcase included innovators in delivery, protein manufacturing and analytical innovators. Speaking to many of them present, dignitaries across the field and friends and industry colleagues who I was grateful to see, all of us energised, reminded me that this is the starting point - where the work begins on the long road from innovation to discovery, to development to policy to implementation.

Later that week, I had the privilege of attending the Gates Foundation’s Grand Challenges Annual Meeting (GCAM) held primarily at Imperial College London and the Royal Geographical Society. Being back on campus brought back some nostalgia for my business school days. The Sherfield Building corridors (that I never particularly liked, only because it added an often unexpected three minutes to my commute), the pods where countless group assignments were hashed out late into the evening, the little things.

The Grand Challenges programme was technically and scientifically dense in the very best way. So many new ideas at the cutting edge of science shared both within and outside of sessions by a collection of innovative minds, thought leaders, researchers and industry leaders. I realised that I can neither type nor write nearly as fast as I wish I could. Sessions included malaria eradication, covering next-generation vector control and next-generation vaccines, biologics and platform technologies; long-acting injectables as a new frontier in global health, and a session on building Africa’s end-to-end biomedical research ecosystem. The scientific tracks ran in parallel, from improving syphilis diagnosis and management in pregnant women and infants to doing drug discovery in Africa while building the system to sustain it. Saturday’s roundtables turned to implementation questions: the diaspora’s role in Africa’s health R&D, fit-for-purpose malaria programmes for the 2020s, scaling diagnostics from lab to last mile, and South-South collaboration as a route to more equitable innovation. Wellcome hosted the Thursday evening reception at the Science Museum, a fitting venue for a week largely about moving ideas out of the display case and into use. The meeting closed with a plenary on the malaria R&D endgame and a keynote and closing conversation from Trevor Mundel, days after his AI keynote at the CEPI Summit. I have spent the past couple of weeks digesting, reflecting and thinking about the ideas discussed; and feeling hopeful for the promise of the progress that can be made for the betterment of human health and society; all while remaining aware that essential financing from many quarters for many of these efforts continues to dwindle, and even the Foundation have set a 2045 closure.

I was struck by the complementarity of these two events that made their substance valuable in a way that reflecting upon either in isolation didn’t quite capture for me. The Summit addressed the planning of the pipeline. Grand Challenges addressed, project by project, what that pipeline has to survive: regulatory uncertainty, thin margins for error and financing models that often assume a smoother path than the technology can deliver. Put together, they address different parts of that long road.

WHO added the first diagnostic test for Bundibugyo ebolavirus to its Emergency Use Listing on 2 July, and patient enrolment has now begun in the PARTNERS platform trial evaluating remdesivir and the antibody MBP134 as potential treatments, a gap that has persisted since the strain’s first identification in 2007. As of the WHO’s 3 July Disease Outbreak News, 1481 confirmed cases have been reported across the Democratic Republic of Congo, Uganda and one imported case in France, with 454 deaths and 229 recoveries; this is now the third-largest Ebola outbreak on record. Ituri province remains the most affected part of DRC. The WHO Director-General flagged that the response continues to face significant challenges, including ongoing insecurity in the region and an attack on a treatment centre in the province. IPPS posted their Major Update on R&D for Ebola Bundibugyo medical countermeasures - Day 45 on the 100 Days clock. Separately, WHO has declared the hantavirus outbreak linked to the M/V Hondius cruise ship over, and health response efforts continue following the twin earthquakes that struck Venezuela on 24 June.

One more thing from June. The great South African jazz pianist, Abdullah Ibrahim passed away, aged 91. I grew up hearing his music, with Mannenberg playing at family gatherings. I have found myself humming it. The morning that Bafana Bafana celebrated their win, and while doing just this and that. Our heroes are mortal and they will pass away, but it is up to us who live to keep those parts of their legacy on earth beyond our generation. The piece takes its name from the township on the Cape Flats where families from District Six were forcibly relocated under the Group Areas Act, and it went on to become something close to an anthem against apartheid. A tune born out of enforced displacement became, instead, a symbol of collective identity. Today, geography, coupled with all the social determinants of health, still decide who can reach a vaccine, a diagnostic, a trial site or even be reached by contact tracing efforts in the midst of an Ebola outbreak; and who cannot.

Thank you, Friend, for reading and engaging with this newsletter. I have written a special piece discussing the concept of Baumol’s Cost Disease below. After over three years of writing to you regularly and having these Conversations, I am more appreciative than ever for our community and will be responding to e-mails soon.

Best wishes,

Christiana

Baumol’s Cost Disease & Biomanufacturing

Baumol’s Cost Disease is an economic concept first described by William Baumol and William Bowen in their 1966 study of the performing arts, and later formalised by Baumol as a model of unbalanced growth.

The underlying distinction is between what Baumol called progressive sectors, where labour productivity rises over time because capital, technology or innovation can substitute for human input; and stagnant sectors, where output is itself a function of labour and cannot easily be decoupled from it.

I genuinely didn’t understand this concept when I was first exposed to it. So I’d like to write it in a way that communicates it well before diving into how I think it plays out in biomanufacturing.

The classic example to illustrate Cost Disease is a string quartet performing Beethoven. It takes the same four musicians and roughly forty minutes today as it did in 1826. There can be no productivity gain to the performance, because the performance itself is the labour. Nevertheless, musicians’ wages still have to rise over time, because labour markets are shared across sectors: musicians can compete for the same pool of skilled work as employees in progressive sectors, where rising output per hour justifies rising pay. If musicians’ wages didn’t rise to keep pace, despite their work not becoming any more ‘efficient’ in any tangible way, the theory explains that the profession would gradually empty out as workers moved to better-paid, more productive sectors.

Thus, the relative cost of the ‘stagnant’ sector’s output climbs steadily. Not because the sector has become more efficient but because the price of its labour is set in a market shared with sectors that are able to become more efficient.

Healthcare is the most familiar modern illustration: a nursing shift does not get faster because software elsewhere in the economy became ten times more capable, yet the nurse’s wage still has to rise to remain competitive with alternative employment. This being said, this account of health cost growth is contested. Hartwig’s 2008 empirical test of the hypothesis across OECD health spending found that Baumol-type relative price effects explain a substantial share of the sector’s cost growth, but the fit is not universal, and critics argue that some of what looks like cost disease is really mismeasured output, since many health interventions today are simply more effective than they were decades ago. Nevertheless, I feel that the argument still stands in a comparative sense, against other sectors of the economy.

In biomanufacturing there is a version of this same cost disease tension, between pace of the science and the labour that drives the sector. We tend to assume that as a manufacturing technology matures, it gets cheaper across the board. Cell lines become more productive, platforms get faster, yields improve. But where the necessary allocation of funds in a manufacturing site actually goes is more uneven.

My argument is not that biomanufacturing is a stagnant sector in the classical Baumol sense. It clearly is not. Rather, it is a mixed-productivity system: upstream scientific and process improvements can generate rapid productivity gains, while downstream, quality, regulatory and institutional functions remain more labour, judgement and compliance-bound. The result is that aggregate learning curves can conceal persistent cost pressures in the less automatable parts of the value chain.

The first issue is that vaccine manufacturing doesn’t really sit perfectly within either of Baumol’s two categories of progressive and stagnant. It is much more appropriately described as a ‘mixed-productivity’ system: some stages resemble progressive sectors and others stagnant sectors. Upstream, cell line development, process optimisation and platform design are progressive in Baumol’s sense: they benefit from automation, from digital twins and modelling and increasingly from AI-assisted design. Output per unit of labour thus rises over time.

Downstream, fill-finish, quality assurance, and quality control sit slightly closer to the ‘stagnant’ category, though not entirely: single-use bioprocessing, isolator technology and process analytical technology have all measurably reduced labour intensity per batch over the past two decades. The claim here is one of degree, not absolute stagnation, and the more defensible version of it is not that fill-finish labour cost is flat in absolute terms, but that it has plausibly stayed flat or ‘risen’ as a proportion of total cost of goods, precisely because upstream costs have fallen faster than downstream ones. That is the Baumol-consistent prediction, though the underlying mechanism, a shared labour market pulling stagnant-sector wages upward functions somewhat differently if we were to consider the wage gaps that exist across a globalised skilled market, rather than a strictly national context.

The elasticity of substitution between labour and capital in these stages, i.e. how easily a machine or algorithm can stand in for a trained person, is still low relative to upstream. A fill-finish line needs roughly the same number of trained QA staff per batch whether it is producing 10 million doses or significantly more (within reason, as staffing here too will also ultimately need to increase with scale), because the tasks within this classification are inspection and judgement, not necessarily throughput. That residual labour cost does not fall the way a unit cost normally would at scale, and the wage bill for that labour still rises in line with the broader economy and ordinary wage inflation around it.

The second issue is what this does to financing assumptions. Most manufacturing business cases build in an implied productivity growth rate, often drawn from historical learning curves. This, incidentally, is something that a supply chain/buyer friend of mine at a major FMCG firm has discussed with me on many occasions. Their packaging, processes and older product elements become cheaper over time as a function of the same phenomenon. Unit costs fall by a consistent percentage with every doubling of cumulative output. That relationship holds reasonably well upstream. But applied uniformly across the whole value chain, including the more stagnant, labour-bound stages, it embeds an assumption the underlying economics does not support. A model that prices in economy-wide productivity gains for stages that are structurally exempt from them will understate the long-run operating cost of fill-finish and QA/QC specifically. I wondered in passing if this may be one reason technology transfer to LMIC manufacturers so often runs behind schedules built into the original business case. Using a single, blended productivity assumption and applying it to a value chain that actually contains two different economic regimes, or at least different shades of grey along the progressive to stagnant continuum. Though it's worth acknowledging that some of the same cost pressure comes from a deliberate engineering choice rather than a labour-market one: distributed, regionally sited manufacturing of the kind CEPI's network discusses trades away the scale economies of a single large facility for outbreak-response resilience, and part of what looks like persistent downstream cost share is simply the price of that trade-off.

Third, regulatory strengthening compounds this rather than offsetting it, at least for now. National Regulatory Authorities (NRAs) in the geographies that might be placed to host new manufacturing capacity are, in many cases, still strengthening the technical and human capacity to assess complex biologics at the pace global demand requires. WHO’s Global Benchmarking Tool that evaluates and ranks NRAs by Maturity Levels has driven real progress in a number of jurisdictions, and regional reliance mechanisms, where one authority’s assessment informs another’s decision rather than duplicating the full review, are a rational response not only to expediting approvals during emergencies, but also to a fixed-cost issue: strengthening full assessment capacity independently in every jurisdiction is a ‘duplicative’ cost that reliance is designed to avoid. I have an almost unreasonable interest in reliance mechanisms and I have, over the years, had the opportunity to ask different, very qualified people my sometimes half-baked questions on their application in an African context. So it is important to highlight how nuanced this is outside of the framework of Cost Disease, where reliance mechanisms run into real friction in practice. Some of it is information asymmetry: differing legal bases for accepting another authority’s decision, and uneven confidence in the originating assessment. But some of it is political rather than technical: legal liability exposure for the relying authority, legitimate sovereignty concerns about a domestic public health decision resting on another country’s assessment, etc. It can also just purely interfere with that NRA’s financial and institutional model to forego many of its internal processes - few cases are as black and white as they may seem. None of this is a reason to doubt the clear benefits of reliance but outside of emergency situations it may be a reason to make considerations in costing, forecasting and developing models regarding timeline and expected savings.

Biomanufacturing business cases may ultimately overstate the long-run benefits of technological maturation when they apply upstream learning curves to downstream, quality and regulatory functions that do not experience the same productivity trajectory.

So does AI change things?

Baumol acknowledged that the boundary between progressive and stagnant sectors is not fixed. A sector can migrate from one category to the other with time as the underlying technology changes the elasticity of substitution between labour and capital. AI is beginning to do exactly this in parts of the labour-intensive side of the pipeline. Automated visual inspection for particulates, AI-assisted deviation investigation, and predictive maintenance are already reducing the labour required in some places. AI-assisted regulatory dossier preparation is starting to shorten the human hours NRAs need to reach a decision. This does not render cost disease irrelevant, because it does not eliminate the labour input entirely. Direct human oversight of sterile fill-finish, skilled technician judgement in QC, and regulatory sign-off by an accountable human reviewer are unlikely to be substitutable in the way, say, document formatting is; the marginal product of the remaining human labour in these tasks is high precisely because the tasks that could be automated already have been. It should also be hoped that policy and regulation keep up with these developments. But the boundary between the ‘automatable’ and the purely manual segments of this value chain is moving, and financing models built even a few years ago may already need revisiting.

Some to watch this fortnight:

• PDVAC, 6–9 July: WHO’s Product Development for Vaccines Advisory Committee meets in Geneva, reviewing the pipeline for vaccines against diseases with the greatest public health need.

• Pandemic Agreement IGWG7, 6–17 July: the seventh meeting of the Intergovernmental Working Group continues negotiations on the Pathogen Access and Benefit Sharing (PABS) system, with outcomes due to the Eightieth World Health Assembly in May 2027.

Behind the scenes

Life feels colourful. Heart full.

Greetings. Hoping to outsmart the weather, I spent an evening on a glorious hike through a hidden trail in the heart of the city with a dear friend. Crossing the water on a bridge above the point where the Rhône and the Arve rivers meet, three merrymakers floated by on inflatable donuts. Arms outstretched with the earnest, unbridled sense of freedom and possibility that is accorded by the first breaking of the summer weather. As we took in the beauty of our surroundings, we were yet unaware that we were standing right above a giant sign that read “NO G7”.

Opposition to G7, G8 & G20 summits is certainly nothing new. The G8 summit in 2003 brought demonstrations that escalated and caused disruption and damage in the city of Geneva in a way that many anticipate may repeat itself during the upcoming G7 Summit in nearby Evian-les-Bains in France. Shops have already begun boarding up their windows and facades in anticipation of the protests that will be held in Geneva and UN staff as well as those of many multinationals have been recommended to work from home. Nevertheless, something does feel different in 2026. I thought the same thing during WHA79, walking down the street one afternoon, observing the big blue bus protesting pandemic agreement negotiations drive by. Protests are a regular occurrence and one can become slightly desensitised after a while. But there is a solid feeling that populations globally are turning their support away from multilateral structures in many quarters; and in some cases, losing trust in their elected leaders.

A little over a fortnight ago I previewed the World Health Assembly. I framed it the way one often frames significant events: an agenda, stakes, a list of what to watch. And then I spent the week following resolutions on stroke, on drug safety, on health workers. But the circumstances under which WHA79 took place was against a backdrop of an organisation whose budget has just been cut by a fifth, whose corridors are emptier by a quarter and whose contingency fund for the next outbreak holds less than a fifth of what it should. WHA79 was not business as usual; it was watching an institution attempting to achieve tangible future outcomes with tangibly less means and leverage to meet them. To misquote Gramsci, as neatly outlined by the Guardian recently, the old world dying, the new struggling to be born, and in the interval, a great variety of morbid symptoms. We might be approaching the interval.

Hanging over all of it was Ebola BVD. When I last wrote on the eve of WHA79, the night the outbreak was declared a public health emergency of international concern, it stood at seventeen confirmed cases. A strain with no approved medical countermeasures and a single imported case in Kampala. On Sunday evening I sat down to review the numbers, at which point the most recent figures were 134 confirmed cases and 18 deaths. Today, the toll reported by the Director-General from Bunia on Wednesday has climbed to 359 confirmed cases and 61 deaths across the DRC and Uganda; and while some sources had estimated as many as a thousand suspected cases, WHO has since refined the backlog of suspected cases down to 116. This has already been called the third-largest Ebola outbreak on record, behind only the 2014–16 West African epidemic and the 2018–20 Kivu outbreak.

Since the end of last week, the confirmed count multiplied roughly 2.5 x and fatalities have more than tripled. The United States has moved to send Americans exposed to the virus to a new quarantine facility in Kenya, a country with no cases. A Kenyan court has since suspended the plan. Protests in Nanyuki resulted in the deaths of two protestors.

I found myself thinking about Peter Singer's drowning-child thought experiment. If you pass a shallow pond and see a child drowning, you wade in, ruined clothes and all, because the cost to you is trivial against a life. But what if that child was on the other side of the world? His point was that distance should not change the calculation. A child in danger far away has the same claim on us as the one in our backyard. Much of what I have described this fortnight, both in this letter and in the FiRs, made me reflect on the importance, and in some cases urgency, that all of us, as a community and as a community of professionals, retain the borders of the pond wide enough to include affected lives equally, wherever they are. Prioritisation is a choice. We must also resist any redrawing of the pond's edge that would contract that scope. The responders in Bunia are wading in regardless. That, this evening, is the sentiment I wish to hold onto.

Wishing you a lovely weekend ahead, Friend.

Best wishes,

Christiana

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1. Bundibugyo: the seventeenth outbreak

When I wrote last, on the night the PHEIC was declared, the determination rested on eight laboratory-confirmed cases and a cluster of suspect deaths in Ituri, plus one case in Kampala. Speaking from Bunia on Wednesday 3rd June, WHO Director-General Dr Tedros Adhanom Ghebreyesus put the DRC total at 344 confirmed cases and 60 deaths across 24 health zones in three provinces: Ituri, North Kivu and South Kivu. The IOM has called this the third-largest Ebola outbreak on record; behind only the 2014–16 West African epidemic and the 2018–20 Kivu outbreak; and it is only the third ever to be declared a PHEIC. Earlier in the week some sources had estimated as many as 1000+ suspected cases, but as the backlog has been worked through, each one confirmed or ruled out, that figure has been refined to 116. The decline is in the suspected case count. The number of confirmed cases has continued to climb.

Beyond DRC, Uganda reported 15 confirmed cases and one death, including a Congolese resident who travelled on to the United Arab Emirates and then Uganda; a US citizen infected in the DRC is being treated in Germany. WHO’s risk assessment holds at very high nationally, high regionally but low globally. WHO is thus pressing countries to lift blanket travel bans now disrupting response supply chains, among them the United States, which barred entry to travellers from the DRC, Uganda and South Sudan days after the emergency was declared.

The US response also included a decision to not repatriate its citizens exposed abroad. The administration planned to divert them to a new quarantine facility at Laikipia Air Base in Nanyuki, Kenya, a country with no Ebola cases of its own. US Secretary of State Marco Rubio said Washington “cannot and will not allow any cases of Ebola to enter the United States.” The plan, backed by a $13.5 million US pledge and defended by Kenya’s President Ruto, met resistance. Kenya’s High Court has suspended it pending a challenge by the Law Society of Kenya and on 1 June, protests in Nanyuki turned deadly when police opened fire on demonstrators, killing two and injuring three. A group of US health experts and former officials warned Congress the scheme raises “profound clinical, ethical, operational, and legal concerns.”

The countermeasures gap

Here is a link to the IPPS (Day 15) tracker, tracking the PHEIC against the 100 Days Mission. There is still no approved vaccine, therapeutic or point-of-care diagnostic for Bundibugyo. The diagnostic gap is significant. GeneXpert does not detect Bundibugyo (early Bunia samples read negative before pan-filovirus PCR caught them), leaving reference-lab assays and a single near-point-of-care kit to fill the gap. Fewer than 1500 tests have been run since mid-May; WHO says five decentralised labs, capable of up to 1000 tests a day between them, should be running across the outbreak zone by early next week. For treatment, a WHO expert group has prioritised the antibody combination MBP134, the antibody maftivimab and the antiviral remdesivir, with oral obeldesivir for post-exposure prophylaxis; the DRC has already approved the trial protocols, and two trials, PARTNERS and EBO-PEP BUNDI, are due to begin soon.

On vaccines, Ervebo covers only the Zaire strain (SAGE advises against using it here outside research); the prioritised Bundibugyo candidates are IAVI’s rVSV-BDBV-GP (7-9 months away from clinical-grade scale-up for supply) and Oxford/Serum Institute of India’s ChAdOx1-BDBV (possibly three), with a Moderna mRNA candidate behind them. The sobering arithmetic: the 100 Days clock runs to 25 August, and even at best no vaccine reaches Ituri in time to bend this outbreak. The access-versus-innovation gap.

Where the response stands

WHO’s Director-General said we had a big head start, and we’re still behind, but we are catching up. The binding constraints are not on the biomedical front. Contact tracing is reaching only about 45% of contacts against the 90% plus needed, in a region that already hosts some 3.6 million internally displaced people (nearly 922,000 in Ituri alone) a crisis deepened by the Rwanda-backed M23’s capture of Goma, which has driven the largest displacement wave in over a decade and where at least 16 health workers have been infected. The crisis in Eastern Congo over the past years has been a time-bomb.

Eight people have recovered, six in the DRC, two in Uganda with early care. Bunia now has three treatment centres and 80 beds, with units standing up in Mongbwalu, Beni, Goma and Bukavu, run alongside MSF, ALIMA and Samaritan’s Purse.

CEPI has just added $9.7 million to a rapid-response vaccine platform aimed at the next Disease X. And WHO set the right test: not whether this outbreak is stopped (it will be) but whether the response prevents the eighteenth, and whether those who survive Ebola are not then lost prematurely by other causes of morbidity and mortality such as malaria or malnutrition. And, I editorialise to add, the effects of war, poverty and displacement. Currently the apparatus designed to keep us buoyant at times of crisis is being tested as it is starved of funds: WHO and Africa CDC will launch a $115 million emergency appeal for the response on Friday 5th June. It is so far only 35% funded for even its initial phase, against a Contingency Fund for Emergencies that Maria Van Kerkhove had already called “dangerously low.”

(Source: WHO; Health Policy Watch; IPPS; IOM; ABC News)

(Image Source: WLIW NPR)

2. WHA79: the full ledger

WHA79 ran 18 to 23 May under the theme “Reshaping global health: a shared responsibility.” Dr Víctor Atallah Lajam of the Dominican Republic was elected president and member states adopted more than 20 decisions and 13 resolutions.

Four NCD firsts. A first-ever stroke resolution, led by Egypt, addressing the world’s second-leading cause of death, with 87% of those deaths in low- and middle-income countries. Formal recognition of steatotic liver disease, which affects an estimated 1.7 billion people. A first precision medicine resolution, updating a 2004 genomics text. And a pharmacovigilance overhaul, dragging a drug-safety framework that dated to 1963 and the thalidomide era.

Emergencies, systems and workforce. A 10-year Emergency, Critical and Operative Care strategy targeting roughly 38 million treatable deaths a year. The first revision in 16 years of the health-worker recruitment code, after an expert review found it isn’t working, with high-income countries saving on health workers trained abroad while promised investment in source countries never came; it now covers care workers and applies in emergencies. A teleradiology resolution to let specialists read scans across borders, plus endorsement of a post-2030 TB strategy.

AMR and the fight that nearly sank it. A new 10-year Global Action Plan (2026 to 2036), the first overhaul since 2015, pivoting from new-drug development toward prevention and writing in environmental obligations for the first time. It was nearly derailed by a months-long contention: Brazil, Colombia and Indonesia objected to language confining technology transfer to “voluntary and mutually agreed” terms, which is at bottom a question of whether developing countries can override patents to make generics in a crisis. The softened compromise references “international and national rules,” which access advocates read as preserving that right; the UK, Germany and IFPMA put on record that they still read it as voluntary. That is largely at the heart of the deadlock stalling the PABS Annex to the Pandemic Agreement, now pushed to May 2027 (or a late 2026 special session), and until it is settled the whole Agreement cannot be ratified.

The budget emergency, and what it is doing to the mandate. Following the US withdrawal, WHO’s 2026 to 2027 budget was cut by 21%, to $4.2bn, leaving the organisation roughly a billion dollars short across the biennium. The headquarters has shrunk from 11 divisions to six and from 67 departments to 36, and the total workforce fell nearly 10% to 8,569 in 2025. Outstanding assessed contributions rose to $184 million, three-quarters of it owed by the US but with another 46 member states also failing to pay their 2025 dues on time. And the structural vulnerability persists. Of WHO’s $3.1bn revenue in 2025, 83% was voluntary contributions and only 8% was fully flexible, which is why chronically underfunded areas such as NCDs remain underfunded.

Importantly, these constraints and changes are reshaping WHO’s role and scope. It has begun stepping back from direct delivery in selected areas, discontinuing scientific leadership of some clinical-trial platforms, including for tuberculosis and multi-country newborn health, while keeping its normative role; ceding protection-linked work in menstrual health and sexual and reproductive health in humanitarian settings to UNFPA and UNICEF; and handing logistics functions to other partners.

Broader development assistance for health fell 21% in a year, led by a 67% US drop, with Germany down 53%, the UK down 39% and France down 33%, and a WHO report released just before the Assembly found the world on track to miss all 52 health-related SDG targets by 2030.

Architecture reform. An Economics of Health for All strategy (2026 to 2030) set out a ‘well-being economy’ framework. The headline governance move was global health architecture reform: a joint process led by member states and run with the UN and major agencies, steered by a 25-member task force and reporting to WHA80 in 2027. The objective, as framed by member states, is to elevate national health sovereignty and country ownership, reflect changing disease burdens, reckon with AI and digital technologies and confront the contraction in health financing, drawing on the UN80 Initiative and parallel efforts such as the Accra Reset. The catch is in the fine print: the mandate explicitly precludes recommending mergers or revisions to existing institutions’ mandates. Wellcome and several states, including Belgium, called it cosmetic; Pakistan warned that “lean must not become synonymous with less,” and civil society condemned its exclusion from the core task force. Ilona Kickbusch framed it as a debate about power: who holds it, who is losing it, and who intends to use this moment of rupture to consolidate it.

The geopolitics. The Assembly moved to suspend US voting rights for 2027 over unpaid dues, the first Assembly in memory without the US in the room. It declined to formally recognise Argentina’s withdrawal, leaving a backdoor open. It voted 91 to 2 to condemn Iranian strikes on Gulf states and Jordan and the Strait of Hormuz fallout, with 31 abstentions and China alone naming the US role. A Lebanon resolution passed 95 to 2, with only Israel and Honduras against; Iran’s own counter-resolution was defeated 19 to 30 with 58 abstaining. Decisions on Ukraine and the occupied Palestinian territory were noted, the latter with more than 2000 attacks on healthcare since 2023.

The wins: Elimination certifications for trachoma (eight countries), leprosy (Chile), sleeping sickness (Kenya), malaria (Suriname and Timor-Leste), mother-to-child HIV, HBV and syphilis (ten countries) and trans fat (Portugal and the UAE).

The closing. The final SDG-and-AI item drew no resolution; states noted the reports and closed the file. The WHO Director-General stated that the funding crunch should force digital transformation, saying “the future of health services is digital, whether we like it or not,” and Colombia stated that the world must not replace “old-fashioned inequalities with digital inequalities.”

(Source: Health Policy Watch; Think Global Health; WHO; Public Health Update)

(Image Source: Linkedin via independent author)

3. Also this fortnight

Mpox: finite resources

WHO’s situation report dated 31 May headlines with the update that confirmed cases in Africa have fallen below 200 a week, down from the May 2025 peak. Nevertheless, the decline is partly due to reduced surveillance activities. And WHO has flagged that the DRC’s mpox reporting is now lagging precisely because the country has redirected capacity to the Bundibugyo Ebola response.

The same human and technological resources are now tackling two outbreaks at once. Clade Ib, the strain that drove the 2024 emergency, has produced cases beyond the continent. Cases in Mauritius and community transmission now in nine countries outside Africa, Spain and Germany the most affected. South Sudan, an Ebola-risk neighbour, is seeing an upturn and there was an earlier infant cluster in Sindh, Pakistan that killed eight of 29 confirmed cases. Mpox remains an emergency and some 135 000 vaccine doses are available through the allocation mechanism, with an emergency stockpile due by August.

(Source: WHO Mpox multi-country situation report no. 66; ECDC)

The hidden toll on the plate

Timed to the upcoming World Food Safety Day on 7 June, WHO and The Lancet Global Health published substantially expanded estimates: unsafe food causes some 866 million illnesses and 1.5 million deaths a year, across 42 hazards in 194 countries. The equity pattern is a huge part of the story: children under five, just 9% of the population, bear nearly a third of foodborne illness; Africa and South-East Asia together carry close to three-quarters of cases and 60% of deaths. And a newer finding is that while bacteria and viruses drive most illness, chemical hazards drove 73% of foodborne deaths in 2021, inorganic arsenic and lead alone are linked to over a million through heart disease and cancers. Additionally, climate change and antimicrobial resistance are making it worse.

(Source: WHO; The Lancet Global Health; UN News)

Behind the Scenes

Went into my settings last night and increased my trackpad speed. Now my cursor darts from window to window as fast as my brain after a dirty chai latte and it’s great.

Welcome to WHA79 week. I have just returned from an event hosted in Geneva by the International Pandemic Preparedness Secretariat (IPPS) on the eve of the Assembly. IPPS sunsets its operations early next year. Read my One year left for the 100 Days Mission edition from earlier this year.

Thursday was Ascension Day 🕊️. The long weekend brought news of the Ebola virus outbreak confirmed in Ituri Province in Northeastern Democratic Republic of the Congo (DRC) on 15 May. And in the wee hours of this morning, Sunday 17 May, the Epidemic of Ebola Disease caused by Bundibugyo virus in the DRC and Uganda was determined a public health emergency of international concern (PHEIC) by WHO. This announcement on the eve of the Assembly is huge. Initially shared by a good friend in the field at 3 AM this morning; I had been drafting the outline of this edition last night, already concerned about the highly rapid progression. With only Friday data, however, PHEIC status seemed yet days in the distance. This is the first PHEIC determination since mpox in 2024. All the latest information from official data sources is contained within this newsletter with references provided, below. As we speak, increasing numbers and further information is being shared, some of it yet unofficial.

In the coming hours almost three thousand delegates will be assembled for the Seventy-ninth World Health Assembly in Geneva. This was never going to be an ordinary Assembly. Recent geopolitical shifts, major funding changes, PABS annex postponement and ongoing considerations around the Hantavirus outbreak earlier this month. Combined with the urgent news of the Ebola Bundibugyo virus outbreak; the event takes on a different tone and complexion. Read more in the Fortnight in Resources (FiRs) below.

There is also a breakdown of the main points on the WHA 79 agenda this week. If you are attending and only have five minutes to skim, I have also included some main bulleted talking points for WHA 79 at the end of point 3.

I will be back next fortnight with the Assembly debrief. If you’d like to receive this in your inbox, feel free to subscribe.

