A Ghanaian child receives a  malaria vaccine, which has been credited with reducing deaths in children since its introduction.

New WHO Global Malaria Report points to funding shortfalls, climate change, and antimicrobial resistance as key challenges to control.

Last year saw 263 million new malaria cases and 597,000 deaths in 83 countries worldwide, an increase of almost 11 million cases from the prior year, according to the World Health Organization’s (WHO) newly-released Global Malaria Report. The vast majority of cases occurred in the African continent, with children under five bearing the greatest burden of malaria mortality. 

Targeted interventions like insecticide-treated bed nets and integrated vector management, alongside factors such as improved nutrition, housing, and urbanization, have all reduced malaria transmission and disease in the past decades. More than 177 million cases and 1 million deaths were averted globally in 2023, and Egypt was declared malaria free, a significant milestone for Africa’s third-most populous country, according to the WHO.

Yet despite progress made in reducing the spread of the ancient disease, challenges like climate change, humanitarian crises, drug resistance, and persistent disparities all threaten global malaria progress. 

“Instead of dying, mosquitoes are dancing on the treated bed nets,” said Dr Michael Charles, CEO of RBM Partnership to End Malaria, referring to the growing number of mosquitoes resistant to commonly-used insecticides. 

Malaria burden per country in 2023

The number of new malaria cases actually increased in the past years, the report notes. Malaria case incidence – the number of new cases while accounting for population growth – grew from 58 to 60.4 cases per 1000 between 2015 and 2023. Five countries accounted for the majority of this increase in cases: Ethiopia (+4.5M), Madagascar (+2.7M), Pakistan (+1.6M), Nigeria (+1.4M) and Democratic Republic of Congo (600K). 

The WHO presented its newly-released report on the global state of malaria as a combination of both hard-fought victories, and obstinate and emerging challenges ahead of key replenishment rounds next year.

“No one should die of malaria; yet the disease continues to disproportionately harm people living in the African region, especially young children and pregnant women,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

“An expanded package of lifesaving tools now offers better protection against the disease, but stepped-up investments and action in high-burden African countries are needed to curb the threat.”

 

Africa ‘not on pace’ to meet WHO target

The Africa region bears the brunt of the global malaria burden – both in the number of cases and deaths – with 11 countries accounting for two-thirds of cases worldwide. Nearly half of these deaths occurred in just four countries: Nigeria (30.9%), Democratic Republic of the Congo (11.3%), Niger (5.9%), and United Republic of Tanzania (4.3%). 

Over 75% of deaths in the African region were among children under the age of five. Progress to reduce malaria mortality has barely budged in the past decade. The 2023 malaria mortality rate of 13.7 deaths per 100,000 people at risk was more than twice the WHO global strategy target of 5.5. 

While these rates remain high, many African countries have either stabilized or reduced their mortality rates. Dr Mary Hamel, WHO Team Lead for Malaria Vaccines, credits this to vaccinations for children in conjunction with bed nets and other interventions. 

“The vaccine is recommended by the WHO from five months of age, and during the pilot implementations where the governments of Ghana, Kenya, and Malawi introduced the vaccine …we saw high impact from these young age periods, with reduction in all cause mortality in these young children by 13% in all cause mortality.”

Seventeen countries have since introduced the malaria vaccine alongside childhood immunizations, with supply so far sufficient to meet demand.

WHO goals for malaria mortality rates (green) and projected rates under the status quo (blue).

Climate change, conflict, biological threats undermine progress

The many climate change-related disruptions in rising temperatures and changing weather patterns favor the quick-adapting and anthropophilic mosquito species that transmit malaria. The report warns that these changes are impacting the “health, security, and livelihoods of people around the world,” particularly in the hardest hit African region. 

But climate change is threatening malaria control in other parts of the world, like Pakistan. The devastating floods that submerged a third of the country in 2022 also left pools of standing water – “ideal breeding grounds for mosquitoes” and leading to an 8-fold increase in malaria cases between 2021 and 2023, the report notes.

Cases rose from about half a million to more than four million. The increasing frequency of extreme weather events is expected to increase the burden of malaria in the long term, especially because the mosquitoes that transmit malaria are “highly sensitive” to environmental changes, noted Dr Arnaud Le Menach, Unit Head, Strategic Information for Response, WHO Global Malaria Progamme. 

Conflict and ensuing humanitarian crises are impeding efforts to curb malaria. “In some countries, their conflict is also stopping people from getting the needed health access and the needed commodities,” said Charles. Internally displaced peoples often lack access to malaria prevention and treatment, leaving them “highly vulnerable to the disease,” said Le Menach. The report highlights these additional drivers of malaria transmission, noting that more than 80 million people in malaria-affected countries are internally displaced or refugees in 2023.

Biological threats in the form of resistant mosquitoes and antimicrobial resistance make it increasingly difficult to control vectors and treat patients. Resistance to pyrethroids, a common insecticide, was reported in nearly every country it was monitored, while resistance to artemisinin, the most effective malaria treatment, was reported in four African countries. 

Better global, regional, and country coordination is a key solution, according to Charles, to bring together stakeholders. This includes involving civil society organizations and resource optimization to overcome the above challenges. 

Reaching vulnerable populations

The global report features for the first time highlights the significant disparities in malaria burden, with a particular emphasis on gender equality.

“[W]e need to keep in mind the issue of poverty, poverty being a significant risk factor,” said Alia El-Yassir, director of the WHO Department for Gender Equality. “Malaria takes the heaviest toll on those who are poorest and are the most disenfranchised segments of a society. The data shows that children under the age of five who are living in low income households have the highest prevalence of malaria, and as their socioeconomic status improves, the risk of malaria and the prevalence will decrease.”

A host of biological, environmental, social, structural, and economic factors converge to increase a person’s vulnerability to malaria, “disproportionately” impacting those living in poverty, refugees, migrants, and indigenous peoples, notes the report.

“Poverty is very much gendered…gender norms become so deeply entrenched and institutionalized that they will place many women and girls at a disadvantage, and that affects their risk of malaria and also their access to treatment,” said El-Yassir. To address these challenges, the report urges health system strengthening to collect disaggregated data because current averages “are not giving us the true picture in terms of who is being affected.”

Calls for funding ahead of replenishment rounds

Several panelists made calls for funding at a recent WHO press conference in Geneva given the current “shortfalls” in funding. In 2023, less than half of the target $8.3 billion was invested in malaria response. This gap has widened in the past several years from $2.6 billion in 2019 to $4.3 billion in 2023. The vast majority of these funds come from international sources, with endemic countries contributing 33% in the past decade.

“Next year is a very, very big year for all of us in the malaria world,” noted Dr Charles. “We have two replenishments. We have the GAVI replenishment, and we also have the Global Fund replenishment…The mosquito is so unrelentless and so smart that the longer we wait, the harder it is.”

Even with malaria vaccines available, GAVI, the Global Fund, and the President’s Malaria Initiative all need replenishment “to realize the promise of the vaccine and other interventions,” argued Dr Hamel.

The Global Fund also released a statement urging funding to meet targets, making the argument that “investing more in the fight to end malaria not only has the potential to save millions of lives, but it can also help rebalance global economic power and stimulate trade.

“This, in turn, can unlock additional funding to strengthen health systems and enhance health security both in Africa and around the world. Malaria investment is not just a health imperative—it is a strategic driver of broader, far-reaching economic and social benefits,” said Peter Sands, Global Fund executive director, in a press release.

Image Credits: Fanjan Combrink / WHO.

WHO Director General Dr Tedros Adhanom Ghebreyesus (center) at year-in-review press briefing.

