In the latest episode of Trailblazers with Garry, Garry Aslanyan visits Accra, Ghana, to speak with Professor John Owusu Gyapong, Secretary General of the African Research Universities Alliance.

Gyapong took on the role in 2024, leading efforts to strengthen research collaboration across African universities. His work focusses on building capacity within the continent and supporting locally driven research agendas.

Earlier in his career, when much of global health funding and attention centred on malaria, Gyapong chose to study neglected tropical diseases. These illnesses, he explains, had major social and economic consequences but received far less attention.

Now, as a researcher and educator, Gyapong continues to emphasise the importance of African-led solutions and long-term investment in young scientists. The conversation touches on leadership, research priorities, and why universities play a critical role in shaping Africa’s health future.

Watch the full episode:

Trailblazers with Garry is part of Global Health Matters. Listen to more Global Health Matters shows on Health Policy Watch.

Image Credits: Global Health Matters Podcast.

Rice University’s Harris Eyre in the Davos Alzheimer’s Collaborative ‘Brain House’ describing new  brain capital and brain economy initiatives launched at the 2026 World Economic Forum.

A new initiative that aims to measure and promote the inclusion of  “brain capital” as an economic indicator was launched at the World Economic Forum in Davos last week.  Advocates for the Global Brain Economy initiative, and a companion Global Brain Capital Index argue that using brain health as a development indicator can help spur more awareness and investments in brain health – including dementia related diseases that now rank as the seventh largest cause of death worldwide.  

The discussions, hosted by the Davos Alzheimer’s Collaborative (DAC), marked what several speakers described as a turning point: a shift from viewing brain health primarily as a cost to seeing it as an investable economic asset — one with implications for productivity, resilience, innovation, and long-term growth.

With the launch of the Global Brain Capital Index and the Global Brain Economy Initiative, leaders from economics, neuroscience, policy, and finance argued that recognizing — and monetizing — “brain capital” may be essential to unlocking investment in brain health across the life course, from early development to healthy aging and dementia prevention.

Projected growth curve for dementia risks and deaths 0 from 0.56 million in 1990 to nearly 5 million annually in 2030.

From Idea to Global Movement

The concept of the “brain economy” has evolved rapidly from academic theory to policy and investment agenda, said Harris Eyre. A professor at Rice University and the University of Texas Medical Branch, and a leading member of DAC, he framed the launch moment as the culmination of years of work. 

“We’ve really hit a crescendo point,” Eyre said.  Referring to the newly released flagship report, The Human Advantage: Stronger Brains in the Age of AI, published by the World Economic Forum and McKinsey Health Institute, he noted its resonance across Davos.

“We have a lot of different global challenges, a lot of big macro challenges. But here you can see… that brain challenges are very significant across the lifespan, from the earliest stage of life through to late life.”

Those challenges include early-life malnutrition and stunted development, youth mental health, workforce disruption driven by artificial intelligence, and rising rates of dementia in ageing populations.

“The cost of brain health conditions across the lifespan… is $3.5 trillion to the global economy, and the cost is rising at 3% a year,” Eyre said.

Introducing brain capital

Brain Capital concept

At the heart of the Davos discussions was the concept of brain capital, defined as the combined value of brain health and brain skills.

“Brain capital is the new paradigm here,” Eyre said. “It’s human capital 2.0 — human capital in the age of neuroscience.”

He stressed that brain capital spans mental health, neurological health, cognitive skills, emotional resilience, creativity, and learning — and that these capacities are now more critical than ever.

“Our brains are just so important now than ever before,” he said. “The accelerations of change are so high, we need brain health. We need brain skills.”

Eyre argued that advances in neuroscience, reduced stigma around mental health and dementia, and growing awareness of neurodiversity have created a unique opportunity.

“If you remember one thing today,” he told the audience, “is remember brain capital.”

Dialogues at Davos with global health leaders around the new initiative included conversations with: Bill Gates, WHO Director General Tedros Adhanom Ghebreyesus, and Wellcome’s John-Arne Røttingen, among others, Eyre said.

Brain Capital Index – a new development indicator

Rym Ayadi, president of the Euro-Mediterranean Economists Association, describes the new ‘Brain Capital’ index launched at Davos.

That call for recognition was matched with a new measurement tool unveiled in Davos; the full report was published just this week. 

Called the Global Brain Capital Index, it establishes a set of standardized indicators for measuring brain capital, in the form of brain health and brain skills, across countries and globally. 

The new index was developed by the economist Rym Ayadi, President of the Euro-Mediterranean Economists Association (EMEA).

“Brain capital was a concept,” Ayadi said. “And nowadays I can say to you… it can be measured at national level.”

Ayadi described the index as a response to what she called a blind spot in traditional economic frameworks.

 

Brain health and brain skills are the two main pillars of the brain capital index – with “enablers” as a third important influence in overall outcomes.

“GDP is very quantity-based. It’s not quality-based,” she said. “Brain health was a residual. It’s a cost. But brain health nowadays should be [seen as] infrastructure, an asset. It’s not a cost — it’s an investment.”

The new index brings together over 28 indicators on brain health, brain skills, and enabling environments — the latter includes the quality of education, health systems, governance, and environmental risks, like air pollution, which has now been link clearly to dementia as well as to other forms of cognitive impairment.  The 28 core indicators were derived from a larger collection of 106 indicators, available on an interactive Brain Capital Dashboard, and selected through a systematic process as the best composite measure of trends. 

“It is really a strategic tool, a compass for economic policy thinking going forward,” Ayadi said of the index.

Decline in brain health seen worldwide

A decline in brain health as a component of the brain capital index is seen across countries and regions.

Drawing on data from 1990 onwards, the findings presented in Davos revealed troubling global trends.

“We can see an increase overall in brain health since the 90s, but then there is an overall decline, and this decline is persistent in all countries of the world,” Ayadi said. “So something is wrong here.”

The trend of brain health decline is seen across both OECD and non-OECD countries. And there is also a “huge inequality between OECD and non-OECD countries,” Ayadi said. “And if we don’t really act, it becomes even worse.”

Non-communicable diseases and dementia in focus

Tau tangle proteins in the brain
Abnormal accumulation of amyloid plaques and tau proteins in the brain, are the two hallmarks of Alzheimer’s – the latter forming tangles in neurons, seen here.

Speakers linked the brain health declines to the growing burden of non-communicable diseases, particularly neurological and mental health conditions.

“For the brain health indicators, for example, we have burden of disease, prevalence of depression, suicide rate… Alzheimer’s disease and other dementia, Parkinson’s disease, schizophrenia, stroke, bipolar,” Ayadi said.

Population ageing, combined with underinvestment in brain health, are other contributing factors.

“Brain health overall is under global strain,” she said. “Driven by population aging, raising mental health burdens and cumulative economic and health stressors.”

Despite the scale of the challenge, Ayadi noted that brain health remains systematically underfunded.

“Despite the economic importance, brain health remains systematically underfunded and under integrated into policy framework,” she said.

Brain skills improvements offset brain health declines  

Consideration of brain skills as part of the index provides a more hopeful picture. This includes skills’ indicators, like level of education or the rate of innovation, Ayadi said. Skills indicators, as such, are still rising in many parts of the world, including in low income countries -even if the disparities are huge.

Brain skill indicators such as educational level or the pace of innovation are still rising in many countries, countering negative trends in brain health.