Sending best wishes,

Christiana

P.s. Grateful as always to the community and Friends who regularly share information and updates with me, particularly when a newsletter is afoot. If you would like to share something from your area, organisation or research that I might not have come upon, kindly write in response to any of these e-mails.

Reader question

The Hantavirus outbreak occurred on a Dutch-flagged ship in international waters, with passengers from 23 countries, IHR notification was routed through St Helena, a UK overseas territory; and sequence data is now in some degree of ‘restricted-use limbo’. The PABS annex as currently drafted largely assumes an identifiable provider country. Has this outbreak exposed a gap that the architecture being negotiated?

Please write in response to this email or at christiana@globalhealthwriter.com. Your thoughts are valuable to me and the community. They will be shared anonymously and only if you explicitly permit.

1. Ebola Outbreak: Bundibugyo virus in the DRC & Uganda: PHEIC declared on the eve of the Assembly

The WHO Director-General today, Sunday 17 May 2026, determined that the epidemic of Ebola virus disease caused by Bundibugyo virus (BDBV) in the Democratic Republic of the Congo and Uganda constitutes a public health emergency of international concern (PHEIC). The determination was made under Article 12 of the International Health Regulations (IHR 2005), after consultation with the States Parties where the event is occurring. Under the 2024 amendments to the IHR, the Director-General could now potentially make a separate, higher-threshold determination of a 'pandemic emergency'. At the present moment, the event doesn’t meet the pandemic emergency threshold. An Emergency Committee will be convened to advise on temporary recommendations. Nevertheless, a novel outbreak being escalated to a PHEIC within three days in highly consequential and concerning.

The determination came two days after the Director-General first publicly addressed the outbreak in his 15 May afternoon media briefing, having spoken that morning by phone with the Congolese Minister of Health, Samuel Roger Kamba Mulamba, to confirm the new outbreak of Ebola virus disease in Ituri Province. It is the country’s 17th recorded EVD outbreak since the virus was first identified there in 1976. In that press-conference, WHO initially reported 13 confirmed cases by laboratory testing at the Institut National de Recherche Biomédicale (INRB) in Kinshasa. 500 000 USD was immediately released from WHO’s Contingency Fund for Emergencies and additional experts in risk communication, infection prevention and control, clinical care and logistics were deployed to Bunia.

The picture has widened materially since. The 17 May WHO determination reports that as of 16 May, eight laboratory-confirmed cases (with the species characterised as Bundibugyo virus), 246 suspected cases and 80 suspected deaths have been reported in Ituri Province across at least three health zones, including Bunia, Rwampara and Mongbwalu. Unusual clusters of community deaths with symptoms compatible with Bundibugyo virus disease (BVD) have been reported across several health zones in Ituri, and suspected cases have been reported across Ituri and North Kivu. A laboratory-confirmed case has also been reported in Kinshasa, the capital, on 16 May, in someone returning from Ituri.

The Uganda dimension is now larger than first reported. Uganda’s Ministry of Health, in a press statement on 15 May, confirmed an imported Bundibugyo virus disease case in Kampala: a 59-year-old Congolese male admitted to Kibuli Muslim Hospital on 11 May who passed away in intensive care on 14 May; with samples subsequently tested at the Central Emergency Surveillance and Response Support laboratory and confirmed as Bundibugyo.

The Ministry has deployed screening at official and informal points of entry along Uganda’s western border, transit routes and even pilgrimage corridors; activated response at national level and in high-risk districts including a mobile laboratory at Bwera Hospital, isolated one high-risk contact who is a close relative of the deceased gentleman. All individuals who came into contact with the index case have been placed under quarantine.

The WHO 17 May determination adds that a second laboratory-confirmed case was reported in Kampala on 16 May, with the two confirmed cases having apparently no link to one another, within 24 hours of one another. Both were admitted to intensive care units in Kampala. The “no apparent link” language is key here, as it suggests this was not a single chain, making it more difficult to contain.

The healthcare worker dimension is an important one to discuss and indeed, holds a great deal of the history of how the prioritisation of Ebola research in the decades preceding 2014 came to be structured. The 17 May WHO determination notes that “at least four deaths among healthcare workers in a clinical context suggestive of viral haemorrhagic fever have been reported from the affected area raising concerns regarding healthcare-associated transmission, gaps in infection prevention and control measures, and the potential for amplification within health facilities.”

WHO have highlighted the critical gap in medical countermeasures. Unlike for Ebola-zaire strains, there are currently no approved Bundibugyo virus-specific therapeutics or vaccines.

(Image source: ActuNiger)

The WHO-recommended Ervebo vaccine (rVSV-ZEBOV-GP) and the two approved monoclonal antibody therapeutics, Inmazeb (atoltivimab/maftivimab/odesivimab) and Ebanga (ansuvimab), were developed specifically against Zaire ebolavirus. The DRC maintains a stockpile of approximately 2 000 Ervebo doses. Against a Bundibugyo virus disease outbreak it is thought that stockpile may offer limited cross-protection at best, and the antibody therapeutics have not been validated against this species. The Sabin Vaccine Institute has a Bundibugyo candidate in early clinical development. It is not deployable at scale. The WHO advice to States Parties where the event is occurring now explicitly includes implementing clinical trials to advance the development and use of candidate therapeutics and vaccines. At-risk neighbouring countries have been asked to put in place approvals for investigational therapeutics as an immediate priority for preparedness.

The International Pandemic Preparedness Secretariat and partners started their 100 Days counter today, 17 May, with the trigger being the official declaration of a PHEIC.

The WHO field team in Ituri, DRC, received an initial signal of suspected cases on 5 May. Twenty samples collected in Rwampara health zone and analysed at the Provincial Public Health Laboratory in Bunia using the standard Ebola GeneXpert assay tested negative, because the GeneXpert cartridges in use were calibrated for Zaire ebolavirus. The samples were sent to INRB in Kinshasa for further analysis, where eight were confirmed as Orthoebolavirus by PCR on 15 May. Genomic sequencing confirmed the species as Bundibugyo virus (BDBV).

In that regard, the lag between 5 May and 17 May PHEIC determination is technically explicable but still operationally consequential, particularly given the suspected index case (a nurse), the urban context, and the four healthcare worker deaths now reported.

Ituri sits more than 1 000 km from Kinshasa, it is forested, elevated in parts, served by poor road infrastructure and has been under sustained pressure from armed group activity. An attack in Ituri Province killed at least 69 people the week before the outbreak was confirmed. Mining-related population mobility in Mongwalu, urban transmission risk in Bunia and proximity to the Ugandan and South Sudanese borders are all listed by WHO and Africa CDC among the factors elevating spread risk. The 2018 to 2019 Ebola virus disease epidemic in North Kivu and Ituri provinces killed more than 2 200 people in a comparable operational environment.

A coordinated regional response is now in motion as explained by WHO AFRO Regional-Director Dr Janabi on Friday. Additionally, Africa CDC are convening a high-level coordination meeting with the health authorities of DRC, Uganda and South Sudan, alongside WHO, UNICEF, the US CDC, the European CDC, China CDC, the Public Health Agency of Canada, Gavi, CEPI, the Pandemic Fund, the African Medicines Agency, the Wellcome Trust, the Gates Foundation and a long list of pharmaceutical partners including Gilead, Merck, Johnson & Johnson, Regeneron, Roche, BioNTech and Moderna. So basically, everyone.

The WHO advice for States Parties with land borders adjoining the DRC and Uganda urges enhanced preparedness and readiness capacity, active surveillance, reporting, community surveillance for clusters of unexplained deaths and rapid response team activation. WHO has nevertheless been explicit that no country should close its borders or place restrictions on travel and trade.

The DRC has institutional experience that few countries can match: 16 prior EVD outbreaks, the response infrastructure from the 2018 to 2020 Kivu outbreak and a research apparatus at INRB that few national institutes anywhere possess. The question is whether that experience and expertise will be enough given the species and importantly, the highly security constrained operational environment presented.

Read more: WHO statement: Bundibugyo virus PHEIC determination, 17 May 2026; Uganda Ministry of Health press statement, 15 May 2026; WHO Director-General’s opening remarks at the media briefing; Africa CDC statement, 15 May 2026

2. The Andes hantavirus cluster: where the Hondius response now stands

Two weeks on from the 2 May notification, the Hondius event is moving into a new phase. ECDC’s 16 May update puts the cluster at eleven cases (eight confirmed, two probable, one inconclusive) with no new cases or deaths reported since the previous update. WHO Director-General Tedros Adhanom Ghebreyesus confirmed in Friday’s briefing that more than 120 people were successfully transferred from Tenerife and are now being cared for in their home countries or quarantined en-route to their final destinations. The ship’s captain and 26-member crew remain onboard and are expected to dock in the Netherlands on Monday 18th.

WHO continues to assess the global risk as low.

Andes orthohantavirus (ANDV) is the only species in the family Hantaviridae with documented person-to-person transmission, restricted to close prolonged-contact settings rather than the airborne sustained transmission profile that would change the calculus. Hantavirus cardiopulmonary syndrome (HCPS) has an incubation period of up to six weeks, which means cases may continue to emerge in returning passengers through into mid-June. As the Director-General noted on Friday, “this does not mean the outbreak is expanding; it shows that the control measures are working.” But the framing matters in the current media landscape.

Medical countermeasures for Andes hantavirus do not exist. The UK Health Security Agency convened an open scientific consultation on Andes virus medical countermeasures on 15 May, supported by the WHO R&D Blueprint, with the aim of identifying gaps and establishing priorities for therapeutics and vaccine research and development. There are no licensed vaccines against any Hantaviridae species. There are no specific antiviral therapeutics. Clinical management remains supportive care with mortality at 20% to 40% in confirmed HCPS cases. The IPPS and Impact Global Health 100 Days Mission Scorecard 3.0, published in January 2026, scored the Hantaviridae family with no approved products across diagnostics, therapeutics or vaccines, no candidates in human trials, no platform technologies in use across the product classes and all R&D enablers absent.

The origin question remains open. A single Argentine road trip between Chile, Uruguay and Argentina between November and April has been the leading hypothesis, with attention focused on a bird-watching visit near a landfill site, though experts have publicly questioned that specific theory. The genomic and environmental investigation continues. The IHR (2005) notification chain has held throughout.

And then there is the question the Hondius has handed to the Assembly. The outbreak occurred on a Dutch-flagged ship in international waters with patients drawn from 23 countries. The causative agent is endemic to Chile and Argentina, where the cruise departed from. Laboratory confirmation was performed in South Africa. IHR notification was routed through the United Kingdom because Saint Helena is a UK overseas territory. The first four sequences are now posted on Pathoplexus under restricted-use terms for up to one year. Technically accessible but legally constrained for publication, product development or onward analytical work without submitter sign-off.

The Pathogen Access and Benefit-Sharing (PABS) System annex as currently drafted generally assumes an identifiable provider country with sovereign rights over the pathogen. The Hondius event presents a very different frame. Whether the outbreak even falls within the scope of “pathogens with pandemic potential” is itself a definitional question, given that Andes orthohantavirus has never caused sustained outbreaks beyond the Southern Cone. The fast response to Hondius showed the political willingness of countries to cooperate; perhaps, in part, due to the highly international nature of this case, the element of the cruise; and some have argued, the profile of many of those potentially exposed. The legal questions the outbreak raises around pathogen origin and the structure of the PABS system at large; and how it serves in various forms of events that are not easily anticipated in a globally connected world; are what Member States now have until a little before May 2027 to answer.

The relevance to WHA 79 is that the Assembly opens on Monday with IHR (2005) implementation, the Intergovernmental Working Group (IGWG) on the WHO Pandemic Agreement and public health emergencies preparedness and response all on Committee A’s docket as items 13.1, 13.2 and 13.3. This event as well as the Ebola Bundibugyo virus PHEIC will sit as considerations across informal and formal conversations about pathogen surveillance, point-of-entry coordination, sequence data sharing and what preparedness looks like in 2026.

Further reading: WHO Disease Outbreak News; ECDC threat assessment update, 16 May 2026; WHO Director-General’s opening remarks at the media briefing, 15 May 2026; WHO statement, 7 May 2026; IPPS / Impact Global Health 100 Days Mission Scorecard 3.0; WHO statement: Bundibugyo virus PHEIC determination; Uganda Ministry of Health press statement, 15 May 2026

Past GHC Edition:

3. WHA 79: what is actually on the table this week

The Seventy-ninth World Health Assembly (WHA79) opens at the Palais des Nations on Monday 18 May 2026. It officially runs through Saturday 23 May.

Last year’s ‘One World for Health’ theme landed well - in the wake of significant change, caution, concern; and perhaps more hope from delegates and Member States. This year’s agenda is substantive and concentrated. The provisional agenda (A79/1, from the end of the EB, 19 March 2026) is longer than usual and the interactive contents document will be your friend this week.

Today, as always, kicked off with the Walk the Talk: Health for All Challenge. Everyone in their navy blue t-shirts and on this unusually cold May Sunday, jackets too. It is a relatively recent but valuable drive to promote physical health in light of rising NCDs.

Tip: If you find yourself with only 5 minutes to skim this section, scroll down to the Main talking points for WHA 79 bullet block at the end. :)

The Pandemic Agreement, IHR (2005) implementation and the PABS Annex are the items that will define the week

The Intergovernmental Working Group (IGWG) on the WHO Pandemic Agreement. As covered last fortnight, the PABS Annex negotiations missed their 2 May deadline. The next IGWG session is scheduled for 6 to 17 July. The Assembly will be asked to allow negotiations to continue, with the final Annex to be submitted to WHA 80 in May 2027 at the next WHA; or earlier at a special session in 2026 if possible; but I cannot imagine this to be likely.

Colombia, speaking for the Group for Equity, proposed a change of method, the concept of ‘progressive consensus’, in which once a majority is reached on specific points, a vote should be held if necessary and negotiations should continue. South Africa, for both the Africa Group and the Group for Equity, expressed regret at the continuing lack of consensus and cautioned against approaches that risk decoupling access from benefit-sharing. The Director-General, closing the most recent session, called the negotiations “a roller coaster” and reminded delegates that “the next pandemic is a matter of when, not if.” covers IHR (2005) implementation, with information documents extending the standing recommendations for Mpox.

The IHR mechanism itself is now under live use: the Bundibugyo PHEIC determined Sunday is the most consequential application of Article 12 since mpox in 2024 and the Emergency Committee convening this week will sit alongside the formal Assembly agenda.

I discussed all this in greater detail in last fortnight’s issue.

The Programme Budget 2026 to 2027 is where the financial picture finally gets formal

Financing, implementation and performance framework for the 2026 to 2027 biennium. WHO has proposed a US $4.2 billion budget, a meaningful reduction from earlier projections, and the Director-General has signalled material staffing reductions tied to an in-year funding gap of approximately 25%, much of it attributable to United States withdrawal and unpaid dues. The audited financial statements for the year ended 31 December 2025 will land alongside. The status of collection of assessed contributions including Member States in arrears, is the agenda item where the US arrears situation is technically addressed. Item 18.12 on the Secretariat implementation plan on reform is the other lower priority yet recognised highly consequential item in this cluster.

Antimicrobial resistance gets its decade plan

The draft updated Global Action Plan on Antimicrobial Resistance 2026 to 2036. The previous plan is from 2015. The new plan reflects the 2024 UN General Assembly High-Level Meeting commitments and is one of the items most likely to produce a substantive resolution this week.

Reform of the global health architecture and the UN80 Initiative is the Committee B sleeper

The UN80 Initiative, UN Secretary-General Guterres’ reform agenda timed to the organisation’s 80th anniversary, has direct implications for WHO’s place in the multilateral system.

Topical (not on the agenda): the next Director-General.

As covered last fortnight, Dr Tedros’s second term ends in August 2027. Member States have until 24 September 2026 to submit nominations. The Executive Board will nominate up to three candidates in 2027 before the final appointment is made by the Assembly. The early field is wide and unofficial. The next Director-General will be chosen to answer the broader question of how WHO is positioned within the evolving multilateral system and what Member States now view as its position and function within the broader ecosystem of governance.

The rest of the agenda

1. Malaria elimination, follow-up to the political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases;

2. Mental health

3. End TB Strategy update

4. Universal Health Coverage, including the draft global strategy for integrated emergency, critical and operative care 2026 to 2035 and the new rare diseases priority

5. Report of the Expert Advisory Group on the WHO Global Code of Practice on the International Recruitment of Health Personnel

6. Harmonisation of regulatory approaches, governance and standards for data, digital health and artificial intelligence in the health sector

7. Health of Indigenous Peoples

8. Maternal, infant and young child nutrition

9. Standing Committee B item on health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan. The complete picture is captured in the bullet block below.

Main talking points for WHA 79

• PHEIC determined Sunday 17 May: Bundibugyo virus disease in the DRC and Uganda. First PHEIC since mpox 2024. Emergency Committee to convene this week. No approved Bundibugyo virus-specific therapeutics or vaccines.

• Pandemic Agreement and PABS Annex: Agreement substantively adopted at WHA 78. Annex negotiations missed the 2 May deadline. Next IGWG session 6 to 17 July. Annex to be submitted to WHA 80 in May 2027 or earlier at a special session in 2026. The Group for Equity Member States proposing ‘progressive consensus’. Item 13.3, document A79/8.

• IHR (2005) implementation: Standing recommendations for mpox and COVID-19 extended. Hondius and the Bundibugyo PHEIC are the live test cases. Item 13.2, document A79/7.

• Programme Budget 2026 to 2027: US$4.2 billion proposed, approximately 25% funding gap tied largely to US withdrawal and arrears. Item 18.2, document A79/15.

• Status of assessed contributions and arrears: The agenda item where the US arrears situation is technically addressed. Item 18.3, document A79/17.

• Global Action Plan on Antimicrobial Resistance 2026 to 2036: Decade-long update on the 2015 plan. Item 12.9, document A79/5 Add.2.

• UN80 Initiative and global health architecture reform: Committee B item with implications for WHO’s position in the multilateral system. Item 20.1, document A79/24.

• DG succession in every conversation: Tedros’s term ends August 2027. Nominations close 24 September 2026. Early candidates as covered in the previous fortnight.

• Non-communicable diseases: Follow-up to the 2024 UN HLM political declaration. Item 12.1, document A79/5.

• Mental health and social connection: Includes the outcome of the WHO Commission on Social Connection. Items 12.2 and 15.2.

• Digital health, AI and data governance: Harmonisation of regulatory approaches. Item 12.10, document A79/5.

• End TB Strategy update: Item 12.3, document A79/5.

• Malaria elimination: Standalone item this year. Item 11, document A79/4.

• Health conditions in the occupied Palestinian territory: Resolution EB158.R6 carried forward. Item 17, documents A79/11 and A79/12.

• Lower-profile but consequential: Secretariat implementation plan on reform (18.12), International Recruitment of Health Personnel Code (12.8), health of Indigenous Peoples (15.3).

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Welcome to the month of May. The next time you hear from me will be on the eve of the 79th World Health Assembly in Geneva. If you are not yet subscribed, now is a good time to do so for those important updates.

Last night, a good friend within the field messaged to explain that they had been busy because there had been an event. At first, my mind went to happier possibilities: a birthday, a gala, a gathering. Then I realised they meant an outbreak. Skip to the FiRs below to catch up on what we know so far about the Hantavirus outbreak.

This week, I found notes and photos from my first ‘real’ World Health Assembly, when I was a young postgraduate researcher from UCL in May 2017. I remember standing in the Palais des Nations waiting for the result the year Dr Tedros Adhanom Ghebreyesus was elected WHO Director-General. Nine years later, WHA79 is only weeks away and the next DG process has begun, with nominees starting to be named. Read more in the FiRs below.

As I did last year, I have prepared a list of publicly accessible, non-invitation only side events for researchers and young professionals who may not hold formal credentials. You make up almost 30% of this community and you will not find as comprehensive a list anywhere else. For regular attendees and delegates, the official WHO side events list was also published earlier this fortnight. The non-invitation list is not in the FiRs below. Despite my best efforts, it was just far too long/data heavy to include within this edition. Find the article here on my website blog, it is live and everything is hyperlinked. (The sheer volume of links!)

The Pathogen Access and Benefit Sharing System (PABS) Annex negotiations have stalled again and will not be completed before the World Health Assembly. The Assembly will be asked to allow these complex negotiations to continue, with the Annex to be submitted at the 80th Session in May 2027.

On my side, what a month. It began in London, then Buckinghamshire. I browsed Bloomsbury bookshops and attended my first Pakistani wedding, for the family of a dear friend, with past podcast guest Maria Kasimati, talking endlessly about drugs, pharmaceutical financing and women’s health.

In Paris, I took a late stroll through the 8ème and had the honour of speaking at the historic Bicentenary celebration of my alma mater, UCL, held at the Cercle de l'Union Interalliée. I spoke on an international career in R&D and biomanufacturing policy in Global Health and Health Security; as well as the value of building Community in all facets of personal and professional life.

UCL was the place where I was watered, nurtured, challenged, stretched and found Community. It holds a special place in my heart. It is unique not only for its progressive values and commitment to excellence, but also for how it treats its pupils. I was treated as a professional in training, someone whose views and perspectives held value. I was empowered to succeed by the trust and belief placed in me by colleagues and educators.

A few days later, on a beautiful farm outside Basel, I celebrated a friend's birthday and had enriching conversations with interesting, intelligent people, connecting with new and old friends in the Basel pharma ecosystem. Back in Geneva, I did my best to watch the TIME100 celebration, where INB co-chair Precious Matsoso was honoured for her remarkable work on the Pandemic Accord.

My current read is Vivre avec les hommes, Manon Garcia’s excellent reflection on the Gisèle Pelicot case. Garcia, a feminist philosopher who attended the trial, draws on Hannah Arendt’s idea of the banality of evil to argue that the ordinariness of the accused men is itself part of the indictment.

That argument felt especially apt after CNN’s recent investigation into a website described as a “rape academy”, that 62 million men reportedly visited to learn and exchange tips on how to drug and victimise their children, wives, partners, mothers and other women in their lives and proximity in the month of February. It is one of the larger findings of its kind, but by no means the first. When a German police commissioner later said that, based on the statistics, it is safer for women not to interact with men, many men online responded by threatening his life. Perhaps in response to these repeated revelations, the EU has passed landmark legislation on consent: “Only yes means yes.” Whether it transforms culture as well as law remains, as ever, the longer question. There have been a plethora of harrowing, global stories with upsetting scale over the past two years. One thing is certain: women are not sufficiently safe - neither in their homes or in public.

This time last year, in the Reader Conversations section ahead of the WHA78 post, a member of our community posed the question of whether the pursuit of equity unintentionally sidelines potential allies in the Global North. Today, I can say with greater certainty that this is not the case. We are now grappling with the relevance, or lack thereof, of multilateralism itself. African leaders meeting in Nairobi this week were compelled to declare the end of the aid era, as ODA for health fell by an estimated $31.1 billion in 2025. It seems the question has been answered through facts rather than postulation. African leaders in the space now feel that it was not the pursuit of equity that sidelined allies. Ultimately, for a range of geopolitical and other reasons, those allies left themselves. In this regard, and returning to PABS, Colombia, part of the Group for Equity, has proposed a change of method in light of the extended negotiations. More in the FiRs below.

Until next week, Friend,

Christiana

1. April 2026: Some Important Dates

• Sudan has entered its fourth year of civil war. More than 150,000 people are estimated to have been killed and millions displaced. Khartoum has been devastated. The dignified people of Sudan deserve their home back. Please consider doing what you can within your purview. May their country not become a memory. OCHA Sudan, MSF Sudan, CARE Sudan and UNHCR Sudan.

• April 25 marked World Malaria Day. At a moment when the collapse of development assistance threatens to unravel decades of hard-won progress, it is a sobering reminder that malaria still claims more than 600,000 lives each year, most of them children under five in sub-Saharan Africa.

• April 27 marked South African Freedom Day. On that day in 1994, South Africa became a country for the first time, holding its first democratic elections. Nkosi Sikelel’ iAfrika, “God Save Africa”, is now part of South Africa’s national anthem. The first two verses were composed by Enoch Sontonga. I have never met a South African who does not know it. Yet before freedom and democracy, it was illegal to sing it in South Africa. Here is a version performed by multiple Grammy Award-winning Ladysmith Black Mambazo at the Montreux Jazz Festival in 1989. I often say that freedom was won through intelligence, organised resistance, bloodshed at the hands of a murderous, fascist, white supremacist regime and the arts.

2. The Current nomination process for the next WHO Director General

The nomination process for the next Director-General elect of the World Health Organization has formally begun. Dr Tedros Adhanom Ghebreyesus’ second term ends officially in August 2027, and WHO Member States have until 24 September 2026 to submit nominations. The Executive Board nominates up to three candidates in 2027 at the EB, before the final appointment is made by the World Health Assembly in May.

Dr Tedros has led WHO through one of the most consequential periods in its history: COVID-19, Mpox, multiple Ebola outbreaks, repeated humanitarian health emergencies, the long struggle for a Pandemic Agreement and the continuing defence of universal health coverage as both a political and technical goal. He has always notably counted his tenure in days, not years or months. This is something that I always found revealing. It seems to suggest that every day counts and carries responsibility.

This will not be an ordinary succession. Whoever follows him will inherit an institution under profound pressure: geopolitical fragmentation, constrained donor financing, internal reform demands and the unresolved question of rebuilding trust with Washington. Health Policy Watch reported that the United States withdrawal and unpaid dues have left WHO with a significant funding gap of around 25%. Not to mention the subtle exodus of professionals across the field from Geneva, even beyond WHO to other institutions; and the profound change in morale since early 2025.

Nothing is final or set in stone but the list of names circulating is already long. Among those most discussed are:

• Indonesia’s Health Minister Budi Gunadi Sadikin;

• WHO Chief Scientist Jeremy Farrar, formerly at Wellcome;

• WHO EMRO Regional Director Hanan Balkhy;

• PAHO Director Jarbas Barbosa;

• Current Gavi CEO Sania Nishtar and

• WHO Europe Regional Director Hans Kluge

Additionally, Germany may be considering putting forward Helge Braun, former Chief of Staff to Angela Merkel, while other German names have included Karl Lauterbach and Paul Zubeil. All this being said, a possible German candidacy is somewhat complex. Braun’s fiscal and crisis-management experience may appeal to donors seeking reform, but Germany’s financing cuts, its record on vaccine patent waivers and other recent geopolitical motion could possibly complicate support from certain countries as well as many low- and middle-income Member States.

Newer names reportedly being floated include Qatar’s former Minister of Public Health Hanan Mohamed al-Kuwari and Spain’s Maria Neira, who recently retired from WHO as Director of Climate, Environment and Health. Hanan Balkhy is attracting particular attention as a Saudi national, current EMRO Regional Director and possible bridge candidate.

Member States are likely to weigh technical credibility against political distance from the current WHO leadership, reform credentials, continuity and perceived approach to fiscal discipline.

For now, all of this should be observed carefully - the field remains incredibly unofficial until Member States submit formal nominations. Politics may shift; and they often do. Still, the early contours are clear. The next Director-General will not only be chosen to lead WHO. They will be chosen to answer the broader question of how WHO will be positioned with its evolving role within the equally evolving multilateral system. What Member States now think WHO is for, who it is accountable to and how much solidarity they are still prepared to finance will all be factors in this decision.

(Sources: Lancet, Health Policy Watch and (2), STAT News)

3. Hantavirus Outbreak Update

A rare and serious Hantavirus cluster has emerged aboard the MV Hondius, a cruise ship that departed Ushuaia, Argentina on 1 April 2026, travelling a remote route across the South Atlantic, including bird watching spots across mainland Antarctica, South Georgia, Nightingale Island, Tristan da Cunha, Saint Helena and Ascension Island, before mooring off the coast of Cabo Verde. As of 5 May, WHO has reported two laboratory-confirmed cases and five suspected cases, with three deaths recorded.

CASES 1 & 2: Fatal

The third death reported by WHO remains a mystery, as we only have information on two of them. One, a 70 year old man from the Netherlands who passed away aboard the ship. According to South African minister of Health, Dr Aaron Motsoaledi, his body was embalmed and despite the high likelihood that he succumbed to the new Hantavirus, this has not been able to be confirmed through laboratory diagnosis and forensics. The second, his wife, 69, was flown to O.R. Tambo International Airport in Johannesburg from St Helena to fly back to the Netherlands. It was there in the airport that she passed out and fainted.

It was upon testing post-mortem in South Africa that this Hantavirus clave was thus identified and shared with the international community. The initial cause of death of the first patient had not been identified prior. And thus, she had hitherto not been isolated ahead of her passing.

CASE 3: Critical but stable & Isolated

The third patient, a British national, remains critically ill and in isolation at a private hospital in Sandton, Johannesburg.

South Africans online are not calm, despite repeated calls form calm. As the patients that entered South Africa did so before the virus was identified, they are expected to have had numerous touchpoints with members of the public. Moreover, the incubation period for the virus is up to 6 weeks. Contact tracing efforts have begun in South Africa, which is currently on high alert.

The Story:

South Africa has thus become a focal point of the response because of the Dutch national that entered the country and the British national who remains in hospital in Johannesburg. The 70-year-old man who died on arrival at Saint Helena Island presented with fever, headache, abdominal pain and diarrhoea. His wife had also been suffering from gastrointestinal symptoms before she collapsed at OR Tambo while connecting to a flight home to the Netherlands on 25 April. She passed away at a Kempton Park health facility on 26 April. Her hantavirus infection was confirmed by PCR on 4 May. The South African Department of Health has called for calm, noting that only two patients from the vessel entered South African borders. The National Institute for Communicable Diseases (NICD) is supporting the aforementioned contact tracing efforts, while WHO is actively tracing those who were on the Saint Helena–Johannesburg flight.

Of particular concern is the possibility of human-to-human transmission. While hantavirus is an airborne disease typically transmitted to humans via the urine, excrement or saliva, the pattern of cases aboard the MV Hondius, where cases had very close contact with one another, means human-to-human transmission cannot be ruled out. Indeed, while Hantavirus has no vaccinations, it is a well known disease, studied over several decades.

Primarily affecting the kidneys, it wasn’t until 1993 when the variant most common across the Americas - north, central and south; was found to cause significant respiratory effects. The nature of this virus is that its symptoms are not dissimilar to those of influenza. As South Africa enters winter and flu season, this adds an additional element of concern for community transmission.