WHO Director General Dr Tedros Adhanom Ghebryesus urged a ‘wait and see’ attitude Tuesday in his first public comments on US President-elect Donald Trump’s nomination of Robert F Kennedy Jr as Secretary of Health and Human Services – despite a flurry of fresh criticism by 77 Nobel Laureates over the controversial appointment.

“It’s a transition time for the new US government, give them some space so that they can prepare for the transition. and I hope and believe that they will do their best,” said Tedros, at an end-year briefing with the Geneva UN Press Association (ACANU), that also reflected on the successes and setbacks seen by WHO over the past year – as well as the challenges ahead. 

“The United States has been a good model of partnership, and has been partnering for many years,” Tedros said – shrugging off the bitter criticism levelled by Trump at WHO during the COVID pandemic, when he also tried to pull the US out of the global health agency. 

The WHO Director General also expressed hopes that the new US administration would still back a WHO pandemic accord, which he said could be completed by member states in their next session in February 2025 and approved at the next World Health Assembly, in May.

This despite sharp criticism by conservative pundits in the US and elsewhere about how an accord might impinge on US ‘sovereignty’ – something Tedros and other senior WHO legal officials have rejected over and again. 

More immediately, there are mounting concerns that WHO member states negotiating a deal won’t manage to agree on the last thorny issues that have eluded consensus so far – notably a  formula for more equitable distribution of vaccines and medicines between richer and poorer nations. See related story:

No Pandemic Agreement This Year – And Doubt About Feasibility of May 2025 Deadline

“I still believe that there is very broad support for the pandemic agreement.  I hope that they [WHO member states] will finalize it by the set date,” Tedros told reporters, referring to the May 2025 target date set by the World Health Assembly for approval of a draft agreement.  “I hope they will honour that commitment they already have. And as I said earlier, we are still vulnerable. 

“I believe that the US leaders understand that the US cannot be safe unless the rest of the world is safe,” he added, with regards to the global threat that local outbreaks of deadly pathogens can pose. 

He cited repeated outbreaks of Ebola, and more recently mpox, in the Democratic Republic of Congo, as contemporary examples of remote settings where WHO and its partners have acted to head off the spread of deadly disease threats with a combination of new diagnostics, surveillance and vaccination of at-risk groups. 

Vaccine skepticism causes uproar over Kennedy’s nomination

Anti-vaxxers demonstrating against COVID-19 measures in London in 2022; Kennedy made whirlwind trips around Europe to encourage protests.

Tedros spoke on the same day that the 9 December letter by 77 Nobel Laureates in medicine, chemistry, physics and economics was first published by the New York Times, calling on US Senators to reject Kennedy’s nomination as HHS Secretary.  

“In addition to his lack of credentials or relevant experience in medicine, science , public health, or administration, Mr. Kennedy has been an opponent of many health – protecting and life-saving vaccines, such as those that prevent measles and polio; a critic of the well-established positive effects of fluoridation of drinking water; a promoter of conspiracy theories about remarkably successful treatments for AIDS and other diseases; and a belligerent critic of respected agencies (especially the Food and Drug Administration, the Centers for Disease Control, and the National Institutes of Health),” the scientists wrote. 

“In view of his record, placing Mr. Kennedy in charge of DHHS would put the public’s health in jeopardy and undermine America’s global leadership in the health sciences, in both the public and commercial sectors,” the Nobel laureates concluded. The US Senate, which has a narrow Republic majority, must confirm Trump’s nomination of Kennedy following the president-elect’s inauguration on 20 January 2025.

Trump team rejects Laureate’s appeal as ‘elites telling them what to do’ 

Donald Trump with NBC’s Kristin Welker on Meet the Press: suggests Kennedy might re-open investigations into long debunked claims of vaccine-autism linkage.

In response to the Laureates’ appeal, a spokeswoman for the Trump transition team said: “Americans are sick and tired of the elites telling them what to do and how to do it. Our healthcare system in this country is broken, Mr. Kennedy will enact President Trump’s agenda to restore the integrity of our healthcare and Make America Healthy Again.”

Meanwhile, in a wide-ranging interview with NBC TV, Trump suggested that his pick for HHS Secretary might indeed re-open investigations into a long-debunked theory about a linkage between vaccines and autism,  which Kennedy has at times championed. 

“I think somebody has to find out,” Trump said in an interview with NBC’s Kristen Welker in “Meet the Press”, adding that “if you go back 25 years ago, you had very little autism. Now you have it.”

Childhood vaccines prevent about 4 million deaths a year 

Infant in Rwanda receives a combined measles and rubella vaccine, recommended by WHO.

Welker challenged Trump with data showing that childhood vaccines save several million lives worldwide every year, while increases in autism diagnoses are attributable to increased screening and awareness – not vaccines.

According to the Centers for Disease Control and Prevention (CDC), one out of every 36 children in the US was diagnosed with autism in 2020, compared with one in 150 in 2000.

During the COVID pandemic, Kennedy led a worldwide anti-vaxer movement against SARS-CoV2 vaccines. Along with his organization, Children’s Health Defense, Kennedy has also advocated in the past against other routine childhood vaccines, saying in a 2023 Fox News interview: “I do believe that autism does come from vaccines.” 

“We should have the same kind of testing place or control trials that we have for every other medication,” Kennedy said at the time, claiming that “vaccines are exempt from pre-licensing control trials, so that there’s no way that anybody can tell the risk profile of those products, or even the relative benefits of those products before they’re mandated. We should have that kind of testing.”

In fact, all major childhood vaccines undergo extensive pre- and post-licensing trials for safety as well as for efficacy, prior to regulatory licensing. 

In 1998, a British doctor first claimed a link between autism and childhood vaccines, particularly the measles, mumps and rubella vaccine (MMR). His research was subsequently retracted, and he was later banned from practicing medicine in the United Kingdom. 

Finding common ground 

Dr Mike Ryan, WHO executive director of Health Emergencies: “We need to look for what we have in common.”

Despite the obvious concerns over Kennedy’s position on the vital role vaccines play in  preventing infectious diseases, WHO officials are also clearly looking for entry points where they might be able to build bridges with the new HHS Secretary, should his appointment be confirmed. 

And they don’t have to look very far.

Kennedy Jr. also has been outspoken about the epidemic of non-communicable (aka chronic) diseases faced by Americans – and the need for more emphasis on prevention with healthier diets, environments and active lifestyles – capped by social media posts of the 69-year old showing off his muscles in a workout.

But in fact, these are also increasingly high priorities in WHO’s strategic work  – particularly in a year when the United Nations High Level Meeting on Noncommunicable Diseases will be a featured event at the UN General Assemblies September 2025 meeting.  

Over the past two decades, the agency has also locked horns with increasing frequency with powerful food industry interests on WHO guidance about reducing sugar intake, sugary drinks, transfats, processed meats, and other unhealthy foods – not to mention contaminants in food, air and water supplies.  

“We need to always look for what we have in common. What can we do together? Where do we agree?” said Mike Ryan, executive director of WHO Health Emergencies, at the briefing. 

“And if you’re looking at things like healthier lifestyles, health promotion, the reduction of toxins in food or in the environment, that’s common ground. There’s no question that that’s common ground. And there’s a huge agenda there to be worked on.

“I think we can choose to differ on many things, and sometimes we do have ideological differences. But Tedros often uses the example that we managed globally to eradicate smallpox at the height of the Cold War. 

“So if there ever is a reason to find common ground, [it is] now …when over half the world’s population lacks access to proper healthcare. We have a mental health crisis. We have a nutritional crisis. We have non-communicable disease crisis. 

“We have hundreds of millions of people slipping into fragility and conflict. If there ever was a reason to pull together to find common ground rather than the grounds for conflict, we have those problems now.”

‘No one has the right to take a life’

Saving both individual’s and societies high healthcare costs is yet another reason why national health systems need to “move towards prevention,” Ryan suggested. 

