141Nuclear use. Every new arsenal is a decision center Washington can't reach---and it cascades.
Panda, Narang and Vaddi 25 — Ankit Panda, Vipin Narang and Pranay Vaddi. March 10. Stanton senior fellow in the Nuclear Policy Program at the Carnegie Endowment for International Peace. Frank Stanton professor of nuclear security and political science at MIT; served as acting assistant secretary of defense responsible for nuclear deterrence policy. Senior nuclear fellow at MIT’s Center for Nuclear Security Policy; served as senior director for arms control, disarmament, and nonproliferation on the National Security Council. War on the Rocks, “Nuclear Proliferation Will Haunt ‘America First’,” https://warontherocks.com/nuclear-proliferation-will-haunt-america-first/ Clopus
Second, even with friendly countries that might successfully proliferate, the actions they take after acquiring nuclear weapons may force Washington to intervene in crises or wars against its own interests. For instance, an ally may force a U.S. president to step in and prevent dangerous nuclear signaling or use, as has been the case in the past with the United Kingdom, France, and Israel in 1956 ; Israel in 1973 ; and India and Pakistan after 1998 .
A newly emboldened but still weaker nuclear-armed ally or partner may try to provoke a major U.S. adversary, pulling the United States into a crisis as a mediator, or worse. With more nuclear-armed states, the intersection of crises that may implicate U.S. interests with nuclear weapons uncontrolled by Washington becomes far more likely. In a world of reduced U.S. influence on multiple, skittish new nuclear decision-making centers in Asia, the Middle East, Africa, or elsewhere, states are less likely to consider Washington’s opinion before engaging in nuclear threat-making — or use — to address local grievances or right historical wrongs.
This would hardly serve an ‘America First’ world. The potential for metastasizing nuclear crises assuredly contradict the goal of the “ strategic prioritization ” that former and incoming officials support.
In addition to diminishing American power, further proliferation anywhere — especially by prosperous, democratic allies of the United States, like South Korea — is likely to beget further proliferation everywhere. While some U.S. officials may be comfortable with a nuclear South Korea, they should ask whether they are comfortable with all that may follow in total — such as Japan, Taiwan, Poland, Saudi Arabia, all supporters of today’s nonproliferation regime. Should this dam break, the United States’ relative power and influence stands to decline. And Trump’s dreams of a denuclearization pact with Russia and China will be completely out of reach in a world where multiple new nuclear aspirants emerge. Keeping ‘America First’ in that world becomes a lot more challenging. Keeping nuclear use from occurring, and potentially embroiling the United States, an ally, or other economic partner in a conflict, becomes much more unpredictable.
142Global catastrophe. Backsliding is the accelerant---the states holding the weapons stop bargaining.
Science and Security Board 26 — Bulletin of the Atomic Scientists Science and Security Board, edited by John Mecklin. January 27. A select group of globally recognized leaders with a specific focus on nuclear risk, climate change, and disruptive technologies; sets the Doomsday Clock in consultation with the Bulletin’s Board of Sponsors, which includes eight Nobel laureates. Bulletin of the Atomic Scientists, “2026 Doomsday Clock Statement,” https://thebulletin.org/doomsday-clock/2026-statement/ Clopus publisher refuses automated retrieval---body spot-checked verbatim against the Wayback snapshot
The increasing sophistication of large language models and their applications in critical processes—coupled with lingering concerns about their accuracy and tendency to “hallucinate”—have generated significant public debate over the past year about the potential risks of artificial intelligence. The United States, Russia and China are incorporating AI across their defense sectors, despite the potential dangers of such moves. In the United States, the Trump administration has revoked a previous executive order on AI safety, reflecting a dangerous prioritization of innovation over safety. And the AI revolution has the potential to accelerate the existing chaos and dysfunction in the world’s information ecosystem, supercharging mis- and disinformation campaigns and undermining the fact-based public discussions required to address urgent major threats like nuclear war, pandemics, and climate change.
These dangerous trends are accompanied by another development that undermines efforts to deal with major global threats: the rise of nationalistic autocracy in countries around the world, including in a number of countries that possess nuclear weapons. Leaders of the United States, Russia, and China greatly vary in their autocratic leanings, but they all have approaches to international relations that favor grandiosity and competition over diplomacy and cooperation. The rise of autocracies is not in itself an existential threat, but an us-versus-them, zero-sum approach increases the risk of global catastrophe. The current autocratic trend impedes international cooperation, reduces accountability, and acts as a threat accelerant, making dangerous nuclear, climatic, and technological threats all the harder to reverse.
143Contagion is real---soldiers read the precedent next door and act on it.
Powell et al. 16 — Jonathan Powell, Trace Lasley and Rebecca Schiel. School of Humanities and Social Sciences, Nazarbayev University; University of Kentucky; University of Kentucky. Studies in Comparative International Development, “Combating Coups d’état in Africa, 1950–2014,” https://jonathanmpowell.com/wp-content/uploads/2025/10/powell-et-al-2016scid-combating-coups.pdf Clopus confirm co-authors against the published version
1 signals to other would-be putschists that a coup would be tolerated. Conspirators consume information that is favorable to their predispositions and will Brespond to cues in line with^ them (Li and Thompson 1975,p.81).Whensoldiers witness favorable events in other states, they will sometimes follow with coups of their own. Though empirical research is limited, there is substantial anecdotal support for this Bcontagion^ theory of coups, in Africa and beyond. The removal and murder of Patrice Lumumba was pivotal in launching a coup era in Africa, as it was Bthe first time that the legitimacy of the colonial inheritance was defied^ and this precedent was dramatically reinforced by the ouster and murder of widely popular President Sylvanus Olympio of Togo in 1963 (First 1970). By adopting a formal non-intervention policy, the OAU effectively eliminated external costs for coup-born leaders. Precedents set by Gnassinbé Eyadéma, Joseph Mobutu, and other early coup leaders would reinforce this reality. The willingness of non-African powers to support coup-born regimes not only further advertised a lack of penalties, but potential rewards. Indeed, these factors led to
144AND---the intervention is what stopped it. Fence-sitters moved once Nigerian jets arrived.