The suspected strain in this case is thought to be the Andes variant, the only known hantavirus species with documented human-to-human transmission. Although limited genomic data is available at present. There are also currently no specific antiviral treatments available; patients receive supportive care, including respiratory support.

This is the first recorded hantavirus outbreak aboard a cruise ship. WHO Regional Director for Africa Mohamed Yakub Janabi has described it as “a serious but contained event,” and has stated that there is no need for panic or travel restrictions at this stage. The situation remains active and developing. GHC will continue to monitor it ahead of and during WHA79. CEPI just published this explainer on Hantaviruses.

(Sources: WHO Disease Outbreak News; NICD Statement; NICD Hantavirus Fact Sheet; SA Department of Health Media Statement; SAnews – Call for Calm; WHO Africa – Risk Remains Low; News24 – SA Health Dept urges calm; News24 – WHO tracing Joburg flight contacts; News24 – What is hantavirus?)

4. PABS Update

After nearly a year of talks on this particular annex of the Pandemic Accord, ratified at WHA78 in May 2025 (and with negotiations completed just in time); WHO member states have failed to reach agreement on the Pathogen Access and Benefit Sharing (PABS) Annex before the 2 May deadline.

Negotiations have been extended to July, with the next Intergovernmental Working Group (IGWG) session scheduled for 6–17 July. A resolution will be put to the World Health Assembly, which opens on 18 May, requesting that negotiations continue, with the final agreement annex to be submitted to WHA80 in May 2027, or earlier at a special session in 2026 if possible. As a reminder, the PABS Annex governs how countries share pathogen samples and genomic data during public health emergencies and how the resulting medical products: vaccines, therapeutics and diagnostics are equitably distributed. Without it, the Pandemic Agreement adopted last year cannot come into force.

An important intervention this fortnight came from Colombia.

Speaking as part of the Group for Equity, a large cross-regional alliance that has been pushing for a PABS system that prevents the inequities of the COVID-19 vaccine rollout from being repeated; Colombian Ambassador Germán Velásquez argued that extending the negotiating period without changing its method is insufficient: “It is not possible to continue seeking consensus in the same way. Why not introduce the concept of ‘progressive consensus’? Once a majority has been reached on specific points, a vote should be held if necessary, and negotiations should continue.”

South Africa, speaking on this occasion for both the Africa Group and the Group for Equity, expressed “deep regret” at the continuing lack of consensus, cautioning against approaches that risk decoupling access from benefit-sharing, a reference to a “hybrid” model proposed by some European countries. WHO Director General Dr Tedros, closing the session, acknowledged the talks had been “a roller coaster,” and urged all member states to approach the outstanding issues with urgency: “The next pandemic is a matter of when, not if.”

There’s a road ahead.

(Sources: Reuters; Health Policy Watch)

Behind the scenes

Basel, London, Buckinghamshire, Lausanne, Geneva, Paris, Mum’s birthday 💕 and more. But in the collage I specifically wanted to highlight the ongoing international UCL200 Alumni celebrations and the historic event I had a chance to attend in Paris. If you are part of the alumni community, I encourage you to reach out to UCL or your Local Chapter at this special and historic time. The Bartlett school are also hosting some special events, walking through the built environment and UCL’s heritage in London this week and next. Regardless, do connect, be part of community, give more than you take, make friends and have fun.

I hope that you and yours have had a wonderful Easter period thus far and are enjoying this time of rest and reflection. There are headlines below and two pieces in the FiRs on Gilead’s Lenacapavir and a brief update on PABS. Skip to that section to read more.

I have often heard it said that one ought to create more than one consumes. It is one of those maxims that leans towards that most meta version of modern capitalism. i.e. Seeing as society requires that consumption exceeds creation on a macroeconomic level, the word ‘creation’ is really just a substitute for that key classic factor of production: labour. On an individual level, it is unappealing to regard oneself as a unit of production, hence the motivational rebrand. It is nevertheless imperative that we take time for rest - emotionally, spiritually and physiologically.

As a writer, even a hobbyist one, I believe that I ought to consume far more than I create in order to be effective. When I find myself writing more than I am reading, the process of writing becomes harder. I fall into repetition and my scope of thoughtful influence and even easily accessed vocabulary slowly narrows. Reading for work and pleasure allows me to think, sit with partially formed thoughts, regard situations more objectively and develop nascent opinions. Additionally, and perhaps most evidently within this forum; ‘consuming’ news, studies, financial disclosures, recent publications, etc. makes my commentary more useful and valuable to you, the reader. So if you have spent your weekend doing nothing more than eating a leg of lamb and all the chocolate you could find, chatting with friends and loved ones, soaking up the sunshine, reading a book or binging a series; I feel that this is not only okay but beneficial if it facilitates rest. We are humans, not productivity machines.

This fortnight saw the end of the current session of the Pandemic Accord negotiations on the Pathogen Access and Benefits Sharing Annex. The 23 – 28 March IGWG session in Geneva ended without consensus, with member states still divided over some of the annex’s core issues: how pathogens and related data should be shared, what benefits should be mandatory in return and how the system would be governed and made workable in practice. Talks will now resume on 27 April – 1 May, just ahead of the World Health Assembly.

The other big story of the week concerns Gilead Sciences and MSF, who have recently published an open letter after discussions ended in a refusal from Gilead to sell Lenacapavir to MSF to use in its humanitarian programmes. Gilead has explained that it remains committed to sustainable access through existing partnerships, including through the Global Fund. MSF and others argue that this leaves access too restricted and tightly controlled for a tool with such transformative prevention potential, reiterating their intention to purchase the drug. More on these below.

Hope it is a wonderful weekend. Until next fortnight, Friend.

Christiana

Some headlines from the fortnight that are not addressed in the FIRs.

• Think Global Health: A New Era for Alzheimer’s Disease Diagnosis

• UN resolution against slavery’s historical wrongs

• IVI and Brazil sign letter of intent supporting the establishment of the BRIGHT Fund, advancing a Global South-led model for health innovation

• Serum Institute signs agreement for Shigella, E. coli vaccine R&D

• Gilead Sciences to Acquire Ouro Medicines to Advance First in Class T Cell Engager Program for Autoimmune Diseases

• Think Global Health: The Expanded Global Gag Rule and the Case for Regional Solidarity

• Gates Medical Research Institute CEO Patrice Matchaba retires, interim head appointed

• Stumbled upon this excellent video on the complex sanitation systems in modern day Ghana in the 1800s, long before John Snow’s experiments in London (past podcast episode) where underdeveloped sewerage systems led to London’s widespread Cholera outbreak.

• Vaping Likely to Cause Lung and Oral Cancer

• Two-Speed Multilateralism: Breaking the Deadlock on Climate and Health

• Argentina Has Revoked Key Patentability Guidelines

• New WHO guidelines on TB tests recommend new near-point-of-care molecular tests, easy-to-collect tongue swab samples, and a cost-saving sputum pooling strategy

• Denmark has effectively controlled the main HPV strains with causal links

• Available Cervical Cancer Vaccines Fail to Cover the HPV 35 Genotype Common in Africa

1. Pandemic Accord: PABS negotiations stall - again

The latest round of negotiations on the Pathogen Access and Benefit Sharing (PABS) System annex, convened under the Intergovernmental Working Group (IGWG) from 23 – 28 March 2026 in Geneva week before last was hoped to bring closure to one of the most technically complex and politically sensitive components of the Pandemic Agreement. Ultimately, this time it concluded without consensus. Insiders foresaw this while hoping for the best. As someone who has worked closely alongside the negotiations in the past, I admit that despite my best hopes I anticipated the same. Positions, rightly in many cases, remained largely entrenched and negotiators departed at the end of the week without resolution.

This will be a very high level view of the updates. I will provide more detail after the next session. I have shared some of my past resources on the Pandemic Accord and PABS below.

• Pandemic Agreed, now what?

• Pandemic Accord Negotiations Stall

• Spotlight on Drug Licensing and the Pandemic Accord

• Special: Pandemic agreement round up as INB 11 concludes

• What is the Pandemic Accord, really? (Podcast)

• Drug Licensing and the Pandemic Accord (Podcast)

The Equity group as well as the EU, EEA states, Canada, Australia and others have generally long held firm positions on this particular aspect of the Accord. As you may recall, PABS was once Article 11 within the Pandemic Agreement. Ahead of the last World Health Assembly in May 2025, it was moved to an annex in order to facilitate moving the agreement through; allowing more time to negotiate the most contentious part of the agreement.

The outcome of no outcome underscores a recurring dynamic across the Pandemic Agreement process: broad political alignment at the level of principles, but divergence at an operational level. The PABS annex sits at that intersection.

The annex is intended to ensure two parallel outcomes during future public health emergencies:

1. Rapid sharing of pathogens, genomic sequences and related data;

2. And the fair and equitable distribution of benefits arising from their use, including vaccines, diagnostics and therapeutics (DTVs)

The second point is the biggest sticking point. Most outbreaks occur near the equator, in regions with higher human-animal interfaces, higher likelihood of zoonotic spillover or in the global south more broadly. Genomicists and scientists rarely hesitate to share this data. Nevertheless, the element of sharing the benefits of the resulting DTVs in the form of even being available for purchase in the originating region has remained highly inconsistent. The Nagoya Protocol, while not designed for emergencies, largely covers rapid sharing while requiring prior informed consent which, in practice, could slow down the sharing. Benefit sharing is also a core tenet of the protocol, including stipulations around both monetary and non-monetary benefits (i.e. access to medical countermeasures, tech transfer, capacity building.) Nevertheless, it operates through non-standardised agreements, often bilateral ones and COVID-19 demonstrated its limitations within the acute emergency context.

The structure of the week reflected incremental movement but also a constraint. Early sessions on Monday and Tuesday focused on Section I of the current draft: scope, objectives and definitions; following some disagreement over the negotiating text that slightly delayed progress. By midweek, discussions shifted to operational provisions, including the definition of users (which was always going to be a tricky one to navigate) as well as governance of databases and laboratory networks and modalities for benefit-sharing. Formal negotiations were complemented by numerous informal consultations often extending throughout lunchtimes and late into the evenings, the usual drill, but yielding limited convergence, no matter how tired negotiators may have been.

Negotiators are subject to their capitals with minimal wiggle room. I mention this because time and time again, throughout INB sessions and beyond, the Pandemic Accord negotiations have also drawn protestors to this city, largely galvanised by the concern that WHO as an entity is independently deciding governance that may affect the daily lives of individuals globally. And/or force needles into the arms of civilians. The imagery feels viscerally violent, even to me, the writer; but this is the language employed to encourage backlash and protests. I am infinitely proud that we exist in a society where people have the right to protest. Nevertheless, the information upon which many of these gatherings are mobilised is just not an accurate reflection of reality. Our elected governments and their negotiators here in Geneva are beholden to their respective administrations, and are here to represent their wishes. All have to agree upon the text before it moves from white, to yellow to green.

Nevertheless, the most consequential issues remain unresolved. Three principal areas of contention continue to define the negotiations. For ease, I will use ‘developing’ and ‘developed’ countries but this is a gross over simplification. Many of those in the ‘developing’ camp here are in fact high-income countries and upper-middle-income nations. Similarly, there are ‘developed’ country nation states here that have lower GDPs that the ‘developing’ ones. We live in a non-binary world in this regard (just look at the BRICS) and even ‘Global North/South’ fails to account for the current positions of states such as Australia, Argentina, New Zealand, etc. Generally speaking, we all know who we are referring to with ‘developing’ and ‘developed’ even if these categories are not comprehensively reflective.

1. First, the relationship between access and equity. Developing countries have maintained that access to pathogen materials and sequence data should be linked to predictable and enforceable benefit-sharing commitments, reflecting the inequities experienced during the COVID-19 pandemic. Developed countries have emphasised the need to preserve rapid and unimpeded data sharing, expressing concern that binding obligations could introduce delays or disincentives.

2. Second, the nature of benefit-sharing obligations. Divergences persist over whether commitments should be mandatory or voluntary, the types of benefits to be included, such as product allocation, technology transfer or financial contributions; and the mechanisms through which these would be triggered and/or enforced. These questions link directly to the legal architecture and effectiveness of the system.

3. Third, the design and governance of the system itself. Negotiators are still as divided on issues including traceability of pathogen materials and data, the structure of contractual arrangements with users (including private sector actors) and oversight mechanisms required to ensure compliance and transparency as they were in INB 11, late 2024. These technical elements are absolutely central to determining whether PABS will function as an operational system or remain largely aspirational.

By the end of the week, the negotiating atmosphere had shifted towards a more strategic posture. Resolve was tested and the major players did not signal willingness to adjust core positions. The result was a de facto deadlock, despite continued engagement across both formal and informal tracks.

These structural challenges have been evident throughout the INB and IGWG processes. The PABS annex sits at the convergence of equity considerations, national sovereignty and importantly, commercial interests. This makes compromise particularly complex. Negotiations are further shaped by experience: many countries are operating with the memory of uneven access to countermeasures during COVID-19, which continues to inform positions. Trust also remains a critical underlying factor. The annex is intended to function under crisis conditions, yet is being negotiated in an environment where confidence between negotiating blocs is uneven. This tension is increasingly visible in both the pace and substance of discussions. Even with the trigger distinctions of PHEIC and pandemic still present but no longer key and looking to be largely in the rearview mirror. With no agreement reached by the evening of 28 March, WHO Member States agreed to extend negotiations.

The IGWG will reconvene from 27 April to 1 May 2026, with informal intersessional discussions expected in advance as is pretty much standard at this point. Effectively, there is one final window to resolve outstanding issues before the annex is presented to the World Health Assembly in May. For those negotiators reading, I know this is a specifically stressful time - a marathon until May. I wish you a particularly enjoyable end to the long weekend and please do reach out if there are any perspectives that you’d like me to share when I write a more detailed piece around the time of your next session.

Finally, the implications extend beyond the annex itself. The PABS system is widely regarded as central to the operationalisation of the Pandemic Agreement’s equity objectives. Without a functioning mechanism, the agreement risks lacking the tools required to deliver on its core commitments in a future pandemic. For many, the concern here is that time pressure in early May ahead of the Assembly, given the past years of negotiations will result in a fatigued, watered down version of the annex that doesn’t materially lead to any change in the circumstances that led to such widespread inequity, denial of purchase and suffering that was experienced during the pandemic. A visceral pain point for many nations that found themselves on the losing end both in access to medical countermeasures and in what may have felt like being penalised with travel bans for timely sharing of data. I do not view this as a particularly trivial point - many states, particularly smaller states, rely heavily on tourism and it is important that precedent does not prevent rapid pathogen sequence data sharing.

Following five years of negotiations under the INB and IGWG, the March session demonstrated that the remaining gaps are primarily really no longer as technical as they are political. Let’s hope that the April session can bridge these divides, overcoming existing impasses in a way that is satisfactory for all parties. This will be critical in determining both the outcome of the PABS annex and indeed, the credibility of the Pandemic Agreement as a whole.

Still believing in the value, power and strength of multilateralism.

(Read more: here and here)

(Image source: Thinkglobalhealth.org)

2. Lenacapavir and Gilead - Politics of Access

In late March 2026, Gilead Sciences faced mounting criticism after refusing to sell its long-acting HIV prevention drug, lenacapavir, directly to Médecins Sans Frontières (MSF). The organisation, which operates in some of the world’s most constrained settings, had formally requested to purchase a limited supply for use in its programmes. The request was declined repeatedly over several months.

We have discussed Lenacapavir at length in the past in GHC. A groundbreaking treatment for HIV prevention, administered as a twice-yearly injection. It represents a significant shift in HIV prevention, particularly for those high risk populations for whom adherence to daily oral PrEP (pre-exposure prophylaxis) is challenging.

At present, MSF, like many actors in LMICs, can only access Lenacapavir through a supply channelled via the Global Fund, covering approximately 2 million people over three years. This allocation has been estimated to be a fraction of global need, with demand far exceeding available doses. And some reports have cited echoes of the early days of antiretroviral treatment (ART) in Africa in the 1990s when life-saving innovations were available in high-income countries but out of reach elsewhere. Personally, I think this comparison is somewhat of a stretch seeing as ART is therapeutic and Lenacapavir is preventative but this opinion has been shared by professionals in the field with a far more up to date idea of the scope and circumstances of the at risk populations in question. Nevertheless, the question of who gets access to innovation and when remains. And the delicate balance between maintaining the incentive for innovation and prioritising access does too.

MSF has argued firmly that it is not seeking reallocation from existing stock, but the ability to purchase additional supply directly, as is possible in high-income markets. Gilead, however, has maintained its position; directing organisations to existing mechanisms and pointing to future generic production, expected around 2027.

Critics argue that this deferral is insufficient. Existing licensing agreements exclude large parts of the world, including numerous MICs as well as regions in Latin America, Asia, and the Middle East from early generic access, leaving a significant access gap during the initial years of rollout.

Gilead, for its part, has framed its approach as one of “sustainable access”, emphasising partnerships with the Global Fund and other mechanisms, and noting efforts to scale delivery at no profit in resource-limited settings until generics become available.

As noted in a previous edition of GHC, UNAIDS had already raised concerns around pricing following FDA approval of Lenacapavir, with a reported US list price of over $28 000 USD per person per year, compared to estimated generic production costs as low as $25 - $46 USD. The concern then, as now, was that without early intervention, a breakthrough could fail to translate into population-level impact.

For MSF, however, this is no longer a question of future pricing, but of present access. Humanitarian actors are ready to procure. Demand is established. Production capacity, by Gilead’s own admission, may be expandable. And yet, access remains mediated, capped, and uneven. Their main arguments centre around a controlled roll-out, partnership-based access (through Global Fund) and that through licensing in selected regions generics will be available next year.

MSF penned an open letter to Gilead on 30 March 2026 after discussions in mid February. MSF has requested a follow-up decision from Gilead by 13 April 2026 on whether direct sales will be permitted, at what price, and on what timeline.

(Read more here, here, here, here)

Behind the Scenes:

My fortnight was beautifully spent, but busy with lots of train rides. I enjoyed meetings and suppers with friends and acquaintances including a farewell do and a ladies current affairs group discussing archeology and its applications in modern day forensics, global equity and more. There is a lot to be concerned about at present and this can all weigh very heavily on the soul. Whenever I could, I soaked in the beauty around me. Incredible flower arrangements, the setting sun, incredible food and had fun both dressing up and dressing down in equal measure with the wobbly weather. Hope you had a wonderful Easter, Friend. Keep well.

I hope this evening’s edition finds you well. Just a quick one as we get back to the usual schedule. Late last year I published my annual Global Health Pharma Leadership Index (2025). Today, I have broken down the Q4 Pharma Disclosures. Skip to the FiRs below to read more.

As negotiations on the Pathogen Access and Benefit Sharing (PABS) System annex recommence in Geneva tomorrow, the heat is on. These negotiations need to be concluded ahead of the World Health Assembly in May and will form an important element of our global pandemic prevention, preparedness and response architecture. The topic of ensuring greater transparency around sharing pathogen data and attributing benefits is a highly complex one and highlights the interconnectedness of Biosecurity and Health Security which I discussed last week. Bridging Biosecurity and Health Security: Thoughts on outbreaks, genomics surveillance and dual-use concerns.

I have several past issues from 2025 and 2024 on PABS and the pandemic accord for background which are as relevant today as ever. I also have two past podcast episodes on the same. Links to all of these are available in the relevant section of this past newsletter: Pandemic agreement agreed! Now what?

The International Pandemic Preparedness Secretariat (IPPS) published their first quarterly March 2026 Newsletter. Acting Head of Secretariat, Dr Ines Hassan, emphasised that 2026 will be a decisive year for turning pandemic preparedness ambition into durable structures, with urgent work still needed to accelerate action now and secure how the 100 Days Mission will live on beyond the Secretariat’s mandate. I was also very cheered to see Global Health Conversations Newsletter highlighted as a recommended resource by the Secretariat. It is my hope that I can continue to do justice within this forum to the ongoing work in this important space. Read my February 2026 edition to learn more: One year left for the 100 Days Mission.

As Philippe Duneton, Executive Director of UNITAID’s successful tenure comes to an end ahead of his retirement, I have been hearing many a whisper from different quarters across Geneva over the past several weeks as to who might be in the running. Nevertheless, no successor has been announced and as far as I could find, nothing has been published. This question seems to have captured the interest of the global health, multilateral and diplomatic community. And this might be because of the vital role that UNITAID continues to play in market shaping, health product access and strategic global health financing, all of which remain especially consequential in the current political and fiscal climate.

It has been a peaceful weekend on my end. I had the chance to attend the Salon du Livre book festival in Geneva. Last year I attended with my mum, suitcase in tow, just before heading back to London, the memory of which made my solo visit slightly bittersweet. I have been on a dedicated search for my next read Slow Poison by Mahmood Mamdani, since late January, trying my best to search at small and local bookshops before just ordering online. I also attended the concurrent 45th AMR Jazz Festival in Geneva, supporting and spending time with local talent, enjoying an incredible atmosphere of the music, creativity and thoughtful intellectual conversation. I find that books, art and music have an incredible power to bring people together who might otherwise not have been in the same room to have those conversations. And to an extent, this has been the atmosphere I have tried to foster within this (broader) Conversation - bringing together people from varied yet interconnected fields.

Thank you for reading, Friend. I value your feedback and I’m always reachable in response to this e-mail or at christiana@globalhealthwriter.com.

Warm wishes,

Christiana

Q4 2025 Pharma Financial Disclosures Summary

Now that all the disclosures are out and I’ve had a chance to have another look, I have built upon the summaries in the Global Health Pharma Leadership Index with the additional Q4 2025 data. 2025 was an incredibly interesting year in the space. There was increasing divergence in different therapeutic areas, the GLP-1 RAs race continued, there was speculation about regulatory and policy changes; as well as actual policy updates such as the recognition of RSV for maternal and child health and the post-COVID shifts continued as expected.

Overall, obesity (& weight loss), diabetes and oncology continued to pull in growth and investor attention, while parts of the vaccines market remained softer, outside of RSV which drove vaccine market growth; and several companies were still working through the post-COVID reset. Some firms are now converting scientific leadership into extraordinary commercial momentum; others are trying to steady themselves and possibly find their footing in a world that is changing dramatically. There hasn’t been a five year period like 2020 - 2025 in this space for as long as I can remember. And I believe the sands are still shifting. In September 2023, Novo Nordisk, makers of Ozempic and Wegovy, overtook LVMH as Europe’s most valuable company. And today, that space is moving and evolving too.

Eli Lilly

Lilly was the clearest commercial winner of the quarter. Q4 sales rocketed 43% to $19.3 billion, while full-year 2025 sales rose 45% to $65.2 billion USD. The company’s tirzepatide franchise in diabetes and obesity, Mounjaro and Zepbound, is, for now, increasingly looking to be the ‘best-in-class’ for GLP-1s. Lilly also projected $80 billion-$83 billion in 2026 sales, underlining just how powerful this growth engine has become. It is not only winning the current obesity race; it is using that position to spend aggressively on acquisitions and partnerships across inflammation, immunology and future pipeline-building. They recently acquired Ventyx Biosciences for a reported $1.2 billion USD. (Read more: here, here)

Novo Nordisk

Novo Nordisk is and will always be one of the defining companies of this therapeutic area. Its ‘first-in-class’ semaglutides, Ozempic for diabetes and Wegovy for obesity, took the diabetes care and weight-loss space by storm several years ago, making Novo the first company to truly break open this market at scale. But Q4 suggested a company under more pressure than before. Novo reported $48.9 billion in 2025 sales, up 10%, but warned of slowing revenues and pointed to “unprecedented pricing pressure” in its 2026 outlook. The GLP-1 market is still booming; but it’s no longer a one-company story. As mentioned last year in the 2025 Global Health Pharma Leadership Index, Novo has seemed to be moving through a broader transition that still appears to be playing out. Earlier in the story, I published these: The real toll of weight-loss injections: Semaglutides, the economy & you and Skinny at all costs? Unravelling the weight loss sensation causing supply chain mayhem for Diabetes Type II patients.

GSK

GSK delivered one of the more balanced quarters. Its vaccines business posted 4% Q4 growth to $3.1 billion, helped by strong ex-U.S demand for shingles, RSV and meningitis products, while Shingrix rose 20% to $1.4 billion. Company-wide Q4 sales climbed 8% at constant currency to $11.8 billion, and quarterly HIV sales rose 11% to $2.9 billion. For the full year, turnover reached $44.6 billion, up 7%.

From a global health perspective, GSK remains notable because commercial strength still overlaps with work in vaccines, infectious disease and access. A big part of why they were our GHC 2025 Global Health Pharma Index Leader.

Sanofi

Sanofi’s quarter was solid but somewhat mixed. Vaccine sales fell 2.5% in Q4 to $2.4 billion, though the company said full-year influenza and COVID-19 vaccine performance came in better than expected. Across the business, Q4 sales grew about 13% to $13.3 billion, while full-year 2025 net sales reached $51.5 billion. Dupixent, in immunology, remained the key growth driver, with quarterly sales up 32.2% to $5 billion. Its RSV product Beyfortus, developed with AstraZeneca, remains an important preventive asset in paediatric health, but the bigger story last month around Sanofi was governance. The ousting of CEO Paul Hudson overshadowed the quarter. Speculatively, perhaps a signal of investor impatience despite respectable growth - the sentiment possibly being that promise exceeded outcome. I can see this being the case as Sanofi’s highly diversified product portfolio in key current growth areas makes it a particularly promising prospect. Nevertheless, there is always more to the story than we know and with significant growth, over the year, there likely is more to this story than I have found.

Pfizer

Pfizer’s numbers again reflected the continued fall from the COVID peak. Full-year sales of Comirnaty fell 20% to $4.4 billion, while Paxlovid revenue plunged 59% to $2.4 billion. Overall Q4 sales slipped 3% to $17.6 billion, and full-year sales fell 2% to $62.6 billion. Nevertheless, excluding COVID-19 products, operational revenues grew 6% for the year.

The other brighter point was Abrysvo in RSV, which crossed the $1 billion annual sales mark and grew 36% for the full year; Prevnar sales also edged up 1% to $6.5 billion. Strategically, Pfizer is still refocusing, and one notable additional development this period was its exit from ViiV Healthcare, ending a long-running role in the HIV business.

Merck & Co.

Merck delivered a mixed but solid quarter. Q4 sales rose 4% to $16.4 billion, and full-year 2025 sales reached $65 billion, up 2%. Keytruda in oncology remained the anchor, bringing in $31.7 billion for the year, up 7%, though the company is clearly looking ahead to a post-Keytruda future as patent expiry approaches from 2028.

Personally, I would be very curious to know if there is any life cycle extension work ongoing in new formulation patents/ method-of-use/ dosing, devices or general strategy currently ongoing at Merck. To retain some degree of market exclusivity. I have to admit, I am not against this sort of work, but I do feel that we also need to weigh this strongly against access. In a past life, in 2019, I wrote an extremely tongue-in-cheek blog post entitled something to the effect of ‘ $$$ An ‘Insider’s’ guide on how to make your drug last forever: Life Cycle Management,’ which I stumbled back upon recently. A case study step-by-step guide on a biologic. There’s no chance I’d share here but the internet is vast and wide.

Vaccines, on the other hand, were more uneven: Gardasil sales fell 35% to $1 billion in Q4 amid weaker demand in China as discussed in previous editions and full-year Gardasil sales were down 39%. By contrast, Capvaxive, Merck’s pneumococcal vaccine, continued to outperform expectations. Merck’s decision to split oncology from the broader pharma division suggests the company is already reorganising for what comes next.

AstraZeneca

AstraZeneca’s tone was confident, justified by its numbers. Q4 revenue climbed 2% to $15.5 billion, while full-year sales reached $58.7 billion, up 8%. In 2025, Oncology remained AZ’s main engine, with quarterly oncology sales surging 20% to $7 billion, led by Tagrisso in oncology, up 10% to $1.9 billion, and Imfinzi in oncology, up 37% to $1.8 billion. By contrast, its vaccines and immune therapies business fell 19% to $442 million in Q4. AstraZeneca still looks like one of the more strategically coherent large pharma players, with strength in oncology and continuing interest in cardiometabolic disease, including oral GLP-1 candidate elecoglipron. But I don’t know where my personal opinion stands on this one right now. On one hand, they’re growing and diversifying disease areas wisely; and have some genuinely relevant global health-facing work, including Healthy Heart Africa and its messaging around rare disease partnerships in Southeast Asia. But at the same time, the immune therapies and vaccines performance still give one pause. Including their Sanofi partnered RSV monoclonal antibody. I have not quite put my finger on what makes me unsure of my inward predictions, but I would not be surprised if somewhat of a strategy change were afoot in AZs next two quarters.

Moderna and BioNTech

For the major mRNA companies, the reset continues. Moderna reported Q4 revenue of $678 million, down 30%, and full-year sales of $1.9 billion, down 40%. BioNTech’s Q4 sales slipped 24% to $1.1 billion, though full-year sales rose 4% to $3.3 billion, mainly due to out-licensing revenue. In both cases, the challenge is no longer proving that mRNA can work, but proving it can support repeatable commercial growth beyond COVID vaccines. BioNTech’s leadership shakeup only reinforced the sense of a company entering a new phase. I mentioned their positive news, BioNTech received an injection of funding from Gates some months back in HIV, which might be useful.

Bavarian Nordic, Novavax and others

Among other players, there were a few brighter spots. Bavarian Nordic’s full-year 2025 sales grew 9% to $990 million, driven by travel health, where sales jumped 30% to $470 million, alongside continued mpox-related demand that brought $492 million to its public preparedness unit. Travel health being a post-COVID era adjustment area that seems to be on the up for the time being. Novavax reported $147 million in Q4 revenue, up 67%, and reached $1.1 billion in total full-year revenue, helped by partnerships and licensing deals. Bayer’s Q4 sales were up 2.9% to $13.3 billion, and full-year sales rose 1.1% to $53 billion. Viatris posted $3.7 billion in Q4 sales, up 2% on a divestiture-adjusted basis, while full-year revenue fell 1% to $14.3 billion. Merck KGaA reported full-year organic net sales growth of 3.1% to $24.4 billion, with its healthcare division up 3.7% to $9.9 billion. These seemed to be driven by repositioning and adaptation.