 “No one has a right to take a life,” he observed, commenting on the 4 December murder of a senior health insurance executive in New York City, in an apparent rage attack against the US health insurance industry. 

“But right now, becoming unwell can be both catastrophic to your health, catastrophic to your future, your children’s future.” Ryan added.  “There is a lot more financial hardship associated with people having to directly pay for healthcare when they’re not insured or they’re not part of a national insurance programme, … and that’s happening in many, many countries.

“We need to move towards …a health system that is more focused on keeping people healthy, and less focused on treating disease, reducing what we’re exposed to, in terms of protecting the health of our people, protecting them from what’s out there in the environment, protecting them from anything that was unsafe within our food or farms,” Ryan stressed. 

“Each sovereign country decides how it designed its health system. WHO’s concern is to ensure that every person has a right and access to health. WHO’s concern is that every individual has access to the same level of health care, and that we don’t see inequities in that health care is distributed within the society.”

Image Credits: Sarah le Guen/ Unsplash, NBC, WHO.

Kelly Chibale at his research organisation, the Holistic Drug Discovery and Development Centre (H3D) at the University of Cape Town.

Nearly two decades ago, South African researcher Kelly Chibale recalls participating in a pioneering World Health Organization (WHO) meeting in Abuja, Nigeria, organized by TDR, the WHO-hosted Special Programme for Research and Training in Tropical Diseases, focusing on the concept of an African drug discovery network. 

For Chibale, the main outcome of that encounter was a bad case of food poisoning. But the researcher, who went on to found the University of Cape Town’s (UCT) Holistic Drug Discovery and Development Centre (H3D) a few years later, never forgot the idea.  

Twenty years later, in the wake of the COVID-19 pandemic fallout over the lack of research and development (R&D) and manufacturing on the continent, an African R&D network has finally come of age.

A network of African research institutions engaged in drug discovery research is taking full form. Earlier this year, some 21 research institutions spread across seven countries came together as the Grand Challenges African Drug Discovery Accelerator (GC-ADDA) co-sponsored by the Bill & Melinda Gates Foundation (BMGF) and LifeArc, a UK-based self-funded medical research charity.

The network was conceived in a 2017 conversation Chibale had with Peter Warner, BMGF Senior Program Officer, and Tim Wells, Chief Scientific Officer at Medicine for Malaria Venture (MMV), and the concept was championed by Warner within the foundation, Chibale recalls.

It was incubated between 2019 and 2023 against the backdrop of the COVID pandemic, with a series of Grand Challenges mini-grants disbursed to different African institutions that worked individually on key R&D challenges in malaria and TB drug discovery, among other issues.

Then, in January 2024, the GC-ADDA network came into its own with the $7.2 million grant from the BMGF and LifeArc.

Last month, LifeArc awarded another $6.3 million to H3D to establish a Center for Translational AMR Research (CTAR) at its UCT base.

The new CTAR project aims to identify and develop new precision antibiotics to combat several multidrug-resistant (MDR) Gram-negative bacteria, including Acinetobacter baumannii, which typically infects people with weakened immune systems, including in hospitals, and is a leading driver of antimicrobial resistance (AMR) on the continent.

Chibale, whose H3D Foundation will spearhead GC-ADDA, was in Geneva recently to discuss and promote the GC-ADDA network among African Ambassadors to the UN in Geneva Missions .

He sat down before that meeting to talk with Health Policy Watch about his vision and its development.

Flagship projects

“I can give credit to my colleague Solomon Nwaka of WHO/TDR for initiating the idea [of a network]. It was visionary. But the difference now is that this is a model that is based around specific, concrete innovation projects in research institutions on the continent,” said Chibale, whose H3D in Cape Town offers one such example.  

Based on lessons learnt in the two previous rounds of Grand Challenges Grants, the new GC-ADDA network will focus on four flagship projects. These will be led by research centers in Ghana, Cameroon, South Africa and Zimbabwe, but also involving the other African institutions, including those that were recipients of earlier grant rounds and will be integral parts of the developing network. 

“There was a closed call, to only those people who were already in the network and those strategically identified, to organize themselves, based on complementary expertise, and to propose a consortium project, which is on a much bigger scale than the individual projects,” Chibale said.

Out of seven applications received, two projects for R&D on new TB and malaria drugs were accepted. The malaria project, co-led by the University of Ghana and the University of Pretoria aims to deliver novel anti-malarial drug leads.

The TB project, led by researchers at South Africa’s Stellenbosch University with partners in Kenya and elsewhere, will take a new approach to TB by identifying new drugs that act by degrading essential proteins in Mycobacterium tuberculosis, the causative agent of TB. 

Complementary to that, two other novel projects have been funded as part of the $7.2 million grant from LifeArc and the Bill & Melinda Gates Foundation.

They include a project on African drug metabolism (DMPK) research, led by the Zimbabwe-based African Institute for Biomedical Science and Technology (AiBST)

Finally, there is an effort to build a library of African-derived natural products – so that the active pharmaceutical ingredients in traditional African medicines could be studied systematically.

R&D on drug metabolism in Africans

The drug metabolism project, headed by Collen Masimirembwa, who spent a decade in Sweden with AstraZeneca, has led to the creation of a dedicated laboratory, near Harare, to the all-important goal of studying how drugs are metabolized in livers obtained from African donors.

This, on a continent which boasts the greatest genetic diversity in the world.

“Why is this important for Africa? Is because the way Africans metabolize drugs is not well understood,” said Chibale, who co-authored an article last year in Nature Reviews Drug Discovery, describing the challenges.

The impact of Africa’s genetic variability on response to medicines is not well accounted for in African populations for two reasons, he explains: 

  •  Only about 3.7% of clinical trials are conducted on the continent “and for obvious reasons, medicines are only optimized for people who take part”;
  • Drug candidates are typically tested first in preclinical studies on cellular fractions containing drug metabolizing enzymes and liver cells from donated livers, the main organ in which food and drug chemicals are broken down in the body. In Africa, organ donation is uncommon.  

At the same time, genetic differences in the liver’s drug-metabolizing enzymes can mean that a drug may be processed more rapidly or slowly by the body. So, for instance, when the HIV drug Efavirenz was first introduced in Africa a while ago, a study in Zimbabwe found that the approved dose for Caucasians was toxic for some Africans who had a genetic mutation in the enzyme needed to process the drug, leading to a much slower metabolism.

“They observed people having adverse side reactions. Some would stop taking the medication, and some could even have died from the toxicity of the drug,” he relates. “Upon investigation, it turned out that people were actually being overdosed.”

“So this project aims to strengthen African drug metabolism research so that we can generate more data on how diverse populations in Africa break down drugs. And then we use that data to refine what we should be giving to people who carry particular genes, or genetic mutations in drug-metabolizing enzymes.”

Traditional drug library

Developing an African-based library of active ingredients derived from natural sources  another novel arm of the project, which will be led by the University of Buea in Cameroon.  

Like synthetics, medicinal plants also have active ingredients that bestow them with healing qualities, as part of natural (traditional or herbal) medicines, “these are molecules that come from plants, marine organisms or other natural sources,” he points out. 

“Africa has been endowed with a lot of these natural products. People use traditional medicines, right? But still, they have not been scientifically and clinically validated to the extent or point that they can receive approval from a stringent regulator.

“So the aim is to assemble a collection of well-characterized, purified natural products from Africa, and see how we can use them as a starting point for modern approaches to discovering a medicine – using them to test against causative agents of various diseases – communicable and non-communicable – whatever you want to do.

Concretely, this involves building a collection of such naturally derived “active ingredients”, which are already purified and characterized.

“They can be dispensed in what we call screening boxes – and made available to the African community to screen against any disease – in other words, providing starting points for drug discovery.”