Chin 25 — John Joseph Chin. December 9. Assistant Teaching Professor of Strategy and Technology at Carnegie Mellon University; he maintains the Colpus coup dataset and has documented the history of post-war coups. The Conversation, “Benin’s failed coup: three factors behind the takeover attempt,” https://theconversation.com/benins-failed-coup-three-factors-behind-the-takeover-attempt-271540 Clopus
Responding to two requests for assistance from the government of President Patrice Talon, Nigeria deployed fighter jets and the Economic Community of West African States (Ecowas) deployed elements of its standby force to target and dislodge the pro-coup forces.
Ecowas intervention likely played an important role in undermining the coup’s momentum and restoring order. The dozen or so putschists scored early tactical successes. They captured and broadcast from the national television station , occupied a military camp , and even took the two senior-most army officers hostage . But once Ecowas intervened militarily, any fence-sitters concluded that loyalists would prevail. Rather than a broad-based uprising, only 14 were arrested with a few plotters still at large .
I’m a scholar who maintains the Colpus dataset of coups and I have documented the history of post-second world war coups . As part of this work, I have sought to document the complex causes and effects of Africa’s post-2020 “ epidemic of coups ”, now entering its fifth year.
145AND---the split is arming. Both blocs buy, and each treats the other as the external threat.
Ndiaye 24 — Babacar Ndiaye. September 19. Senior Fellow at the Timbuktu Institute for Peace Studies, former Principal Political Affairs Officer at ECOWAS and transnational organised crime prevention expert at UNODC West and Central Africa. The Defence Horizon Journal, “A Shift Of The Collective Security Architecture In West Africa,” https://tdhj.org/blog/post/collective-security-west-africa-ecowas/ Clopus
The current geopolitical context mirrors the era of the Cold War, marked by deep mistrust among West African states ideologically divided between two opposing blocs, each striving to expand its influence through any means necessary. This includes subversive actions, the importation of weapons, the use of mercenaries or private military services (PMS), miss/disinformation, propaganda and the massive deployment of foreign troops. A notable example is the latest Niger coup, which faced the threat of ECOWAS’s potential use of force to restore constitutional order.
One of the most critical fallouts from such an emerging, conflictual environment in the region is the proliferation of weapons, including advanced military technology, especially in the AES countries, coming to grip with dogged terrorist threats seriously, an internal insurgency, whilst perceiving neighbouring ECOWAS member states as a potential threat to its external security. This opens huge security equipment services opportunities for non-Western security partners, Iran, Türkyie, and especially Russia, the new main strategic security partner.[24] In this regard, it is worth highlighting that in January 2024, Russia announced a military partnership agreement with Niger. And by March, Russian President Vladimir Putin and General Abdourahmane Tiani, head of Niger’s National Council for the Safeguard of the Homeland, discussed a “strategic, multi-sectoral, and comprehensive” cooperation project during a phone call. This partnership materialised between April and May with the arrival of three cargo flights carrying military equipment, including an air defence system.[25]
146AND---the spread is already at the border. Sahelian groups went from nothing to a running campaign in the northwest.
ACSS 26 — Africa Center for Strategic Studies. August 12. The U.S. Department of Defense’s academic institution for African security studies; publisher of the annual militant-Islamist-violence fatality series. Africa Center for Strategic Studies, “Mounting Fatalities Linked to Militant Islamist Violence in Africa amid Shifting Tactics,” https://africacenter.org/spotlight/en-2026b-mig-10yr/ Clopus
Sahelian militant Islamist groups have made inroads into northwest Nigeria over the past year. Fatalities linked to these groups have risen from zero in 2024, to 136 in 2025, and 504 in 2026. Both JNIM and ISGS appear to be collaborating with other armed groups in Nigeria – from Boko Haram’s Sadiku Faction, Ansaru, and Lakurawa, as well as various criminal gangs (locally known as bandits). Lakurawa has been linked to a particularly sharp increase in fatalities. The convergence of violent extremist and organized criminal activity poses a new and growing security challenge for Nigerian authorities.