The main takeaway from Q4 is that commercial power in pharma has been redistributed. GLP-1s are everyone’s darling and vaccines are still doing well, but the market is uneven. From a global health perspective, the question is not only who is growing, but whose growth still carries meaning for patients, access and health systems beyond the richest markets. I look forward to digging deeper in my usual late summer Q2 mid-year review. Here’s 2025’s Q2 Pharma Financial Disclosures Breakdown if you’re interested. I have uncharacteristically not linked the disclosures here as this e-mail was becoming too heavy to send and I would not like to link some but not others. Please reach out if there’s a particular resource you’re looking for.

Relevant Past Podcast Episodes:

Episode 24: What is the Pandemic Accord, really?

This episode takes a high level overview of the Pandemic Accord, its purpose and a walkthrough of some of its most pertinent Articles. A walkthrough. The Pandemic Accord is a proposed global agreement aimed at strengthening pandemic prevention, preparedness, and response. Emerging in the aftermath of COVID-19, the accord aims to address gaps in international coordination, surveillance, and equitable access to medical countermeasures, globally.

Episode 19: Drug Licensing and the Pandemic Accord

In this episode, we look at Colombia’s recent move in issuing its first compulsory license. The country challenged ViiV Healthcare’s monopoly on their patented drug, dolutegravir, an HIV therapeutic, in an attempt to open doors for affordable generic versions and thus improve accessibility & affordability.

If you read and enjoy the Global Health Conversations Newsletter, please share with a colleague or friend! :)

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(See the past four editions: Economics of Prevention, Multilateralism thoughts, One year left for the 100 Days Mission and CEPI: Investing in Preparedness - for background.)

If tomorrow Gmail and the Cloud disappeared, would you be able to find your birth certificate? What about the contact details of a former employer or a friend? One begins to reflect on dependencies and approaches to resilience in the face of uncertainty.

Rising geopolitical instability has sharpened concerns about how global health will be affected, bringing health security firmly to the forefront of our reflections. For decades, international biosecurity and global health security have largely existed in different policy worlds. Silos, if you will. Biosecurity and biodefence have traditionally belonged to the realm of defence and national security in a way that health security has not. The important distinction here is that biosecurity is largely concerned with biological threats. Including those caused by misuse, negligence, accidental pathogen escape from laboratories or even nefarious actors, etc. Health security also has multiple domains but in this context it is concerned with health threats such as endemic disease, epidemics and pandemics; these will additionally include various health threats including novel viral threats, zoonotic spillover events, concerns around antimicrobial resistance, climate driven change in vector-borne disease, etc. In essence, this has meant that the latter is far more likely than the former. But in a world where success is measured in counterfactuals, i.e events that never happened, preventing the former is an important risk-evaluation based exercise. Preventing the development or misuse of biological weapons is governed by a different set of frameworks too, such as the Biological Weapons Convention among others.

Nevertheless, technologies that underpin modern biomedical innovation, including nucleic acid synthesis, gene editing and synthetic biology, are now central both to pandemic preparedness and to biosecurity debates. As the capabilities expand and costs fall, policymakers face the new reality of the continued interlinkage of the governance of biotechnology and that of global health security.

Recent weeks have again highlighted how interdependent our global health ecosystem has become. From surveillance laboratories sequencing pathogens in real time to international negotiations around pathogen sharing and benefit, the systems that underpin pandemic prevention rely on trust, cooperation, and sustained investment. When they function well, they allow outbreaks to be detected early and contained at or near the source. These questions are timely as negotiations recommence next week on the Pathogen Access and Benefit-Sharing (PABS) annex with the convening of next session of the Intergovernmental Working Group. And this example highlights another important area where the Venn diagrams overlap.

There are over 100 new outbreaks in Africa every year with dozens occurring simultaneously across different countries. This is a statistic I shared with a friend over a fireside supper on Friday overlooking Lac Léman and the Jet d’eau. I explained how African genomicists working in sequencing, surveillance, and bioinformatics have been at the forefront of protecting us all from epidemic and pandemic threats.

The figure is often misunderstood. More than one hundred outbreaks annually does not mean a constant succession of novel epidemics. Most of these events are endemic disease outbreaks involving well-known and understood pathogens: cholera, measles, Lassa fever, meningococcal disease, Rift Valley fever and others. Many outbreaks are geographically contained and rapidly controlled. Some are seasonal, linked to climatic patterns or ecological conditions. Others arise from predictable dynamics of human mobility and urbanisation.

A proportion of these outbreaks involve genetic variants or lineages of known pathogens rather than entirely novel organisms. Viruses mutate, bacterial strains evolve and pathogens adapt to new ecological contexts. The difference between a familiar pathogen and a new variant of that pathogen can have significant implications for transmissibility, vaccine effectiveness or disease severity. Addressing these dynamics relies on genomic surveillance networks.

Over the past decades, genomic sequencing has become a core component of modern infectious disease surveillance. By analysing the genetic material of pathogens, scientists track evolutionary changes, identify new variants, reconstruct transmission chains, and infer patterns of geographic spread. Sequencing allows investigators to determine whether an outbreak represents local persistence, cross-border transmission, or the emergence of a previously undetected lineage.

This work is deeply embedded in public health practice globally and across many parts of Africa. Laboratories sequence pathogens, genomic data are analysed locally and shared internationally through platforms such as GISAID and GenBank, enabling scientists around the world to monitor pathogen evolution in near real time.

Although African genomic surveillance gained broader public visibility during the COVID-19 pandemic, particularly following the identification of the Omicron variant of COVID-19 in South Africa in 2021, the practice itself is not new. I recall missing out on my sunny, South African Christmas because of travel bans that year. African laboratories and research institutes have been conducting pathogen sequencing for many years, supported by collaborations between universities, national public health institutes and regional organisations.

Alongside continental lab capacity, a growing ecosystem of bioinformatics expertise has emerged across the continent. Bioinformatics, the computational analysis of biological data, plays a critical role in interpreting genomic sequences, identifying mutations, and mapping evolutionary relationships among pathogens. Regional networks increasingly enable scientists across multiple countries to share analytical tools, training, and datasets. Although there is still further work to be done in standardising data sharing in this area.

Together, these systems form part of the global infrastructure for early detection of infectious disease threats, supporting both global health security and biodefence. Their importance is underscored by the geographic distribution of outbreaks. In Africa, a combination of epidemiological factors, including extensive human–animal interfaces, rapid urbanisation, peri-urban environments, climate-sensitive vector-borne diseases, and cross-border mobility, contributes to frequent pathogen emergence. While these dynamics are not unique to the continent, they create conditions in which outbreaks are regularly detected. As a result, countries working with the support of the WHO African Region and the African CDC, represents one of the most critical regions for the early detection of emerging infectious diseases.

The systems that underpin genomic surveillance also highlight a broader reality about the modern life sciences ecosystem. Pathogen sequencing, global data sharing and rapid drug design all rely on technologies that form part of the same expanding biotechnology toolkit. As these capabilities advance, the infrastructures supporting pandemic preparedness and those governing biological risk are increasingly overlapping. Many tools that support beneficial research can also, in principle, be applied incorrectly. Within biosecurity policy discussions this specific risk is commonly framed as dual-use research of concern (DURC): life-science research that, while conducted for legitimate scientific purposes, could reasonably be anticipated to generate knowledge or technologies with the potential to be misused to pose risks to public health, agriculture, the environment or national security in the wrong hands or circumstances. Advances in synthetic biology, distributed gene synthesis, and computational biology are lowering the barriers to manipulating biological systems. Pathogens can now be reconstructed from publicly available sequence data, modified through targeted genetic engineering, or designed using increasingly sophisticated computational tools. Several major biosecurity assessments have highlighted that the convergence of synthetic biology, artificial intelligence, and widely accessible nucleic-acid synthesis technologies represents one of the most significant governance challenges facing modern biotechnology. As a result, biosecurity experts increasingly emphasise layered safeguards across the biotechnology ecosystem, including nucleic-acid synthesis screening, strengthened laboratory biosafety and biosecurity standards, oversight of high-risk experimental work and responsible management of biological data.

Biosecurity and health security have historically been governed through different institutional and policy communities. That distinction has become more blurred. Biological risks are not limited solely to naturally occurring pathogens. Laboratory accidents, poorly governed research environments, or deliberate misuse of biological technologies could also generate events with significant public-health consequences. As a result, discussions about pandemic preparedness increasingly intersect with debates about biotechnology governance, research oversight, and responsible innovation.

At the same time, increased global sharing of pathogen samples and genomic sequence data has introduced complex questions about access, sovereignty and equity. When pathogens are sequenced and shared internationally they enable the development of diagnostics, vaccines and therapeutics. Yet countries providing biological samples have often argued that they do not always receive equitable access to the resulting medical countermeasures.

These concerns intersect not only with ongoing negotiations on PABS, but with international agreements governing genetic resources, most notably the Nagoya Protocol under the Convention on Biological Diversity, which established principles governing access to genetic resources and the fair and equitable sharing of benefits arising from their utilisation. Although the protocol was not originally designed with pathogens in mind, it has increasingly influenced debates about the governance of pathogen samples and genomic sequence data during outbreaks.

In practice, this has created a complex governance landscape in which public health objectives, scientific collaboration and sovereign control over biological materials must be balanced. Questions about how pathogens and sequence data are shared, how benefits from resulting medical countermeasures are distributed, and how innovation can proceed without undermining trust between countries have become central to international discussions about pandemic preparedness.

Meanwhile, policymakers in several jurisdictions have begun exploring regulatory approaches for emerging biotechnology risks, particularly around nucleic-acid synthesis. Advances in DNA and RNA synthesis allow researchers to construct genetic sequences rapidly and at relatively low cost with lower barriers to entry. One policy response receiving growing attention is the screening of synthetic nucleic acid orders. Screening systems analyse ordered sequences and customer information to detect potentially hazardous genetic material or suspicious purchasing patterns. Industry groups and biosecurity experts have argued that consistent screening requirements are necessary to prevent regulatory loopholes, ensure responsible providers are not disadvantaged, and establish baseline security practices across the rapidly expanding gene-synthesis market.

Within Europe, these discussions have gained momentum through the proposed European Biotech Act. Proposals emphasise the need to move beyond voluntary norms toward more harmonised, possibly mandatory regulatory frameworks, particularly in screening. The recommendation introduced of mandatory screening requirements for synthetic nucleic acids above defined sequence thresholds, alongside verification of the identity and legitimate need of customers ordering gene synthesis materials, is a noteworthy development currently in motion.

The proposed framework introduces mandatory screening for synthetic nucleic acids of concern, including sequences at least fifty nucleotides in length, as well as identity verification and legitimacy checks for customers ordering these materials. The draft regulation also proposes that benchtop nucleic-acid synthesis equipment incorporate automated screening mechanisms capable of detecting sequences of concern, reducing the possibility that decentralised synthesis platforms could bypass established security safeguards.Proponents argue that establishing common screening standards could reduce fragmentation between national systems, strengthen supply-chain resilience, and ensure that responsible biotechnology companies are not disadvantaged by uneven compliance requirements. I would be curious to hear what you think on this increasing convergence of biosecurity and health security, including the strong differences in governance, not expanded upon here.

On another note, in the world of drug development. The Drugs for Neglected Diseases initiative in partnership with Sanofi have advanced acoziborole, as a potential single-dose oral treatment for Human African trypanosomiasis. The candidate emerged from long-standing collaborations between DNDi, academic partners, endemic-country research institutions and industry, reflecting the organisation’s model of coordinated product development partnerships for neglected diseases. If approved, acoziborole could significantly simplify treatment for sleeping sickness by replacing complex multi-day regimens that historically required hospitalisation.

On my side, I spent a long weekend largely offline celebrating a dear friend’s birthday deep in the forests of Transylvania, in a lovely castle where it is said that Nicolae Ceaușescu spent his weekends. I had the privilege of being fully present with old and new friends over chatty meals, walking through gorgeous nature, keeping noisy to deter the bears, and watching snowball fights on a day so perfect that we shed our coats and wore sleeveless shirts. Long-time readers may recall Loredana, the celebrant, from the Women’s Health podcast episode discussing differences in patient outcomes across gender, sex-disaggregation of data, and more; and from the Alzheimer’s Lecanemab treatment and the impact on women newsletter.

As I round up this letter, this week I watched Louis Theroux’s new documentary on the Manosphere, which as someone with only pedestrian exposure beyond the occasional think piece or op-ed, I found somewhat unsettling. It warrants a clear nod to two past book recommendations, impeccable reads by Laura Bates; here and here.

Next fortnight we will take a deeper dive into the 2026 Q4 pharma financials that I briefly touched on last month. In the meantime, here is my Global Health Pharma Leadership Index (2025) with predictions from late last year.

Thank you for reading and for continuing to engage with Global Health Conversations. I remain reachable in response to this email or at christiana@globalhealthwriter.com.

Best,

Christiana

No FiRs this week, just a couple of relevant headlines:

• GSK wins expanded U.S. FDA approval for RSV vaccine Arexvy in adults aged 18–49 at higher risk

• Acoziborole: DNDi, Sanofi and partners work to deliver breakthrough treatment and expedite access to eliminate sleeping sickness

• WHO member states continue negotiations on pandemic agreement Pathogen Access and Benefit-Sharing (PABS) annex ahead of World Health Assembly - negotiations resume next week 23 March 2026

Behind the scenes

Busy, fulfilling weeks in London, Geneva and a lovely break in Transylvania to celebrate Loredana from the Women’s health episode - dressing up as characters, dining, hiking and taking the weekend slow. Had the chance to visit a woman professor who I admire just off a lovely quay in London, small stopovers here and there and taking in the beauty all around us.

Greetings from a gloriously sunny Geneva. I started my fortnight hiking but spent most of it in London, with a quick trip to the English countryside, where our friends across the channel had been enduring an almost 50 day streak of continuous rain. I spent part of Sunday catching up on current affairs in the Economist. I read the op-ed on Gaullism and That irritating feeling that France was right. It occurred to me, once again, that amidst ongoing geopolitical movements and the new structure of multilateralism, the memory of the acute phase of the COVID-19 pandemic continues to drift further away; and with it, the tacit agreement and understanding, even beyond the health space, that health security is as much a matter of national security as defence, surveillance and intelligence.

As CEPI’s CEO, Dr Richard Hatchett emphasised this week, future epidemic and pandemic threats are not theoretical risks but inevitable features of our globalised world. In other words, the question is not whether another pandemic will occur, but how prepared we will be when it does. Rapid urbanisation, ecological disruption, fragile health systems and climate-linked shifts in vector distribution continue to increase the likelihood of spillover events.

On Sunday I also attended an excellent talk over high tea on media legitimacy that made me reflect on my relationship with traditional, non-traditional, international and publicly funded media. As a consumer of all of the above. The talk, organised by the Oxbridge Switzerland society, was rather Swiss focussed so I will not share nuances here. Nevertheless, I found myself in the beautiful position of having changed my mind. Switzerland has a system of direct democracy, voting on policy issues in a referendum style. There is an upcoming vote around reducing the national media contribution that everyone has to pay (unlike a U.K TV license). As someone who does not watch television and owns only one radio, a lovely leather bound thing. Passed from my Grandfather to my Father and of which I see myself as a temporary custodian; I was not against the prospect of halving my tax contribution reduced, unaware of the counterarguments. Our discussions brought the importance of national broadcasters, such as the BBC and RTS into sharper focus. Highlighting the political backdrop against which certain lobbies have stood; as well as the importance of an impartial, non-partisan, state-funded media. Something I have always believed in. There is a certain inherent beauty in the effect of examining facts, updating ones ideas and changing one’s mind.

Last fortnight I discussed the 100 Days Mission, after returning from the IPPS Implementation Report Launch. CEPI, the Coalition for Epidemic Preparedness Innovations, have been a key partner and sponsor in the 100 Days Mission from the start; with a clear aim to to work towards enabling development and access to vaccines against new epidemic and pandemic threats to be ready for emergency use within 100 days of identification. Their new CEPI 3.0 strategy and vision encapsulates this more clearly than ever.

CEPI has launched its 2027–2031 Strategy, CEPI 3.0, alongside an Investment Case, ‘Securing the Future’. It sets out how one of the central institutions of the post-COVID preparedness landscape intends to operationalise speed, equity and scientific readiness over the next five years. The new strategy comes almost 10 years after the Coalition’s 2017 launch at Davos and it will be costly. They have set out to raise $3.6 billion USD with $1.1 billion already secured including pledges and $2.5 billion to go. Nevertheless, the organisation have also set out a full Investment Case outlining the value of investment in preparedness and vaccination. And this investment case is, in my opinion, a vital element of the mission not only to execute the strategy but to persuade. Due to other commitments, I was unable to attend their Geneva Launch event this fortnight, but I had the opportunity to speak about it with CEPI later in the week. I feel that this subject is worthy of all of our attention. I have shared my thoughts, read more in the FiRs below.

For my part, I had a busy, productive fortnight that seemed to fly by. On the fun side I had the pleasure of attending many of the festivities in celebration of the UCL Bicentenary, including a beautiful ball and supper at the British Museum, a lights show on renovated the Quad, discovering my quote in the press release and an incredible reception at the Grant Museum of Zoology; meeting up with friends and industry colleagues besides. Upon my return to Geneva, I had the privilege of hosting a local alumni reception to celebrate 200 years of UCL. It gave us the opportunity to reflect on the founding principles of our alma mater. Principles of progressivism, cooperation and excellence that seem as important today as ever. UCL, London’s first university where I read my first masters, was also the UK’s first institution to admit women on equal footing with men; and the first where students were admitted based on merit; regardless of religion, creed or class.

Other delights of the week were finding some of my close, women role models recognised for the incredible work that they do. Prof Faith Osier who has been piloting a new malaria vaccine using novel techniques and working tirelessly to advance the mission of African vaccine manufacturing and production. Time 100 Health 2026 recognised INB Co-chairs Precious Matsoso and Anne-Claire Amprou for their tremendous work on the Pandemic Accord negotiations as the next session approaches.

P.s. Please excuse the irregular timing of this fortnight’s edition, owing to a small accident involving my laptop and water bottle in my handbag.

Until next Fortnight, Friend.

Warm wishes,

Christiana

Let me begin by saying that CEPI’s 3.0 five-year Strategy and Investment Case are worth reading for yourself. My reflections here are my own. The Coalition for Epidemic Preparedness Innovations unveiled CEPI 3.0 this month. The plan sets out to transform how the world can more effectively tackle epidemic and pandemic threats going forward. The strategy, due to begin in 2027, is accompanied by a call for US$2.5 billion in additional funding, bringing the total requirement for 2027–2031 to US$3.6 billion.

The strategy is organised around three interconnected pillars. First, developing vaccines to tackle both known and emerging threats. Second, advancing rapid-response platform technologies. Third, supporting global networks that can be activated quickly to execute the 100 Days Mission, the ambition to develop safe, effective and accessible vaccines against a virus with pandemic potential in as few as 100 days. Modelling suggests that had vaccines been available within 100 days of the identification of SARS-CoV-2, more than 8 million lives could have been saved and trillions of dollars of global economic damage averted.

One element that stood out to me was the framing of preparedness as an investment in time. The time dimension is central and, in the context of the above, speed is presented as a lever of economic and humanitarian mitigation.

Within the first pillar, CEPI will continue advancing response-ready vaccine candidates for pathogens such as Lassa, Nipah and Rift Valley fever while generating scientific tools, data and knowledge across most of the WHO viral families deemed to harbour pandemic-capable pathogens. This viral family approach is not new - it aims to provide a scientific head start against newly emerging viruses by developing prototype vaccines and standardised research tools in advance. Scientifically, it reduces uncertainty. Economically, it reduces marginal development time when a new pathogen emerges from a prioritised family. Antigen design, assay validation, early toxicology and translational research are among the most time-consuming components of vaccine R&D. Shifting these elements into interpandemic periods changes the cost curve of response.

The second pillar focuses on rapid-response platforms. CEPI intends to accelerate platform technologies and embed them with regional manufacturers so that countries and regions can move quickly against outbreaks. Regulatory preparedness is emphasised as being integral and quite well embedded within this pilar, with CEPI and partners working closely with regulators to ensure access to platform performance data in advance. This approach is designed to enable rapid vaccine development, faster manufacturing scale-up and more efficient regulatory assessment. Platform validation reduces duplication. It allows regulators to rely on established backbones and safety data. It lowers the marginal cost and timelines associated with adapting to a new pathogen. So the risk of delays is ultimately reduced.

The third pillar focuses on global networks. CEPI aims to connect, strengthen and rigorously test scientific networks so they are ready to respond seamlessly from early R&D through to manufacturing. A concrete component of this is securing access to between one and two billion doses of regional manufacturing capacity to enable fast and fair outbreak response. Manufacturing capacity is framed not solely as an equity objective, but as a resilience requirement. Concentrated production during COVID-19 exposed vulnerabilities to export restrictions and supply chain disruption. Distributed capacity reduces systemic risk. At the same time, sustaining warm-base facilities between outbreaks carries ongoing costs. Preparedness economics therefore intersects directly with industrial policy and long-term procurement commitments.

CEPI was launched in 2017, shortly after the 2014 - 2016 Ebola epidemic in West Africa. As such, CEPI 1.0 and later CEPI 2.0 (2022-2026), developed in the post-pandemic context, were shaped by lessons learned during crises and were largely focused on the practicalities of recovery and scaling. CEPI 3.0 builds on these earlier strategies but reads more as an infrastructural blueprint for long-term sustainability. It emphasises the pre-validation of platforms, pre-negotiation of regulatory pathways, pre-positioning of manufacturing partnerships, and the stress-testing of networks before they are needed. This represents a more advantageous position for sure, particularly for establishing, systematising, and embedding preparedness architecture within existing frameworks. Nevertheless, it is always easier to boil water when the stove is already hot.

It is worth clarifying that while CEPI 3.0 is structured around three pillars, the architecture functions more as an ecosystem than as three vertical (or triangular?) silos. In fact, triangular might be a more appropriate visualisation here. Vaccines, platforms and networks are interdependent layers of the same operating system. The strength of the strategy lies not simply in the existence of each pillar, but in their designed interoperability. In my opinion this systems framing is one of the stronger evolutions of CEPI’s framing as it enters a new era.

Manufacturing capacity is framed as both an equity and resilience requirement. Concentrated production during COVID-19 exposed deep vulnerabilities in export restrictions, supply chain and so much more. Distributed manufacturing capacity reduces systemic risk. At the same time, sustaining warm-base facilities between outbreaks carries heavy ongoing operating expenditure.

The financial architecture of CEPI 3.0 makes these trade-offs explicit. Research cited suggests that global losses from future pandemics could average more than $700 billion USD per year. Against this backdrop, the requested investment is framed as proportionate to the scale of risk. In conversation with CEPI’s Saul Walker, he emphasised the health impact of the Strategy and compared the destruction caused by epidemics and pandemics to that of other security-based possibilities that nations, regions and multilateral structures prepare for, highlighting that health security should be regarded in a similar way; stating “This investment has to be made so that we’re ready when we need it.”

Vaccines are historically among the most cost-effective public health interventions available. Routine immunisation programmes consistently demonstrate low cost per disability-adjusted life year (DALY) averted. The data has always been clear about the cost-effectiveness of vaccines as a public health intervention. Pandemic vaccines magnify this dynamic because the externalities extend beyond health. Early containment mitigates labour market disruption, educational interruption, fiscal strain and so on. Thus, the return on investment is cross-sectoral.

Nevertheless, we also live in an era in the world wherein the U.S has recently cut back recommended routine childhood immunisations, which has repercussions for access in terms of how health insurers pay for these. Furthermore, Pharma is already feeling the pinch of reduced U.S. vaccine sales.

The current global political climate complicates the vaccine value narrative. Public trust in immunisation has become more volatile in several high-income countries. Uptake variability affects demand forecasting, which in turn affects private sector incentives to maintain surge capacity. Preparedness cannot be isolated from public sentiment and domestic politics. If confidence in routine vaccination weakens, the economic logic underpinning pandemic vaccine readiness also becomes harder to defend politically. This is a real challenge, and one I touched on earlier this year, in this past article on multilateralism.

Epidemic vaccine development often falls into market failure. Demand is episodic and uncertain. The benefits of readiness accrue globally, while costs are immediate and concentrated. Private actors cannot reliably capture the full social value of preparedness.

CEPI’s financing model addresses this asymmetry by providing catalytic capital to sustain pipelines that would otherwise stall. If a future pandemic were to be shortened by even a matter of weeks, the macroeconomic savings would likely exceed the five-year budget. Yet, preparedness remains politically vulnerable because its benefits are counterfactual. When it works, the crisis does not escalate. Insurance premiums are rarely popular in calm periods. Earlier this year, I discussed the nuances between the economics of disease prevention vs epidemic/pandemic prevention. That article can be found below.

It is interesting to see that the Strategy also integrates four main cross-cutting capabilities, including artificial intelligence to accelerate antigen design and data integration, while maintaining a focus on equity, regional partnerships and embedded biosecurity. Speed, equity and scientific readiness are presented as interdependent objectives rather than competing ones. The Pandemic Preparedness ‘Engine’ concept, integrating surveillance, genomic analysis, immunogen design and regulatory data, is emblematic of this ambition to compress timelines structurally.

The viral family approach is strong and well-established. However, viral family prioritisation will always have blind spots. Pathogens can and will continue to surprise us. AI-enabled biological risks introduce new governance questions even as they promise acceleration. And further, donor concentration exposes preparedness financing to geopolitical cycles. Sustaining manufacturing capacity between outbreaks requires credible demand signals and long-term procurement frameworks.

Preparedness funding competes with immediate domestic pressures and even pressures around financing other priorities, such as defence. In the absence of visible crises, finance ministries often discount low-probability, high-impact risks. Or minimally, struggle to garner the broader political buy-in from the public, allied ministries and from government. The counterfactual nature of success in financing epidemic and pandemic prevention and preparedness complicates the equation.

Despite these challenges, I found that the ‘Securing the Future’ Strategy presents a technically strong and economically defensible approach to pandemic risk mitigation. Vitally, it treats preparedness as systemic infrastructure rather than an area for donation without yield. And I think that this macroeconomic rationale is necessary. It presents epidemic and pandemic preparedness as stabilisation rather than discretionary health spending. The emphasis on time compression, distributed manufacturing, regulatory familiarity and network interoperability reflects and incorporates lessons learned from 2020–2022. Perhaps in the implementation, beyond ongoing cooperation with three major African manufacturing hubs, we will see greater expression around how collaboration with these hubs over the next five years will really look as they take shape. There will be a need to address and ultimately confront questions around ‘warm-readiness,’ operational expenditure and integration with the National Regulatory Authorities (NRAs) of the nine African countries that have now reached ML3 status. This must be done in a way that ensures swift and reliable bioproduction, while also strengthening regional alignment. That includes more targeted support to reinforce resilience mechanisms in these regions that were most affected by the lack of access to vaccines and other medical countermeasures after COVID-19. CEPI’s role is catalytic: embedding platforms and exercising readiness rather than sustaining operations indefinitely. And it is my hope that this vital element will be well embedded in the five years ahead.

One of the more forward-leaning elements of CEPI 3.0 is its explicit acknowledgement of AI-enabled biological risk. This is not merely about accelerating antigen design. It is about recognising that dual-use technologies, with implications for biosecurity, often evolve faster than governance structures.

Stepping back, the preparedness landscape in 2026 is entirely different compared to 2019. Platform technologies are no longer theoretical. Regulatory collaboration is no longer improvised. Regional manufacturing is no longer aspirational rhetoric. The scientific base is deeper, the institutional memory is fresher, and the macroeconomic case for preparedness is clearer than ever. CEPI 3.0 does not promise perfection. It promises compression of time, reduction of uncertainty and distribution of risk. In a fragmented geopolitical moment, that alone is meaningful progress. The stove may not be as hot as it was in 2020, but it is no longer cold. The economics of preparedness are compelling. The remaining question is whether political continuity will match technical ambition. And I think that the Securing the Future Strategy have made as strong a case as could be expected in the current climate.

Behind the scenes

An incredibly busy, yet fulfilling fortnight. In the midst of all the busyness - so much gratitude for the energy to keep running, for successful events, engaging conversations, guidance from mentors, projects progressing, weekends in nature, friends, family and a sense of pure freedom.

Past Podcast Episodes you might have missed

Episode 24: What is the Pandemic Accord, really?

This episode takes a high level overview of the Pandemic Accord, its purpose and a walkthrough of some of its most pertinent Articles. A walkthrough. The Pandemic Accord is a proposed global agreement aimed at strengthening pandemic prevention, preparedness, and response. Emerging in the aftermath of COVID-19, the accord aims to address gaps in international coordination, surveillance, and equitable access to medical countermeasures, globally.

Episode 20: The Profitability of Skinny - How Semaglutides made Novo Nordisk Europe’s most profitable company

In this episode, we explore the economics of thinness and the phenomenal rise of GLP-1 receptor agonists in the weight loss market. Novo Nordisk, the Danish pharmaceutical company behind Ozempic and Wegovy, has become Europe’s most profitable company, surpassing even the luxury giant LVMH. We delve into the social and economic capital associated with thinness, examining how societal attitudes toward body image drive the profitability of weight loss drugs

Episode 19: Drug Licensing and the Pandemic Accord

In this episode, we look at Colombia’s recent move in issuing its first compulsory license. The country challenged ViiV Healthcare’s monopoly on their patented drug, dolutegravir, an HIV therapeutic, in an attempt to open doors for affordable generic versions and thus improve accessibility & affordability.

After a fortnight living mostly out of a tiny suitcase, I was glad to return to some home comforts, chilly but pleasant weather and nature.

I attended the International Pandemic Preparedness Secretariat’s (IPPS) annual Implementation Report Launch in Paris, tracking the progress of the 100 Days Mission. The 100 Days Mission is the ambition to accelerate the availability of diagnostics, vaccines and therapeutics within 100 days of the identification of a PHEIC. So why one year left? The IPPS is an independent, time limited entity that was established to support the 100 Days Mission following G7/G20 endorsement of the mission in 2021. It is expected to complete its work by early 2027. Five years on from the COVID-19 pandemic, progress in preparedness efforts is already stalling. R&D investments are declining while emerging pathogens and the likelihood of new global health threats is increasing. I have expanded on this topic and the findings of the report in the FIRs below. This requires all of our attention.

Following the U.S. withdrawal from WHO, discussed last fortnight, Some Thoughts on Multilateralism Today; Argentina plans to follow through on its intention to withdraw from WHO but remain a member of PAHO. However, under the WHO constitution there is no real legal mechanism for a member state to withdraw from the organization, the U.S.’ case being a pre-negotiated special provision. So it will remain to be seen if this is formalised and ratified in May at the World Health Assembly.