Supporting local manufacturing of APIs

Complementary to the GC-ADDA R&D network is a parallel initiative in which H3D is engaged, which aims to support more local manufacturing of ‘active pharmaceutical ingredients’ (APIs) in Africa.

As was painfully evident during COVID, most of those APIs are currently produced in Asia and imported to Africa – and that hobbles the ability of African manufacturers to be competitive in the drug manufacturing space.

With the support of USAID, H3D, together with a private local pharma firm, Chemical Process Technologies (CPT) Pharma, is using and testing a “continuous flow reactor technology” that could make API production of antiretroviral drugs for HIV more economical, Chibale said.

“If and when we demonstrate the cost competitiveness of the process of making the three antiretroviral drugs we are working on as a pilot, we will license that technology to CPT Pharma, who can do the commercial manufacture.”

See related story: https://healthpolicy-watch.news/empowering-africas-pharmaceutical-future-the-critical-role-of-local-api-manufacturing/

Drumming up support for African R&D

The support of African governments, as well as the pharma industry, is critical to foster an ecosystem of R&D and manufacturing in Africa, says Chibale.

“And when I say support it is not always about giving money,” he stresses. “For African governments it can be as basic as supporting local researchers with the right policies that allow them, for example, to easily buy chemicals and reagents, which can be subject to high import fees or delays when donated equipment gets stuck in customs.”

In terms of the pharma industry, skills development and the exchange of scientists is a critical, practical pathway to fostering tech-transfer, said Chibale, whose own early formative experiences included a sabbatical as a visiting professor at Pfizer in 2008 at the company’s Sandwich R&D site in the United Kingdom.

Finally, he says H3D, as the GC ADDA network administrator through the H3D Foundation, can “bring excellence to this programme, because we’ve been through this ourselves.

“We can continue to provide access to infrastructure that we’ve developed, of course – with support from many partners, including pharmaceutical companies, including Medicines for Malaria Venture.

“And of course, the government of South Africa has been a major factor. It’s an important thing to highlight what a government can do, even when there are enormous social challenges.”

 

Image Credits: Je'nine May.

Africa CDC Director-General Dr Jean Kaseya (centre) during a visit to the DRC last week.

There is still no clarity about the cause of the mystery disease affecting people in the Panzi district of Kwango province in south-west Democratic Republic of Congo (DRC), despite hopes that it would be diagnosed by the past weekend.

Getting laboratory test results is proving more challenging than previously hoped as the district’s “limited laboratory capacity means that samples have to be transported to the national reference laboratory in [the capital of] Kinshasa”, according to the Africa Centres for Disease Control and Prevention (Africa CDC).

But the 700 km journey to Kinshasa currently takes about 48 hours due to poor roads and the rainy season, according to the World Health Organization (WHO).

The communication network is also limited in Panzi, a rural community of around 200,000 people spread over more than 7,000 square kilometres.

Suspected diseases

By last Thursday, 406 cases and 31 deaths of the undiagnosed disease had been recorded (case fatality ratio of 7.6%). However, the reported cases peaked in epidemiological week 45 (week ending 9 November 2024), according to the WHO. It took almost six weeks for Panzi health officials to notify national health officials about the unusual rise in cases.

All severe cases were malnourished, according to the WHO’s Disease Outbreak News (DON) from Sunday.

“The clinical presentation of patients includes symptoms such as fever (96.5%), cough (87.9%), fatigue (60.9%) and a running nose (57.8%),” according to the WHO.

Almost two-thirds of cases (64.3%) are children under the age of 15 , and over half of the children’s cases involve kids under the age of five. Some 71% of deaths occurred in children under 15.

“The area experienced deterioration in food insecurity in recent months, has low vaccination coverage and very limited access to diagnostics and quality case management,” according to the WHO.

In addition, the area is experiencing a shortage of supplies and health workers, with limited malaria control measures and access to transport.

Given the context of Panzi and patients’ symptoms, the WHO has listed the main diseases that are suspected. These include measles, influenza, acute pneumonia (respiratory tract infection), hemolytic uremic syndrome from E. coli, COVID-19 and malaria. 

Both the WHO and Africa CDC have sent health experts to assist the DRC’s team to assess the situation, accelerate diagnostic testing, and implement control measures.

The multidisciplinary team includes epidemiologists, laboratory scientists, infection prevention and control experts.

Since the mpox outbreak, the Africa CDC has been working closely with the DRC’s Ministry of Health (MoH), the National Institute of Biomedical Research (INRB), the National Public Health Institute (NPHI) to strengthen disease monitoring through genomic surveillance. 

“This collaboration focusses on creating a sustainable national pathogen genomics strategy and decentralising laboratory capacity to improve outbreak response and preparedness,” according to Africa CDC.

INB co-chair Precious Matsoso (centre) ends the 12th meeting, flanked by co-chair Anne-Claire Amprou and Dr Tedros.

There will be no pandemic agreement by year-end and, with only 10 days of formal talks set aside in 2025, some parties doubt whether an agreement can be reached by the May 2025 deadline.

The week-long extended 12th meeting of the Intergovernmental Negotiating Body (INB) made progress, particularly on research and development (Article 9) and financing (Article 20). 

While disagreement remains on a couple of key obstacles, informal talks will continue alongside the formal talks.

Dr Tedros Adhanom Ghebreyesus, the World Health Organization’s (WHO) Director General, suggested at the close of the meeting on Friday evening that delegates consider negotiating on “packages” rather than clause by clause to “break the stalemate”.

“When I see what’s left, I believe – and this is honest from my heart – it is not really difficult to conclude in a few days of negotiation, but between now and the next meeting it would be good to think about the issues left and find a middle ground,” said Tedros.

Earlier in the day, INB co-chair Anne-Claire Amprou took exception to criticism of the process and lack of progress from some NGO observers.

Noting that the nature of multilateral negotiations means finding a “landing zone” that is acceptable to everyone, France’s Amprou said sharply: “I don’t agree when you say that nobody gains anything. I invite everyone – delegations, stakeholders – to look at what we have already achieved. We have achieved a lot.”

She stressed that the INB would deliver on its mandate: “We need a pandemic agreement which is meaningful, and it will be.”

‘Not a colouring book’

Amprou’s response came after Medicines Law and Policy commented that while there is some new “green text”, indicating agreement on the draft agreement, “it’s important to remember that the pandemic agreement is not a colouring book”. 

The European think-tank continued: “Substantive provisions on very difficult issues such as equity and access, transfer of technology, intellectual property and [pathogen] access and benefit-sharing remain largely absent, or are, at best, weak.”

Third World Network (TWN) followed, saying: “Every time we hear a new text is green, we are looking to figure out what has been compromised, especially in terms of equity.

TWN added that the agreement lacks “a baseline of legal rights and obligations”, and  “protects the interest of business, not people’s rights”.

Oxfam presented a list of questions and objections on behalf of 26 stakeholders including that member states appeared to be under “extreme pressure” to defer agreement on a pathogen access and benefit-sharing (PABS) scheme to an annex, the contents of which would be decided on after the pandemic agreement had been signed.

The Pandemic Action Network (PAN) and the Panel for Global Health Convention both urged negotiators to keep the momentum going and asked for clarity on the way forward.

Rafael Gracia of Pandemic Action Network and Dame Barbara Stocking representing he Panel for Global Health Convention

Eloise Todd, PAN’s executive director, told Health Policy Watch after the meeting that while the INB has not reached a conclusion, “there is a more urgent sense of progress around the negotiations which we need to encourage”.

Todd called on “high-income countries in particular to dig deep and remember the reason why we need this agreement is because of the deep-seated inequality in the COVID response”. 