But even when those enablers are considered, the composite trends in many parts of the world, including high and lower-income regions, still reflects worrying signs of stagnation or decline, she underlined – reflecting the way the decline in brain health can ‘drag down’ progress overall. 

Evolution of composite brain capital index including enablers. More positive trends in brain skills and related enablers, like education and health infrastructure, offset declines in brain health.

From measurement to investment

The central argument emerging from Davos was that measurement enables monetisation of risks and benefits to brain health and brain capital. Consequently, monetizing brain capital could unlock large-scale investment in prevention, care, and skills development.

“If, in fact, we are able to measure, and we are able to govern, we can… finance,” Ayadi said. “And then it becomes in the economic and financial system.”

This idea resonated strongly with investors and business leaders attending the sessions.

Steve Carnevale, moderator of the DAC session and himself a venture capitalist, reflected on the power of quantification:

“When we can quantify something that previously wasn’t quantifiable, and when we can quantify it, we can turn it into a growth story,” Carnevale said. “That’s when people are really going to follow us.”

Toward a ‘brain-positive’ economy

The Davos discussions also signal a broader rethinking of development indicators. Gross Domestic Product (GDP) continues to be the dominant indicator of socio-economic development. While this has been under challenge by academics for sometime, GDP’s binary nature is even more out of date in the age of AI, panelists argued. 

“Brain health has to become a priority within our national policies, and also brain skills. This index could be a new policy compass beyond GDP,” Ayadi argued, saying that development indicators need to shift “from quantity-based skills into neurocognitive assets… and from growth to resilience.”

Along with that, the new brain economy initiative launched at Davos aims to spur policymakers from theory to action, Eyre said. 

The initiative focusses on safeguarding brain health, fostering brain skills, investing with a “brain lens,” and mobilizing public-private partnerships.

“We need brain lens investing to sit above global financial architecture – and channel it towards brain positive investments.”

Added Drew Holzapfel DAC COO, “Brain health has long been treated primarily as a health issue, which it is. But when it’s understood as an economic issue, it opens the door to more resources and a broader, more sustained commitment. What we have the opportunity to do is take the concept of brain capital and translate it into something that focuses the minds of finance ministers.”

Brain capital all the more important in AI era 

DAC founder George Vradenburg opening the panel on brain capital and the brain economy at a WEF side event in Davos last week.

Recognizing the importance of brain health and brain capital is all the more critical in the age of fast-evolving AI systems – so that humans can keep abreast of these changes – and benefit from them – rather than the reverse, said George Vradenburg, founder of the Davos Alzheimer’s Collaborative, and convenor of the Davos session.  

“We need to be referring to AI as Augmented Intelligence and not Artificial Intelligence,” Vradenburg said. 

At a “Davos wrap” webinar this week, hosted by EMEA, Lucy Pérez, global leader of the McKinsey Health Institute, underlined the critical moment faced. 

“There’s no more urgent time to invest in brain capital than right now,” Pérez said. “The demographic shifts that we’re experiencing, the geopolitical shocks, the economic shocks, the way technology is impacting not only the workplace, but also our daily lives.”

But its the opportunity – as compared to the threat – that policymakers need to appreciate: 

“Scaling existing brain interventions already is going to unlock over $6 trillion in economic opportunity,” Pérez said. “And that’s with innovation we already have in hand.”

Image Credits: DigitalRalph, Journal of Prevention of Alzheimer’s Disease, August 2024.  , EMEA, 2026, National Institutes on Aging .

A baby in Rwanda receives a combined measles and rubella vaccine. 

The US government has frozen funds to Gavi, the global vaccine alliance, until it commits to a plan to phase out the preservative thimerosal from all the vaccines it distributes.

The US demand, first reported by Reuters, is linked to the unproven belief held by US Health and Human Services (HHS) Secretary Robert F Kennedy Jr and allies that thimerosal, which contains mercury, is linked to autism.

However, even the US Food and Drug Administration has pronounced that “thimerosal has been the subject of numerous studies and has a long record of safe and effective use preventing bacterial and fungal contamination of vaccines, with no ill effects established other than minor local reactions at the site of injection.” 

The FDA also notes that a vaccine with 0.01% thimerosal as a preservative contains “roughly the same amount of elemental mercury [as] contained in a three-ounce can of tuna fish”.

Around 14% of Gavi’s vaccines contain thimerosal, which is used in some multi-dose vials to destroy any bacteria and fungi that may enter a vial each time a new dose is drawn.

Multi-dose vaccines are used in many low- and middle-income countries as they are cheaper.

Affected Gavi vaccines include the five-in-one pentavalent vaccine (Diphtheria, Pertussis , Tetanus, Hepatitis B and Haemophilus influenzae type b), the Diphtheria, Pertussis and Tetanus (DPT) vaccine, Tetanus-Reduced Diphtheria (Td), Hepatitis B, Meningococcal A Conjugate (MenA) and Pneumococcal Conjugate Vaccine (PCV).

Most US vaccines do not contain thimerosal, while it is seldom found in Europe, which relies mainly on single-dose vaccines.

Scientific consensus

“We received a request from the US government to remove thimerosal from our portfolio. We remain in contact on this subject,” a Gavi spokesperson told Health Policy Watch.

“While we very much hope to find a pathway to welcoming the US back as a donor, any decision related to Gavi’s portfolio would require a decision by Gavi’s Board and input from preceding governance committees, which will be guided by scientific consensus.”

Hanging in the balance is some $300 million already allocated by the Biden administration but not yet paid, as well as any new funds.

All Gavi-supported vaccines have to be recommended by the World Health Organisation’s (WHO) Strategic Advisory Group of Experts (SAGE), an independent body that examines all available scientific evidence and issues global guidance on the use of vaccines.  

In addition, each manufacturing site where Gavi-supported vaccines are produced must be approved or “pre-qualified” by WHO.

Gavi-supported vaccines must also be recommended by the National Immunisation Technical Advisory Group (NITAG) in each country where they are being used. Most Gavi-supported countries also require vaccines to be approved by their own National Regulatory Authorities (NRAs), in addition to WHO approvals.

In June last year, Kennedy told Gavi that the US would withhold funds until it “re-earned the public trust”, claiming that it had “ignored vaccine safety”. The US recently lost its seat on the Gavi board as it has failed to pledge any funds to it.

Image Credits: Twitter: @WHOAFRO, WHO.

Kenyan women at a family planning clinic.

Global health organisations have reacted with anger to the new US foreign aid policy, which prohibits all aid recipients, bar military, from performing or promoting abortion, “gender ideology”, or “diversity, equity and inclusion” (DEI).

“Catastrophic”, “bullying”, “draconian” and “ideologically driven” – are some of their reactions to the Promoting Human Flourishing in Foreign Assistance (PHFFA) policy, announced by US Vice-President JD Vance at an anti-abortion event last Friday evening.

The policy’s three parts were published in the Federal Register on Tuesday as Protecting Life in Foreign Assistance, Combating Gender Ideology in Foreign Assistance and Combating Discriminatory Equity Ideology in Foreign Assistance Rules.

The new rules apply to all foreign and US NGOs and “international organisations”, including multilateral UN agencies still funded by the US and bodies such as the Global Fund to Fight AIDS, TB and Malaria.

However, in countries that allow abortion, governments and parastatals (government agencies) will need to place any US funds in “a segregated account” to ensure they’re not used for abortions and related activities.

Governments and parastatals “may” also be required to agree that they won’t use US funds to promote or engage in “gender ideology” or DEI.