In Geneva, the meeting of the Electoral Board took place last week. In his closing remarks, the Director-General repeatedly returned to the theme of focus: a leaner organization, clearer priorities, and a renewed effort to define where WHO adds the greatest comparative advantage. The message was as much financial as anything else - reform, avoidance of duplication and a demonstration of value to countries at a time when confidence in multilateralism is under visible strain. The next Intergovernmental Working Group (IGWG) responsible for negotiating the Pathogen Access and Benefit Sharing (PABS) annex of the Pandemic Accord will take place in late March and the clock is ticking to May’s World Health Assembly. The technical work is far from over, even as political momentum and various external pressures continues to test the process.

I had the pleasure of spending a couple days in Zurich, attending a vernissage and reuniting with some of the UCL community, many of whom are in Pharma. I did a little in-train reading as the Q4 financial disclosures begun to pour in. Late last year I published the Global Health Pharma Leadership Index for 2025. We’re seeing more of the anticipated patterns - GLP-1 RAs continuing to boom and Eli Lilly’s Mounjaro & Zepbound starting to solidify their respective best-in-class positions while Novo Nordisk’s first-in-class winners, Ozempic and Wegovy, continue to grow slowly and face pricing pressure according to their CEO. RSV vaccines are still driving growth in the vaccine space, especially for Pfizer - Abrysvo massively exceeded expectations. Last year’s leaderboard winner, GSK, posted better than expected earnings, mainly due to its vaccine portfolio outside the U.S, where demand fell and growth in HIV. BioNTech’s steady decline has continued with its COVID-19 heavy portfolio. But the situation might be changing. The Gates Foundation has granted almost $25 million USD for the evaluation of an mRNA-based HIV vaccine.

I took a brief, welcome pause in Bucharest. My very first time. A city rich in culture where I enjoyed art galleries and great food with a friend. I started reading Technofeudalism, reflecting on our new world, the changing role of multilateral organisations, donors, bullies and ostriches. The steady attempts at dismantling BRICs etc. Meanwhile, outbreak surveillance continues to offer a sobering reminder of why these agreements, negotiations and processes matter. They need to be leaner, but not eliminated. A fatal Nipah virus case was confirmed in Bangladesh this week, part of the now-familiar seasonal pattern linked to date palm sap exposure. While WHO currently assesses the wider risk as low, the virus remains on the priority list precisely because countermeasures are still limited.

Against that backdrop, CEPI and partners are intensifying efforts to test what rapid response could look like in practice, from advance manufacturing arrangements to large-scale simulation exercises designed to stress regulatory and production pathways. The ambition of the 100 Days Mission is not one of perfection but of improvement towards better operational readiness.

As always, thank you for reading, Friend.

Until next fortnight,

Christiana

The first thing I have to say is that the International Pandemic Preparedness Secretariat’s most recent annual report published at the top of this fortnight is worth reading yourself. They have the Implementation Report, the Scorecard 3.0 and other resources and publications on their website. Below are the highlights that stood out to me and that I wanted to share with you. My thoughts are my own, and with no ties to the secretariat, they may or may not agree with my reflections. But it was nevertheless important to me to share my views here as I believe in and support their mission.

The International Pandemic Preparedness Secretariat (IPPS’) latest implementation report arrives at an important but politically complex moment for global health security. The COVID-19 pandemic demonstrated how quickly R&D can move when political urgency, financing and regulatory flexibility align. The 100 Days Mission is not just an aspirational slogan but a galvanising framework against which performance can be measured. The report, as always, is a ‘stocktake’ of whether the systems, levers and enablers required to deliver diagnostics, therapeutics and vaccines within one hundred days of the declaration of a PHEIC are actually taking shape.

Technical capability and capacity is advancing across multiple domains, but the enabling environment needed to translate discovery into deployable countermeasures remains inconsistent and, in some areas, fragile.

The 100 Days Mission was designed to institutionalise appropriate timelines for the availability and accessibility of medical countermeasures. Rather than relying on improvisation in the heat of crisis, it calls for preparedness during ‘interpandemic’ periods to optimise the process if and when needed. Pre-agreed financing triggers, validated platforms, regulatory plans & familiarity, manufacturing arrangements and clear pathways for data and sample sharing. If those elements are in place, the sprint becomes possible. Without them, we see delays and disruptions.

2025 provided further evidence of both progress and vulnerability. The adoption of the WHO Pandemic Agreement, albeit with the Pathogen Access and Benefit Sharing (PABS) annex still in negotiation, signalled that governments indeed continue to recognise the need for common rules, even with several major donors having reduced health and R&D budgets. The Scorecard analysis shows how dependent the ecosystem still is on a small number of funders, with the United States in a dominant position across most pathogen areas. When priorities shift in one capital, global pipelines feel the effect. Nevertheless, according to this recent article in the Lancet, China now leads globally in R&D investment.

Outbreaks during the year reinforced the stakes. Mpox, H5N1, Ebola, Marburg, Rift Valley fever, Chikungunya and resurgent measles all placed demands on surveillance and response systems. These events did not produce the kind of global mobilisation seen in 2020, but they repeatedly exposed familiar weaknesses. The patterns of delayed detection, fragmented coordination and uneven access to tools that many of us hoped would not persist in the same way in a Post-COVID world. Hoping and trusting that we had solidified lessons learned from the past. These episodes serve as reminders that the intervals between emergencies is shortening while readiness still remains uneven.

The 100 Days Mission Scorecard, now in its third iteration, developed in collaboration with Impact Global Health, attempts to bring comparability and discipline to what is otherwise a diffuse landscape of initiatives. The methodology draws on disbursement data, pipeline tracking, regulatory and scientific indicators and structured feedback from the preparedness community. By organising information into dimensions of current readiness, future preparedness, and enabling conditions, the scorecard is intended to reveal where bottlenecks are likely to arise.

What emerges from this year’s scorecard is a pattern of concentration and vulnerability. Funding remains clustered geographically and institutionally. Several pathogens show minimal late-stage depth. Many candidates sit in Phase 1 development with uncertain prospects for progression. In a number of areas, previously visible projects have now become inactive. It demonstrates the value of routine measurement. Without it, the gradual erosion of capacity between crises would be harder to detect.

Across diagnostics, therapeutics and vaccines, investment trends are on a downward slope. Funding for many priority pathogens declined further in FY2024. Many pipelines are concentrated in early development stages, with limited movement into mid- and late-stage trials. Attrition remains high, particularly once outbreaks subside - because to a large degree urgency and perceived demand are the major drivers of investment. Nevertheless, the Report’s analysis notes that scientific opportunity has not disappeared, but the continuity required to carry candidates forward is often missing.

In diagnostics, 2025 brought greater clarity about the nature of the problem. Work undertaken with FIND and the Brown University Pandemic Center mapped structural barriers across the value chain. Continued advances in multiplex technologies, target product profile development and regional laboratory mapping are positive steps. Yet practical obstacles persist. Access to well-characterised specimens remains slow and, oftentimes, politically sensitive. Regulatory pathways are numerous and poorly aligned. Market incentives for manufacturers’ participation are weak outside emergency periods. As a result, several candidates in the diagnostics area have gone inactive despite technical promise.

Therapeutics development was possibly the least developed pillar. The clinical pipeline is thin, progression into advanced trials is limited and commercial drivers are uncertain. Against this backdrop, the movement of the Therapeutics Development Coalition toward operational readiness is one of the report’s most valuable and consequential developments. The Coalition aims to coordinate portfolios, share risk, and maintain momentum between outbreaks. However, it enters 2026 with modest resources and will need demonstrable early projects to validate its model and attract broader backing. It is important to reflect upon the relationship between diagnostics and therapeutics. Diagnostics, generally heavily underfunded, are vital to identifying patients requiring treatment and also what treatment those patients require. One cannot function without the other.

It’s like trying to raise your left eyebrow without making any movement to your right eyebrow. Some people can do it, but in most cases, it isn’t. And even when achieved, there is some pressure applied to hold the right eyebrow in place. Running on that image, try to raise either one of your eyebrows without crinkling your forehead. And that, in my opinion, demonstrates the interconnectedness of all three.

Vaccines continue to show comparatively stronger performance. But they cannot function on their own entirely when the diagnostics and therapeutics pillars are not in place. Multiple candidates advanced through early phases and the major platform approaches of mRNA and viral vector vaccines retain their value here. Regional ambitions for manufacturing and regulatory strengthening, particularly in Africa, are expanding. Great news! Nonetheless, the report emphasises that even this pillar is vulnerable to funding volatility, supply chain limitations and the persistent challenge of hesitancy and misinformation. Late-stage trials still tend to depend on the presence of active outbreaks, a constraint that complicates predictable development.

My personal background is in biopharma and drug development, later moving into bioproduction in industry. So I know well that vaccines will always dominate amidst these three. Why? Because while the unitary cost of vaccines is lower, they thrive on scale. A vaccine campaign does not rely on people being ill and requiring treatment, nor being diagnosed with a condition. Vaccines are by and large rolled out to healthy populations and this is why we see, even in the Q4 and 2025 Pharma disclosures that outside of GLP-1s, vaccines, particularly for RSV at this moment, are the most significant drivers of growth. Nonetheless, development in this area is just as much tied to demand and political buy-in as anything else. The RSV boom followed a WHO guideline inclusion and many nations following with policy, such as the United Kingdom and NHS England, requiring the vaccine for pregnant women last year. Policy can shift demand calculations and make accelerated innovation possible and profitable. We should remember this, too, when it comes to diagnostics and therapeutics.

The question of where products will ultimately be produced from drug substance and drug product, filled and finished, released, etc. was exceptionally well addressed under the banner of geo-diversified manufacturing. The report treats this not simply as an equity objective but as a resilience requirement. Concentrated production leaves systems exposed to export restrictions, supply interruptions, and political bargaining during emergencies. Progress in 2025 included continued build-out of regional vaccine and monoclonal antibody capacity, technology transfer partnerships and steps toward regulatory harmonisation, including reliance mechanisms that could allow products to move more rapidly across borders. Afrigen, Biovac and the Institut Pasteur de Dakar, among others, are cited as evidence that distributed capacity is becoming more tangible. There are other considerations here, and these can be linked to my many past newsletters and podcasts around PABS. At the same time, the scale of current facilities, workforce constraints, and dependence on external financing mean that many hubs and spokes alike remain vulnerable to shifts in donor priorities. Sustainable demand between outbreaks is still limited, and without predictable procurement or volume guarantees, maintaining warm-ready capacity will be difficult.

Platform technologies are a major source of future acceleration. Standardised backbones, modular manufacturing, and reusable processes could allow rapid adaptation to new pathogens while reducing regulatory uncertainty. Artificial intelligence is increasingly integrated into antigen design, drug repurposing and surveillance analytics. That said, the report underlines that governance and biosecurity frameworks must evolve alongside capability. Faster design without agreed safeguards could introduce new risks.

One of the important themes is the limited progress in R&D enablers. Only a few new target product profiles were issued during the year, consensus correlates of protection remain rare, and the animal rule pathway is still underused. These tools are critical for advancing candidates when traditional efficacy trials are impractical. Without them, developers remain dependent on unpredictable outbreak windows.

There are encouraging signals at regional and national levels. More African national regulatory authorities (NRAs) have achieved maturity level recognition (ML3 or above), continental harmonisation initiatives are advancing, and some countries are translating the 100 Days Mission framework into domestic preparedness planning. Rwanda’s adaptation of the scorecard approach is highlighted as an example of how global metrics can inform national investment and accountability. Such developments point toward a more distributed model of capability, though they are not yet sufficient to offset broader financial contraction.

Looking ahead, the report is explicit that 2026 will be decisive because the Secretariat’s mandate concludes early the following year. Priorities therefore focus on institutionalisation. The Therapeutics Development Coalition must shift from architecture to implementation. Diagnostics partners need to convert analytical recommendations into funded infrastructure and simplified pathways. Vaccine development momentum requires protection from political and fiscal swings. Perhaps most importantly, governments and organisations must determine how monitoring and coordination functions will persist once independent, galvanising groups like IPPS step back.

The scientific base is stronger than it was before COVID-19, and important pieces of infrastructure have emerged. Yet the system still struggles to maintain continuity between crises, and financing remains reactive. The ambition of delivering countermeasures within 100 Days depends less on isolated breakthroughs than on routine cooperation, predictable investment, and mechanisms that activate automatically when threats appear. The report frames preparedness as an exercise in reliability. The tools exist or are within reach.

The question is whether the global community can organise itself to use them quickly, equitably and at scale - to avoid severe inequities as well as supply chain delays despite willing payers due to manufacturing scale. The coming year will show whether recent initiatives harden into durable operating systems or remain promising but provisional arrangements.

Here’s a past article that you might find interesting:

Behind the scenes

A beautiful fortnight spending time with family altogether interspersed with bits from Paris, Geneva, Bucharest and Zurich. Privileged to have met many interesting people, thought leaders, artists and academics. Learning is continuous. My cup is full.

Relevant Podcast Episodes you might have missed!

Episode 24: What is the Pandemic Accord, really?

This episode takes a high level overview of the Pandemic Accord, its purpose and a walkthrough of some of its most pertinent Articles. A walkthrough. The Pandemic Accord is a proposed global agreement aimed at strengthening pandemic prevention, preparedness, and response. Emerging in the aftermath of COVID-19, the accord aims to address gaps in international coordination, surveillance, and equitable access to medical countermeasures, globally.

Episode 20: The Profitability of Skinny - How Semaglutides made Novo Nordisk Europe’s most profitable company

In this episode, we explore the economics of thinness and the phenomenal rise of GLP-1 receptor agonists in the weight loss market. Novo Nordisk, the Danish pharmaceutical company behind Ozempic and Wegovy, has become Europe’s most profitable company, surpassing even the luxury giant LVMH. We delve into the social and economic capital associated with thinness, examining how societal attitudes toward body image drive the profitability of weight loss drugs

Episode 19: Drug Licensing and the Pandemic Accord

In this episode, we look at Colombia’s recent move in issuing its first compulsory license. The country challenged ViiV Healthcare’s monopoly on their patented drug, dolutegravir, an HIV therapeutic, in an attempt to open doors for affordable generic versions and thus improve accessibility & affordability.

Things aren’t going great in the world at present. At least not for human health, development, climate, natural ecosystems, etc. But there are silver linings to be found everywhere if one tries hard enough. It is that silver lining energy that I have tried bring to this publication over the past year. But this evening is particularly busy and the best I could manage are some thoughts on the past week - a week that will stand out in history for many reasons. Nevertheless, the BBC’s Uplifting Stories section is full of palate cleansers. And it is my hope that you are starting the week energised, with a spring in your step and ready to take on the challenges ahead.

Some thoughts on Multilateralism today and Global Health

Years before I started this newsletter in 2023, I had a blog. One of my very first articles in 2015/2016 was a round-up of the Millennium Development Goals (MDGs), just as we were entering the Sustainable Development Goals (SDGs) era. I came of age in a time when everything was getting better in basically every development metric from poverty to female education and practically every health metric too - access to medicines for neglected diseases, maternal and child mortality, road traffic accidents, etc. And I loved late professor Hans Rosling’s charts plotting all this progress, feeling like we only have a little further to go in this disease area or the other. What we inherited in the 2010s was a still compromised yet recovering economy, an affinity for avocado on toast and, with hindsight, a general air of optimism about the future; bolstered by the sense of inhabiting a world with a relatively attuned moral compass that would only become more precise with time.

So this current moment in global health feels defined less by crisis than by an erosion of trust, of shared rules and of the multilateral reflex that shaped the past quarter century. Budget retrenchment across major donors, geopolitical fragmentation and an increasingly transactional approach to international cooperation are converging in ways that risk deepening inequality and undoing hard-won gains in health outcomes, particularly in low- and middle-income countries. It is painful to reflect that it is quite likely that many of the MDG & SDG era wins may be undone within the current international global architecture within a few years.

In an increasingly polarised, uncertain and erratic world of what could be described as political malevolence, it is no wonder that so many Gen Alpha and Gen Z, according to think pieces, are falling into numbness and nihilism.

The mood was palpable this week in Davos. At the World Economic Forum, Canadian Prime-Minister Mark Carney delivered what many saw as a landmark speech, arguing plainly that the post-war rules-based international order is fading and that clinging to its assumptions now risks strategic blindness. As he put it, “We are no longer transitioning between systems; we are living in the gap between what was and what is yet to be built.” The speech resonated precisely because it named what many have been reluctant to say aloud. Some criticism has followed, notably that such clarity comes only now that the instability we have all suffered throughout the post WW2 era is reaching wealthier countries. That critique is not wrong, but for those of us from the Global South, this diagnosis is not much of a revelation as much as a confirmation of how international systems and multilateral structures have always functioned.

Nevertheless, it is unsettling and Carney’s intervention matters not because it is new, but because it signals that this reality is now impossible for the international community at large to ignore. And it is noteworthy that this came at a time of rather acute concern around Greenland, which was in turn shortly after what was hailed by many as a successful military operation in Venezuela. Moreover, the health, sustainability and climate agenda was significantly reduced this year. And even within dedicated health and health financing events, there was a general sense of anxiety within the room about what might happen. It’s fair to say that Health has fallen far and fast on many a national and international agenda, particularly in the midst of an increased emphasis in discussions on funding defence over education and health. A worrying development because robust health systems, infrastructure, research and development (including those beyond AI applications) underpin societies and productivity - particularly during crises.

A major consequence of this shift, and one I wrote about last year, is a broader move from soft power to hard power in global affairs, with health increasingly caught in the middle. The United States’ progressive disengagement from multilateral institutions, including the World Health Organization which became official this week, climate bodies and other UN-linked agencies accelerates this trend. The formal U.S exit from WHO, following the expiry of the one-year withdrawal period after the announcement made on President Trump’s first day in office in January 2025, reflects a deeper retreat from collective problem-solving in favour of national interest calculations.

Today, U.S. global health engagement is increasingly channelled through bilateral arrangements. In Africa, this has meant a growing emphasis on government-to-government agreements that formalise co-financing commitments, reduce long-term U.S obligations and tie continued support to performance benchmarks. While framed as a move towards sustainability and national ownership, these agreements are time-limited, non-binding and contingent on shifting political priorities, leaving recipient countries exposed to sudden pauses or reversals if they fall out of favour for one reason or another. The model also places new demands on domestic fiscal capacity and governance, raising questions about whether bilateralism can substitute for the predictability once offered by multilateral systems. In fairness, this is a form of soft power, too - much like the soft power that China has long exerted in parts of Africa.

History offers an uncomfortable parallel. The collapse of the League of Nations, undermined in part by U.S disengagement, stands as a reminder that international institutions rarely fail suddenly. They hollow out gradually, as commitment wanes and legitimacy erodes. Today’s United Nations system faces different pressures, but the lesson is familiar: without sustained political backing from major powers an increasingly weakened United Nations becomes more symbolic and less effective.

It is important to remember how central multilateral institutions such as the United Nations and the World Health Organization are to global health, governance, financing and standardisation, not because they are perfect, but because they provide the only globally agreed framework for treating health as a shared public good. Through policy standards for drugs, vaccines, and regulation, including the WHO’s Essential Medicines List, these institutions shape what is prioritised, financed and made accessible worldwide. They set norms and standards, pool risk and resources, and create a degree of predictability and accountability that bilateral arrangements rarely sustain. They also offer smaller and lower-income countries a formal voice in setting these norms, helping to moderate the power imbalances that dominate bilateral arrangements. As multilateral systems weaken, the result is not greater efficiency, but greater fragmentation, volatility, and inequality.

Reporting one year after the end of PEPFAR funding highlights disruptions to HIV services, uncertainty for health workers and renewed pressure on already stretched national systems. These are not simply funding gaps; they are signals of what happens when long-term, multilateral commitments are replaced with short-term, interest-driven choices without enough clarity and notice for finances to be mobilised in its stead. From January 24th 2025, almost 160 000 adults and over 17 000 children died due to the funding freeze.

These dynamics are visible well beyond the health sector. In Davos, the US President’s ratification of a new ‘Board of Peace’ for Gaza, established outside existing UN frameworks, underscored the preference for bespoke institutions over multilateral ones, even in domains traditionally governed by international law and humanitarian coordination. This was hardly surprising, the president had previously stated that he does not need international law and that his power is limited by his own morality. At the same time, South Africa’s decision to temporarily exclude itself from the G20 in 2026, after U.S. pressure highlights how geopolitical leverage is increasingly exercised through access and accreditation rather than consensus.

South Africa became persona non grata to the U.S from the first day of the current presidency. It is a shame that the continent of Africa will thus not be represented in the G20 this year. Nevertheless, I find it interesting that South Africa’s long held and often criticised foreign policy position of active non-alignment in trade, as a member of BRICS, has now been adopted by countries such as Canada - its prime minister describing it as a ‘middle power’ this week, after signing a trade deal with China. In more encouraging news, a US funded hepatitis B vaccine study among newborns in Guinea-Bissau under RFK Jr, following widespread concern about exploitative research design has been cancelled.

Taken together, these developments, and all the others that I have omitted suggest that global health and our world today exists in a more unequal, fragmented era. A plane that most of us have never experienced. The challenge now is not to defend multilateralism as it once was, but to reckon honestly with how power is shifting and first and foremost, act in the interest of patients. We need to ensure that moving forward, health will be treated as a shared global good, and not as a playground or arena for leverage, power and competition.

Best wishes,

Christiana

• There’s still time to Register for the IPPS’ Launch of the 5th 100 Days Mission Implementation Report - Tuesday 27th January 2026

• Controversial US study on hepatitis B vaccines in Africa ‘cancelled’

• Not All Diseases Are Equal: How a World Economic Forum Report quietly reshaped the NCD agenda

• WEF White Paper: Acting Early on Non- Communicable Diseases: A Framework for Health System Transformation

• EU Parliament Backs Critical Medicines Act, Sparking Supply Concerns in Africa

• HIV vaccine trial back on track after USAID pulls funding - South Africa’s Medical Research Council and Gates Foundation step in to revive the trial

• CEPI backs updated Zaire ebolavirus vaccine that aims to improve vaccine affordability and accessibility

• US loses Gavi board seat after withholding funding

• CEPI backs all-in-one filovirus vaccine effort

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Happy new year! Wishing you a wonderful 2026 ahead. It’s a time for new beginnings, reflection, hope and renewed commitments.

In 2026, global public health faces an increasingly complex landscape. Geopolitical developments and tensions are shaping health priorities and demanding rapid adaptation. At the same time, there is a pressing need in some quarters to rebuild confidence in science and push back against health misinformation. Both will be essential for success. Multilateral institutions, while critical, are no longer universally regarded as the centres of gravity they once were. The World Health Organization continues to navigate chronic underfunding and reform pressures, even as expectations of leadership remain high. Meanwhile, development banks, regional alliances, hybrid public–private philanthropic mechanisms and growing reliance on bilateral agreements are exerting greater influence over priorities and financing. This shift can be seen as creating space for innovation, but it is also fragmenting the system, making coordination, legitimacy, and accountability harder to secure. Added to this, the oscillation between soft and hard power on the geopolitical stage has created a sense of volatility that contrasts sharply with the relative stability of the pre-COVID era and its ways of working.

Second, scientific progress continues to outpace policy and delivery systems. mRNA platforms, long-acting injectables and AI-enabled diagnostics point to an innovation pipeline stronger than ever. Yet access lags behind capability, for reasons that are well understood and frequently debated. Disagreements over intellectual property, manufacturing concentration and technology transfer persist. The defining question of 2026 is no longer whether we can innovate, but whether global systems are equipped to translate innovation into equitable impact, before the next emergency exposes their weaknesses again.

Third, trust has become a strategic issue. Confidence in global health institutions, data and decision-making has been repeatedly strained, often undermined online by loud and polarising voices. Mortality estimates have been contested, adherence to standard health reporting has wavered, and past failures have been sharply criticised. Rebuilding trust is partly a communications challenge, but it is primarily an exercise in action and storytelling: delivering results, taking credit for successes, being accountable for missteps and ensuring that populations and allied industries are aware of both. This will require greater transparency, strong governance and a willingness to confront whose knowledge is valued within global health spaces.

Finally, preparedness is increasingly recognised, at least in principle, as a long-term commitment. Years after COVID-19, ongoing negotiations on the Pandemic Accord underline just how difficult it is to embed preparedness into financing models, manufacturing capacity and global governance. Health security cannot depend on political memory or emergency funding cycles. It is built through routine investment decisions, workforce planning and resilient supply chains long before a crisis emerges.

Nevertheless, as we look to 2026 and beyond, there is room for optimism. In the words of former WHO DG, Dr Margaret Chan, “The history of public health is a history of victories against adversity.”

Thank you for continuing to read, reflect, and stay engaged. The direction of travel is still being set and our conversations, now and in the months ahead, matter more than ever.

Sending warm wishes your way,

Christiana

Special: The Economics of Prevention and why we never Fund it: A Paradox

In the history of public health and healthcare there has long been a tension between how resources are allocated across the two paradigms of disease prevention and treatment.

The concept of prevention is often presented in the following terms: spend a little today, save a lot tomorrow. But when we look closely at how prevention works across a whole population, the picture becomes much more complicated. Prevention is not always cheaper than cure. Once scaled up, it often becomes one of the most expensive parts of a health system.

The first issue is that prevention measures target everyone, while only a few people directly benefit. Geoffrey Rose called this the Prevention Paradox. An intervention can bring big gains to the population while offering very little to most individuals taking part. In economic terms, most people in a prevention or screening programme receive something that brings them very little personal benefit. That’s why incremental cost-effectiveness ratios (ICERs) can rise quickly at the population level. Most of the spending is on people who were never going to become ill. A national screening programme tests millions to save the lives of a relatively small number. A lifestyle programme recruits thousands to prevent disease in a smaller subset. Most participants would never have developed the condition. Even when prevention works, it diverts large resources toward avoiding relatively few cases. This sits awkwardly beside the popular belief that prevention is always the cheaper choice.

The second challenge is scale. Treating disease is expensive, but treatment only goes to the people who are sick. Prevention has a low cost per person, but it is delivered to millions. A £5 vaccine looks inexpensive until it is offered to 50 million people. A £50 screening test balloons into a huge line item when applied nationwide. Policymakers look at total programme costs, not unit costs, and the totals can look enormous. These programmes also depend on human labour: nurses, GPs, technicians, etc. So they cannot become dramatically more efficient over time. As Baumol’s Cost Disease illustrates (a deep dive for another day), labour-intensive sectors tend to get more expensive, not less. Prevention also faces diminishing marginal returns: reaching the first majority of a population is relatively easy; reaching the last few percent is slow, incredibly costly and often the least efficient part of the programme. This is well demonstrated by the fight to control and eliminate Polio.

This part of the equation also sits squarely within vaccine economics: perhaps the most economically efficient prevention measure. Nevertheless, it is one that most clearly exposes the limits of the logic that prevention is ‘cheap’. Vaccines generate powerful population benefits through herd immunity, but those benefits depend on reaching and sustaining very high coverage, long after disease has become rare and individual perceived benefit has faded. And we can see these examples everywhere - measles, for example. As incidence falls, costs remain, ICERs can worsen and political tolerance for continued investment erodes, even though withdrawing vaccination would rapidly reverse gains. Value is created not through visible health care delivered, but through risks avoided, outbreaks that never occur and systems kept resilient by sustained, often uncomfortable, spending.

Time makes things more difficult. Prevention pays off slowly, sometimes very slowly. Vaccination in childhood protects against outbreaks decades later. Smoking cessation reduces heart disease years into the future. Diabetes prevention only shows its impact across a long horizon. In cost-utility terms, the QALYs gained far in the future are heavily discounted; they ‘count’ less in economic models, and even less in political ones. Treasuries look at annual budgets. Ministers look at electoral cycles. Neither is rewarded for investing in outcomes that emerge long after they have left office. Economists call this time inconsistency. Behavioural scientists call it present bias. Either way, long-term prevention often loses out to short-term pressure.

And there is always pressure. Prevention must compete with problems that are loud, visible and immediate. Hospitals may be overcrowded. Emergency departments may be short-staffed. Waiting lists grow. These issues generate headlines and political risk. The key to understanding this is appreciating that when prevention succeeds, it produces no drama at all. Bowel cancer mortality falls quietly. A hypertension programme prevents strokes that no one notices. Better antibiotic stewardship reduces antimicrobial resistance decades later, long after the decision-makers have moved on. Prevention lacks salience. Human attention naturally gravitates toward what is vivid and urgent, not what is avoided, abstract or invisible. Prevention provides slow, statistical benefit to people who may never know they were helped.

Third, interestingly, screening brings its own complications. Many prevention programmes create significant downstream costs in the form of follow-up tests, false positives, incidental findings and ‘overdiagnosis’. These are normal features of screening, not signs of failure, but they are expensive. Every false positive triggers imaging, biopsies, and specialist referrals. Every incidental finding launches a cycle of monitoring. At a population level, these downstream costs can outweigh the savings from detecting disease early. Many formal evaluations reflect this: some programmes reduce mortality but still fail to meet cost-utility thresholds because the extra activity they generate is so large.

The most uncomfortable point is this: prevention is usually cost-effective, but very rarely cost-saving. Cost-effective means good value for the health gained; cost-saving means total spending goes down. They are very different metrics. When prevention succeeds, people live longer. Long enough to later require care for other age-related conditions. Someone whose diabetes is delayed may later need heart disease or dementia care. Screening reduces mortality but expands long-term surveillance. Lifestyle interventions improve wellbeing but rarely reduce lifetime health expenditure (which is, in my opinion, a good thing - naturally, longer lives often accrue greater lifetime health expenditure). Prevention generates QALYs (quality adjusted life years - i.e. more years of life lived in good quality of health); it does not reliably generate savings. Its logic lies in health gain, not lower budgets.

All these factors explain why prevention occupies such a strange place in healthcare decision-making. It is described as the rational choice but often looks irrational from within systems driven by short-term financing cycles.

This is not a philosophical problem; it is a structural one. Prevention demands steady investment and long-term thinking. Cure demands resources too, but offers visible results quickly. In health systems shaped by budgets, funders, election cycles, behavioural biases, discounting, and media attention, it is not surprising that prevention remains fragile. It works, but it works in ways that are hard to defend within the political and economic realities that govern modern healthcare. Visible results and results that are turned over quickly are often preferred.