1471. MECHANISM---conflict manufactures resistance. Water, diagnostics and stewardship break together.
Abbara 25 — Aula Abbara, Clare Shortall, Richard Sullivan, et. al. April 12. Department of Infection, Imperial College London. Médecins Sans Frontières, Operational Centre Amsterdam, Manson Unit, London. Centre for Conflict and Health Research, King’s College London. npj Antimicrobials and Resistance, “Unravelling the linkages between conflict and antimicrobial resistance,” vol. 3 Clopus
Over the last three decades, there has been a rise in the number and complexity of armed conflicts and related forced displacement, with the additional, often simultaneous, impact of disasters and climate change 1 . These further degrade health and eco-systems in fragile and conflict-affected settings contribute to environmental degradation and toxic waste production, stifling the potential for antimicrobial resistance (AMR) detection, mitigation and control 2 . These include negative impacts on water and sanitation 3 , diagnosis and surveillance, infection prevention and control and antimicrobial stewardship, all essential components of AMR control. Such degraded environmental conditions, rising temperatures and changing disease patterns due to climate change and natural disasters can fuel social and political tensions that can lead to conflicts. Alongside this, the humanitarian system is grappling with multiple crises amid funding shortfalls to key areas e.g. WASH 4 , vaccination 5 , enhancing healthcare service capacity, impacting on protracted crises, which, in turn, affect the ability of health systems and responses to address AMR effectively. As of 2024, 33 countries globally are affected by armed conflict and 110 million people are forcibly displaced globally (33.5 million as refugees (UNHCR/UNRWA) and 72.5 million are internally displaced people (IDPs)), numbers which are growing every year 1 . Arguably, these factors are increasing in scale and complexity and require high-level political support, global commitment and institutional investment to tackle them through evidence-based decision-making and tailored policies to address AMR in these settings. They also necessitate ground-up, contextualised evidence and sustainable approaches to address local concerns meaningfully.
Addressing AMR in settings affected by armed conflict and disasters requires targeted, evidence-driven, ground-up approaches which tackle the myriad drivers of AMR within these environments. For example, the breakdown of water and sanitation systems may lead to increased risks of infections, e.g. diarrhoeal illnesses, skin conditions, which can lead to over prescribing of antibiotics or inability to appropriately clean wounds, leading to further infections. Poor access to antibiotics through poor healthcare access or interrupted supply chains may lead to AMR through inappropriate use or overuse, particularly where there are poorly enforced policies or in acute armed conflicts where such measures are not respected. Such factors are compounded where there is inadequate or lack of diagnostic infrastructure for detection and epidemiological surveillance and limited capacity to interrupt to halt the spread through improved infection control 2 , 6 Additionally, the voices of affected communities—service users and providers—must be centred in these discussions as they arguably hold both knowledge of the local contextual drivers and are integral to the solutions 7 , 8 . Engaging these communities enables a deeper understanding of the issues and helps in crafting customised solutions that effectively tackle local contributing factors. For example, if access to healthcare in general, and essential antimicrobials in particular, for refugees and migrants, is interrupted, it may contribute to behaviours which may lead to overuse, misuse, hoarding of antimicrobials or omission, which could lead to harm 9 . In other settings, the response to humanitarian crisis e.g. mobile clinics with a lack of diagnostics support, can potentially contribute to antimicrobial overprescribing or ineffective antibiotic choices. Additionally, there can be widespread concerns about counterfeit, substandard or poor-quality antibiotics with inadequate governance or quality control further exacerbating the issue.
Evidence from affected populations can also inform the responsibilities of wider transdisciplinary collaborators—including health practitioners, engineers, water, sanitation and hygiene (WASH/WATSAN) specialists, anthropologists, environmentalists, sociologists, politicians, and economists, among others—to prevent and tackle AMR in the particular contexts in which they exist 10 . This includes those who have been forcibly displaced into tented settlements, urban or peri-urban informal settlements and slums or who are living among host communities. This approach must also recognise the interconnectedness of human-animal-environment within the One Health framework in armed conflict settings, ensuring a comprehensive strategy against AMR 11 .
In the much anticipated zero draft 12 of the political declaration on AMR, we see the initial framings, which aim to solidify AMR’s place in the global agenda in the lead-up to the United Nations High-Level Meeting (UNHLM) in September 2024. In the first iteration, while there is a commendable focus on access, there was a notable omission of the specific challenges areas affected by armed conflict or complex humanitarian crises face. Additionally, in the final political declaration, global targets put forward lack sufficient data to substantiate their effectiveness, relevance, and transformative potential in humanitarian settings. Failing to address the unique ecosystems of armed conflict and humanitarian crisis through tailored, transdisciplinary collaborations that extend beyond human health will fail to tackle AMR in these settings 13 . Beyond this, it is vital to explore the direct and indirect impacts of armed conflict and their role in unmasking or catalysing the emergence of AMR through various contributing factors.
It is in this space that the breakdown of health care and essential infrastructure, including water and sanitation infrastructure, electricity and roads, coupled the loss or exodus of health workers, alongside ongoing violence and insecurity, can impede top-down approaches, such as policies and regulations relevant to AMR 14 . Health system governance in these areas is also disrupted, leading to poor enforcement of antimicrobial policies, weak infection control practices, substandard antimicrobials and their injudicious use in human, environmental and agricultural practices 10 . For example, poor stewardship of antimicrobial use in animal husbandry or dairy, poor animal welfare, improper carcass disposal and related environmental or water contamination can all exacerbate AMR or propagate its entry into the human food chain 11 . Additionally, surveillance is also hampered by inadequate microbiology capacity, data capture and reporting mechanisms, impacting on availability of essential data with proper regulatory and ethical oversight. As a result, the generation and consequences of AMR cannot be fully understood from one specific epistemological viewpoint, as they are inextricably linked to broader access challenges and their determinants, which is particularly evident in these settings. The interplay of such factors is summarised in Fig. 1 .