The US State Department defines “gender ideology” activities as those that provide or promote “sex rejecting procedures” (defined broadly to include puberty blockers, hormones, surgeries); promote or counsel social transition; use materials that discuss changing one’s sex or pronoun usage not aligned with biological sex; lobby foreign governments on gender identity issues; and support drag queen workshops, performances, or similar activities”.

Aid recipients are also compelled to agree to US officials visiting their offices unannounced to inspect their documents and activities, and to speak to people receiving their services. This is potentially a violation of patient confidentiality.

Imposing ‘extremist ideology’

Since 1984, successive Republican governments have imposed a “Global Gag Rule” (also known as the Mexico City Policy) on foreign NGOs receiving global health aid, barring them from using this money – or even money they have raised from other sources – for any abortion-related activities, including referrals.

However, the second Trump administration is the first to extend this to all non-military foreign assistance, including humanitarian assistance, and to widen the scope to include US NGOs, international organisations and – potentially – governments.

“Bullying countries into complying with anti-rights and extremist ideology is despicable and unacceptable. The imperialist goals of this administration are on full display in these conditions to foreign assistance,” Anu Kumar, CEO of the global reproductive justice organisation, Ipas, told a media briefing this week.

In 2024, $39.8 billion in US foreign aid was dispensed over 160 countries, with the largest share (41%) going to multilateral agencies, according to KFF.

“This is tens of billions more than the amount of global health assistance subject to the policy under the first Trump administration’s previously expanded policy ($7.3 billion in 2020),” notes KFF.

This “catastrophic expansion” is going to be especially harmful to “women, young people, girls and LGBTQI+ people”, added Ipas senior researcher Jamie Vernaelde.

“There is an agenda here from the US government to push these ideologies across to other countries, both through direct government-to-government funding, but also forcing multilateral organisations to be subject to the ideology of one specific country.”

Impact on Kenya

The bilateral Memorandums of Understanding (MOU) that the US has signed with 15 African countries as part of its “America First Global Health Strategy” all contain a clause compelling countries to comply with the Global Gag Rule.

“What we’ve realised is this inclusion of the Global Gag Rule in the MOUs was basically a Trojan horse, in the sense that now the governments have signed, they are obligated to implement these expanded conditions, for example, on gender ideology,” said Ipas’s Kenya director, Dr Musoba Kitui.

Kitui said that 40,000 health workers had already lost their jobs in his country since the closure of the US Agency for International Development (USAID), leading to the “weakening of the health system”.

Many African governments “are very, very desperate” to inject resources into their health systems since the closure of USAID, and were willing to sign bilateral MOUs with the US, despite some of the unfavourable conditions, said Kitui.

Kenya’s MOU would be complex to implement, and there is “no way the US can monitor compliance without seeing patient records,” added Kitui, highlighting a concern about patient privacy which has resulted in the MOU being challenged in court.

However, “this MOU grants US personnel diplomatic immunity, insulating them from any local courts against judicial processes for any violations of data privacy, or even crippling the health system for that matter”, he added.

“Sexual and reproductive health is not a diplomatic bargaining chip. It’s a fundamental human right. Essential health care services must be separate from political agendas. What is really important is to protect the progress that we have made over the years, including in countries like Kenya,” Kitui stressed.

Impact on humanitarian aid

South Sudanese women survivors of violence shared their stories with a visiting UN delegation. The narrow redefinition of US global aid will affect survivors of gender-based violence who need access to rape kits and emergency contraception.

Dr Jean-Claude Mulunda, who heads Ipas work in the Democratic Republic of Congo (DRC), said that his organisation assisted displaced people in camps with family planning services, abortion care and also supports survivors of gender-based violence (GBV). 

With the demise of USAID, “rape kits” for GBV survivors containing medicine to protect women and girls against sexually transmitted infections and pregnancy are no longer available.

“Ipas is trying, with our limited funds, to buy unit-by-unit, the different medicines in these kits,” said Mulunda. “Many women who are victims of rape can’t access abortion care, even though the country has signed the Maputo Protocol which allows access to abortion in case of rape.” 

The more onerous aid conditions are going to make it even harder for displaced women to access sexual and reproductive services.

“The risk of unsafe abortion is elevated in humanitarian settings where it’s even harder for people to access medical services,” warned Médecins Sans Frontières (MSF) in its reaction to the new policy.

“In 2023, MSF provided more than 31,000 consultations for post-abortion care, most of which were due to complications related to unsafe abortion. With the reinstatement of the Global Gag Rule, MSF expects these already troubling numbers to increase.”

The new policy, PHFFA, “escalates a pattern established across both Trump administrations: the systematic subordination of scientific evidence and patient needs to ideological and political objectives,” added MSF. 

“Versions of the Global Gag Rule have been introduced by Republican administrations since 1984, and extensive research has repeatedly documented that the policy disrupts health services and causes cascading adverse health outcomes in low- and middle-income countries, with the chilling impact enduring even when the policy has been rescinded,” MSF noted.

MSF added that the State Department’s definitions of “gender ideology” and “discriminatory equity ideology” are so broad “that it is likely to result in barring or limiting access to essential health services for LGBTQIA+ individuals, women and girls, racial and ethnic minorities, and other marginalized groups”. 

‘Abdication of decency’

US Vice President JD Vance addressing the March for Life last Friday, where he announced the new policy.

“President Trump and his anti-abortion administration would rather let people starve to death in the wake of famine and war than let anyone in the world get an abortion – or even receive information about it,” said Rachana Desai Martin, chief US program officer at the Center for Reproductive Rights. 

“People are already dying because of this administration’s slashing of foreign assistance. Now, they’re making it harder for doctors and aid workers to provide food, water, and lifesaving medical care. This isn’t about saving lives – it’s a stunning abdication of basic human decency,” Martin added.

“Trump’s expansion [of the Global Gag Rule] continues on a path of instrumentalising those most marginalised. It marks increasing attempts to capture global health and human rights with a deeply regressive act of imperialism masquerading as foreign policy,” said Mina Barling, International Planned Parenthood Federation’s global director of external relations. 

“This is yet another attack on national sovereignty and colonial intervention through the curtailing of sexual and reproductive rights.”

“The dismantling of USAID has already caused widespread harm: more than 45 million women and girls have lost access to contraceptive care and clinics around the world have been forced to close,” said Marieke van der Plas, executive director of the Dutch reproductive rights organisation, Rutgers.

“Now, the Trump administration is further reshaping global health policy through new government agreements that embed ideological conditions and deepen political control.”

The Senate Foreign Relations Democrats said in a statement: “By blocking US funding to any entity that does not conform to his extreme ideological agenda, the administration is exporting MAGA culture wars overseas and turning lifesaving aid into a political tool. 

“This order goes far beyond anything we’ve seen before. It will shrink global resources to fight disease, respond to humanitarian crises and protect women and girls from violence, while forcing many of our trusted partners to shut their doors or betray their missions. In doing so, it also leaves Americans more vulnerable to infectious diseases and health threats that do not respect borders.”

Image Credits: saac Billy/ UN Photo, KFF.

Flagship UN report finds irreversible damage to global water systems affects three-quarters of the global population, threatens food security and thrusts the world into a new era of the water crisis.

The world has entered the era of “global water bankruptcy” as water systems relied on by six billion people, and half of the world’s food production, are pushed beyond the point of recovery, a United Nations (UN) report has found.