So does the prevention paradox apply to Epidemic & Pandemic Prevention?

The prevention paradox was originally formulated to describe population-level health interventions that act directly on individuals, such as screening, vaccination, or risk factor reduction. Pandemic prevention activities such as genomic surveillance, pathogen discovery, platform technologies, prototype vaccines, manufacturing readiness and early-stage drug development do not operate on populations in the same way. They do not reduce individual risk incrementally across society. Instead, they reduce the probability, scale, or severity of rare but catastrophic health events. The paradox nonetheless applies, albeit through a different economic mechanism.

Pandemic prevention exhibits a similar mismatch between who pays, who benefits, and when those benefits materialise. Investments in genomic sequencing or surveillance generate little immediate value in periods of apparent calm. Most sequences never lead to action. Most detected signals do not escalate into crises. From an annual budget perspective, these activities appear to produce data rather than outcomes. Their value lies almost entirely in their ability to shorten response times or avert worst-case scenarios that may never occur.

This creates a familiar underinvestment dynamic. The costs of preparedness are continuous, visible, and easy to quantify. The benefits are contingent, probabilistic, and realised only in counterfactual form. A surveillance system that detects nothing looks inefficient; a platform technology that is never deployed looks redundant. Yet when prevention fails, the costs are no longer marginal but systemic, cascading across health systems, economies, and political structures.

Economically, pandemic prevention resembles insurance more than traditional public health intervention. It reduces tail risk rather than average burden of disease. Standard cost-effectiveness frameworks are poorly suited to valuing this kind of protection because they discount rare events and are limited in incorporating uncertainty, option value, and systemic spillovers. As a result, investments that are rational from a risk-management perspective often appear weak when assessed using conventional health economic tools.

The COVID-19 pandemic briefly disrupted this logic. Surveillance gaps, manufacturing constraints, and underinvestment in platform technologies were rendered visible almost overnight. Emergency funding flowed rapidly into vaccine platforms, genomic sequencing and medical countermeasure development. But as immediacy faded, so did political tolerance for sustained spending on capabilities whose success would again be measured by absence.

In this sense, pandemic prevention shares the core feature of the prevention paradox: it generates its greatest value when it appears to do nothing at all. The difference is scale. Whereas classic preventive interventions distribute small benefits across large populations, pandemic prevention concentrates large benefits in rare moments. Both challenge systems that prioritise visible outputs, short-term accountability, and annualised efficiency. Understanding pandemic prevention through this lens helps explain why preparedness cycles oscillate between panic and neglect, why financing remains episodic, and why institutional memory erodes so quickly. The problem is not uncertainty about value, but the persistent difficulty of sustaining investment in protections whose success is defined by the crises that never happen.

Welcome to the final fortnight of 2025. And what a year it has been! At the end of the year, its always valuable to take stock of the good, take learnings from the neutral and bad; and begin to step out of the past and lean into the brightness of what lies ahead. :)

I love the Christmas period: the lights, the warmth, the general atmosphere. And I have made sure to take in all the festive joy along with some moments of levity these past weeks. Enriching discussions with fascinating people; catching up with friends and family in Paris, London and Geneva. Reflecting on the year, personally, I am endlessly grateful for the experiences and learning that I have had. This week’s side quest, however, is more mundane: I endeavour to close all my 1000+ tabs across 4 devices. Every last one addressed, bookmarked, responded. (Slightly ambitious, but I can get it done) As this edition goes on, forgive me for the uncharacteristic lack of links - this is a data heavy edition and excluding the links while mentioning the sources allowed me to ensure that this makes it into your inbox.

If there was a single word that defined global health, development and pharma in 2025, it might be unsettling or at least, shifting. Not because nothing worked, but because many long-standing assumptions no longer held. The foundations of how global health is financed, governed, innovated and delivered shifted. As the Johns Hopkins review of the year described it, this was a seismic moment for public health, destabilising institutions long treated as permanent. And yet, something else emerged too: innovation, resilience, and at times improvisation, all in service of adapting systems to better support the communities they exist to serve.

Nowhere was fragility more exposed than in global health financing. By mid-2025, development assistance for health had fallen by more than 20% in a single year, driven largely by U.S. funding cuts and broader retrenchment across the sector as defence and domestic priorities took precedence. Programmes stalled, procurement chains fractured and assumptions about donor reliability were shaken up.

The human consequences were stark. Updated analysis from the Center for Global Development suggests these cuts may have contributed to between 500,000 and 1.6 million additional deaths in 2025, largely through disruptions to HIV treatment, malaria control, food aid and humanitarian relief. Stock-outs of antiretrovirals, interruptions to therapeutic food supplies and suspended services became lived realities across many low-income and fragile settings.

And yet, even as funding retreated, the work did not stop. At the Global Fund’s 8th Replenishment in Johannesburg, during South Africa’s G20 presidency, governments, advocates and health workers showed up, fully reaffirming commitments to HIV, TB and malaria in one of the most turbulent geopolitical moments in recent memory. The year’s defining stories were human stories: mobile TB teams operating in Ukraine; community health workers navigating floods in Bangladesh; digital surveillance tools in the DRC detecting outbreaks earlier.

The year also forced a reckoning with sovereignty. As external financing grew less predictable, African leaders increasingly reframed health security within the broader, domestic, economic infrastructure framework - work that is still underway. By necessity, the push for health sovereignty, including regional manufacturing and regulatory capacity, gained further momentum.

This shift was echoed across multilateral spaces. South Africa’s successful G20 presidency closed out the forum’s first full cycle with a sober assessment: the G20 still matters, but its effectiveness has eroded amid some multilateral fragmentation and geopolitical strain. Health remains on the agenda, but increasingly framed through productivity, resilience and preparedness rather than crisis response.

In terms of epidemic preparedness and response, CEPI translated years of investment into progress against high-risk pathogens, launching the world’s first Phase II Nipah virus vaccine trial, advancing Rift Valley fever vaccines in endemic settings and pushing mRNA pandemic influenza candidates into pivotal trials. The International Pandemic Preparedness Secretariat anchored preparedness in governance and delivery, stewarding the 100 Days Mission, engaging deeply with the G20 and advancing diagnostics and therapeutics coordination, as well as vaccines. Both acknowledge the world remains underprepared, but together they showed that sustained, collaborative work is still moving forward.

Another moment of alignment came late in the year, when the UN General Assembly overwhelmingly adopted a political declaration on non-communicable diseases and mental health, with only the U.S. and Argentina voting against. Targets on hypertension control, tobacco reduction and mental health access marked a rare win for multilateralism and reflected the growing weight of chronic conditions shaping productivity, longevity and wellbeing.

Few developments captured 2025 like the rise of GLP-1 receptor agonists. These therapies rapidly expanded, prompting the WHO’s first global guidelines on their use for obesity, boosting the recognition of obesity as a chronic disease in itself, as opposed to solely a risk factor for other NCDS (Diabetes mellitus, cardiovascular conditions, etc.) while cautioning that medication alone is not the solution. At the same time, the GLP-1 moment exposed cultural fault lines. As thinness re-emerged as an aspirational ideal, as discussed in the Guardian, concerns grew that medical interventions were being drawn into older narratives around body image, women’s beauty standards and worth. The tension between clinical benefit, equity, stigma and social pressure remained largely unresolved.

Global health innovation also came under pressure. Disruptions to USAID-linked research pipelines and other major R&D funders raised concerns about future leadership. And yet, progress continued. The International Vaccine Institute advanced schistosomiasis vaccine trials in Burkina Faso, expanded research infrastructure across Africa and Asia, and accelerated mRNA platforms for emerging threats like Rift Valley fever and mpox. The broader picture remained mixed: while millions have gained access to health services since 2015, only around 35% of SDG targets are on track, and financial hardship from health costs remains concentrated among the poorest.

At a systems level, 2025 revealed another paradox. As the latest OECD Health at a Glance report revealed, in many high- and middle-income countries, survival from heart attacks and strokes improved, trust in primary care remained high, and health workforces continued to grow. Yet, persistent gaps, particularly in women’s health outcomes and access, endured. Artificial intelligence began to play a more tangible role, improving outcomes in stroke care, outbreak detection and clinical decision support, but notably, this was largely in areas where systems were already functional.

Climate loomed large over health throughout the year 2025. Extreme heat, floods, pollution and food insecurity repeatedly translated into health crises, reinforcing that climate is no longer a future health issue, but a present one. At COP30, the launch of the Belém Health Action Plan signalled growing recognition that resilient health systems are central to climate adaptation.

Health diplomacy is the thread that ran through all of this, in this era where politics and health have become so strongly intertwined. The adoption of the Pandemic Agreement at the World Health Assembly in May 2025 was one of the most consequential, multilateral health achievements of the post-COVID era; the product of patient, consensus-building. The recognition of Malebona Precious Matsoso as Doha’s Best Negotiator of the Year felt emblematic, reminding us that global health still depends on the most skilled, patient, principled leadership that the world has to offer; willing to hold the line when politics are most complex. An incredible achievement for the INB co-chair, and very well-deserved.

2025 taught us that global health no longer operates in a world of assumed goodwill or stable funding. Resilience now means adaptability, too; sovereignty and solidarity will need to coexist in the coming world. And that the future of health will depend on what we structurally and financially protect.

Global health has already changed. It is incumbent upon us, in this community and beyond, to move with it and to keep patients at the centre. 2026 will be a year to be grounded, fearless and strongly tethered to the mission that first brought us here.

Thank you so much, as always, for reading, Friend. Today, and throughout the year. Your reading, engagement and participation means so much. Wishing you and yours rest, peace, joy, a Merry Christmas and a Happy New year. Eat well, and be happy.

With love,

Christiana

P.s. here’s a jazzy Christmassy track if you’re still in the office (or just seeking the joy of a virtual gingerbread biscuit, but in sound format.)

A Year of Recalibration: Global Health Conversations in 2025

Looking back on 2025 with a little distance, it is clear that this was not a year defined by one singular shock, but by a steady build-up of pressures that reshaped how global health is discussed, viewed, governed and financed. The most popular editions of Global Health Conversations over 2025 reflected this shift: away from the post-pandemic urgency and toward a complex reckoning with geopolitics, economics, institutional fragility and responsibility. 2025 offered inflection points. Below is an overview of the issues that most consistently surfaced and resonated across the year.

1. A New Era in Global Public Health

Early in 2025, the idea that global health had entered a “new era” gained traction, not only as a slogan but as an observation grounded in funding withdrawals, political shifts and institutional uncertainty. The reduction or suspension of major U.S. funding streams, alongside broader donor fatigue, placed strain on programmes long assumed to be stable, from HIV and TB services to pandemic preparedness and climate–health initiatives.

At the same time, there was growing recognition that this moment could not be approached solely through alarm. Conversations increasingly turned to diversification of funding, regional leadership, and the limits of over-reliance on a small number of political actors. Solidarity remained a recurring theme, but it was discussed less as an abstract value and more as something requiring deliberate, structural support. Read more here.

2. Health, Power, and Geopolitics

One of the clearest threads running through 2025 was the entanglement of global health with geopolitics. Discussions of foreign aid cuts, vaccine diplomacy and development partnerships were increasingly framed in terms of power; particularly the role of health as a form of soft power that shapes alliances, trust and long-term stability. As European and U.S. governments shifted spending priorities toward defence and domestic industry, the downstream effects on health systems in low- and middle-income countries became more visible. We were reminded that global health financing and diplomacy was never only about service delivery; it was also about influence, data access, and the ability to shape global norms. In several regions, the retreat of traditional partners coincided with the entry of new actors, underscoring how quickly relationships can be reshaped when health cooperation weakens. Read more here.

3. Multilateralism Under Pressure: WHO and WHA78

The World Health Assembly provided a focal point for many of these tensions. Coverage around WHA78 captured a moment of both achievement and strain. The formal adoption of the Pandemic Agreement marked the end of years of negotiation, even as the most contentious issues (particularly pathogen access and benefit-sharing) had been deferred and currently still negotiated. Alongside this, WHO itself faced significant restructuring, leadership changes and funding gaps exacerbated by the absence of the United States. Discussions reflected concern about workforce losses, institutional morale, and the long-term sustainability of multilateral health governance. Yet there was also a sense that multilateralism, while weakened, had not disappeared and that its survival would depend on adaptation rather than nostalgia.

4. Trade, Tariffs, and the Health–Economics Interface

Trade policy emerged repeatedly as a health issue in its own right. Analyses of U.S. tariffs, EU–US trade dynamics, and pharmaceutical supply chains highlighted how decisions made in trade ministries and finance departments ripple through health systems globally. Concerns centred around drug affordability, supply chain resilience and the viability of R&D investment under rising costs. These discussions reinforced a broader reality of 2025: health no longer sits outside economic strategy. Industrial policy, protectionism, and market access debates are central to questions of health security, particularly for countries dependent on global pharmaceutical manufacturing networks.

5. The Pharmaceutical Sector After the Pandemic Boom

By mid 2025, attention increasingly turned to the pharmaceutical industry’s evolving role. Financial disclosures showed clear winners and losers as COVID-era revenues faded, GLP-1s dominated headlines and companies adjusted pipelines. Beyond earnings, there was growing interest in how companies positioned themselves in relation to global health priorities, from access strategies and regulatory behaviour to responses to antimicrobial resistance and vaccine equity. The sector was no longer operating in a moment of exception, but in a more constrained and politically charged environment, where public expectations and market realities do not always align.

6. Public Health as Economic Infrastructure

One of the most reflective discussions later in the year returned to fundamentals: the economic logic underpinning public health itself. Framed historically, we looked at public health, not as a charitable endeavour, but as infrastructure and an investment: essential to productivity, stability and long-term growth.

In a year marked by funding cuts and austerity narratives, this perspective resonated. When investment in prevention, surveillance, and health systems declines, the costs tend to reappear elsewhere, through lost productivity, avoidable outbreaks and widening inequality. The resurgence of vaccine-preventable diseases and the economic consequences of ill health served as reminders that health spending has always been closely tied to economic outcomes.

Behind the scenes:

It’s the most wonderful time of the year! A perfect Dirty Chai, Christmas carols at church, Santas pants at winter wonderland, long chats beside fantastic Christmas trees and a bucket list worthy 20th anniversary Darius Brubeck Quartet show with one of my dearest friends in London. Wonderful family reunion and beautiful performance of Swan Lake with dear a friend in Geneva (followed by dash to Globus for the perfect chai blend to ensure I never again go without.) Museums, long walks, long suppers, Christmas market and cafes with friends in Paris, and so much more in between. My heart could not be more full as 2025 comes to a close. Here’s to a more wonderful, full and fulfilling 2026!

Relevant Past Podcast Episodes you might have missed!

Episode 24: What is the Pandemic Accord, really?

This episode takes a high level overview of the Pandemic Accord, its purpose and a walkthrough of some of its most pertinent Articles. A walkthrough. The Pandemic Accord is a proposed global agreement aimed at strengthening pandemic prevention, preparedness, and response. Emerging in the aftermath of COVID-19, the accord aims to address gaps in international coordination, surveillance, and equitable access to medical countermeasures, globally.

Episode 19: Drug Licensing and the Pandemic Accord

In this episode, we look at Colombia’s recent move in issuing its first compulsory license. The country challenged ViiV Healthcare’s monopoly on their patented drug, dolutegravir, an HIV therapeutic, in an attempt to open doors for affordable generic versions and thus improve accessibility & affordability.

This fortnight’s highlight is the summary of the Q3 2025 Pharma financials. Here is a link to the Q2 financial disclosures summary for background.

We’ve done something slightly different this year. I have ranked the top earning companies not in order of quarterly earnings alone, but taking other metrics into account based on a little Global Health Conversations ‘formula’ that I started devising after a conversation I had with a consultant a few weeks ago. I cannot speak for the Global Health Sector. But I believe we have a place in stating, alongside earnings, who we feel have been allies and continue to provide value in their capacity to the patients and populations that we work for. So I’d like to know what you make of my rankings and the ‘Global Health Pharma Leadership Index’. Skip to the FiRs below to read more.

Until next fortnight, Friend. Keep well.

Christiana

Discussion of Key Headlines

I had an interesting conversation with past podcast guest, Mary, this fortnight about antibiotic use across various countries. Looking at Statista data on antibiotic prescriptions across various countries. We concluded that the data on antibiotic use is only as good as the systems in place to measure this data; as well as the assumption of control of access to antibiotics - often obtained without prescription in some regions. Moreover, we learned that in some of the best performing, nordic countries, reducing antibiotic use has led to increased infections after routine dental treatments, for example. Something I discussed with dental expert, Ema Prohic, last year. Ultimately, the solution to keeping antibiotic resistance at bay, despite the numerous hurdles and challenges will be novel drug development. The last, novel, antibiotic class was discovered in 1968. There have been a few recent developments, these (1; 2) were published in Nature earlier this year.

Regulation is often the vital piece of the puzzle - and may go a long way to explaining why independent Swiss organisation, Public Eye, reported this week in an article headlined ‘Africa’s baby food sugar scandal’ that Nestlé has been failing to comply with WHO guidelines in infant cereals in Africa; products that allegedly contain zero added sugar in Switzerland and the EU. A particularly interesting piece of journalism worth a read. At the end of the day, guidelines are guidelines and are most useful when used to inform policy. Markets will not regulate themselves in the interest of public health; and companies will and do remain viable within regulatory environments that protect populations.

(Source: Public Eye)

The UK COVID-19 enquiry published its second report of findings this fortnight. And the Economic Response Module should be broadcast via livestream tomorrow morning, 24 November 2025. It is worth a read (summary videos are available) and findings offer an opportunity for reflection on the current role of emergency and epidemic preparedness.

It discusses the effect of what has been called ‘group think’. As well as some commentary on the effect of what we are currently experiencing - the growing politicisation of health. This week, RFK Jr. instructed the CDC to change its autism and vaccines guidance to include proven false information that lends credence to long-debunked anti-vaccine claims, suggesting scientists “have not ruled out” a link despite overwhelming evidence to the contrary. Science and politics have always been linked. And this is an excellent example. Experts warn the move imports fringe rhetoric into a federal health authority’s public guidance. But more than that, it signals a shift in the credibility of one of the world’s leading public health agencies; referenced, respected and consulted by scientists, policymakers and clinicians globally.

UNICEF is preparing to shift nearly 300 Geneva-based posts to Rome amid a projected 20% funding drop and WHO is bracing for further restructuring, cutting up to 25% of staff globally. Meanwhile, the United States is moving aggressively on bilateral MOUs across Africa that offer five-year aid packages in exchange for 25 years of access to pathogen data and national health information systems; terms many observers have described as “extractive,” and which clearly represent efforts to bypass ongoing WHO negotiations on pathogen-sharing and benefit-sharing frameworks.

The G20 summit concluded today in Johannesburg without the United States. World leaders nevertheless successfully pushed through a joint declaration, at the first ever summit held in Africa, despite a full U.S. boycott. South Africa framed the outcome as a triumph of multilateralism: the Declaration prioritizes climate adaptation, renewable energy targets and debt relief for low-income countries. The diplomatic fallout between Trump’s government and South Africa was initiated by Trumps’ false claims that the South African government is involved in a genocide against white South Africans - something that is and has always been completely untrue. A collection of prominent Afrikaaner groups gathered over 1500 signatures on an open letter entitled ‘Not in our name’ - once again rejecting the claims of racial persecution in South Africa; ahead of the G20 Summit. The boycott further complicated the handover that was to take place, with the U.S. holding the next G20 presidency in 2026. At the last moment, and against G20 protocols, Washington announced it would send a junior diplomat to the Summit of world presidents to partake in the closing ceremony and handover. In response, the South African government invited the U.S. to collect the documents at the Department of International Relations and Co-operation offices from Monday. Beyond the theatrics, the summit was successful in achieving its aims, for now. Nevertheless, this has truly underscored widening geopolitical fractures; yet also a growing willingness among the rest of the G20 to act without Washington when needed.

Another important milestone achieved ahead of the G20 Summit in South Africa was the Women’s Shutdown, organised by Women for Change SA. On Friday 21st November, South African women withdrew themselves from paid and unpaid labour for a day, turned their profile pictures purple and had a 15 minute silent lie down at noon in honour of the 15 women who are murdered every day. The protest was against Gender Based Violence and Femicide (GBVF), with several months of advocacy in the lead up. As a result, on Thursday, ahead of the shutdown, the South African government declared and designated GBVF as a crisis. A historic, precedent setting win for women everywhere.

Finally, COP30 concluded in Belém, two major international meetings in LMICs this year, but with a fragile deal that fell short of expectations. Countries failed to agree on any fossil-fuel phase-out language, an omission that caused a great deal of tension. And Brazil’s presidency struggled to bridge divides between major fossil-fuel producers and countries pushing for stronger ambition. Still, the UN’s climate chief stressed that achieving consensus in today’s political climate is evidence that “climate cooperation is alive and kicking,” a reminder that multilateralism may be battered but is not yet broken.

There’s a lovely quote from The Office about not realising you’re in the ‘good old days’ until much later. It is hard to feel as though we are in the good old days, currently. But I feel that in all the stories I have discussed this evening in this letter, there are embers of hope. And hope itself means that there’s something that can be revived.

The Global Health Pharma Leadership Index (2025)

This list represents the how major pharmaceutical companies are performing against the priorities of the global health community, as well as those of their shareholders. It has considered revenues, R&D pipelines and partnerships that are aligned with goals of improving access. The data used takes Q1,2 & 3 earnings into account, focussing on Q3, as Q4 data is not yet available. The index aims to highlight which firms are emerging as constructive global health partners while remaining competitive in overall earnings. The reason that both of these angles are considered is to prove that profitability and useful collaboration are possible. :)

1. GlaxoSmithKline 🏆

GSK tops the Global Health Pharma Leadership Index on the strength of a portfolio that continues to align closely with infectious disease and HIV priorities. In Q3 GSK reported revenue of $11.3 billion, an 8% increase; and raised full-year sales guidance. HIV remained GSK’s largest product area, with sales up 12% to $2.6 billion; long-acting regimens drove most of that growth, as Cabenuva brought in $472 million (up 48%) and Apretude (for PrEP) rose 75% to $159 million. Vaccines were a weaker point in financial terms, reaching $3.5 billion in sales on modest 2% growth, with shingles and flu vaccines under pressure in the U.S., but demand remaining robust in Europe and Japan. From a global health perspective, the combination of expanding long-acting HIV options and a broad vaccines footprint keeps GSK at the centre of access, prevention and health security debates, even as it navigates a more volatile U.S. vaccine market.

2. Novartis 🥈

Novartis balanced strong commercial performance with a pipeline that remains relevant to global health. Their third quarter net sales reached $13.9 billion, up 7% year-on-year, although growth was slightly overshadowed by a plateau in sales of heart failure drug Entresto as U.S. generics enter the market, prompting litigation to protect its IP and regulatory rights. Investors reacted negatively, sending the share price down more than 4%, but the Q3 earnings update also highlighted a key global health asset: the novel non-artemisinin malaria combination ganaplacide–lumefantrine, developed with Medicines for Malaria Venture and now planned for regulatory submission in 2026. The planned $12 billion acquisition of RNA therapeutics specialist Avidity Biosciences earned them some further innovation points, alongside a diversified portfolio and commitment to R&D. Taken together, Novartis combines solid earnings, a still-formidable cardiovascular and oncology portfolio and now malaria efforts with clear LMIC relevance, keeping it near the top of the ranking.

3. AstraZeneca 🥉

AstraZeneca showed steady growth and a visible commitment to chronic disease management in African health systems through 2024 to date. The company reported a 10% rise in total Q3 revenue to $15.2 billion, beating expectations on the back of an 18% jump in oncology sales to $6.6 billion. Vaccines and immune therapies are still a relatively small unit, but still grew 2% to $416 million, with Sanofi-partnered RSV monoclonal Beyfortus contributing $236 million and posting 29% sales growth. Beyond the numbers, AstraZeneca used its earnings release report to spotlight the expansion of the Healthy Heart Africa initiative to include chronic kidney disease, adding CKD care to programmes in Côte d’Ivoire and Rwanda in partnership with health ministries and PATH. AZ have a combination of strong financials, expanding NCD work in LMICs and continued RSV prevention efforts.

4. Sanofi

Sanofi’s third-quarter performance reinforces the success of its diversified portfolio across vaccines and chronic disease. The company reported Q3 sales of $14.5 billion, up 7% from a year earlier, driven largely by the Regeneron-partnered anti-inflammatory blockbuster Dupixent, which grew 26% to $4.9 billion. The vaccines division had a more challenging quarter: revenue fell 7.8% to $3.9 billion as influenza shot sales declined 17% amid price competition in Europe and weaker uptake in the U.S. Nonetheless, AstraZeneca-partnered RSV prophylactic Beyfortus grew nearly 20% to $860 million, demonstrating ongoing strength in high-priority paediatric prevention. Despite the headwinds, Sanofi’s scale in vaccines, its central role in RSV prophylaxis, and its continued exposure to lower- and middle-income markets sustain a robust global health leadership position. It’s worth a reminder that the general uptick in RSV across the sector is strongly related to WHO guidance for pregnant women and infants earlier this year, followed by countries taking up these guidelines, such as the NHS England guidelines introduced this summer.

5. Gilead Sciences

Gilead secures a top-tier slot in the ranking thanks to its HIV franchise and move into long-acting prevention. The path hasn’t been linear in 2025 with Lenacapavir. But in July this year, as discussed in past GHC editions, a deal was struck with Global Fund and other partners to license the drug, opening it to the biosimilars market in some low-income countries, which was expected to drive the price down dramatically to about $40 per dose. In Q3 2025, the company reported overall revenue of $7.8 billion, up 3%, while product sales slipped 2% but excluding Covid threapeutics there was an overall rise of 4%. Biktarvy, its once-daily HIV combination, remained the main revenue driver based on reporting, with $3.7 billion in sales and 6% growth, accounting for more than half of company revenue. Newly launched Yeztugo (Lenacapavir) contributed $39 million and management highlighted rapid payer coverage for the injectable. At the same time, Gilead’s investor messaging placed heavy emphasis on patent life, including a delayed arrival of U.S. generics for Biktarvy until 2036. This mix of highly impactful HIV innovation and assertive IP defence yields a strong but slightly qualified global health rating, too.

6. Johnson & Johnson

Johnson & Johnson’s portfolio has tilted further towards oncology and also further away from infectious disease. The company reported $24 billion in third-quarter sales, one of the highest on this list and a 4.4% improvement, slightly above expectations. Their oncology products is where they stood out, with sales up 19.2% to $6.5 billion, while infectious disease revenue declined 4.3% to $829 million, though at a slower rate than in the previous quarter. Alongside the results, J&J announced plans to separate its orthopaedics business, DePuy Synthes, which generated about $9.2 billion in 2024 sales, indicating a continued strategic focus on higher-margin pharma and medtech franchises. All things considered, J&J’s legacy in TB and HIV, its scale and its ongoing role in critical therapies keep it in the upper tier of the index, even as its centre of gravity shifts away from ‘traditional’ global health areas.

7. Roche

Roche’s third-quarter earnings underscore the dual importance in both pharmaceutics and diagnostics, both of which matter for global health systems. The company recorded Q3 sales of $18.8 billion, representing 6% growth year-on-year! Its pharma division accounted for most of the revenue and momentum, generating $14.5 billion and growing 7%. China featured prominently, with pharma sales in the country rising 9% over the first nine months of the year, helped by the inclusion of breast cancer treatment Phesgo in the national reimbursement list and strong uptake of influenza drug Xofluza. By contrast, the diagnostics business was squeezed by Chinese healthcare pricing reforms, which contributed to a 15% drop in Asia-Pacific diagnostics revenue over the same period. Roche’s combination of innovative therapies, influenza and other infectious disease products and a continued commitment to extensive diagnostic infrastructure put them at 7th place on this list.

8. Pfizer

Pfizer’s had a more uncertain growth story in recent quarters as Covid revenues continue to fade. In the Q3 2025, however, the company reported sales of $16.7 billion, down 7% when Covid products are included but up 4% on a ‘non-Covid’ basis, and this shift was highlighted in its earnings narrative. Sales of the BioNTech-partnered Covid vaccine fell 20% to $1.2 billion, while the Prevnar pneumococcal franchise slipped 4% to $1.7 billion amid the rise of Merck’s competing PCV21. Pfizer’s RSV vaccine Abrysvo also struggled, with Q3 sales down 22% to $279 million, despite what the company described as strong international momentum, and the momentum is indeed real, something I suspect will continue in 2026. Looking ahead, Pfizer is deferring its Phase 3 adult PCV25 trial to 2026 and pushing the late-stage paediatric study to the same timeframe, even as it pursues $7.2 billion in cost cuts by 2027 and competes with Novo Nordisk to acquire obesity-drug startup Metsera.

9. Sandoz

Sandoz enters is much smaller than most of the companies on this list. Its inclusion is due to a combination of earnings and its role in generic antibiotics and broader affordable medicines. The company reported net sales of $2.8 billion in the third quarter, up 6% year-on-year, with 54% of revenue derived from Europe. In its Q3 announcement, Sandoz warned of “trade distortion” in the penicillin market, noting that U.S. tariffs had pushed Chinese suppliers to sharply lower prices for key APIs, creating a situation where a packet of antibiotics is sold cheaper than a pack of M&Ms. Chief executive Richard Saynor called on European governments to commit to sourcing at least 20% of antibiotics from local suppliers. They have a portfolio anchored in essential but off-patent medicines and vocal advocacy on antimicrobial supply-chain resilience which aligns strongly with global health priorities in access and health security.

10. Bayer

Bayer completes the top 10, recognised for their targeted moves that link commercial activity to women’s health and local capacity. The company reported third-quarter sales of $11.2 billion, a 1% increase from the prior year that fell short of expectations, weighed down by generic competition affecting older drugs and weak demand in its consumer health business. However, at the end of October Bayer signed a MOU with Nigeria’s Chromedix Pharmaceuticals and the Nigerian government to explore collaboration on distribution, capacity building and potential technology transfer, beginning with short-acting hormonal contraceptives. This initiative, if realised, would support both access to contraception and local systems development in a major African market.

Other Mentions 🌿

I couldn’t leave out Novo Nordisk and Eli Lilly - our two big players in the continuously unfolding metabolic disease, weight-loss, GLP1RA market. I’ve tied them in 11th place.