1482. BASELINE. Africa already carries the worst burden and the deficit is regulatory, not medical.
Ohemu 26 — Gerald Peter Ohemu, Babafela Awosile, Kome Otokunefor, et. al. June 24. School of Veterinary Medicine, Texas Tech University, Amarillo. Department of Microbiology, University of Port Harcourt, Rivers State. Department of Internal Medicine, University of Port Harcourt Teaching Hospital. Antimicrobial Resistance and Infection Control, “A message to Africa as Nigeria hosts the 5th Global High-Level Ministerial Conference on antimicrobial resistance,” vol. 15 Clopus
Abuja, Nigeria, has been selected to host the 5th Global High-Level Ministerial Conference on AMR. This will be the first time this pivotal convening is held on African soil. For a region bearing the world’s highest per capita AMR mortality burden, this is more than a diplomatic achievement. Sub-Saharan Africa records 23.7 AMR-attributable deaths per 100,000 people, substantially higher than estimates for high-income regions like North America [ 2 ]. The Nigeria Center for Disease Control and Prevention (NCDC) reports that AMR causes 64,500 deaths annually, contributing to a 7% loss of gross domestic product (GDP) and an 11% decline in livestock productivity [ 3 , 4 ]. A 2024 Africa CDC report highlighted that, without collective action, AMR-associated deaths on the continent could quadruple to 4.1 million per year by 2050 [ 5 ].
Hosting the 5th Global High-Level Ministerial Conference on AMR gives Africa something it rarely has in global health diplomacy: convening power. But the deeper question is what Africa will do with it. What makes this conference significant is not where it is held, but whether Africa will arrive with a coherent, continent-owned agenda that moves beyond receiving commitments to shaping them, and beyond political declarations to full-scale implementation.
Addressing this requires confronting a difficult truth: Africa’s AMR challenge has its own face, and it does not look like Europe’s or America’s. It is structurally different, shaped by pressures from antibiotic overuse and underuse, weak regulatory systems, environmental contamination, community-level transmission dynamics, and health systems stretched thin by limited resources. Deep socioeconomic determinants, including poverty, food insecurity, and economic vulnerability, compound these pressures. These factors drive communities toward antibiotic use as a rapid, affordable response to illness, even in the absence of a confirmed bacterial infection. In low-resource communities, when clean water is scarce and waste management is unreliable, infection rates rise, antibiotic demand increases, and resistant bacteria find fertile ground to grow. Any response that does not account for this complexity will fall short.
This perspective is written with the deliberate intention of contributing to an African-led Abuja discourse on what the continent must demand, commit to, and build toward, both pre- and post-conference. After the conference, this perspective challenges African leaders to be the authors of their own AMR futures, to be accountable to their own populations for the commitments made in, and to measure progress against the seven priority areas outlined here.
What Africa must rise to
High-income countries have invested heavily in enforceable regulations, national stewardship programmes, integrated surveillance, and stringent agricultural standards. While progress has been uneven and targets remain out of reach in many settings, these investments have produced measurable gains in specific resistance indicators that low- and middle-income countries have yet to replicate at scale [ 6 ]. Although socioeconomic contexts differ and similar investments may not automatically yield comparable results in African settings, these gains have hinged on strengthening institutional capacity, regulatory infrastructure, and health system functionality. Africa must chart its own path toward the same destination. But the route is different and, in many respects, more complex.
The most urgent priority for Africa is regulation and enforcement. But regulation and enforcement do not operate in a vacuum. They depend on a functioning health system, available diagnostics, and reliable pharmaceutical supply chains. Strengthening enforcement without these conditions risks restricting legitimate access to essential antimicrobials and driving people toward even more informal and unregulated channels. Across much of Africa, antibiotics remain available over the counter without a prescription, and national surveillance data, where it exists, rarely informs real-time policy decisions [ 7 ]. Strengthening and enforcing pharmaceutical regulations to ensure equitable access to medicines, aligning national AMR surveillance with WHO’s Global Antimicrobial Resistance and Use Surveillance System (GLASS), investing in water, sanitation, and hygiene (WASH) infrastructure, and embedding stewardship within both public and private health facilities are not nice-to-haves; they are the essential pillars of an effective AMR response.
But regulation and enforcement alone address only part of the picture. AMR in Africa is also an environmental issue. Pharmaceutical effluents, hospital wastewater, agricultural runoff, and inadequate solid waste disposal systems create environmental reservoirs where resistance genes can accumulate and spread, often in the same waterways communities rely on for drinking, bathing, fishing, and irrigation [ 8 ].
Simultaneously, deficits in infection prevention and control (IPC) and in water, sanitation, and hygiene (WASH) infrastructure mean that preventable infections continue to drive antibiotic demand [ 9 ]. These are not secondary concerns to be addressed later, after regulatory frameworks are in place; they are co-determinants of antibiotic demand and the spread of resistance and must be tackled side-by-side. In agricultural systems, for instance, unregulated antibiotic use in livestock and aquaculture, often as growth promoters rather than therapeutic agents, closes the One Health loop in ways that human health policy alone cannot address. Many smallholder farmers rely on antibiotics to compensate for the absence or inadequacy of veterinary services or biosecurity infrastructure. Africa’s AMR response must span these domains and address the underlying production pressures as a single, integrated challenge, rather than as parallel programmes managed by separate ministries.
This integration is where Africa’s lived experience of One Health becomes a genuine asset rather than a burden. In many African communities, people, animals, crops, and water sources share the same physical and economic space. This proximity creates AMR transmission pathways that high-income countries rarely encounter at the same scale. But it also means that well-designed community-level interventions can address multiple transmission routes simultaneously.