The report marks the first time UN scientists have declared water systems “bankrupt” rather than “stressed or “in crisis”, a distinction that denotes irreversible damage to natural water systems, as opposed to acute, time-limited shortages due to factors like weather, high demand or economic shocks.

“This report tells an uncomfortable truth: many regions are living beyond their hydrological means, and many critical water systems are already bankrupt,” said Kaveh Madani, director of the UN University’s Institute for Water, Environment and Health and lead author of the report.

“If we continue to manage these failures as temporary crises with short-term fixes, we will only deepen the ecological damage and fuel social conflicts,” Madani said. “We must act because water bankruptcy is a justice and security issue. The cost of the hydrological overshoot that the world is facing falls disproportionately on those who can least afford it.”

The UN report arrived ahead of high-level meetings in Dakar, Senegal, this week to prepare the agenda for the 2026 UN Water Conference, set for December in the UAE. It calls on member states to formally recognise water bankruptcy, establish global monitoring frameworks and position water investments as fundamental to achieving climate, biodiversity and food security targets.

This year’s summit is only the second major international meeting on water governance this century, following a 2023 summit at UN headquarters in New York. The only other global water conference in history was held in Mar del Plata, Argentina, in 1977.

“Declaring bankruptcy is not about giving up, it is about starting fresh. By acknowledging the reality of water bankruptcy, we can finally make the hard choices that will protect people, economies, and ecosystems,” Madani said. “The longer we delay, the deeper the deficit grows.”

‘Day Zero’ threatens major cities

The world’s third largest lake, the Aral Sea, lying between Kazakhstan and Uzbekistan in 1989 (left) and in 2025 (right).

The UN report draws on satellite data, hydrological modelling and over 300 case studies to document the scale of water loss.

More than half of the world’s large lakes have lost water since the early 1990s, over 30% of glacier mass since 1970 has disappeared in certain regions, while about 410 million hectares of natural wetlands—a land mass nearly equal to that of the European Union—have been destroyed over the past five decades.

“Surface waters are shrinking. Those are our checking accounts that get renewed every year, that nature is kind enough and generous enough to deposit some budget, give us some income,” Madani explained. “It is normal to go to the savings account and buy resilience for the dry years. But what we are seeing around the world is that the savings accounts are also draining – we are exhausting them.”

The Middle East, North Africa, South Asian and parts of the American Southwest face the most severe threat as high water stress collides with extreme vulnerability to climate change. Over 1.42 billion people, including 450 million children, already live in conditions of high or extremely high water vulnerability, according to UN Water data.

Water scarcity has been a major driver of public outrage at Iran’s regime throughout the recent wave of protests. After six years of drought, reservoirs around its capital, Tehran, are on the brink of the next “Day Zero” event. / Satellite image: Institute for the Study of War.

For some of the world’s largest cities, the crisis has already arrived. Metropolises around the globe, from Cape Town to Sao Paolo and Tehran, have already faced their first “Day Zero” emergencies – events where water supplies for a city are near complete depletion. Kabul, meanwhile, is on the brink of becoming the first major city globally to run out of water.

While cities survived, these first “Day Zero” events are warning shots, and many – particularly the urban poor – continue to live with the consequences, the UN warned.

“Emergency measures—severe restrictions, tariff changes, rapid drilling of new wells, reliance on tanker supplies, and behavioural campaigns—helped some cities narrowly avoid a complete shutdown of taps,” the report found.

“Yet in many of these places, the underlying aquifers, reservoirs and catchments remain degraded, and poorer neighbourhoods continue to live with intermittent service, tanker dependence, and high water costs long after the media attention has moved on.” 

Half the world’s 100 largest cities experience high water stress, while 38 – including Beijing, New York, Delhi, Los Angeles and Rio de Janeiro – face “extremely high stress” levels, according to a separate analysis published by Watershed Investigations this week.

Another study published this year by the University of Utrecht, analysing 21 global water scarcity hot spots, found that hydroclimatic change – long-term changes in water cycles driven by climate change – was cited in 49% of case studies, but typically was not the sole driver of scarcity, operating alongside population growth (31% of cases), agricultural overuse (77%), industrial demand (30%) and municipal consumption (46%).

Disease and displacement

Water access is a fundamental determinant of health, yet nearly 2.2 billion people lack safely managed drinking water, while 3.5 billion lack safely managed sanitation, according to WHO figures. 

These gaps expose populations to cholera, typhoid, polio, dysentery, hepatitis A and diarrhoea. Waterborne diseases and inadequate water supplies kill an estimated 3.5 million people annually, according to UN Water. WHO research estimates that 900 children under five per day die from diarrheal diseases caused by unsafe water.  That is one child every two minutes, adding up to 328,500 deaths every year.

About four billion people—nearly two-thirds of the global population—face severe water scarcity for at least one month every year, forcing communities to use water contaminated with agricultural runoff, industrial waste and untreated sewage for basic health activities such as handwashing and bathing. This amplifies the breeding grounds for infectious waterborne disease spread and raises risks of poisoning from chemicals like lead or arsenic.

Water scarcity also drives displacement, which cascades into health crises as populations move into areas with inadequate sanitation, limited healthcare and overcrowded conditions that accelerate health risks. Over 700 million people are projected to be displaced by water scarcity by 2030, according to UNICEF.

“Bankruptcy management requires honesty, courage, and political will,” Madani said. “We cannot rebuild vanished glaciers or reinflate acutely compacted aquifers. But we can prevent further loss of our remaining natural capital, and redesign institutions to live within new hydrological limits.”

Water-driven conflicts rise

Water-related violence has nearly doubled since 2022, rising from 235 incidents to 419 in 2024, according to Water Conflict Chronology, a database updated this week by the Pacific Institute that tracks water-driven violence throughout history.

The dataset contains 2,757 conflicts dating back to a dispute in ancient Sumeria over water and irrigation that led to nearly a century of war in 2500BC. The latest incident added documents of residents punching and beating firefighters in Manila, Philippines, blaming them for a lack of water.

Water has increasingly been a target in major wars, despite Article 54 of the Geneva Convention classifying attacks or destruction of water infrastructure or supplies necessary for civilian survival as a war crime.

Recent examples include Israel’s systematic destruction of Gaza’s water systems and desalination plants, Russia targeting hydropower dams in Ukraine, and tensions over the Indus River treaty between India and Pakistan, the report found.

Water Conflict Chronology’s tracker lists nearly 3,000 wars over water since 2500BC.

Oxfam’s water security lead, Joanna Trevor, told the Guardian that her team has observed “an increase in localised conflicts over water due to climate change and water insecurity” as competition for dwindling reserves intensifies.

“In East Africa and the Sahel, water is becoming increasingly insecure, and people are moving into new areas to access water, which in itself can trigger competition and conflict with the host population,” Trevor said.

UNICEF estimates that by 2040, roughly one in four children—about 450 million—will live in areas of extremely high water stress.

“Water bankruptcy is becoming a driver of fragility, displacement and conflict,” said Tshilidzi Marwala, UN Under-Secretary-General. “Managing it fairly is now central to maintaining peace, stability and social cohesion.”

Food systems dry up

Total freshwater withdrawals for agriculture, industry and domestic uses across the globe from 1900 to 2010.

Three billion people and more than half of global food production are concentrated in areas where total water storage is already declining or unstable, according to the report.

With agriculture accounting for an estimated 72% of global freshwater withdrawals, the report’s concern is echoed by recent research by the World Resources Institute (WRI), which found 25% of the world’s crops are grown in areas where water supply is highly stressed or unreliable.