“⁠⁠It is crucial for negotiators to see the bigger picture with these negotiations. The pandemic agreement will serves as an important marker the world’s coordination and cooperation in times of pandemic threats – which we know will become more and more frequent. It’s time to deliver on this vital step forward that will benefit people in every country,” said Todd.

However, Spark Street Advisors’  CEO and long-time talks observer Nina Schwalbe was less positive: “They have missed a once-in-a-generation opportunity to make a difference because national interests prevailed over global solidarity.”

Crux of the stalement

The stalemate centres on differences between the European Union (EU) and the Africa Group. The EU wants an annex linked to Article 4 (pandemic prevention) that outlines countries’ responsibilities to prevent pandemics. The Africa Group is reluctant to agree to costly responsibilities and it wants an annex related to the operationalising of a system for pathogen access and benefit-sharing (PABS) in exchange.

What the Africa Group wants from PABS is preferential access to any pandemic-related products that are developed from them sharing information about pathogens that could cause pandemics. This is anathema to the pharmaceutical industry, largely represented by the EU and the US.

The Africa group is also concerned that a prevention annex could impose costly requirements that they are unable to finance. However, the first beneficiaries of prevention measures are individual countries’ citizens who would be protected by, for example, heightened surveillance of bats that harbour Ebola and Marburg.

“These two areas are the make-or-break articles of the negotiations. If we can reach agreement on these, we will make the deal,” co-chair Precious Matsoso noted in an address to scientists recently.

Health leaders wanted an early agreement

Tedros has long urged delegates to reach agreement sooner rather than later and Dr Jean Kaseya, head of Africa CDC, has also expressed hope for an early agreement.

On a recent visit to South Africa, Matsoso noted: “We don’t have six months left to finish negotiations. We only have a couple of days left, precisely because the geopolitical environment is so challenging. There is huge, huge pressure on the talks and we don’t know what the outcome will be.”

The elephant in the room is the Donald Trump presidency, largely expected to take an axe to what Team Trump terms “globalism” – virtually anything that puts global good before national interest.

Delegates paid tribute to US Ambassador Pamela Hamamoto for her positive contribution to the pandemic agreement, as that was her last INB meeting.

Further INB meetings are scheduled for February and April, with a completed agreement supposed to be ready to be voted on at the World Health Assembly in May.

Mosquito and dengue
Mosquitoes, which can carry dengue virus, thrive at warmer temperatures. Climate change is already fueling increases in dengue cases globally.

Nearly one fifth of dengue cases in Latin America and the Caribbean, or about 45 million infections a year, are attributable to climate change, in the past decade, according to a new study by researchers at Harvard and Stanford Universities. 

Rising temperatures combined with mosquito species uniquely suited to sprawling urbanization and deforestation are fueling the staggering increase in dengue cases, with a proportion of cases measurably attributable to climate change, according to the first ever study to “meaningfully” quantify that number. 

Over the past year, both Latin America and the Caribbean saw a record-breaking number of cases – and fatalities – of the so-called “break-bone” fever. Even with the recent regulatory approval of two new vaccines, Takeda Pharma’s Qdenga® and Sanofi’s Dengvaxia, slow rollout and continued challenges in production scale-up have meant the jabs made little impact so far. 

The researchers compiled data from 21 countries in the Americas and in Asia to identify the causal effect of climate change-related temperature increases and dengue cases. The study was presented at the Annual Meeting of the American Society of Tropical Medicine and Hygiene (ASTMH) 13-17 November, and is available in pre-print form.

The researchers also estimated how different climate change scenarios will impact dengue burden. By 2050 under a high CO2 emissions scenario, the authors predicted  a 61% increase in dengue incidence. Active climate mitigation would cut that figure to roughly 40%. 

At least 257 million people now live in countries where warming temperatures could cause dengue to double by mid-century in either scenario. 

“We can see the direct policy implications of reducing emissions at the global scale,” Dr Kelsey Lyberger, an ecologist at Arizona State University and one of the study authors, told Health Policy Watch. The magnitude of dengue cases will not increase equally, either, Lyberger noted. “Some of the highest relative increases are in places where they don’t necessarily have a high burden currently.”

Dengue and climate change projections
Countries in cooler climates are projected to have the largest increase in climate change-related dengue cases.

But already now, increasing temperatures and extreme weather events are already changing the burden of infectious diseases – particularly vector-borne diseases. These temperature increases are already responsible for 45 million excess dengue cases, which the studied identified.  

The study, whose release coincided with the UN Climate Conference (COP29) in Baku, provides further evidence that climate action is “health action,” as termed in a recent WHO COP29 special report.

Cooler regions will see largest change

Dengue responds non-linearly to average daily temperature, with cases peaking at average temperatures of 28℃, and then decreasing. This creates “optimal” conditions for the two primary dengue mosquito vectors, Aedes aegypti and Aedes albopictus, where both species breed and feed faster. But in places where average temperatures are cooler – 15-20℃ on average – climate-change related warming has the largest effect on dengue caseload. 

As a result, projected warming will fuel dengue cases unequally across the globe. “It’s not across the board that we see this increase,” said Lyberger.  

Some cooler regions of Mexico, Peru, Bolivia, and Brazil, for instance, are predicted to see over 150% increases in dengue incidence due to climate change under any emission scenario, the study notes. 

Lack of surveillance data excludes Africa, India, Western Pacific from analysis

Dengue infographic
WHO’s Western Pacific region was among those excluded from the study due to a lack of reliable surveillance data.

While dengue cases continue to rise globally, including in much of the African continent, the lack of high quality surveillance systems means experts are left to guess the impact of climate change on dengue in these regions. 

Countries in the America, Brazil in particular, have felt the burden of dengue cases most acutely, but they often have surveillance methods in place to track infection rate fluctuations.

“We needed a long enough time series of cases to estimate a baseline level of dengue,” said Lyberger. Many African countries face surveillance hurdles in detection, reporting and management, the lack of local laboratory capacity, and the misclassification of cases, noted researchers at Africa CDC. Without a solid surveillance system, countries are at a critical disadvantage–including little early warning systems for dengue surges.

In India, the country’s “poor” surveillance network leads to “huge” under-reporting and a lack of public health response to outbreaks, as a Lancet editorial comments in India’s 2015 dengue season. A 2020 assessment of the country’s surveillance efforts found that dengue surveillance needs to be strengthened, and integrated into existing government initiatives. In that time frame alone, from 2015-2019, cases in the South Asian region increased by 46% according to WHO estimates. The organization attributes climate change, in addition to “high rates of population growth, inadequate water supply and poor waste management systems” coupled with the absence of effective treatment and suitable vector control to the high burden of dengue in the region. 

Preparing for the future

With these new estimates of how climate change will increase dengue cases, researchers hope that such high-burden countries will be motivated to do more tracking and reporting, while those that historically have had few cases can prepare with funding for surveillance and integrated vector management. 

“Since we’ve established this relationship between temperature and cases, the next step is to see how warming, both in the past and in the future, is going to affect the number of cases that we have or will see,” explained Lyberger.

This led researchers to compile data from 21 countries where dengue is endemic – including Brazil, Cambodia, Colombia, and Vietnam – and to examine other factors that could affect dengue infection rates like rainfall, seasonal changes, viral strains, economic shocks, and population density, to isolate the distinct effect of temperature. 

“We were able to pin down that historical warming has already increased dengue cases by about 20%,” said Lyberger. 

“It’s evidence that climate change already has become a significant threat to human health and, for dengue in particular, our data suggests the impact could get much worse,” said Erin Mordecai, PhD, an infectious disease ecologist at Stanford’s Woods Institute for the Environment and the study’s senior author in a press release. 

See Health Policy Watch’s ongoing coverage of dengue here.

Image Credits: Marissa L. Childs, Kelsey Lyberger, Mallory Harris, Marshall Burke, Erin A. Mordecai, WHO.