1493. MAGNITUDE. Countermeasure resistance is one of four worst-case traits---each is already proven alone.
Millett 17 — Piers Millett and Andrew Snyder-Beattie. September 1. Senior Research Fellow at the Future of Humanity Institute, University of Oxford, former Deputy Head of the Biological Weapons Convention Implementation Support Unit at the United Nations. Director of Research at the Future of Humanity Institute, University of Oxford. Health Security, “Existential Risk and Cost-Effective Biosecurity,” vol. 15, no. 4 Clopus
In the modern context, no single disease currently exists that combines the worst-case levels of transmissibility, lethality, resistance to countermeasures, and global reach. But many diseases are proof of principle that each worst-case attribute can be realized independently. For example, some diseases exhibit nearly a 100% case fatality ratio in the absence of treatment, such as rabies or septicemic plague. Other diseases have a track record of spreading to virtually every human community worldwide, such as the 1918 flu, 10 and seroprevalence studies indicate that other pathogens, such as chickenpox and HSV-1, can successfully reach over 95% of a population. 11 , 12 Under optimal virulence theory, natural evolution would be an unlikely source for pathogens with the highest possible levels of transmissibility, virulence, and global reach. But advances in biotechnology might allow the creation of diseases that combine such traits. Recent controversy has already emerged over a number of scientific experiments that resulted in viruses with enhanced transmissibility, lethality, and/or the ability to overcome therapeutics. 13-17 Other experiments demonstrated that mousepox could be modified to have a 100% case fatality rate and render a vaccine ineffective. 18 In addition to transmissibility and lethality, studies have shown that other disease traits, such as incubation time, environmental survival, and available vectors, could be modified as well. 19-21
Although these experiments had scientific merit and were not conducted with malicious intent, their implications are still worrying. This is especially true given that there is also a long historical track record of state-run bioweapon research applying cutting-edge science and technology to design agents not previously seen in nature. The Soviet bioweapons program developed agents with traits such as enhanced virulence, resistance to therapies, greater environmental resilience, increased difficulty to diagnose or treat, and which caused unexpected disease presentations and outcomes. 22 Delivery capabilities have also been subject to the cutting edge of technical development, with Canadian, US, and UK bioweapon efforts playing a critical role in developing the discipline of aerobiology. 23 , 24 While there is no evidence of state-run bioweapons programs directly attempting to develop or deploy bioweapons that would pose an existential risk, the logic of deterrence and mutually assured destruction could create such incentives in more unstable political environments or following a breakdown of the Biological Weapons Convention. 25 The possibility of a war between great powers could also increase the pressure to use such weapons—during the World Wars, bioweapons were used across multiple continents, with Germany targeting animals in WWI, 26 and Japan using plague to cause an epidemic in China during WWII. 27
1501. ADDITIVE---a system running on donor money has no slack, so the next shock lands harder.
Nwofe 26 — Joel O. Nwofe, Elizabeth A. Ojo, Faith E. Owolagba, et. al. February 4. Department of Laboratory Services, Surveillance and Global Health Security, APIN Public Health Initiatives Nigeria, Abuja. Centre for Interdisciplinary Studies of Children, Families, and Society, University of the Western Cape. Globalization and Health, “U.S. withdrawal from WHO and aid programs: implications and opportunities for Africa’s global health security,” vol. 22 Clopus
Through these mechanisms, U.S. investments have supported HIV/AIDS treatment and prevention, vaccine delivery, disease surveillance, and emergency response across Africa [ 1 ]. PEPFAR alone has saved more than 25 million lives [ 2 ], primarily through declines in HIV-related mortality achieved by the scale-up of antiretroviral therapy, prevention of mother-to-child transmission, and broader health system investments supported by the program. Beyond disease-specific outcomes, PEPFAR and USAID funding contributed to the establishment of molecular laboratory networks, initially designed for HIV viral load testing, and the deployment of platforms such as GeneXpert—a cartridge-based molecular diagnostic system used for rapid detection of tuberculosis and other pathogens. These investments also included the provision of basic laboratory infrastructure, such as hematology and chemistry analyzers, in secondary and tertiary hospitals, alongside workforce training and quality assurance systems. Collectively, these capacities were later leveraged during the COVID-19 pandemic and continue to support diagnostics for Mpox and other infectious diseases.
In parallel, the United States has been a major contributor to WHO-led initiatives, providing approximately 20% of the organization’s assessed and voluntary budget since 2022 and offering technical support for pandemic preparedness, disease surveillance, and immunization programs [ 1 ]. Through this support, WHO has coordinated global surveillance systems, facilitated real-time data sharing, and deployed rapid response mechanisms to contain outbreaks. The recent U.S. decision to withdraw from WHO and freeze USAID funding therefore marks a significant turning point. Reduced financial and technical support threatens the continuity of treatment programs, constrains laboratory operations, and weakens disease surveillance systems that are critical for early outbreak detection.
The implications extend beyond immediate programmatic disruptions. Delays in surveillance, laboratory confirmation, and coordinated response increase the risk that localized outbreaks escalate into wider epidemics, particularly in settings where health systems rely heavily on external financing for routine operations. In African countries with high donor dependence, funding freezes may translate into reduced testing capacity, slower information flow, and delayed emergency responses, thereby amplifying disease transmission and undermining global health security.