“One out of every 11 people in the world grapples with hunger,” WRI found. “A hidden and growing driver is lack of water.”

As water stress soars, the world will need to produce 56% more food calories in 2050 than it did in 2010 to feed a projected population boom to 10 billion people.

Yet current production is already under threat: one-third of rice, wheat and corn produced globally—which provide more than half of global food calories—is grown in water-stressed regions, while irrigation water demand is forecast to increase 16% over the next two decades due to warming temperatures, according to WRI.

“We need to decouple growth from water,” Madani said. “We need to move away from the asumption that economic prosperit requires ever-increasing water withdrawals – the problem that has got us in this situation.”

Just 10 countries produce 72% of the world’s irrigated crops, with two-thirds of that production facing high to extremely high water stress. India, the world’s largest rice exporter, is losing up to 30 centimeters of groundwater per year in some regions, with depletion rates projected to triple by 2080.

Over 170 million hectares of irrigated cropland—equivalent to the combined land area of France, Spain, Germany and Italy—are under high or very high water stress. An additional 106 million hectares have been degraded by salinisation, the UN report found.

“Millions of farmers are trying to grow more food from shrinking, polluted or disappearing water sources,” Madani said. “Without rapid transitions toward water-smart agriculture, water bankruptcy will spread rapidly.”

“Despite its warnings, the report is not a statement of hopelessness,” he concluded. “It is a call for honesty, realism, and transformation.”

Image Credits: Art Poskanzer, Institute for the Study of War , Pacific Institute.

WHO flags
The US accused the WHO of “holding hostage” the American flag that once flew outside the Organization’s Geneva headquarters (seen here in 2025).

A dispute over an American flag has become symbolic of the bitter public dispute between the US and the World Health Organization (WHO) after the US withdrew from the organization on 22 January.

In a joint statement by Secretary of State Marco Rubio and Secretary of Health and Human Services Robert F Kennedy Jr on the termination of US membership of the WHO, they accused the organization of keeping the American flag that hung outside its Geneva headquarters captive.

“Even on our way out of the organization, the WHO tarnished and trashed everything that America has done for it. The WHO refuses to hand over the American flag that hung in front of it, arguing it has not approved our withdrawal and, in fact, claims that we owe it compensation. From our days as its primary founder, primary financial backer, and primary champion until now, our final day, the insults to America continue.

“We will get our flag back for the Americans who died alone in nursing homes, the small businesses devastated by WHO-driven restrictions, and the American lives shattered by this organization’s inactivity,” the statement said.

A day after the official withdrawal, the State Department declared victory, posting: “Under @POTUS leadership, the @StateDept and @HHSGov have secured its return, now safely held by U.S. Marines @usmissiongeneva, and on its way back to USA.”

The dispute over the flag underscores broader and long-simmering tensions between the Trump administration and the WHO, particularly over the Organization’s handling of the COVID-19 pandemic.

US still owes WHO $260.6 million

The US’s highest-ranking health officials, including National Institutes of Health director Dr Jay Bhattacharya, rose to prominence during the pandemic for their criticism of COVID-19 policies, tapping into widespread public anger over restrictions, school closures, and vaccine mandates.

In the view of current US leadership, the WHO is an organization “beyond repair.”

Instead, the Trump administration has begun pursuing a series of bilateral agreements with 14 sub-Saharan African countries, aiming to recreate aspects of the WHO’s multilateral system for pooling scientific and public health data.

But according to global health policy experts at Georgetown University, Sam Halabi and Lawrence O Gostin, this “transactional alternative” assumes that the US could strike comparable agreements with nearly every country in the world – “which of course it cannot,” they wrote in a commentary published in the Washington Post.

The WHO is expected to discuss how to address the US withdrawal at its upcoming Executive Board meetings on 2 February and again at the annual World Health Assembly in May. The organization also maintains that the US owes $260.6 million in unpaid membership dues.

WHO says withdrawal makes US and world ‘less safe’

WHO Director General Dr Tedros Adhanom Ghebreyesus at a press briefing in Geneva. Tedros defended the Organization’s COVID-19 response.

The WHO responded to the US’s accusations on Saturday, saying that “[w]hile no organization or government got everything right, WHO stands by its response to this unprecedented global health crisis. Throughout the pandemic, WHO acted quickly, shared all information it had rapidly and transparently with the world, and advised Member States on the basis of the best available evidence.”

WHO Director General Dr Tedros Adhanom Ghebreyesus echoed the sentiment, saying: “While WHO recommended the use of masks, physical distancing and vaccines, WHO did not recommend governments to mandate the use of masks or vaccines and never recommended lockdowns. 

“WHO supported sovereign governments with technical advice and guidance that was developed on the basis of evolving evidence on COVID-19 for them to make policy decisions in the best interests of their citizens. Each government made their own decisions, based on their needs and circumstances.”

The WHO pointed to the US’s global participation in some of the world’s greatest public health achievements, despite the fact that the US promises to continue “leading the world in public health” without collaborating with the UN organization. 

“As a founding member of the World Health Organization, the United States of America has contributed significantly to many of WHO’s greatest achievements, including the eradication of smallpox, and progress against many other public health threats including polio, HIV, Ebola, influenza, tuberculosis, malaria, neglected tropical diseases, antimicrobial resistance, food safety and more.

“WHO therefore regrets the United States’ notification of withdrawal from WHO – a decision that makes both the United States and the world less safe.”

This story is a continuation of Health Policy Watch’s coverage of the US-WHO withdrawal. See related stories here:

Stars and Stripes No Longer Flying at WHO – But US Can’t Really Leave Until Dues are Paid, Agency Says

America First is Not America Absent

 

Image Credits: Arkansas Advocate , E. Fletcher/Health Policy Watch.

Healthcare workers
The mission to ensure safe, effective and affordable diagnostics, therapeutics and vaccines (DTVs) within 100 days of a pandemic threat being identified is not possible in many regions, according to the International Pandemic Preparedness Secretariat.

Global pandemic preparedness is becoming “increasingly fragile at a time of growing biosecurity and geopolitical risk”, according to the International Pandemic Preparedness Secretariat (IPPS), which launched its Fifth Implementation Report of the 100 Days Mission on Tuesday.

IPPS is an independent entity that promotes the “100 Days Mission”, the global ambition to develop safe, effective and affordable diagnostics, therapeutics and vaccines (DTVs) within 100 days of a pandemic threat being identified. 

But pressure on global R&D pipelines, declining investment in pandemic countermeasures, and heavy reliance on a small number of funders mean that the 100-day target is not possible in many areas, according to the report.

“Major reductions in global health and research budgets in 2025 have exposed structural vulnerabilities, disrupted development pipelines, and weakened preparedness,” the IPPS notes in a media release.

“Investment in pandemic countermeasure R&D continued to decline through 2024, with the steepest impacts seen in therapeutics. Pipelines across diagnostics, therapeutics and vaccines remain uneven and clustered in early stages, with limited progression into mid-stage and late-stage development. 

“Progress on enabling systems, including regulatory preparedness, clinical trial readiness, data-sharing frameworks and manufacturing coordination, remains slow,” the media release notes.

Outbreaks of mpox,  a continental health emergency in Africa until last week; the zoonotic spillover risk of H5N1; and outbreaks of Ebola, Marburg, Rift Valley Fever and Chikungunya “have highlighted persistent challenges in early detection, coordination and equitable access to countermeasures”, according to the IPPS, which is funded by the Wellcome Trust and Gates Foundation

“The science needed to respond faster to pandemics continues to advance, but this report makes clear that progress in applying these advances to delivering effective tools is insufficient,” said Dr Mona Nemer, chair of the IPPS Steering Group and Chief Science Adviser of Canada.