DRC Director-General of Health, Dr Dieudonné Mwamba.

The Democratic Republic of Congo (DRC) expects to diagnose ‘Disease X’, which has killed at least 79 people in the Panzi district of Kwango Province by the weekend, according to the country’s Director-General of Health, Dr Dieudonné Mwamba.

“The disease is characterised by fever, headaches, cough and sometimes difficulty breathing,” Mwamba told a media briefing hosted by Africa’s Centre for Disease Control and Prevention on Thursday. 

So far, around 376 people have been infected and the disease appears to be airborne, he added. Females are slightly more affected than males, and the majority of cases (52%) are under the age of 5. The second biggest group of patients is people aged over 25 (almost 30%).

“Given that we do not have a specific diagnosis, we don’t know whether we are faced with a viral or bacterial disease, but we believe that, in under 48 hours, the results of the laboratories will help us,” he said.

However, he noted that people in the impoverished rural Panzi district were “vulnerable” as there is a malnutrition rate of almost 40%, it recently experienced a serious typhoid outbreak. The DRC is also experiencing a seasonal influenza outbreak.

Panzi does not have the capacity to test the specimens taken from patients with the unknown disease, so they have been sent to a laboratory in Kikwit some 500km away.

The first case of the unknown illness was identified on 24 October in the largely rural south-eastern province bordering Angola. However, central authorities were only notified of a possible outbreak on 1 December, according to Dr Jean Kaseya, Africa CDC Director-General, who addressed the briefing from the DRC.

“We want to reinforce the surveillance. We have a delay of almost five to six weeks, and in [that time], so many things can happen. This is why we are supporting the country to build strong capacity for surveillance,” said Kaseya.

A team from Africa CDC, including an epidemiologist and laboratory and infection prevention control (IPC) experts, is being sent to Panzi on Friday to assist officials, he added.

Mpox continues to spread

Meanwhile, Mpox continues to spread, particularly in Central Africa, with 2,700 new cases in the past week, up from 2,618 new cases the previous week,  said Kaseya.

The outbreak has affected 20 African countries. After laboratory testing, Zambia and Zimbabwe have confirmed that their outbreaks are Clade 1b.

“In total, we have 62,171 cases. Last week, we lost 36 people, and that brings a total of 1200 deaths since January 2024,” said Kaseya.

However, only 13, 579 of the cases have been clinically confirmed as laboratory testing remains a challenge in many areas.

The DRC remains the worst affected by mpox, with both clade 1a and 1b circulating. The lion’s share of the week’s new cases – 2,115 – were identified in the DRC and all 36 of the week’s deaths were in the DRC.

However, testing remains a challenge in the country, with only 20% of cases confirmed by laboratories.

Africa CDC also flagged the links between high burdens of mpox cases and measles cases in DRC, but has not yet established a causal link between the two diseases.

 

Three-wheelers and motorcyclists trapped in smog in Lahore, Pakistan in late November, 2024

LAHORE, Pakistan – Capital of the agriculturally rich Punjab Province, Lahore, has been engulfed in intense smoke for nearly a month. 

The government closed schools in Lahore and parts of the province on 7 November but even though they reopened a few weeks later, air pollution has remained at record, hazardous levels throughout the region.

Air Quality Index scores were 218-425 in the first few days of December. Scores of 150 and above are considered a “red alert” while 300 or higher ranks as emergency conditions in the Index, which rank ozone, PM2.5 and other pollution levels in a scoring system modelled on the US Environmental Protection Agency.

Along with mandatory mask-wearing for students and the public and banning outside sports and activities, the government ordered offices to reduce staffing by 50%, thus reducing workers’ exposures. 

Lahore was ranked fifth most polluted city in the world in 2023, with the top four slots going to Indian cities, according to IQAir.

In what has become almost an annual ritual, Senior Minister Punjab Marriyum Aurangzeb, in a press conference, blamed neighboring India for the high air pollution in Lahore.

Blame game or shared airshed?

Air pollution levels in Pakistan’s Punjab Province, India’s Punjab State and across the Indo-Gangetic plain as far as Dhaka, Bangladesh on 3 December 2024.

Aurangzeb said that as winds blow from east to west, smoke from seasonal crop stubble fires in India, where farmers burn their fields to sow winter wheat, drift into the skies of Pakistan. 

However, international experts point out that when winds blow the other way, around 30% of India’s pollution in Punjab may be coming from Pakistani Punjab across the border. And roughly one-third of the air pollution in Bangladesh, is blown in from India, around this time of year.  

The two rival countries, as well as Nepal and Bangladesh, all share an important airshed along the Himalayan foothills and Indo-Gangetic Plain and the pollution of each nation affects the others. 

In the late autumn and early winter, crop stubble burning plays a significant role in air pollution on both sides of the India-Pakistan frontier, according to a 2023 UN report on Sustainable Management of Crop Residues in Bangladesh, India, Nepal, and Pakistan: Challenges and Solutions. 

Punjab environmental officers put out fires set by Pakistani farmers in Province – an annual ritual on both sides of the border that leaves the entire Indo-Gangetic Plain shrouded in smoke.

The problems typically begin in late October when farmers, in a hurry to prepare their land for winter wheat sowing, burn the rice stalks that remain in their fields. Thousands of fires visible across the region from satellite images. 

Experts have long said that a shift to more modern crop residue technologies is critical to reducing the harmful effects of stubble burning in both India and Pakistan, which are the world’s largest, and fourth largest, rice exporters respectively.

Although across the Indo-Gangetic plains region, a wide variety of other pollution sources also play a role, from inefficient traditional brick kilns, to smoky household wood and coal fires, as well as polluting factories and diesel vehicles.

Punjab Province launches ambitious smog control programme 

Punjab Chief Minister Maryam Nawwaz launches super seeder programme for farmers

In April 2024, Punjab’s new Chief Minister, Maryam Nawaz set out to change that.  She launched an ambitious new Smog Control Program, aimed at a range of far-reaching measures intended to better control the region’s heavy air pollution from a variety of sources. 

These included shifting brick kilns to more modern technologies, along with other industrial pollution sources, encouraging a transition to electric vehicles (EV’s) and a shift away from burning crop residue. Observers say that the transition to cleaner brick kiln technology shows signs of progress, while the introduction of EVs will take much more time. 

The crop residue programme, meanwhile, included a stick and a carrot. The stick was a ban on stubble burning, punishable by fines of $170 for offenders. The carrot was the offer of new generation “Super Seeder” machines subsidised by 65%. 

Despite the smoggy skies over Lahore,  Health Policy Watch conversations with Punjab farmers and experts suggest that the new “Super Seeder” technology shows some promise, although its benefits won’t be reaped this season.   

Happy Seeders didn’t work well

Hamza Cheema sits atop his conventional tractor – which he uses to clear rice stubble. He’s waiting to see how the Super Seeder performs.

The SuperSeeders represent an upgrade from first-generation “Happy Seeders” – which were introduced in Pakistan a decade ago, but never really took off. 

Speaking with Health Policy Watch, Hamza Cheema, a farmer from Wazirabad District, around 150 kilometres north of Lahore, explained why. 

“I tried the Happy Seeder once as well, but the [wheat] seeds often remain on the surface rather than going deep into the wet soil. That yields a poor wheat crop,” he explained.

The Super Seeder’s new features address this by plunging the seed deep in the earth.

But even with the generous subsidies offered on new machines, they remain a hefty purchase  and farmers like Cheema are still waiting to see how they perform over time. 

“It softens the soil, making it easier to plant seeds deep into the ground and removes the rice straw residue, but I have not used it because it costs around $5000 USD (PKR 1. 5 million) to purchase,” he said. 