1512. THEIR OWN AUTHOR separates them---conflict is the driver and money only compounds it.
Onyeaghala 25 — Chizaram Onyeaghala and Michael Iroezindu. December 9. Department of Internal Medicine, University of Port Harcourt Teaching Hospital, Rivers State, Nigeria. Department of Medicine, University of Nigeria Teaching Hospital, Ituku, Enugu. BMJ Global Health, “The 2024-2025 upsurge of mpox in Africa: another opportunity to accelerate global solidarity for a neglected disease,” vol. 10 Clopus
Following the August 2024 declarations, WHO and Africa CDC launched a joint action plan aimed at mobilising diagnostics and vaccines, engaging with affected communities and strengthening surveillance. 15 Despite these coordinated measures, several entrenched challenges continue to undermine progress.
Armed conflict remains a major driver of uncontrolled transmission. 16 The advance of M23 fighters in Eastern DRC during late 2024 led to the closure or severe limitation of hospital operations, with many patients abandoning isolation centres to flee violence. 17 Such movements disrupted contact tracing and reduced case detection, while insecurity made it dangerous for healthcare workers to travel or conduct vaccination campaigns. Sample transportation from conflict areas was frequently delayed, further weakening surveillance efforts.
Funding shortfalls have compounded the difficulties posed by conflict. The Africa CDC has reported a significant gap in resources needed for a sustained mpox response. The suspension of USA foreign aid in early 2025 exacerbated this shortfall, 18 underscoring the vulnerability of outbreak control measures to shifts in geopolitical priorities. While significant mobilisation of resources has come from the African Union and global partners, long-term resilience will require predictable domestic investment.
1523. In Nigeria they run together---and the reporting itself is going blind where presence shrank.
SHCC 26 — Safeguarding Health in Conflict Coalition and Insecurity Insight. April. A coalition of more than forty organizations documenting violence against health care in armed conflict, reporting incident data compiled by Insecurity Insight. Safeguarding Health in Conflict Coalition, “Care in the Crosshairs: Violence Against Health Care in Conflict,” https://www.insecurityinsight.org/wp-content/uploads/2026/04/2025-SHCC-Annual-Report.pdf Clopus
Nigeria THE CONTEXT In 2025, non-international armed conflict persisted in Nigeria, with the Nigerian Armed Forces (NAF) and support forces being involved in protracted hostilities with the armed groups Boko Haram and Islamic State West Africa Province (ISWAP). Nigeria received support from the Multinational Joint Task Force (MNJTF),58 and on December 26, the United States reportedly carried out air strikes in northwest Nigeria targeting two camps of the jihadist group Lakurawa in Sokoto state. Violent anti-government and separatist actors continued to operate in southeastern Nigeria, while in the northwest, criminal bandit groups were responsible for widespread kidnappings, killings, sexual violence, and theft of livestock. Nigeria experienced worsening security in 2025, with a 5.6% rise in explosives-related incidents and over 20 attempted ISWAP and Boko Haram attacks on military sites in Borno state. In response, President Tinubu declared a national security emergency in November amid widespread violence across multiple states. School abductions recurred and remained an ongoing threat in 2025, including the kidnapping of 400 students in Niger state in November, leading to the closure of over 20,000 schools across seven states and threatening children’s access to education. In 2025, food insecurity in Nigeria worsened due to attacks on markets, farming communities, and rural livelihoods, with armed violence and intercommunal clashes displacing farmers, disrupting agricultural production, and limiting access to food, deepening the humanitarian crisis. Rising displacement and humanitarian needs characterized much of the year. By December 2025, over 1.2 million people were affected by worsening insecurity and waves of violence, including an estimated 260,000 who had been newly displaced between September and November. Funding cuts resulting from the USAID aid-funding freeze limited Nigeria’s humanitarian health care responses. Between 2022 and 2024, Nigeria received about USD 8 billion from USAID for health programs, including combating HIV and malaria, and supporting other public health initiatives. The cuts threatened the health care system’s capacity, leading to approximately 28,000 health workers losing their jobs. To mitigate the impact, Nigerian lawmakers allocated an additional USD 200 million to the health sector in the 2025 federal budget. VIOLENCE AGAINST OR OBSTRUCTION OF HEALTH CARE IN 2025 In 2025, violence against or obstruction of health care increased in Nigeria. Cases were spread across 16 states – four more than in 2024 – with new incidents being reported in Anambra, Adamawa, Kano, Ondo, Edo, and Nasarawa states. Attacks on health care in Zamfara state – where communal militia violence is at high levels – nearly tripled in 2025, while reported incidents declined in the BAY states (Borno, Adamawa and Yobe), possibly due to a reduced humanitarian presence. The majority of incidents affected health care providers operating in national health structures, with two affecting NGOs.59 47 CARE IN THE CROSSHAIRS: VIOLENCE AGAINST HEALTH CARE IN CONFLICT | 2025
Nigeria Most incidents were attributed to unidentified men armed with guns. Katsina militia were implicated in two attacks on health centers during which health workers were killed and injured.60 Zamfara militia carried out a road ambush, kidnapping a health worker and other civilians. 61 Fulani militants armed with AK-47s and machetes raided a hospital, abducting and raping an unspecified number of women.62 ISWAP was linked to five incidents across the BAY states, mostly involving health facilities being raided, set on fire, and looted of medicine and food supplies. 63 Boko Haram ambushed an ambulance in Borno state, injuring the driver, stealing medical supplies and seizing the vehicle.64 The NAF and police reportedly arrested health workers on accusations of links to opposition groups in Katsina, Niger, and Sokoto states. 