“Today, despite the landmark WHO Pandemic Agreement, the world remains vulnerable to funding shocks, uncoordinated R&D efforts and fragile development pipelines – particularly for therapeutics.”

Priorities for 2026

For the first time, the 100-day scorecard includes an assessment of pandemic preparedness and response (PPR) capacity in Africa. 

This evaluates the continent’s capabilities in clinical trials, laboratory systems, regulatory frameworks and manufacturing.

“Advances in platform technologies, including mRNA, monoclonal antibodies and artificial intelligence, continue to offer opportunities to accelerate development,” according to the report, which also identifies “significant pressures”.

However, it notes that Africa shows “growing regulatory maturity and manufacturing capability”. It highlights Rwanda’s integration of the 100 Days Mission framework and scorecard into national preparedness planning as an example of how the mission can be operationalised at the country level.

The report, launched in Paris, identifies 2026 as a decisive year as France begins its G7 presidency.

It  identifies four priority action areas for 2026:

  • Operationalising the Therapeutics Development Coalition to address persistent gaps in antiviral R&D.
  • Enhancing coordination across the diagnostics ecosystem and implementing recommendations from the Global Diagnostics Gap Assessment.
  • Sustaining vaccine investment and strengthening alignment across diagnostics, therapeutics and vaccines.
  • Agreeing on a sustainable mechanism for pandemic preparedness monitoring, including a long-term path for the 100 Days Mission Scorecard beyond the IPPS mandate(which ends in 2027).

 

 

Image Credits: PREZODE , Photo by Carlos Magno on Unsplash.

WHO member states at an Intergovernmental Working Group meeting, negotiating a pathogen access and benefit-sharing (PABS) system.

Only 12 more negotiating days remain until WHO member states hit the May 2026 deadline for an agreement on a Pathogen Access and Benefit Sharing (PABS) system, as part of the new Pandemic Agreement adopted at last year’s World Health Assembly (WHA). 

The gap between developed and developing blocs of countries remains large, and progress has been slow in bridging the divide. A bloc of approximately 100 low-and middle-income countries (LMICs) continues to call for mandatory benefit sharing, including guaranteed LMIC access to vaccines, therapeutics, and diagnostics (VTDs) as the price of their rapid sharing of information on novel pathogens that might pose a pandemic risk.  

High-income countries, on the other hand, remain focused on protecting the pharma innovation ecosystem and ensuring open pharma access to pathogen sequence data. In terms of benefit-sharing, they tend to favor more flexible and voluntary commitments by manufacturers and research institutions to share products and manufacturing know-how with LMICs. 

While some elements of the PABS might actually be settled in time for adoption at  this year’s 79th WHA (18-23 May), other issues are likely to be kicked further down the road, potentially to a future Pandemic Agreement Conference of Parties (COP).  

In the seventh issue of the Governing Pandemics Snapshot, Daniela Morich dissects the choices facing member states.

Longstanding tension between rapid pathogen sharing and access to benefits

Cheers among the lead negotiators as the World Health Assembly adopts the Pandemic Agreement, 20 May 2025

On 20 May 2025, the global health community welcomed the adoption of the Pandemic Agreement (PA) as a much-needed triumph of multilateralism in a year marked by significant challenges and strains on global cooperation.

Although adopted, the Agreement will not be opened for signature until a supplementary Annex on the Pathogen Access and Benefit Sharing (PABS) system is completed—an uncommon feature in international law that temporarily halts the Agreement’s progress toward entry into force until the details of the Annex are agreed.

At the core of the Annex lies a longstanding tension: how to ensure rapid and reliable sharing of pathogens and their genetic sequence data – crucial for managing health emergencies and for the development of health products – while also guaranteeing fair and meaningful access to the benefits derived from their use, such as vaccines and therapeutics.  

Article 12 of the PA sets out the foundational principles of the PABS system. But the specifics – such as the recognition of obligations for countries and manufacturers, benefit-sharing arrangements, and implementation mechanisms – remain to be negotiated. An ad hoc Intergovernmental Working Group (IGWG), open to all WHO member states, has been tasked with translating these principles into operational rules.

Wide divide from the start

Ethiopia representing the position of the Africa group during pandemic agreement negotiations in March 2024.

The IGWG officially began its work in mid-2025. In August, WHO Member States submitted 17 textual proposals reflecting the views of approximately 100 countries. These proposals revealed, from the outset, deep divergences in how countries imagine the PABS System, and those differences have continued to shape the negotiations ever since.  

Developing countries advocate for strong equity provisions, including mandatory benefit-sharing and guaranteed access to vaccines, therapeutics, and diagnostics (VTDs). Their approach relies on transparency and traceability, with a strong role for WHO in administering the system and oversight by a future Conference of the Parties (COP).

Developing country blocs also have placed a greater emphasis  on technology transfer, and as part of that, licensing of medicines and vaccines as core benefits they should reap from the PABS agreement. As such, their proposals prioritize binding obligations operationalized through contractual mechanisms to ensure traceability and enforceability of commitments and to support the development of regional production capacity.

Consistent with this approach, the leading LMIC negotiating blocs, known as the Africa Group and the Group for Equity, as well as Egypt, Libya, Somalia and Sudan jointly submitted an ad hoc proposal for draft contractual agreements for negotiation (see Adam Strobeyko’s piece Avoiding Contract Fatalism.).

High-income countries, by contrast, focus on protecting the innovation ecosystem, maintaining open access to pathogen sequence data, and preserving incentives for private-sector research and development, which is still mainly happening in the Global North.

With regards to benefit-sharing obligations, they tend to favor voluntary and flexible commitments for manufacturers and research institutions. Their concern is that overly rigid obligations could undermine scientific collaboration or discourage investment in pandemic-related technologies.

First draft text does not bridge divides

IGWG3 gets underway on 4 November 2025.

In October 2025, the IGWG’s Bureau, a six-person panel steering the negotiations, released the first Draft Text of the Annex ahead of the Group’s third meeting. Although the text drew significant criticism from many delegations, it nonetheless became the basis for negotiations during the two subsequent meetings in November and December.

Progress was extraordinarily slow. Delegations used the sessions not to narrow differences but to reinsert the language they considered had been omitted from the Bureau’s proposal. As a result, the document expanded from seven pages to 37, producing a dense and unwieldy “rolling text” in which every proposal reappeared.

The only areas where common ground emerged were a few preliminary words on governance elements, notably that the COP would oversee the PABS System and that a PABS Advisory Group would be created.

Following calls for more transparency in the proceedings, the second IGWG meeting marked a surprising shift by deciding, on a pilot basis, to invite stakeholders to observe discussions starting at IGWG3 in November 2025. 

However, this openness was quickly revoked at the beginning of IGWG3, with no access to the negotiating room granted to observers. Further constraints on meaningful participation were introduced in January 2026, when participation was limited to virtual attendance. It is hoped that greater transparency will be allowed as the process moves forward.

Revising the Draft: Gains Limited to Pathogen Definition

The fourth session of the IGWG made some progress in clarifying the definition of a pathogen with pandemic potential. Here, a microscopic view of  SARS-COV-2. 

In the fourth resumed session of the IGWG (20–22 January 2026), progress remained slow. The Bureau, following regular intersessional informal meetings, released a revised draft text.