While many of his neighbors still prefer to pay the fines for crop-burning, imposed by government regulators, Cheema’s farm of about 100 acres lies adjacent to a forest, which he doesn’t own but still cherishes, and he fears that smoke would harm the tree cover. 

“So I continue to level the rice stalks on my land by plowing them under with a tractor,” said Cheema. Even though that process, followed by seeding, is time-consuming. 

Super Seeders: cost remains a barrier 

Super Seeders – upgraded machine yielding better results.

About 200 kilometres south-west of Lahore, farmer, Dilawar Khan Rath was an early adopter of the new Super Seeder, and he’s happy with the results despite the investment it required. 

Rath, who farms about 125 acres, purchased his machine in 2023. He believes that the investment will pay off in the long-term, in terms of field operations. The machine mixes the stubble into the soil, which helps increase the fertility of the land- as compared to crop-burning, which depletes soil fertility.

“It also saves time, as a single pass is required for land preparation, fertiliser placement, and seed sowing,” Rath explained.

The machine’s expense makes it feasible largely for larger landholders. As the owner of 125 acres of fertile land, he falls into that category but could just about afford the investment. 

Maintenance costs are high because trained technicians are not widely available and fuel consumption is also significant. 

However, if the government reduced the interest rates on purchase loans and launching a leasing programme through local farm councils, the machines would catch on much more widely, he asserts. 

“The Punjab government is providing Super Seeders on subsidy, which is a good initiative, but their numbers are limited,” Rath said.

Meanwhile, Rath is also conscious of the health and environmental benefits of using Super Seeders. Smog remains a serious problem in his district .

Super Seeders: not the only solution 

Vaqar Zakriya

Indeed, the Punjab government intends to launch a leasing programme for the new machines, according to the office of Punjab’s Chief Minister. 

“There are 300 Super Seeders in the whole of Punjab, and the government is adding 1,000 more, with a total of 5,000 to be added over the next five years,” said a statement by Chief Minister Nawaz. The price of purchasing a machine outright will be set at $1,800 – with the remaining $2,800 covered by the government.   

“Public cooperation is essential to eliminate smog,” she added.

While pollution from burning crop residue is indeed an issue, it should also not be seen as the primary cause of environmental pollution, Vaqar Zakaria, an environmental activist, told Health Policy Watch.  

He said that there remains a lack of data, overall, on the contribution of crop-burning to Punjab’s overall pollution load. 

“This technology has helped address the issue of residue burning for farmers, but that the current focus should be on increasing its availability to reach more farmers,” Pakistan’s former Federal Minister for Climate Change, Malik Amin Aslam, told Health Policy Watch in an interview. 

He noted that the Super Seeder technology was in fact first introduced three years ago by the previous government – and since then it has gained significant popularity among farmers, resulting in a notable reduction in residue burning in Punjab.

But regional dialogue and data exchange is also essential to tackle smog effectively – as East Asian countries did successfully, he stressed.

“Only through data sharing and regional cooperation, can this issue be managed, adding that he believes India might be willing to participate in such efforts.”

Image Credits: Punjab Enviornment Department, IQ Air , YouTube/Business Recorder , Rahul Basharat, Engro Energy.

Sudanese women, many of whom became leaders of the 2019 revolution, are being targeted by soldiers using rape as a weapon of war.

Rape is common across Africa yet inadequate laws, weak implementation and cultural barriers mean that many perpetrators go unpunished, according to new research by Equality Now.

“After examining rape laws across Africa, it is clear that to end impunity for perpetrators, governments urgently need to carry out comprehensive legal reform of rape laws, strengthen enforcement mechanisms, and improve access to justice and support for survivors,” said Jean Paul Murunga, a human rights lawyer and the report’s lead author. 

The report looked at rape laws and their enforcement in 47 African countries with an in-depth analysis of nine of these: Cameroon,  Democratic Republic of Congo, Madagascar, Rwanda, Senegal, Sierra Leone, South Africa, South Sudan, and Zambia.

Equality Now Africa Director Faiza Jama Mohamed says that the report identifies “key gaps in rape law that result in routine denial of justice to survivors of sexual violence”. 

“The gaps include laws allowing the perpetrator to walk free on reaching some form of ‘settlement’, including marrying the victim; laws framed in terms of morality rather than bodily integrity, thereby perpetuating a cycle of violence and discrimination; laws that explicitly permit rape in marriage, even of children,” notes Mohamed, writing in the foreword of the report.

Narrow definition of rape

Approximately 33% of women in Africa have experienced intimate partner violence or sexual violence in their lifetime, while in West, East, Central, and Southern Africa, the rate 44%, according to UN Women.

The African Development Bank’s Gender Data Index 2019 reported that intimate partner sexual or physical violence ranges from 10% to 40% across the continen

“It is critical for its definitions in the various jurisdictions within Africa, both in the context of conflict and peace, to be clear and based on human rights standards,” adds the report.

Rape is when a person has not given voluntary, genuine, and willing consent for sexual interaction – and that this consent can be withdrawn anytime during the interaction.

“True consent is impossible in situations of dependency or extreme vulnerability, for example, in educational settings, correctional facilities, or when a victim is incapacitated, such as being intoxicated or infirm,” according to the report.

Several countries’ definitions of rape or legal frameworks fail to recognise all forms of unwanted sexual penetration (anal, oral, or vaginal by use of any body part or object) as rape .

Some 25 African countries have penal codes that are “incomplete or ambiguous and do not meet international standards” by, for example, confining the definition to acts of violence and failing to recognise rape involving intimidation, coercion, fraud, and unequal power dynamics. 

Marital rape not recognised

Justice for rape survivors

Cote D’Ivoire, Gambia, Seychelles, Equatorial Guinea, Ethiopia and South Sudan do not criminalise marital rape. South Sudan explicitly notes that non-consensual sexual intercourse within marriage does not constitute rape. 

The Penal Code of Côte d’Ivoire provides for the presumption of married couples’ consent to the sexual act unless proven otherwise. 

Eritrea only criminalize marital rape when spouses are not living together, while Tanzania criminalizes it if the couple is not living together. Lesotho recognises marital rape under certain conditions.

In Gabon, where child marriage is legal, if an abductor has married an abducted minor, he can only be prosecuted after the marriage is annulled.

“International human rights standards require states to criminalise all forms of rape, irrespective of the relationship between the perpetrator and their victim,” says Murunga. 

“Failing to specifically criminalise marital rape ignores how consent must be ongoing and freely given, regardless of marital status. Legal recognition provides clarity to law enforcement, prosecutors, and judges that marital rape must be treated as a serious crime and prosecuted accordingly.”

Harmful traditional beliefs

Although 20 African countries have consent-based definitions of rape, rapists are often shielded by traditional beliefs and societal attitudes towards sex. 

“Rape survivors and their families frequently face stigma, victim-blaming, and threats. This is commonly accompanied by pressure to remain silent, withdraw criminal complaints, and settle cases out-of-court through informal community mediation,” according to the report.

In Equatorial Guinea, for example, out-of-court settlements are legally permitted when a rape victim explicitly or tacitly forgives the perpetrator. 

This often results in rape survivors being pressurised to agree to this route.

In several countries, officials opt not to investigate, prosecute, or convict rape cases unless there is physical evidence, especially which indicates a victim fought back. 

“Many jurisdictions emphasize force, morality, or circumstances and apply gender-discriminatory concepts such as ‘honour’ and ‘modesty’. This prejudices judgments over victims’ behavior and “chastity” and whether they are perceived as deserving justice for having been raped,” the report notes.

Rape survivors and their families frequently face stigma, victim-blaming, and threats. This is commonly accompanied by pressure to remain silent, withdraw criminal complaints, and settle cases out-of-court through informal community mediation. 

Inadequate punishment

Sudanese women wait for treatment at Fashir Reproductive health centre. Many women are pregnant as a result of being raped during the conflict.