65 An NAF air strike reportedly targeting a camp belonging to an armed group killed a health worker treating a wounded fighter.66 At least four incidents in the BAY states involved health centers being deliberately set on fire, often during wider attacks in the area where other civilian infrastructure was also damaged. On one occasion, an improvised explosive device (IED) planted by an unidentified armed group damaged staff residences at a hospital in Kebbi state.67 Kidnapping incidents increased by over 70% in 2025 compared to 2024, while the number of health workers who were kidnapped remained similar to those reported in 2024. Most kidnapped health workers were abducted outside Nigeria’s northeast in areas where kidnappings for profit are common. Maternal care services in Nigeria were affected by conflict-related violence in 2025 when unidentified attackers raided a nursing and maternity center in Kaduna state and abducted a health worker, a security guard, and five patients, including a nine-month pregnant woman and a nursing mother with her baby.68 Source: Insecurity Insight for the SHCC. 48 CARE IN THE CROSSHAIRS: VIOLENCE AGAINST HEALTH CARE IN CONFLICT | 2025
Nigeria Health worker kidnappings In 2025, 32 health workers were kidnapped in 21 incidents, compared to 35 in 14 incidents in 2024 and 24 in 17 incidents in 2023. Most kidnapped health workers were abducted by unidentified attackers outside Nigeria’s northeast region. In one case, a health worker in Adamawa was kidnapped by an armed group and taken with other captives to an area along the Nigeria-Cameroon border.69 Abducted health workers included doctors, drivers, pharmacy owners, and surgeons who were forcibly taken from hospitals, clinics, in road ambushes, and at illegal checkpoints. Ransoms were demanded as a condition for release in several kidnapping cases, while armed groups also abducted health staff to provide care to fighters. Ten of the 35 kidnapped health workers were released. A doctor who was shot and abducted by an unidentified group in front of his house in late December 2025 70 was released in January 2026, only to be shot again and killed. The fates of the remaining 25 remain unclear. Source: Insecurity Insight for the SHCC. 49 CARE IN THE CROSSHAIRS: VIOLENCE AGAINST HEALTH CARE IN CONFLICT | 2025
Health worker killings In 2025, six health workers were killed in five incidents, compared to three in three incidents in 2024 and six in five incidents in 2023. Three health workers were killed in shootings inside hospitals in Edo and Katsina, including a physiotherapist who was killed during an attack by gunmen at the University of Benin Teaching Hospital.71 Following the attack, the facility’s health workers staged a protest on the hospital premises. THE IMPACT OF ATTACKS ON HEALTH CARE In 2025, Nigeria’s health care system faced significant strain, with Nigerian Association of Resident Doctors president Muhammad Suleiman calling it a “difficult year” for doctors. Together with the challenges caused by USAID funding cuts, a Lassa fever resurgence resulted in 955 confirmed cases and 176 deaths by November, with the case fatality rate rising to 18.4% despite fewer overall cases than in 2024. High rates of internal displacement in Nigeria further strained the overburdened health system, with overcrowded IDP camps facing heightened risks of disease, gender-based violence (GBV), and limited access to health care, clean water, and sanitation . This disruption intensified demand for medical care, hindered treatment continuity, and increased the risk of disease outbreaks, including malaria, typhoid, and stomach ulcers. Residents reported the dire consequences of medication shortages, with one stating, “if we don’t get drugs, we just sit and watch the sick person helplessly, ” while also facing heightened risks of GBV. Between October and December 2025, acute malnutrition remained a critical issue in northern Nigeria, where nearly one-third of local government areas were classified as IPC Phase 4 (Critical), showing a worsening trend compared to previous years. The IPC identified poor food consumption, disease burden (including fever, malaria, and diarrhea), inadequate WASH (water, sanitation and hygiene) practices, and acute food insecurity as key drivers. Ongoing violence and displacement further limited access to food and health care. An estimated 12.5 million children under the age of five and over two million pregnant and lactating women would need treatment for acute malnutrition between October 2025 and September 2026, further straining the health care system. Maternal mortality remains extremely high in northeast Nigeria, with 1,848 deaths per 100,000 live births, second only to the northwest region. This chapter is based on 2023-2025 NGA SHCC Health Care Data. Download this data on the Humanitarian Data Exchange (HDX). Insecurity Insight updates data continuously and numbers may change if new information is made publicly available. For the latest available figures, see Insecurity Insight’s global map on attacks on health care. Nigeria 50 CARE IN THE CROSSHAIRS: VIOLENCE AGAINST HEALTH CARE IN CONFLICT | 2025
1531. THEIR OWN AUTHOR---the ecological estimate rests on modeling because nobody is counting.
Davis 25 — Natalie A. Davis, Madeline A. Kenyon, Bruno M. Ghersi, et. al. March 31. Center for Conservation Medicine, Cummings School of Veterinary Medicine, Tufts University. Department of Public Health and Community Medicine, School of Medicine, Tufts University. Viruses, “Assessing the Environmental Drivers of Lassa Fever in West Africa: A Systematic Review,” vol. 17 Clopus
Lassa fever (LF), a viral hemorrhagic disease endemic to West Africa, is intricately linked to ecological, environmental, and climatic factors, underscoring the complex relationships between the disease, its reservoir hosts, and the environment. The etiologic agent for the disease, Lassa virus (LASV), belongs to the Arenaviridae family and is predominately transmitted to humans by the multimammate rat, Mastomys natalensis , through contact with urine, feces, saliva, and blood [ 1 , 2 , 3 ]. LASV infections in humans are largely dependent on the spatial distribution of M. natalensis , a known agricultural pest and commensal rodent species predominately found in human settlements, with a preference for scavenging in indoor environments and in surrounding agricultural cultivations due to the availability of food sources [ 4 ]. Understanding how environmental factors influence LASV host dynamics is critical for evaluating the disease’s epidemiology and developing effective public health interventions.