11. Novo Nordisk & Eli Lilly

Novo Nordisk’s third-quarter results underscored both its dominance in metabolic disease. Sales rose 11% to $11.5 billion, but the company cut its full-year growth guidance for the fourth time, now expecting just 8–11% instead of the initially projected 16–24%, citing capacity constraints and intensifying GLP-1 competition. More concerning is its reported 15% drop in the number of “vulnerable patients” reached in 2025, alongside its withdrawal of top insulin products in India and the non-renewal of South African supply contracts, all while expanding GLP-1 production, decisions that diminish the global health value of an otherwise transformational NCD portfolio. This company has been making big and exciting moves these past years, and if you’ve been reading GHC for a while, you’ll know I've been writing about them for over two years now. I sense that Novo Nordisk are not yet out of their period of transition into the market leader that they have become, and I think the Q4 data might reveal a more encouraging picture.

Eli Lilly’s earnings reinforced its growing lead in the GLP-1 race but also highlighted how access to its flagship drugs remains concentrated in high-income settings. Third-quarter revenue surged 54% to $17.6 billion, driven by spectacular growth in tirzepatide: Mounjaro sales more than doubled to $6.5 billion and Zepbound rose 185% to $3.6 billion, making tirzepatide the world’s best-selling medicine. Lilly raised full-year guidance and announced a $3 billion investment in a Dutch manufacturing site for oral GLP-1s, as discussed on GHC several months back. This was not their best move but it seems that this did not affect earnings.

Roundup of other results

Merck delivered a mixed third quarter from a global health perspective. Worldwide sales rose 3% to $17.3 billion, but the company narrowed its full-year guidance and continued to lean heavily on Keytruda, which grew 8% to $8.1 billion but missed expectations and faces patent expiry from 2028. Capvaxive (PCV21) was a rare bright spot in vaccines, posting $244 million in sales, yet overall vaccine revenue fell 8% as Gardasil (HPV vaccine) slumped 25% on weaker demand in China and MMR/varicella sales slipped, reflecting uneven momentum across Merck’s portfolio. Evidently, there’s nothing Merck could have done about these market-based outcomes and their numbers still place them very high overall.

Across the rest of the sector, quarterly results reflected cooling vaccine demand, shifting revenue bases and ongoing consolidation of Covid-era gains. Moderna’s sales fell to $973 million as Covid vaccine revenue nearly halved and its RSV vaccine generated only $2 million; Novavax posted $70 million in revenue, underscoring its reliance on partners; and Bristol Myers Squibb recorded 2% growth to $12.2 billion. BioNTech saw a 22% revenue rise to $1.7 billion driven by out-licensing, even as Comirnaty sales slid, while CSL postponed the spin-off of Seqirus amid volatility in the U.S. influenza market. Meanwhile, Chinese and Korean manufacturers delivered gains: CanSino reported a 17.7% revenue increase to $43.6 million on stronger vaccine sales and international funding, and SK bioscience’s revenue jumped 145% to $104.7 million due to its IDT Biologika acquisition, though its underlying vaccine performance was mixed.

Disclaimer: In all these analyses, there is every possibility that I might have missed something. If so, feel free to let me know :)

(Sources: earnings reports from various companies, Linksbridge earnings summaries, ATMI 2024)

Behind the scenes

It has been an obscenely chilly week and I still haven’t found my right hand glove. I have a curious habit of misplacing right hand gloves. Having undergone an intense search I have since discovered two more gloves. Both left hand. Otherwise, a busy but beautiful fortnight. A mountain hike in the Salève with a view of lac leman, snacking, fondue, pausing between commitments to enjoy lovely, peaceful Lausanne, spending time with friends in Geneva. Another fantastic fortnight - body tired, heart full.

It has been a full fortnight since we last spoke. Weeks can go by so fast at certain times of the year - and once again, this little e-mail has snuck into your inbox. I appreciate you reading and I always appreciate your feedback - I’m contactable in response to this e-mail. I’ve been playing around with our format here and there, so feedback is particularly welcome at this time.

I would like to highlight the rapid and deadly escalation of the conflict in Sudan that continues and has led to death and untold horror. (read more, CNN) How to help: GIVEDARFUR. Next fortnight, the Q3 pharma financials. And the fortnight’s updates are below in the FIRs section.

Warm wishes until next time,

Christiana

Here’s a thought that has been on my mind this week:

Public health as we know it, is an inherently economic construct. While it has become part of our social contract, its purpose is to ensure workforce productivity and manage direct and indirect costs associated with ill health.

When Edwin Chadwick published his Report on the Sanitary Condition of the Labouring Population of Great Britain in 1842, he wasn’t thinking in the language of rights or morality. He was thinking in pounds and pence. Britain’s factories were full, its cities crowded and workers were dying faster than they could be replaced. Disease was both tragic and expensive. Chadwick’s conclusion was that it would cost the state less to prevent disease than to treat it. The report, now described by the UK Parliament as “the most important 19th-century publication on social reform,” laid the foundations for modern public health, but also for a new kind of economic logic.

Throughout the 1900s, public health wasn’t only prioritised to keep people well, it was prioritised to boost economic productivity. Public health spending has always been justified by externalities. Clean water, sewers, vaccines and food safety were investments in ensuring labour. The healthier the workforce, the fewer days lost, the higher the output and also the consumption. By the end of the Second World War, the new welfare states of Europe, and later, the World Health Organization, were built on the understanding that a nation’s health was part of its economic recovery plan. And with the fundamental understanding of public health as a public good. Health at the state level was no longer just a cost centre; it was a proven and viable growth strategy.

As deindustrialisation continued and factories moved abroad, with the globalisation of trade and manufacturing, health became important as a global priority and engine for global economic development and growth. Institutions like the World Bank framed disease control as part of developmental economics, something that would help emerging economies become better trade partners. Health aid and global health diplomacy were as much about maintaining global productivity as they were about compassion.

We are now seemingly at the tail end of that post-war bargain, where global prosperity was linked to both domestic investment in health systems within the Global North and global health investment in the Global South. Across Europe and North America, the political mood has turned toward domestic industry, economic sovereignty and even fertility. Two pieces in The Economist this week, one on the MAGA movement’s interest in procreation (“Make America Procreate Again”) and another called “Generation Single,” both point to a growing unease about shrinking workforces, aging populations and pro-natalism - a movement with notable tech tycoon funding.

Nevertheless, the modern economic logic of health is still playing out and, in some regards, unravelling. The new Think Global Health vaccine preventable disease tracker shows that vaccine-preventable diseases like measles and whooping cough are making a comeback, driven by reduced funding in LMICs and vaccine hesitancy in HMICs. When people get sick, productivity falls. When governments cut funding, the bill eventually returns.

On an unrelated note, but perhaps not entirely, New York just elected Zohran Mamdani as its next mayor. A little moment of recent joy for a good portion of the U.S’ left flank. His top priorities? Universal childcare and a rent freeze. Both are social reforms, but they’re also rooted in economic sustainability in the city. A push for universal childcare brings more women back into full-time work. A rent freeze keeps workers in the city. The politics may look new, but the principle is similar.

A larger question, however, is how long this logic holds. If artificial intelligence reduces dependence on human labour, does that weaken the economic argument for funding public health?

Public health began as a pragmatic answer to a complex set of problems: how to keep the workforce alive and thriving. Centuries later, that equation still drives the way our governments think about health spending. Reflecting on traditional economic arguments in support of public health investment in an evolving world may be valuable for considering the future. Last fortnight, I re-read Animal Farm, with its lessons on power and pragmatism. Systems built in the name of care often begin, and end, with efficiency.

1. G20 Seventh Health Working Group Meeting – South Africa Presidency

The seventh G20 Health Working Group (HWG) meeting under South Africa’s presidency advanced the health agenda framed around “Solidarity, Equality, Sustainability.” Building on the G20 Health Plan, in Limpopo, members focused on accelerating universal health coverage (UHC) through primary health care (PHC), investing in the health and care workforce, addressing noncommunicable diseases, strengthening pandemic preparedness and response, and leveraging science and innovation for economic growth.

South Africa’s presidency emphasised alignment with the African Union’s Agenda 2063 and the Agenda 2030 SDGs, promoting PHC as the most equitable and cost-effective path to health for all. Key outcomes included plans for a global PHC dashboard to track financing and progress, a joint health–labour dialogue on workforce investment and exploration of new domestic and international financing options for workforce retention.

However, consensus fractured over climate and pandemic language. The United States, supported by Argentina, blocked adoption of a final communiqué, opposing references to climate-health cooperation. Ultimately, members issued an “Outcome and Chair’s Statement,” reaffirming commitment to the WHO Pandemic Agreement and the timely completion of the Pathogen Access and Benefit-Sharing (PABS) Annex. (More on this under point 4)

Despite these divisions, the G20 health track under South Africa leaves a substantive roadmap for 2026 focused on equitable health systems, PHC-led UHC, climate–health resilience, and a strengthened global health security architecture.

(Sources: Health Policy Watch, G20.org)

2. U.S. GLP-1 Drug Deal with Lilly and Novo Nordisk

The Trump administration announced landmark agreements with Eli Lilly and Novo Nordisk to reduce the cost of GLP-1 weight-loss and diabetes drugs domestically, including Wegovy, Ozempic, and Zepbound, through a new “TrumpRx” framework. The deal cuts monthly costs from over US $1,000 to about US $350 for consumers and roughly US $245 for Medicare, with patient co-pays capped near US $50. Framed as part of a “Most Favoured Nation” model, it aims to align U.S. prices with peer economies and expand federal coverage for obesity and metabolic disorders.

In return, manufacturers gain incentives such as accelerated FDA review, three years of tariff relief, and predictable federal procurement contracts. Implementation is expected by mid-2026, potentially extending GLP-1 access to 10–15 million Americans. Analysts note that while the lower list prices will squeeze margins, expanded coverage and faster market entry could drive overall revenue growth and sharpen global competition in the obesity-drug sector.

The agreement also reflects elements of the Heritage Foundation’s Project 2025, which promotes market-led healthcare and executive-driven deregulation. Rather than imposing statutory price controls, this seems like a selective deregulation move. Three-year tariff relief shields profit margins from import costs, fast-track FDA approvals bring products to market months sooner and new tax-advantaged U.S. investments offset lost revenue through accelerated depreciation and credits. Most crucially, expanded Medicare and Medicaid coverage opens an incredibly high-volume market, allowing Novo and Lilly to exchange high-price exclusivity for scale. By cooperating, the firms also sidestep future price-control legislation and secure a visible role in the administration’s “America First” health agenda. This is a photo from the press conference that circulated this week following an unfortunate incident resulting in the conference ending early.

3. Regionalised Vaccine Manufacturing Collaborative (RVMC) Update

The Regionalised Vaccine Manufacturing Collaborative (RVMC) released its first global status report this fortnight, showing uneven progress in establishing sustainable regional vaccine production. The assessment across Africa, ASEAN, and Latin America and the Caribbean found regional output meeting only 1%, 29%, and 25% of vaccine demand, respectively.

While ASEAN leads in scaled operations and Latin America in platform diversity, Africa remains furthest behind, producing just one of sixteen regional priority vaccines. Barriers identified include fragmented procurement, weak regulatory harmonisation and limited technology transfer. The report calls for predictable regional procurement mechanisms, stronger regulatory alignment and investment in innovation and diversified platforms to achieve measurable equity by 2027.

RVMC Managing Director Frederik Kristensen called the moment “a generational opportunity” to build lasting regional self-reliance. The report urges governments and partners to move from commitment to coordinated, fully funded action. A follow-up assessment in 18 months, coordinated with Africa CDC, PAHO, and ASEAN initiatives, will continue to track progress.

(First status report - RVMC)

4. Pandemic Agreement – Pathogen Access and Benefit-Sharing (PABS) Annex

Member states met in Geneva this week to continue negotiations on the Pathogen Access and Benefit-Sharing (PABS) Annex to the WHO Pandemic Agreement, the mechanism that will govern how pathogen samples and genetic data are shared, and how countries gain equitable access to resulting vaccines, therapeutics, and diagnostics. (29 Oct PABS annex draft here)

Initial discussions were tense, with many countries calling the first draft “inadequate” and “unbalanced,” arguing it lacked enforceable benefit-sharing commitments. Several states, including South Africa, Brazil, and Indonesia, urged binding provisions and non-exclusive licensing models to promote regional production. HICs continued to prioritise procedural flexibility, leading to slow but substantive progress toward common principles on transparency, timeliness, and equity.

I have numerous past newsletters on PABS and the pandemic agreement, including this Special Edition. As well as a few podcast deep-dives for background.

WHO Director-General Tedros Adhanom Ghebreyesus welcomed the progress, calling solidarity “our best immunity.” Negotiators need to finalise the annex by May 2026 for adoption at the next World Health Assembly, so the clock is ticking and the race is on. The PABS framework is absolutely central to the agreement and to ensuring equitable global access during future pandemics, testing the Pandemic Agreement’s credibility as the first major reform of international health law since the 2005 International Health Regulations.

Multilateralism, do your thing. We still believe in you.

(Source: Health Policy Watch, WHO)

5. COP30 and Climate Update

As COP30 opens this week in Belém, Brazil, the UN Secretary-General warned that breaching the 1.5°C warming limit is now inevitable, condemning global inaction as a “moral failure.” António Guterres called for a paradigm shift to limit the overshoot through rapid emissions cuts, accelerated fossil fuel phase-outs and reduction of short-lived climate pollutants such as methane and black carbon.

The World Meteorological Organization’s latest report confirmed that 2025 is likely among the three hottest years on record, with global temperatures 1.42°C above pre-industrial levels. Ocean heat content and greenhouse gas concentrations remain at record highs.

At the summit, the World Health Organization, partnering with Wellcome, has opened a Health Pavilion in the Blue Zone to centre health and equity in climate negotiations. Sessions focus on air pollution, extreme heat, and climate-related health impacts, as well as adaptation strategies for resilient health systems.

Writing in The New York Times early last week, Bill Gates argued that technology alone cannot solve the crisis, urging “radical pragmatism” that couples innovation with systemic reform and behavioural change. Together, the evidence from science and policy at COP30 underscores the shrinking window to curb warming and restore temperatures below 1.5°C before century’s end. According to a study reported by Newsweek earlier this year, the U.S. military is the biggest institutional polluter in the world.

(Source: NYT, Health Policy Watch 1 & 2, Newsweek)

I hope this finds you well and well rested. Autumn has truly arrived with all of its glorious colours. I’ve found myself alternating between fondue dinners with visiting friends and evenings curled up with music or a book. Lately, I’ve revisited Chopin’s Nocturnes: gentle, intimate, deeply human works that feel like the antithesis of the grandeur and drama of the Symphonies of Beethoven. I was reluctant to make an analogy out of this one, afterall, the symphonies are some of the most masterful, intricate and incredible musical works. But I could not help but think that if the state of global health today were a musical composition, I would aspire more to the Nocturnes steadiness, measured, comforting, than to the Symphonies sense of motion and less certain tension. But, as you’ll see in the fortnight’s resources and headlines, things still oscillate between the two.

The World Health Summit in Berlin brought reminders of this duality. Global Fund’s Peter Sands warned that malaria, long overshadowed by other global priorities, is now resurgent, with almost a million additional deaths projected by 2030 if current funding cuts persist. Germany’s €1 billion pledge was welcome but is still a 23% reduction from previous years. Sands said, ‘it’s going the wrong way.’ Amid these discussions, there were sparks of progress: African scientists are advancing genomic surveillance for drug-resistant malaria, while new vaccines and long-acting treatments offer tools that could transform prevention if paired with sustained investment. As always, the science is not the constraint, the politics and priorities are.

From Africa, the tone was both pragmatic and forward-looking. Leaders at the 2025 Conference on Public Health in Africa (CPHIA) spoke candidly of a continent still unprepared for another pandemic, but unwilling to remain dependent on donors. Senior figures across industry and governments called for faster regulatory harmonisation and procurement reform to make the AU’s vision of producing 60% of its vaccines by 2040 a reality. In South Africa, with HIV funding from PEPFAR and the Global Fund expected to fall sharply by 2027, a Bhekisisa op-ed this week urged South Africa to plan for self-financing through health insurance reform, domestic procurement, and industrial partnerships. More on these in the FiRs below.

At the same time, Europe’s political climate around public health is showing signs of shifting. The launch of the Make Europe Healthy Again movement in Brussels, framed as a citizen-driven ‘refoundation of health,’ speaks to the growing entanglement within Europe between vaccine misinformation and far-right politics. It is modelled rather similarly to the, Make America Healthy Again movement initially born out of the COVID-19 pandemic. Public trust can erode just as fast any virus can spread; and public health is inherently political. In 2024, polio vaccination in Europe decreased. It is important that trust in science and evidence-based, epidemiological interventions, such as routine childhood immunisations, is maintained. Movements like this one remind us that health security is as much about trust and governance as it is about access and availability of medical countermeasures. Availability requires parents, patients and populations to want to be ‘availed’ of these interventions. This week, my good friend Leena Ghalib made some poignant points on a panel at a UN80 initiative event in Copenhagen, reminding the audience that ‘rights must be real’ and that UN governance must evolve to meet the scale of today’s challenges. Her words resonated deeply in a moment when credibility in global governance feels more urgent than ever.

So perhaps this fortnight, after this reflection, I find myself thinking less about Beethoven or Chopin and more about the dance in global health currently as the sector takes steps to find its new tempo. Something more like this excellent song by Senegalese jazz/afro-pop band, Orchestra Baobab. Between donor fatigue and political fragmentation there is some dissonance but also important and notable strides in a forward direction. I’ve been keeping one eye on the Q3 Pharma Financial Disclosures as they are released for a detailed exploration in November. This fortnight I have highlighted a few important headlines and explored a few in the FiRs too.

Thank you as always for reading, Friend.

Warm wishes,

Christiana

• Health Policy Watch: ‘Make Europe Healthy Again’ Launch is Dominated by Anti-Vaxxers and Far Right Politicians

• World Health Summit: Global Health Leaders Urge Fewer Agencies Amid Funding Crisis

• Declarations Without Delivery: Weighing UN Plans for NCD Medicine Access

• Why Yellow Fever Demands a Seat at COP30’s Climate Negotiations

• Launch of African Manufacturing Market Intelligence & Network Analysis (AMMINA) - Africa CDC Press Release

• Serum Institute of India and CEPI supercharge pandemic response preparedness targeting H5N1

• Bhekisisa Health Op-ed: Time to innovate, not panic. Here’s how SA should plan for HIV without donor funding

• Malaria Resurgence Could Kill Nearly One Million by 2030 as Funding Cuts Hit

• WHO Report: Global report on neglected tropical diseases 2025

• Time: Women Hold the Key to Ending Polio for Good

• WHO: PAHO highlights 31 years without polio in the Americas and calls to strengthen vaccination efforts

• Politico: Trump is cutting foreign aid. He’s not the only one

• Africa Seeks More Self-Reliance Amid Disease Outbreaks and Decline in Donor Funds (A look at CPHIA)

• Top African Pharma Executive Bluntly Lists Barriers to Local Manufacturing

• Time to innovate, not panic. Here’s how SA should plan for HIV without donor funding

• Pfizer touts positive Phase 2 data for maternal GBS shot (and here)

1. ‘Make Europe Healthy Again (MEHA)’ Movement Launched - and the direction of travel

On 15 October 2025, the Make Europe Healthy Again (MEHA) movement was launched at the European Parliament in Brussels under the patronage of Austrian MEP Gerald Hauser.

Styled after the U.S. Make America Healthy Again (MAHA) network founded by vaccine-sceptic physician Robert Malone and allies of Robert F. Kennedy Jr., the European iteration presents itself as a citizen-led effort to ‘reclaim public health’ from bureaucratic and corporate control. The event gathered figures such as Christian Perronne, Louis Fouché, and Malone himself. Voices who gained prominence during the COVID-19 pandemic for opposing vaccination mandates and questioning mainstream biomedical institutions.

The Brussels launch of its European offshoot followed a similar template, with speeches denouncing ‘technocratic elites’ and calling for a ‘sovereign Europe of health.’ Hosted by the Patriots for Europe Foundation, a political network aligned with Hungary’s ruling Fidesz party, the event served as a bridge between numerous European far-right politicians and transatlantic anti-establishment health movements.

While MEHA’s organisers claim to promote transparency and ethical reform in health governance, the initiative’s underlying agenda appears tied to broader efforts to delegitimise scientific institutions and supranational cooperation in health. I found this pro MEHA article on France Soir. However, as Health Policy Watch noted, its platform merges anti-vaccine activism with nationalist and anti-globalist messaging, reflecting a growing trend in which public health becomes a vehicle for ideological mobilisation. The launch thus highlights how debates over pandemic preparedness, pharmaceutical regulation and WHO reform are increasingly being reframed through a political lens, a troubling development that risks further eroding trust in evidence-based health policy across Europe.

Sources: Health Policy Watch, France Soir

2. Africa’s Push for Health Sovereignty: Financing, Manufacturing, and the Future of Preparedness

Across Africa, a clear message is emerging from policymakers and industry leaders: the continent can no longer depend on rapidly reducing donor funding to secure its health future. Solutions have been discussed at great length over the past year.

At this year’s 2025 Conference on Public Health in Africa (CPHIA) in Durban, Africa CDC Director-General Dr. Jean Kaseya stated that Africa is not ready for another pandemic. Fragile surveillance, limited laboratory capacity and the sharp decline in donor support hinder preparedness. Nevertheless, momentum is building. Governments are moving toward new public finance frameworks, local manufacturing and stronger governance to achieve greater health sovereignty.

Aspen Pharmacare’s Dr Stavros Nicolaou warned that regulatory delays and fragmented procurement are stalling the AU’s goal of producing 60% of Africa’s vaccines by 2040. He and other leaders, including South Africa’s Dr Blade Nzimande and AfricaBio’s Dr Nhlanhla Msomi, highlighted faster regulatory harmonisation, pooled procurement, and targeted financing to strengthen regional R&D capacity and supply chains in their statements. In South Africa, tax-payers fund the majority of its HIV programme, the largest in the world. As donor funding reduces and donor priorities shift, national strategies such as South Africa’s plan for a self-funded HIV response signals a broader effort towards sustainability.

As reported in Bhekisisa Op-ed this week, South Africa’s looming ‘donor cliff’ in HIV funding with major reductions from PEPFAR and the Global Fund expected by 2027 is both a challenge and an opportunity. Rather than panic, the call has been made for greater innovation and fiscal planning: introducing a national health insurance framework capable of absorbing HIV programmes, restructuring procurement to favour local manufacturers and harnessing sin taxes and levies to sustain domestic treatment and prevention. The hope is that donor withdrawal should not have to spell disaster if countries are able leverage it to reimagine new financing models that build self-reliance from within. ‘Time to innovate, not panic.’ I will keep an eye on this situation in the coming months and years to see how solutions, outcomes and discourse evolves.

These arguments along with Africa CDC’s push for new governance and financing mechanisms in the face of sharp funding reductions. By embedding more health economists and public finance experts within ministries of health, the agency aims to bridge gaps between fiscal policy and disease control. Simultaneously, leaders across the region are largely sustaining momentum on the importance of sustainable manufacturing and financing being integral to pandemic preparedness and continental health security. The transition away from donor dependency will require politically difficult reforms but the long-term dividends could be transformative.

Together, these efforts reflect a deeper recalibration of Africa’s health security agenda: one that aligns pandemic preparedness with industrial policy, financing, and governance reform. The call for self-reliance is not just about independence — it’s about resilience.

(Sources: Health Policy Watch 1, 2, Bhekisisa Health

3. Yellow Fever: A Climate Wake up call for Vector movement & control

Yellow fever’s resurgence across the Amazon (270 cases and 108 deaths in early 2025) highlights the growing overlap between climate change, deforestation, and pandemic risk. In their report, Think Global Health note that the spread of this mosquito-borne disease into new regions illustrates how ecological disruption and warming temperatures are driving pathogen spillover and testing fragile surveillance and vaccine systems.

At COP30 in Belém, Brazil’s Belém Health Action Plan, developed with WHO, aims to link ecosystem protection with epidemic prevention by integrating health adaptation into national climate goals and unlocking climate finance for vaccination and early warning. Nevertheless, persistent gaps in immunisation, diagnostics and coordination are still present. From a health security standpoint, yellow fever is a warning: climate-driven outbreaks can no longer be treated as isolated events. Continuing to embed disease prevention into climate policy (and indeed, vice versa, i.e. continuing to prioritise embedding climate policy as well as one health in disease prevention) could help build more resilient preparedness systems that take environmental protection, public health and investment into account together and promote sustainable advancement.

(Source: Think Global Health)

Behind the scenes

A cozy fortnight enjoying the glorious autumn. Another successful UCL alumni event. And Leena Ghalib following her panel on the UN80 initiative at UN City Copenhagen.

Autumn greetings from London. I took a little time off in September to read, reset and reflect. It was a lovely period, I spent time in one of my favourite mountain nooks overlooking the Montreux riviera; and a cozy weekend in La Clusaz. In the city, I met people doing interesting work across our fields and learned from them. Finally, I undertook a fun, month-long, extracurricular side quest that I might share in future.

A great deal has happened since we last spoke. There was a particularly noteworthy 80th United Nations General Assembly, wherein most states demonstrated a continued commitment to multilateralism and boldness in the face of bullies (See Pres. Ramaphosa on tariffs, WTO and the structure of the Security Council). While one or two others showcased their unique flair.

The World Health Summit in Berlin commenced today, bringing together global health leaders to revisit priorities around health financing, equitable access, and innovation in an era of constrained resources. Discussions will no doubt echo the themes emerging from Geneva and New York this autumn: rebuilding trust in multilateral cooperation, safeguarding progress and strengthening preparedness through strategic partnerships.

CEPI and the African Vaccine Regulatory Forum (AVAREF) announced a renewed commitment in the form of a new partnership providing $1 million USD over two years to help African regulators and ethics committees accelerate emergency reviews of vaccine trials. The funding will enable joint reviews and scientific advice to be completed within 10–15 days during outbreaks, an important step towards continental self-sufficiency in health security and the 100 Days Mission.

Another more uplifting development has been the landmark agreement on strategic price reduction for Lenacapavir, Gilead’s long-acting injectable for HIV prevention, discussed at length in past editions of this publication. Priced at over $28 000 USD per patient per year, it will soon be made available for just $40 USD per person annually. The deal, brokered through a collaboration between Unitaid, the Clinton Health Access Initiative, Gates Foundation and Indian manufacturers, Dr. Reddy’s and Hetero, will manufacture and supply LMICs. Distribution will begin through Global Fund and PEPFAR-supported programmes. The mechanism combines voluntary licensing, upfront financing, and volume guarantees; allowing generic manufacturers to scale up rapidly and ensure cost parity. WHO has now prequalified both the injectable and oral forms of lenacapavir, marking the first prequalification under its new abridged regulatory pathway.

Meanwhile, Geneva-based FIND faced turbulence following a report in Swissinfo of internal governance crises and donor suspensions. The Foundation issued a response outlining its governance reforms, diversity and equity investigations, and financial stabilisation measures.

Negotiations on the Pandemic Agreement have entered their final and perhaps most consequential phase. Following WHO’s decision to open the final round to accredited stakeholders, the Intergovernmental Working Group is tackling the Pathogen Access and Benefit-Sharing (PABS) annex. Developing countries have rallied around proposals for non-exclusive licensing and mandatory benefit-sharing to ensure equity when pathogen samples lead to commercial products. WHO Director-General Tedros Adhanom has reiterated that it is “critical” that the full agreement be completed in time for endorsement at the UN High-Level Meeting on Pandemic Prevention and Preparedness in 2026.

At the same time, donor fatigue remains a reality. The Global Fund’s latest results report warned that cuts in global health funding, combined with climate pressures and conflict, are already threatening progress on HIV, TB, and malaria. Malaria deaths could rise again this year, particularly among children under five and momentum on maternal and child health has been uneven despite affirmative rhetoric. Across many health programmes, donor retrenchment continues to shape the operational landscape, testing countries’ capacity to sustain life-saving interventions.

Moreover, the broader public conversation on maternal health has been unsettled by disinformation; notably recent remarks by U.S. President Trump questioning safety of paracetamol use during pregnancy. The backlash from scientific and medical communities was immediate, but the damage to public trust may take longer to repair, particularly as misinformation continues to circulate across borders and social media platforms.

As the autumn colours abound, a kaleidoscope of bronze, amber and orange drifting south with gravity; slippery and touched by the morning drizzles of our shorter, colder days; global health feels both burdened. Carrying the weight of retaining hard-won gains, celebrating notable wins; and more than ever, fighting for survival.

I have been reading, as ever. This fortnight I read Hillbilly Elegy. I was surprised by how humanising it was, how well the current U.S. VP adapted his tone to the era in which it was written, as we have seen him do since. He is someone who I view as an ideologue. But this read tells me that he might be more pragmatic than I had previously estimated - able to rework to get ahead, and that is a very specific quality. A notable watch this week was Ross Douthat’s NYT interview of Hasan Piker. That said, my best read (despite heavy competition) of 2025 remains unchanged: Everything is Tuberculosis by John Green. From modern beauty standards, to the ways in which our societies are shaped through health systems, arts and culture - everything really is Tuberculosis and the author demonstrates this masterfully. It’s a good, well-researched, easy read - for experts and laypersons alike.

It is such a pleasure to have the privilege of writing to you this evening. And it feels great to be back. I have loaded up the curated headlines I’d like to point you towards this fortnight from the past month, foregoing the normal deepdives FiRs. I am always contactable in response to this email - or at christiana@globalhealthwriter.com.