The African Commission on Human and People’s Rights recommends 16 years imprisonment for rape, but many countries have thresholds well below this. 

In Equatorial Guinea, Article 429 of the Criminal Code states that “rape of a woman shall be punished with minor confinement.

Guinea Bissau includes an exemption where ‘the behavior of the victim has considerably contributed” to the rape.

Even where not elaborated in the law, settlements with respect to rape are reportedly common in Benin, Cameroon, Chad, Côte d’Ivoire, The Gambia, Ghana, Guinea, Liberia, Nigeria and South Sudan.

In South Africa, there is a serious backlog of rape cases and insufficient funding for the justice delivery system. In May 2022, the Minister of Justice announced that only 19% of reported cases were going through the courts.

With the breakdown of the rule of law and security in conflicts, women and girls are rmore vulerable. In addition, rape is still being used as “a weapon of war to denigrate, disempower, demoralize and destroy communities”, the report notes. 

During conflict, reporting cases, collecting evidence and prosecution are often huge challenges.

Providing justice to survivors of sexual violence and ensuring perpetrators do not enjoy impunity is critical in preventing and addressing rape

With so many legal, procedural, and societal obstacles to addressing rape, very few cases make it to court, and even fewer result in conviction.

Urgent reform 

Urgent reform is needed to ensure legal definitions of rape encompass all acts of non-consensual sexual penetration, with no exceptions for marital rape, according to the report.

It also calls for adequate training of government officials to ensure laws are implemented and other measures including a register of sex offenders. 

“Effective legal implementation is equally crucial, requiring robust mechanisms to enforce justice and hold perpetrators accountable. Transparency and accountability are essential to building trust and ensuring fairness in how cases are handled,” the report notes.

It advocates for supportive systems for rape survivors that” facilitate healing and enable them to pursue justice if they choose”

Rwanda is highlighted as a positive example for promoting a “victim-centered approach to investigating and prosecuting sexual violence cases” that includes .gender-based violence recovery centers in numerous districts, providing survivors with witness protection, medical and psychosocial support, and legal aid.

Image Credits: CC, Mohamed Zakaria/ UNICEF.

Ambassador John Nkengasong, head of PEPFAR.

As a political appointee, Ambassador John Nkengasong, head of the US President’s Emergency Plan for AIDS Relief (PEPFAR), said that he will be obliged to resign when President-elect Donald Trump is inaugurated on 20 January.

“The rules that govern a transition are that all the political appointees have to resign on the 20th and then their resignation is either accepted or they are asked to stay,” Nkengasong told a Global Fund media briefing on Monday.

However, he stressed that PEPFAR has been a bipartisan programme since its inception in 2003 when it was launched by Republican President George W Bush.

“It has since enjoyed the support of all administrations,” said Nkengasong, the US Global AIDS Coordinator in the Bureau of Health Security and Diplomacy.

Nkengasong was appointed by President Joe Biden, confirmed by the US Senate in May 2022, and he started work the following month. 

PEPFAR achievements 2024
PEPFAR’s achievements by 2024.

Nkengasong is a Cameronian-born US citizen, who first attracted global attention as the first head of the Africa Centres for Disease Control and Prevention (Africa CDC), where he led the continent’s response to the COVID-19 pandemic. Prior to that, he had worked for the US Centers for Disease Control and Prevention, as well as at the World Health Organization. 

“We should always think about PEPFAR, not the individual – 26 million lives saved over the last 21 years,” Nkengasong stressed at the briefing, although his re-appointment prospects are regarded as slim.

“PEPFAR was reauthorised [by the US Congress] for one year last year. That reauthorisation expires in March, and we are hoping that we’ll get a clean five-year reauthorisation going forward,” he added.

But this may not be plain sailing. PEPFAR has come under attack from US and African conservatives who claim – incorrectly – that some aid recipients are promoting abortion. This is why the programme only received a one-year extension rather than the usual five years.

Trump has made cutting government spending and opposing abortion cornerstones of his election campaign, which does not augur well for the campaign to end AIDS by 2030.

HIV money is drying up

HIV is incurable but thanks to antiretroviral (ARV) drugs, it has become a controllable chronic disease and if people living with the virus have an undetectable viral load, they don’t transmit HIV.

As many as 25 million people depend on PEPFAR and the Global Fund to subsidise their ARVs, which they need to take for life. 

Yet money is drying up. About 60% of the HIV response is paid by domestic finances, and this fell for the fourth consecutive year, with a 6% drop in 2023. Meanwhile, donor resources for HIV dropped by 5%, UNAIDS Deputy Director Christine Stegling told the briefing.

UNAIDS deputy director Christine Stegling.

Global Fund executive director Peter Sands said that global overseas development assistance is under pressure, and health has lost its “prime spot” to both climate change and conflict.

“There is a particular issue with funding for HIV/ AIDS, which is that we run the risk of being a victim of our own success. Because the number of people dying has dropped so much, and because HIV/ AIDS is no longer seen as that much of a threat in donor nations themselves, it’s dropped off the radar screen and seems like an old problem; one that’s largely won or gone away,” said Sands.

“But HIV is a formidable adversary. We are nowhere near getting a vaccine, and we don’t have a cure for it yet.”

But the single-minded focus on eliminating HIV has made “extraordinary progress”, Sands added.

“AIDS-related deaths have come down by 51% since 2010 and more than three-quarters of people living with HIV are on treatment, but we still have another nine million people not on treatment and we still have 1.3 million new infections each year,” according to Stegling.

Shift to domestic financing

Economist Professor Dean Jamison, co-chair of the Lancet Commission on investing in health, says it is unlikely that for a better response to funding HIV globally. 

“So that does put greater emphasis on a transition to domestic finance where the reliance has been substantially on donors. It’s not to say that the external finance is likely to go away and then there won’t be important additions to that. I would be looking to parts of Asia for external finance, but on the domestic side, what are the range of options?” asked Jamison, who is an emeritus professor of Global Health Financing at UCSF, UCLA and the University of Washington.

Poor countries would prioritise HIV spending, likely focusing on preventive interventions and treatment. Drawing on private resources, perhaps through payroll taxes, may also be a solution.

Professor Dean Jamison

Stegling singled out debt, low economic growth and insufficient revenue as the main obstacles to domestic financing for HIV.

“Last year in GDP term, Sierra Leone spent 15 times more on public debt servicing than on health. Chad spent 12 times more on debt servicing than on health,” she noted.

Meanwhile, sub-Saharan Africa loses about $80 billion in uncollected tax revenue.

Debt relief, future financing at affordable rates and better tax revenue collection are the solutions UNAIDS is focusing on.

“These are the issues of the future that we need to look into if we’re talking about self reliance, more resilient systems for health that are financed by countries, by every country themselves,” Stegling noted.

With South Africa being the chair of the G20 next year, she sees “an amazing opportunity” for African leadership debt restructuring and different financing mechanisms. 

What lies ahead?

Stegling says donors are likely to move into “gaps”, such as human rights protections for particular marginalized groups that might not immediately find support from their governments.

Meanwhile, Nkengasong stressed that progress should not be confused with success.

“The progress that we have made is very fragile,” Nkengasong stressed.

PEPFAR did an analysis of 10 to 12 high-burden countries that it supports and found that, to maintain their programmes if PEPFAR was unable to fund them would result in debt risk increasing by 400 percentage point,.

“Are we ready to live with this? We pride ourselves with the success we’ve made over the last 25 years or so against HIV. But the response to HIV is extremely fragile. It’s extremely fragile because it requires that the millions of people that are receiving treatment receive that treatment every day.

“We cannot afford to leave them behind. If we do that, the billions that we’ve put into the fight against HIV AIDS will be completely wasted.”

Image Credits: US State Department.