Some advancement was seen in clarifying language on the definition of “pathogen with pandemic potential,” an important step in defining the system’s scope, but little progress was made elsewhere in the text. Despite a generally positive mood in the room, the ticking clock reinforced a sense of urgency. Progress in bridging the divides continues to be painfully slow.

A small but highly engaged group of relevant stakeholders continues to follow the process closely, although it remains state-led and conducted behind closed doors. Interaction with delegates is limited to short briefings led by the Bureau and is restricted to stakeholders duly accredited to the process.

Are we nearing the finish line?

With the May 2026 deadline approaching – and only 12 actual negotiation days remaining – clear divergences between blocs of countries remain a significant obstacle. 

Additionally, while some issues—such as laboratory networks, databases, and traceability—have been discussed, other critical topics, including financing, have yet to be meaningfully addressed, as highlighted by Suerie Moon in her companion article “Could money grease the wheels of compromise on PABS?”

Against the ticking clock, an overarching  question now looms: which elements of the PABS  parties might be willing to settle now –  and which they might further kick down the road to a future Pandemic Agreement’s COP.

Problematically, these negotiations also unfold against the backdrop of a spate of US  bilateral agreements with  developing countries – so far 15 in all. In these arrangements, seen as a cornerstone of the new US global health policy, aid and commercial deals are offered in exchange for access to pathogen samples and data about disease outbreaks. 

Some experts worry that these deals will negatively affect the negotiations in Geneva, and the future PABS systems, as they could create structural dependency that constrains a country’s ability to share data independently with regional or WHO-coordinated networks.

With only a few months remaining, parties will need to be realistic about what can be achieved. Successfully concluding this work would consolidate years of effort and strengthen the foundations of a more equitable global pandemic preparedness and response system.

Daniela Morich is head of policy engagement and Global Health Platform at the Geneva Graduate Institute’s Global Health Centre.

Explore the three other articles available in the seventh issue of the Governing Pandemics Snapshot:

In  “Avoiding Contractual Fatalism: Lessons from PIP Framework for Standardising PABS contracts” Adam Strobeyko looks at how the experience of the Pandemic Influence Preparedness (PIP) Framework could help inform the PABS process. He examines WHO contracts that enable pharma access to a global network of influenza samples in exchange for benefit-sharing commitments channelled through WHO.

In PABS laboratory networks: building a new system or using what we have? Gian Luca Burci examines whether existing WHO-managed networks, such as the Global Influenza Surveillance and Response System (GISRS), could take on the additional role of a PABS laboratory network, presuming an agreement is reached.

Finally, in her piece, Could money grease the wheels of compromise on PABS? Suerie Moon explores how finance for Access and Benefit Sharing (ABS) could be generated in “interpandemic” times when the absence of a clear pandemic threat provides limited incentive to pharma companies to invest in related products. 

Image Credits: NIAID-RML .

Women are being taught how to access information about contraception on their smartphones in Indonesia. The UN’s Universal Periodic Review (UPR) provides an avenue for human rights activists to advocate for more rights for citizens.

Grassroots organising, using the United Nations’ Universal Periodic Review (UPR) and creating new multilateral coordination are some of the ways to counter the current attack on sexual and reproductive health (SRH), according to activists.

There is a “rise of unapologetic, unabashed, hegemonic masculinity and really harmful gender stereotypes,” Paola Salwan Daher, Women Deliver’s senior director for collective action, told a webinar on the anti-rights pushback.

Far-right governments “are bringing the message that women should not have the same rights as men,” and tech billionaires “have put their incommensurable wealth behind this”, she added.

“We are seeing deeply biased misinformation around women’s bodies, around women’s health, and the undermining of women and girls’ agency.”

To counter what she describes as “Conservative International”, Women Deliver is convening a global gender equality conference in April to enable like-minded organisations “to meet each other to strategise together”. 

“We are organising to push forward a more progressive agenda that really centres the autonomy, the rights to dignity for women and girls,” she said.

Salwan Daher added that the current “crisis of multilateralism doesn’t come from nowhere”.

“It has been exacerbated by the postures of the Trump administration, but really, it was brewing before. It was brewing because of double standards in the application of international law. The genocide in Palestine has really exposed the fault lines,” said Salwan Daher.

“We do not want a world without multilateralism. So now is the time to reimagine collectively what multilateral can look like. How do we make it people-centred? How do we make accountability at the root of everything, every process and every global space? How do we ensure the legal obligations of states?”

Abortion taboo

Pauline Fernandez, coordinator of the Philippines Safe Abortion Advocacy Network (PINSAN), said that despite her country having one of the harshest laws against abortion, there was growing recognition of the need to decriminalise abortion.

“Despite it being criminalised, abortion remains a widespread and urgent reality in the Philippines,” said Frenandez.

“Data shows that upwards of a million women undergo abortions annually, and because of abortion-related complications, up to three women die every day in the Philippines.”

Sustained organising about the importance of decriminalisation had seen PINSAN to her grow from 10 to 130 organisations.

Over 30,000 people have signed PINSAN’s petitionin support of decriminalisation, helped by a recent Netflix documentary on the subject by a famous local filmmaker.

Regular reviews

Dr Virginia Kamowa, regional and country manager at the Global Center for Health Diplomacy and Inclusion (CeHDI), which co-hosted the event, said that the Universal Periodic Review UPR) provides a lever to ensure better SRH services.

“The UPR is the only mechanism of UN that reviews every country on a regular cycle against the human rights obligations of the governments, and produces a public on-the-record government commitment,” explained Kamowa.

“More and more recommendations have been on health,” she said, adding that aroung 82% of health recommendations were accepted by the country being reviewed.

Improving maternal health involved many aspects of SRH, she noted.

Rwanda was reviewed last week, while the reviews of St Lucia, Namibia, Mozambique, Somalia, Seychelles, Sierra Leone and Eswatini are imminent.

“All 193 UN member states undergo a UPR. There’s a national report that is written by the government within the country, but also the UN bodies within the country that also do their own population and stakeholder research, civil society, NGOs and human rights institutions also compile their summary reports.

“During the process, other states ask questions and make recommendations to the country that is being reviewed, and the reviewed country can accept or not those recommendations, and then there is follow up in the next cycle of the UPR review.”

Image Credits: ©Gates Foundation/ Prashant Panjiar.

Stars and stripes lowered at WHO headquarters.

One year after the United States announced its withdrawal from the World Health Organization, a former WHO Headquarters Staff Association President reflects on how presence, governance, and leadership shape influence in global health.

In January 2024, I stood before the WHO’s Executive Board, chaired by Qatar’s Minister of Health, Dr. Hanan Mohammed Al Kuwari. I was speaking as an elected staff member representing more than 10,000 staff across the WHO and its partner agencies. When I opened my remarks by honoring a colleague killed in Gaza, the room, filled with health delegates from 194 member states, fell silent. Across political lines, delegates expressed empathy.

That moment reminded me that global health cooperation does not run on treaties or budgets alone. It is held together by trust, the fragile belief that even adversaries can remain in the same room long enough to cooperate on what keeps people alive.

I did not set out to work in global health. I began my career at a New York investment bank. During the pandemic, I helped lead launch preparations for a COVID-19 therapeutic and saw American leadership at its best through Operation Warp Speed.