Warm regards,

Christiana

Women’s Health

• Female and Maternal Health: FGM - A Growing Number of Health Workers Are Performing Female Genital Mutilation in South East Asia (Health Policy Watch)

• Female and Maternal Health: New Guidelines Recommend Lower Bleeding Threshold to Diagnose Postpartum Haemorrhage (Health Policy Watch)

• Flying Blind: unveiling the patchy landscape of global R&D for endometriosis, polycystic ovary syndrome and uterine fibroids (Report & Summary)

• Gates Foundation to Invest $2.5 billion in Women’s Health Amid Debilitating US Funding Cuts

NTDs & HIV

• Gilead Announces Partnership With PEPFAR to Deliver Twice-Yearly Lenacapavir for HIV Prevention for up to Two Million People in Primarily Low- and Lower-Middle-Income Countries (Via Gilead)

• TB Alliance: New Study Finds Investing in Shorter, More Effective TB Treatment Pays Off

R&D and Regulatory Environment

• African Medicines Agency (AMA) Treaty signup counter

• WHO Lenacapavir Prequalification

• Why Global Health R&D is a Win Win for High-and Lower-income countries (GSK op-ed)

Immunisation & Other Public Health

• Global Immunization Rate Steady at 85% – but Coverage Gaps Propel Outbreaks of Measles and Other Diseases

• Hunger Declines Globally, but Rises in Africa

• WHO releases new reports on new tests and treatments in development for bacterial infections

• Very Interesting: Shifting the Narrative on Global Road Safety (Think Global Health)

• Around the World, Chronic Diseases Are Rising

• Responding to the challenge of antibiotic-resistant bacteria (Boston Children’s Hospital)

• FP: Why the World Turned on NGOs

Reports & Governance

• WHO Landscape analysis of commercially available and pipeline in vitro diagnostics for bacterial priority pathogens

• A ‘hostile takeover’: ousted CDC official raises alarm over RFK Jr approach to infectious disease

• Holding Drug Companies Accountable: NIH Access Plan vs. Pandemic Treaty

• Child mortality: Two Years of the Gaza War in Three Health Charts

• WHO Opens Door to Stakeholders in Final Phase of Pandemic Agreement Talks

• China Ties Manufacturers’ Access to Pathogen Information to Host Country’s Commitment to Pandemic Agreement

• The ripple effect: how global health R&D delivers for everyone

• Access to Medicine Foundation: Harnessing Africa’s untapped clinical trial potential

• FP: Can China Replace USAID?

• FP: The End of Development

Behind the scenes:

A little catchup. And a reminder: If you find yourself in Geneva on Wednesday 15th October, I’ll be hosting a UCL alumni gathering. Sign up here to join us! (LINK)

Past Podcast Episodes you might have missed!

Episode 24: What is the Pandemic Accord, really?

This episode takes a high level overview of the Pandemic Accord, its purpose and a walkthrough of some of its most pertinent Articles. A walkthrough. The Pandemic Accord is a proposed global agreement aimed at strengthening pandemic prevention, preparedness, and response. Emerging in the aftermath of COVID-19, the accord aims to address gaps in international coordination, surveillance, and equitable access to medical countermeasures, globally.

Episode 22: Project 2025’s Impact on Healthcare, Women’s Health and Regulation

In this episode we explore and discuss Project 2025’s proposed policies, which could dramatically impact health, women’s health and safety. The plan includes lifetime caps on Medicaid, reducing coverage for millions, and increased out-of-pocket costs for Medicare recipients. It threatens reproductive rights and seeks to curtail the CDC’s public health role, potentially weakening responses to health crises. Basically, an anti-epidemic preparedness vision and plan.

Episode 20: The Profitability of Skinny - How Semaglutides made Novo Nordisk Europe’s most profitable company

In this episode, we explore the economics of thinness and the phenomenal rise of GLP-1 receptor agonists in the weight loss market. Novo Nordisk, the Danish pharmaceutical company behind Ozempic and Wegovy, has become Europe’s most profitable company, surpassing even the luxury giant LVMH. We delve into the social and economic capital associated with thinness, examining how societal attitudes toward body image drive the profitability of weight loss drugs.

I realised how tuned in I usually am to global politics this fortnight when I returned from a week’s vacation in Barcelona, where I was largely disconnected from news cycles and current affairs. In some ways, it was bliss. I spent the week with a dear friend and did nothing but eat incredible food, socialise, philosophise, pray, browse museums and galleries, and sit working poolside on rooftops. My cup is full. Nevertheless, I had some catching up to do ahead of this fortnight’s edition.

Today, we turn to the Q2 2025 pharma financial disclosures. (Here are links to my summaries of Q4 ’24: , and Q2 ’24) I found the shifts and changes that took place last quarter particularly interesting.

Three themes stood out. First, vaccines: RSV has become a rising star. This could partially be because late last year England made a move to provide the RSV vaccine to pregnant women; as well as anyone who turned 80 before a certain 2024 date; and earlier this year WHO published guidance to protect infants from RSV. Pfizer’s Abrysvo posted 155% growth, Sanofi and AstraZeneca’s Beyfortus more than tripled sales and SK Bioscience’s revenues jumped more than sixfold - constituting the largest growth (by percentage) of the quarter. Meanwhile, Merck’s Gardasil (HPV vaccine) fell by 55%; undercut in China by cheaper domestic HPV vaccines. I have occasionally wondered, in a sort of musing way, why companies don’t lobby harder to shift policy towards vaccinating boys against HPV, too. Gaining up to twice their current market share in those regions and securing a win for public health by reducing transmission of the cervical cancer causing virus. Everybody wins. The second bucket was, of course, weight-loss drugs: Eli Lilly and Novo Nordisk both reported growth (38% and 18% respectively), but investors are recoiling. Lilly after its oral GLP-1 pill underperformed injectables and Novo Nordisk after cutting its growth outlook in the face of U.S. competition and compounding. Third, diagnostics: Abbott and Roche had flat/falling demand in Q2, tied to cuts in U.S. foreign aid and changes in African procurement, which immediately impacted access to HIV testing. Skip to the Fortnight in Resources section below to read more.

Thank you, Friend, for reading. As always, I welcome your comments and reflections.

With warmth & gratitude,

Christiana

• Nature: Moderna’s mRNA-based HIV vaccines elicited a “potent immune response”

• BARDA abandons mRNA vaccine R&D

• Africa CDC and European Commission Launch New Initiative to Strengthen Mpox Testing and Sequencing Across Africa

• Kenya’s BioVax Institute expects to launch studies for its first locally manufactured vaccines

• Time: The (anti-vax motivated) CDC Shooting is a Dark Sign for Science and America

• Climate change is already causing measurable harm to children. Extreme heat can raise newborn death risk by 22 percent (Vox article)

• Switzerland facing 39% US tariff as president leaves Washington empty-handed (& government warns companies that they cannot route exports via Liechtenstein)

• WHO Awards Top-Level Recognition to Regulatory Authorities in Canada, UK and Japan

• US Non-profits Vow to Fight on After Court Rules They Can’t Challenge Trump Aid Freeze

• HPW: Update on UN Plastics Treaty

• Update: Global Chikungunya Outbreak now said to have hit 100+ countries (Also from Scientific American earlier in the fortnight: How the New Chikungunya Virus Outbreak in China Could Reach the U.S.)

• NPR: U.S Administration rolls back Title X - providing contraception, STD prevention & care and cancer screening for low-income women - under Medicaid reform (Which we expected as it was cited in Project 2025 - listen to my past podcast episode on that here) and read more via this NYT op-ed

Breakdown of Q2 2025 Pharma Earnings

The Q2 Pharma Financial reports reveal a pharmaceutical sector in flux: innovation is powering record vaccine and weight-loss revenues, but access and policy decisions are reshaping outcomes just as much as science. RSV products are booming while Merck’s Gardasil struggles against cheaper domestic rivals in China; GLP-1s continue to boom even as investor confidence slightly falters; and diagnostics show how donor funding cuts have reduced access and revenue.

1. SK Bioscience posted revenues of $116.9 million, more than six times higher than a year ago, thanks to its acquisition of IDT Biologika and rising vaccine sales. Zoster vaccine sales climbed 32% while Sanofi-distributed vaccines rose 11%. The company is also advancing a next-generation influenza candidate with nonprofit adjuvant support. (Earnings release documents)

2. BioNTech more than doubled sales to $304 million, driven by renewed COVID vaccine demand. But despite the bounce, the company remained in the red as R&D costs exceeded revenues. The company also pivoted toward oncology-focused mRNA therapies. And in other news, the U.S. have halted large parts of their mRna program.

3. Eli Lilly saw sales soar leading to 38 % growth to $15.6 billion, cementing its dominance in the GLP-1 weight-loss space, at this time replacing Novo Nordisk. Yet investor reaction was not as positive: shares fell 14%, the steepest drop in 25 years, after its oral GLP-1 pill delivered underwhelming trial results compared with injectables. (Press release)

4. Novo Nordisk reported 18% growth but cut its full-year outlook to 8–14% based on changes in the market in the U.S, including compounded GLP-1 competition and slower-than-expected uptake. The company also accelerated its retreat from the insulin pen market. (Press release)

5. AstraZeneca grew revenues 11% to $14.5 billion, driven by oncology (+18%) and a 54% jump in vaccines and immune therapies. Its RSV antibody Beyfortus more than tripled sales to $126 million. The company also announced a $50 billion U.S. investment plan through 2030, its largest ever. (AZ (H1-Q2); Linksbridge)

6. Novartis matched AstraZeneca with 11% growth, reporting $14 billion in sales. Kisqali soared 64% to $1.2 billion, Kesimpta rose 33% to $1.1 billion, and Entresto added 22% to $2.4 billion, underscoring the strength of its innovative portfolio. (Press release)

7. Pfizer posted 10% growth, with revenues of $14.7 billion. Abrysvo RSV vaccine sales leapt 155% to $143 million, while Comirnaty and Paxlovid also rebounded strongly. Prevnar sales remained steady, providing stability in its broader vaccine franchise. (Pfizer quarterly highlights; Linksbridge Pharma)

8. Sanofi also grew 10%, with revenues of $11.6 billion. Vaccine sales increased 10.3% to $1.4 billion, led by strong demand for pediatric combinations and the continued success of Beyfortus. Dupixent remained the backbone of the portfolio, generating $4.4 billion in the quarter. (read their press release)

9. GSK reported 6% growth to $10.6 billion. Largely due to a 9% increase in vaccine sales. Shingrix grew 6% to $1.1 billion and meningitis vaccines rose 22% to $503 million, while Arexvy added 13% in the quarter but remains down sharply year-to-date due to weak U.S. uptake.

10. Gilead saw growth of 2% to $7.1 billion, led by its HIV portfolio, most recently including Lenacapavir (Yeztugo), discussed in past fortnights (+7% to $5.1 billion). Their CEO stated that it has already far exceeded their expectations. And according to Bloomberg, Gilead has reached its 10 year highest rating with its closing price. Its twice-yearly PrEP injection Yeztugo launched strongly in June before the end of the quarter, and the company has already begun trials of a once-yearly formulation. (Gilead; Linksbridge Pharma)

11. Abbott grew 7% overall to $11.1 billion, but diagnostics slipped 1.4% to $2.2 billion, reflecting pressure from U.S. aid cuts and China’s procurement policies.

12. Roche similarly grew 7% but to $38.5 billion for the first half, though diagnostics remained flat at $8.7 billion. The company cited weaker HIV testing demand in Africa after USAID funding reductions.

13. Merck struggled as Gardasil sales plunged 55% to $1.1 billion, dragging total sales down 2% to $15.8 billion. The slump followed lower demand in China, where cheaper HPV vaccines have altered its position. This comes after Merck announced a U.S based, $1B vaccine plant for Gardasil in March 2025.

14. Moderna posted a 41% sales decline to $142 million. The company had relatively low RSV vaccine uptake despite approvals in 40 markets. The company announced a 10% workforce reduction and reiterated its $1.5 billion cost-cutting target. (Press release)

15. Novavax saw revenues drop 42% to $239 million, but shares rose 15% after the company raised guidance on the back of commercialization deals with Sanofi, Takeda, and the Serum Institute of India. (Linksbridge)

16. Bristol Myers Squibb reported flat revenues of $12.3 billion, with growth products up 17% but legacy drugs down 15%. A new CMO from AstraZeneca and a Bain Capital-backed immunology spinoff signals its bid to work to reset strategy and regain their momentum. (BMS)

Past Podcast Episodes you might have missed!

Episode 24: What is the Pandemic Accord, really?

This episode takes a high level overview of the Pandemic Accord, its purpose and a walkthrough of some of its most pertinent Articles. A walkthrough. The Pandemic Accord is a proposed global agreement aimed at strengthening pandemic prevention, preparedness, and response. Emerging in the aftermath of COVID-19, the accord aims to address gaps in international coordination, surveillance, and equitable access to medical countermeasures, globally.

Episode 22: Project 2025’s Impact on Healthcare, Women's Health and Regulation

In this episode we explore and discuss Project 2025's proposed policies, which could dramatically impact health, women’s health and safety. The plan includes lifetime caps on Medicaid, reducing coverage for millions, and increased out-of-pocket costs for Medicare recipients. It threatens reproductive rights and seeks to curtail the CDC's public health role, potentially weakening responses to health crises. Basically, an anti-epidemic preparedness vision and plan.

Episode 20: The Profitability of Skinny - How Semaglutides made Novo Nordisk Europe's most profitable company

In this episode, we explore the economics of thinness and the phenomenal rise of GLP-1 receptor agonists in the weight loss market. Novo Nordisk, the Danish pharmaceutical company behind Ozempic and Wegovy, has become Europe's most profitable company, surpassing even the luxury giant LVMH. We delve into the social and economic capital associated with thinness, examining how societal attitudes toward body image drive the profitability of weight loss drugs.

I hope this evening’s newsletter finds you well and well-rested. For my part, I could think of no better way to conclude a long and lovely weekend.

There’s an undeniable sense of shifting sands in the sector that has been with us all year. Not instability, exactly, but movement. Whether in trade deals, health workforce negotiations, funding recalibrations, or the pipelines of the largest pharmaceutical players; this feels like a season of recalibration. And sometimes, recalibration brings opportunity.

This week’s main story is the impact of the EU–US Trade Deal on the pharmaceutical industry. To choose it, I took an unusual approach: I ran an Instagram poll on my personal account and this idea, presented by a friend, won by a clear margin. At its core, the deal will increase pharma costs by 19%, a figure that will prompt careful recalculations across the sector and could lead to ripple effects such as reduced R&D spending. Switzerland, not part of the EU, has been hit with a 39% US tariff, one of the highest globally, threatening pharmaceutical exports. Skip to the FiRs below to read more.

The broader implications touch market access, intellectual property and the interplay between health, economics, and governance. In many ways, it reminded me of my last summer reading and foray into French Philosophical thought, of Michel Foucault and his work on Biopower. The idea that states and corporations can exert control over populations not only through laws and armies, but through the management of life, of social determinants and of health. From pandemic preparedness to drug pricing and regulation, the mechanics of power over health are just as present in trade negotiations as they are in any clinical setting.

I preface all this with the fact that I am a lay-person in the field of philosophy. But I believe that there is also a positive form of biopower: public health itself - the structures, frameworks, policies and metrics that enable the longer, healthier and thus, more economically productive lives of populations. Socialised healthcare systems like the NHS are prime examples, lowering barriers to healthcare access, improving population health, and maximising workforce productivity. Positive biopower, enacted through positive biopolitics. I may be applying this with a health economist’s lens rather than a philosopher’s, but if this is positive biopower, what happens when we stop funding the infrastructure that underpins health access, disease prevention, surveillance and treatment; nationally or globally?

This fortnight, the UK’s NHS once again faced strike action by resident doctors. More on this in the FiRs. On the global stage, Gavi has endorsed a series of adjustments to its five-year plan in light of a $3 billion shortfall, including greenlighting a maternal RSV vaccine programme following WHO prequalification of Pfizer’s Abrysvo jab. Meanwhile, the Fleming Fund, a UK-backed initiative addressing antimicrobial resistance, will close following budget cuts. In South Africa, already burdened by 30% tariffs, the Treasury and Department of Health are scrambling to fill HIV treatment funding gaps. Health Minister Aaron Motsoaledi told parliament that the Gates Foundation and Wellcome have pledged R100 million ($5.5 million) if matched by R200 million from the Treasury, a deal the government has gladly accepted, pledging R400 million in total. This, however, falls far short of the nearly R8 billion previously anticipated from various US aid programmes. (And on a separate yet related note, I happened to calculate that if South Africa were able to afford Gilead’s Lenacapavir; the treasury’s R400 million would only be sufficient for 780 patients for one year - as a blockbuster prevention drug for HIV)

In the private sector, Q2 pharma financial disclosures are now out. I’m pretty excited about this and I’ll be doing a deep dive into the numbers, trends, and their implications in the 17 August 2025 edition. In another week of unfortunate news for the European pharma giant, Novo Nordisk’s stock plunged over 20% after it cut its 2025 sales growth forecast, citing slower-than-expected US expansion for Wegovy and competition from Eli Lilly’s Zepbound. The leadership baton will pass to Maziar Mike Doustdar. Moderna, facing collapsing COVID vaccine revenues and cancelled US contracts, has abandoned plans for an mRNA facility in Japan, after pausing a similar project in Kenya last year. And in Ghana, a California-based CDMO has acquired the assets of USP Ghana, moving to expand egg-based vaccine and diagnostic production in the region.

Through my most recent revisit of French philosophy, I came across critiques, too. For Agamben, the concept of biopower carries the risk of reducing life to something managed rather than lived. He spoke of two types of life from the Greek concepts: Zoê and Bios. Being alive biologically vs. living and having life in community and in fullness. It made me think of how I conceptualise us, here. A community of people who care. And by the mere fact of having the ability to care for those beyond ourselves, who we may never meet, we benefit from that bios state of living. Perhaps, therefore, the task for us as humans interested in public health is to invert that standard Biopolitical equation. To use the mental space from which we benefit to think beyond familiar frameworks and design systems of health to expand life’s possibilities - focussing on not just longer lives, but fuller ones, too. For ourselves and for others.

Until next fortnight, Friend

Christiana

• The International Pandemic Preparedness Secretariat (IPPS) published their July newsletter with resources addressing post Pandemic Agreement priorities, highlighting proposals for a Global Pandemic Risk Observatory and new coalitions to tackle persistent diagnostics and therapeutics gaps. Subscribe here. Read latest publications on the 100 Days Mission

• Countering vaccine misinformation originating from the U.S with a significant global reach: “A clear global strategy is needed to “counter vaccine misinformation from the United States,” Heidi Larson and Simon Piatek write in The Lancet this week.”

• Guardian: NHS Doctors’ five-day strike: More info on this in the FiRs

• African countries are working to optimise finances for HIV treatment and prevention. South Africa has streamlined its ARV program to allow patients to get 6 months ARV supply at a time. (Note: this is not related to Lenacapavir)

• Missed headline: Senegal and Rwanda gain WHO Maturity Level 3 status for their National Regulatory Authorities, making eight African countries at ML3!

• Public Health Leader and WHO Envoy, Dr David Navarro, passes away. 🕊️

• Novo Nordisk lowers sales and operating profit outlook for 2025

• Avril Biopharma acquires USP-Ghana assets

• Gavi Board focuses on health impact as priority guiding principle in a resource constrained world

• Keynote Talk Climate Change & Infectious Diseases, Prof Tulio de Oliveira, EDCTP Forum, Rwanda 2025 (Video)

1. ‘REBALANCING ACT’: EU-US Trade deal – Impacts on Pharma and Public Health

(Image source: Centre for European Policy Studies)

Overview: What is the deal & what does it entail

The Transatlantic EU-US trade deal was agreed on 27 July 2025 in Scotland (Why Scotland? Skip to the bottom of this sub-segment). We saw videos of EU President Ursula von der Leyen and President Donald Trump smiling and shaking hands at the post-deal press conference. Von der Leyen described this as the biggest deal each of them have ever struck. The deal is not without important implications to the pharmaceutical industry and healthcare.

For the EU, this meeting was about avoiding the proposed 30% tariffs that the U.S. was set to impose. On an economic level, the deal was undeniably a win for the U.S. The EU have agreed to put zero tariffs on U.S. imports (according to WTO this was already low – around 2.4%,) purchase $750 bn in U.S. energy products and military equipment over the next three years and the EU has agreed to invest an ‘additional’ $600 bn in the U.S.

In exchange, the U.S. agreed to reduce its tariff imposed on the E.U to 15%. In the EU, the sentiment is generally the same: this was the ‘least bad’ outcome. A sentiment that has been echoed by big business; Germany and Italy, viewing the move as a necessary compromise to avoid further escalation. French Prime minister Francois Bayrou viewed it as a capitulation – describing ‘a dark day for Europe’.

Reading the two press statements from the European Commission and the White House, I was struck by the difference in tone in how the deal was communicated, despite the documents being factually aligned. The Commission report focused on stability and preservation; the White House on dominance and economic patriotism. Notably, the EU stressed regulatory sovereignty, including pharma standards, and the fact that certain generic drugs will be exempt and return to pre-2025 tariffs. These two points were not directly specified in the White House document. Conversely, the White House’s document emphasizes EU purchases of US military equipment – this was not mentioned in the Commission’s report. Putting together this analysis this evening took a lot of reading and nuanced comparison across various credible sources. I am limited in how many links I can include in any single issue, so I have included the most important ones to allow you to read further. Moreover, there are a lot of related issues across the relevant political landscapes that unfolded this fortnight – I have not touched on most of these in order to remain zeroed in on the topic at hand: the effects of the transatlantic rebalancing agreement on pharma, R&D and healthcare.

All this came at the end of Trump’s five days in Scotland with the agreement made on Sunday after playing golf at Turnberry and opening a new course in Abderdeenshire. The US president had an overall mixed reception in Scotland, with some Scots expressing their general displeasure about the visit, the security budget and the personality of the U.S president in unique ways.

(Image Source: Telegraph)

Direct Effects on the Pharmaceutical Industry

The inclusion of pharmaceuticals in the tariff schedule marks a significant departure from decades-long norms in transatlantic trade, where drugs were largely exempt from customs duties in recognition of their critical public health role. Under the deal, most branded pharmaceuticals manufactured in the EU for export to the United States will be subject to a uniform 15% tariff. While Commission officials have stated that the current zero tariff will remain in place pending the outcome of a U.S. Section 232 national security investigation, the expectation in Brussels is that the 15% rate will ultimately apply once that process concludes. Certain generics have been granted exemptions, though the list remains undefined, creating uncertainty for manufacturers operating on low margins.

For major European exporters, particularly Ireland, which ships approximately $50 billion of pharmaceuticals to the U.S. annually, the imposition of tariffs represents both a direct cost burden and a strategic risk. Industry analysts estimate potential annual losses of $13–$19 billion across the EU pharmaceutical sector. Faced with these prospects, companies such as AstraZeneca have already accelerated plans to expand U.S. manufacturing capacity, while others are adopting short-term measures such as inventory stockpiling to mitigate price volatility.

Direct Effects on Healthcare

The anticipated tariff application has direct implications for healthcare systems on both sides of the Atlantic, too. In the U.S., the pass-through of higher import costs is expected to exert upward pressure on drug prices, with the potential to affect patient access, reimbursement frameworks and even formulary decisions. Public payers, private insurers, and hospital procurement bodies will face difficult choices balancing budgetary constraints against the imperative to provide access to innovative therapies.

In the EU, the combination of reduced export competitiveness and the potential for diversion of capital expenditure toward U.S-based production facilities could begin to weaken the continent’s pharmaceutical manufacturing base in the long-term. I haven’t had a chance to speak to friends in Brussels in the sector on this just yet; but this would be my estimation, too - the diversion of greater investment towards the U.S side of operations; and volatility around margins, supply chains and the varied costs and inputs across pharmaceutical manufacturing, particularly for biologics. This may have downstream effects on clinical trial infrastructure, supply chain resilience, and the EU’s own capacity to respond to future public health emergencies. Moreover, Ireland’s heavy exposure, coupled with vulnerabilities in Italy’s and Germany’s pharmaceutical sectors, underscores the asymmetric burden within the bloc.

Broader Healthcare and Pharma Effects from Tariffs and the Trade Landscape

Beyond immediate pricing and market share impacts, the altered tariff regime risks fragmenting global pharmaceutical supply chains. U.S. purchasers may increasingly source from domestic or non-EU suppliers to avoid tariff costs, potentially disadvantaging EU-origin products even in therapeutic areas where they maintain technological leadership. The development of parallel ‘dual supply chains’ tailored to tariff and non-tariff markets could reduce economies of scale, raise per-unit manufacturing costs, and complicate regulatory harmonisation efforts.

Switzerland, not an EU member, is a critical pharmaceutical exporter and home to global companies such as Roche, Novartis, and Lonza. It faces its own tariff challenge after the U.S. announced a 39% import duty on certain Swiss goods. Swiss Business Minister Guy Parmelin has signalled openness to revising Switzerland’s offer to Washington to avoid the most punitive measures. Analysts warn that if the tariffs are implemented in full, they could trigger a mild recession in Switzerland, given the high proportion of GDP generated by chemical and pharmaceutical exports. For the sector, such duties could hasten the relocation of high-value biologics and advanced therapy manufacturing to the U.S. or Asia, and disrupt integrated EU–Swiss supply chains for active pharmaceutical ingredients (APIs).

The broader European industry has already voiced concern over this trade environment. Novo Nordisk, Europe’s most valuable pharmaceutical company and the global leader in diabetes and obesity treatments, has warned that the combination of sustained tariff pressure and U.S. drug price control measures amounts to a “double squeeze.” Tariffs increase landed costs for its U.S. sales, while current domestic U.S. policy moves to lower list prices further compress margins. The company has stated that it will continue to explore manufacturing localisation in the United States to mitigate risk, especially for its GLP-1 portfolio, and has recently revised its financial forecasts downward to reflect the changing market conditions. In parallel, Novo Nordisk has also undergone a leadership transition, electing a new chief executive to steer the company through what it has described as a “more volatile and politically driven” operating environment in its largest market.

Addressing the Reshaping Global Health and Pharma Landscape

This agreement is somewhat emblematic of a broader shift toward economic nationalism in strategic sectors, including healthcare. For the United States, the move aligns with an industrial policy emphasis on reshoring production of critical medicines and active pharmaceutical ingredients, reducing dependency on foreign, particularly European, supply. For the EU, the deal illustrates a reactive posture, prioritising damage limitation over proactive shaping of trade norms.

By breaking with the long-standing principle of tariff-free trade in medicines, the deal may set a precedent for other major economies to impose their own duties under the banner of health sovereignty. Such a precedent could complicate the functioning of global health procurement mechanisms, from vaccine alliances to antimicrobial stockpiles, where cost and timely delivery are essential. In the long-term, both public and private stakeholders will need to navigate a more fragmented, politicised, and cost-sensitive pharmaceutical trade environment, where market access and supply security are as much matters of diplomatic leverage as they are of industrial capability.

Differing Transatlantic Perspectives

From Washington’s perspective, the deal represents a historic rebalancing designed to secure fairer trade terms, enhance domestic manufacturing, and address perceived national security vulnerabilities in drug supply. The White House has been explicit in framing the tariff inclusion as a strategic tool to realign production geography.

In Brussels, the prevailing interpretation is that of a necessary but unsatisfactory compromise, avoiding the immediate imposition of 30% tariffs at the cost of significant economic concessions. While the European Commission emphasises the preservation of regulatory autonomy, particularly with respect to pharmaceutical standards; highlighting exemptions for certain generics, member state reactions have been mixed.

Closing Summary

In summary, the EU–US trade deal represents both a pragmatic truce and a structural inflection point for global pharmaceuticals and healthcare. By averting the immediate shock of 30% tariffs, the agreement has delivered short-term stability, but it has also normalised the politicisation of pharmaceutical trade - the very thing many nations sought to avoid in the aftermath of the COVID-19 pandemic - and introduced a durable cost burden that will reshape investment, manufacturing and supply chain strategies on both sides. For the U.S., the deal is a lever to accelerate industrial repatriation and exert pricing control; for the EU, it is a reluctant concession that may weaken long-term competitiveness and deepen dependence on external markets. The ripple effects extend beyond EU and U.S. borders, pulling in non-EU exporters like Switzerland and prompting strategic recalibration from global leaders such as Novo Nordisk. In this emerging landscape, the interplay of trade policy, industrial strategy, and public health imperatives will increasingly define not only the economics of drug production and distribution, but also the geopolitical architecture of healthcare itself.

(Sources: Reuters, Politico, Guardian, FiercePharma, EuroNews, ThePharmaLetter, Pharmaceuticalcommerce)

2. CEPI Launches the world’s first library of vaccine-enhancing adjuvants

CEPI, in partnership with the UK’s MHRA, has launched the world’s first global library of 25 vaccine-enhancing adjuvants to speed development of potent vaccines against threats like mpox, Ebola, COVID-19, and Disease X. Acting as a “matchmaking” platform, the library enables rapid testing of vaccine–adjuvant pairings, improving efficacy, reducing doses, and supporting the 100 Days Mission to deliver vaccines against new threats in <100 days.

Available to CEPI-funded developers from late 2025, the repository addresses supply bottlenecks seen during COVID-19 and promotes equitable, non-exclusive access. By strengthening the vaccine component pipeline, this initiative complements efforts to bolster medical countermeasures and aligns with broader global health monitoring and response systems.

(Source: CEPI)

3. UK National Health Service Doctors’ Strike

This fortnight resident doctors in England went on a five-day strike from 25 - 30 July 2025. The strike saw a lower turnout than previous industrial actions, with NHS England estimating that fewer than a third of resident doctors participated, reduced by 7.5% compared to last year’s strike. Furthermore, The NHS reported that 93% of planned operations, tests, and procedures went ahead. Health Secretary, Wes Streeting, and NHS Chief Executive, Sir James Mackey, credited the outcome to a more robust operational approach and the efforts of staff across the health service.

The British Medical Association (BMA), however, rejected NHS England’s figures, arguing that complex work schedules, on-call patterns, and annual leave, particularly in July, made it “almost impossible to know” how many doctors actually joined the strike

At the heart of the dispute is the BMA’s call for a 29% pay rise to restore real-terms earnings lost over the past decade, with doctors also citing concerns about workload pressures, staffing shortages, and retention in the profession. The government has offered a 5.4% increase for 2025–26, which the union says falls far short of what is needed. Ministers argue that budget constraints rule out higher pay awards but the BMA insists that without a credible offer, further strikes are inevitable.

The political stakes here remain high. The Conservative Party joined the conversation with a pledge that doctors’ strikes would be banned if they were to win the next general election. Although some trusts reported minimal disruption, NHS leaders acknowledged that thousands of patients still faced delays, underscoring the urgency of resolving the dispute.

(Sources: Guardian, Sky News, NHS England, British Medical Journal)

Behind the scenes

It was a fortnight of prioritising rest, reading and socialising with friends by the lake and against beautiful cityscapes. Shopping for home goods. Thought I bought four, cool geometric candle holders but only got this itty bitty one (and its ability to safely hold a candle - doubtful), treated myself to a night in with some sushi grade salmon like the vegetarian that I am not, watching the August 1st fireworks from my painting station. Surrounded by beauty, heart full.