I joined the WHO to work on vaccine supply equity so that, in the next pandemic, access and supply chains don’t break along geopolitical lines.  I eventually reported to a senior Chinese official who had risen through the ranks at headquarters. We were supposed to be adversaries. My Taiwanese heritage and American upbringing placed me in a rivalry I did not choose. Yet she treated me with professionalism and fairness. Over time, we built trust and found common ground on expanding access to essential medicines.  But trust is only half the equation. The other half is presence.

America pays, others decide

WHO Director General Dr Tedros Adhanom Ghebreyesus and his senior leadership meet with the WHO Headquarters Staff Association in Geneva in March 2024.

The United States has historically been the WHO’s largest funder contributing roughly 18% to the annual budget through a combination of assessed fees and voluntary donations. Yet Americans are chronically underrepresented in the professional workforce. 

According to the latest workforce data to be presented at the 158th session of the Executive Board in early February, U.S. citizens continue to hold roughly 7% of professional positions.  The European region holds about one in three professional posts, more than four times America’s representation. This influence gap runs to the top. No American has ever served as Director-General. For years, Washington has tried to influence the organization from outside through press releases and funding threats. In these institutions, indignation is noise. Seats are power.

I learned this first hand when headquarters staff elected me President of the Staff Association of WHO’s headquarters, representing about 3000 staff in Geneva as well as HQ-managed offices in Japan, New York City, Budapest, Lyon, Berlin and Tunis. It was a role that put me regularly in the room with Director-General Tedros Adhanom Ghebreyesus and senior leadership. Institutions like the WHO rarely change because they are denounced from afar. They change because people stay in the process long enough to turn criticism into votes, rules and resolutions.

Downsizing Is Not Accountability

WHO
WHO Director General Dr Tedros Adhanom Ghebreyesus meets with staff association presidents for WHO’s African, European and South-East Asian regions and Headquarters (Liu), in Lyon in December 2024.

None of this requires romanticizing the WHO.

It is a glacial bureaucracy. Last year, leadership launched one of the largest downsizings in its history, announcing plans to cut roughly a quarter of the workforce by June 2026, in a massive restructuring exercise. But making an institution smaller is not the same as making it accountable. Thousands of front-line staff were terminated while a shadow workforce of consultants remained. This narrowed a roughly $1.7 billion funding gap without changing how power is exercised or decisions are made and enforced.

The finality of the US decision, and its inevitable budget impacts, began to permeate in December 2024, shortly after the US Presidential elections.

On 17 December WHO leadership gathered in Lyon, France, with President Emmanuel Macron for the opening of the new WHO Academy. The setting was elegant. It felt like a toast raised on the proverbial cruise ship deck while someone, somewhere, had already spotted  the iceberg. Yet the music played on.

In the afternoon session, the mood shifted.  Dr. Tedros paused and said quietly, “Let’s give them a peaceful holiday.” Shortly afterward, WHO staff were told they would receive two additional days of leave. It was a kind gesture, and also a telling one. The calm before the storm. By then, those of us who had been in Lyon knew the die was already cast – the US would withdraw on Day 1 or Day 2 of President-elect Donald Trump’s second term in the White House.  On Inauguration day, 20 January 2025, the announcement was made.

Navigating the Rupture: Beijing’s Opportunity in America’s Absence

China speaks at the February 2025 WHO Executive Board meeting. The US largely abstained from participating following January’s announcement of its withdrawal.

The United States withdraws largely alone. Except for Argentina,  every other WHO member state has chosen to remain. And in fact, for historical reasons there is no real legal provision allowing WHO member states to withdraw, with the exception of the United States. 

With the next Director-General election approaching in 2027, leadership choices and reform priorities are being shaped by those still present. The question is whether American absence makes China’s influence easier, or harder, to counter.

We have seen this before. In 2019, China ran a disciplined campaign to win the top job at the United Nations Food and Agriculture Organization (FAO). U.S. officials were caught off guard. “It made us look like complete fools,” one State Department official was later quoted as saying. This is not about relitigating 2019. It is about not repeating the same mistake.

In May 2025, Beijing arrived at the World Health Assembly with about 180 officials, according to press and delegate accounts, and announced a $500 million pledge to the organization. Washington sent no delegation. Taiwan was again blocked by WHA member states from being granted observer status, this time without visible resistance.

Winning the 2027 Director-General election is an even bigger strategic prize. The organization that sets global health standards and coordinates pandemic response is an asset Beijing will pursue with patience. The groundwork is being laid now, while the United States steps away.

Reform Requires Presence

Countries indicating their wish to speak about the pandemic agreement in Committee A, just prior to a vote approving the agreeement.

So who wins when America leaves? It is a Catch-22.

US Secretary of State Marco Rubio and Secretary of Health and Human Services Robert F Kennedy Jr have been clear that the United States should no longer write blank checks to international bureaucracies that lack accountability. 

As Rubio recently put it, “sometimes true leadership means knowing when to walk away.” Demanding results is not retreat. It is a leadership responsibility, some critics of continued engagement might say.

They raise a fair point. Staying only works if reform and cooperation are possible. 

But in global health, they are – if and only if U.S. leadership is present. Allies do not follow a country that leaves the room. They follow one that shows up with a plan. The world is not waiting for us. It is waiting for someone to lead.

What Re-engagement Would Require

WHO’s 78th World Health Assembly meets at Geneva’s Palais des Nations 19-27 May, 2025.

If Washington really wants a more effective and accountable WHO, the pathway to getting that is clear and concrete.

Reengage with conditions tied to transparency and governance. Align representation with contribution by rebuilding the American professional pipeline. Place American experts where technical norms and standards are written.

Demand enforceable oversight, not cosmetic restructuring. Work with our allies on the Executive Board to advance a serious reform agenda. Reinvigorate WHO’s technical expertise as a truly merit-based organization that recruits and hires the most qualified staff at all levels transparently and internationally – and not through fixed appointments, political favoritism, or over-reliance on consultants who just happen to be living in relatively close proximity to Geneva. Deliver a genuine reset, not just headlines.

Make WHO great again.

The Way Forward: Leadership is a Choice

World Health Assembly member state delegates pose with WHO Director General Tedros after a critical HA Committee vote adopting the Pandemic Agreeemnt on 20 May 2025.


Today, the American flag no longer flies at WHO headquarters. That absence is visible to every delegation, every staff member, and every government navigating the institution that remains.

The Pandemic Agreement is moving forward, and the campaign to elect a new WHO Director-General in 2027, when Tedros’ second term ends, is already underway. WHO will evolve with or without the United States. Even Dr. Tedros has described U.S. withdrawal as a “lose-lose.” On that point, he is right.

America First cannot mean America absent. While our stars and stripes have come down, the threats to our health, security, and sovereignty have only gone up. I remain hopeful that one day our flag can fly again over an institution worthy of American taxpayers’ support and the American people’s trust. Leadership has always been a choice, and we the American people can make it again: to lead as one Nation, indivisible, with peace, strength, and the accountability our citizens deserve.

Christina Liu

Christina Liu served at WHO from 2022 to 2025 as a technical officer on vaccines and access to medicines. She was the President of WHO Headquarters Staff Association from 2024-2025.

A US citizen and native of California, she is currently a Board Advisor for Global Public Health at BioLiterate.  She has over 18 years of experience spanning global health, international policy and in the pharmaceutical industry, including with Roche and Novartis. Liu holds a dual Masters in Biotechnology/MBA from The Wharton School and the University of Pennsylvania.  

Image Credits: Anonymous/HPW, Christina Liu, WHO, WHO/Pierre Albo .