LASV was first discovered in the Borno State of Nigeria in 1969 and is now endemic to multiple West African countries, with notable past and current outbreaks occurring in Nigeria, Guinea, Liberia, and Sierra Leone [ 5 ]. Infected rodents and sporadic human cases have more recently been reported in Mali, Togo, and Benin, suggesting the endemic range may be expanding [ 6 , 7 ]. Critical disease underreporting has resulted in a distinct underestimation of infections and case fatality rates [ 8 ]. As a result, disease estimates rely on mathematical modeling studies, which have estimated that approximately 37.7 million individuals in 14 West African countries reside in areas with suitable conditions for zoonotic transmission of LASV, with a projected annual incidence of 897,700 human infections, half of which are predicted to occur in Nigeria [ 2 , 9 ]. Based on these projections, it is estimated that 18,000 people die each year from LF; however, global climate change, mounting evidence of new rodent hosts, urbanization and expansion of agricultural practices in West Africa threaten to expand the ecological niche for LASV and influence disease spread into previously non-endemic areas [ 2 , 10 , 11 , 12 , 13 , 14 ]. Lassa virus is categorized as a Category A bioterrorism agent by the US Center for Disease Control, and Lassa fever was listed as a World Health Organization priority disease for research in 2016 due to its status as a hemorrhagic virus capable of widespread death and disease [ 15 , 16 ]. LF was further determined to be a priority zoonotic disease for West Africa by the Economic Community of West African States (ECOWAS) [ 16 ]. Despite these critical calls for action, LF remains a crucially understudied hemorrhagic disease largely due to a lack of available diagnostic assays and limited clinical research infrastructure [ 6 , 17 ].
LF epidemics have historically been seasonally dependent, with human cases typically peaking in January–February during the dry season in West Africa, and secondary peaks occurring in March [ 11 , 18 ]. The seasonal epidemiology of LF is largely attributed to the population dynamics of the primary rodent reservoir, M. natalensis , with differing evidence on whether this is due to seasonal fluctuations of virus prevalence in the host species, increased rodent abundance indoors during the dry season, host breeding cycles, or a balance of all three factors [ 4 , 18 ].
Further, the transmission of LASV is influenced by land-use patterns, with M. natalensis populations predominating in rural human homes and surrounding agricultural fields and having a lesser abundance in forested or urban areas [ 8 ]. The distribution and LASV seropositivity of M. natalensis are strongly positively correlated with increased habitat fragmentation, agricultural expansion, and savanna conversion, indicating a high dependency on human settlements and vulnerability to habitat expansion due to increased human development [ 11 , 19 , 20 ]. Projected climatic and land-use changes in West Africa are expected to create more favorable habitats for M. natalensis , driving species growth and potentially increasing the risk of LASV spillovers to humans [ 19 ].
The mechanisms by which seasonal precipitation, land-use conversion, and host dynamics drive LF outbreaks in West Africa are not fully understood, highlighting a need for further research to explore these complex relationships. This study aimed to systematically synthesize and critically evaluate the environmental drivers of LASV in West Africa and identify knowledge gaps in current research to target future efforts. A thorough understanding of how ecological and environmental variables relate to seasonal outbreaks of LASV is essential for guiding future public health efforts in the face of climate change, landscape alteration, and human settlement expansion.
1542. Modeling where spillover should happen has produced zero actionable data---only detection does.
Gurley 25 — Emily S. Gurley and Raina K. Plowright. August. Professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health. Professor of disease ecology in the Department of Public and Ecosystem Health at Cornell University. Emerging Infectious Diseases, “A Roadmap of Primary Pandemic Prevention Through Spillover Investigation,” vol. 31, no. 8 Clopus
A spillover occurs when a pathogen infects a new host species ( 2 , 3 ). The vast majority of spillovers will not lead to an outbreak or pandemic. However, for pathogens with pandemic potential, each spillover into a human is an opportunity to launch a pandemic. Most pandemic prevention plans focus on finding outbreak events earlier, notifying neighboring countries, assembling effective outbreak response teams, and enhancing global surveillance for spillover and outbreak events. Those measures are all crucial. However, preventing the spillover in the first place should be a fundamental component of our global strategy for preventing pandemics.
Numerous initiatives have attempted to identify potential pandemic causing pathogens before they cause outbreaks. One approach is to model geographic areas at high risk for spillovers, correlating putative drivers with locations of past spillovers and overlap of humans and reservoir species ( 4 – 6 ). Those efforts aim to focus surveillance and resources on areas or species of high risk. Substantial investments have led to the discovery of new viruses infecting rodents, bats, and primates, including viruses that were phylogenetically related to outbreak causing pathogens, suggesting a potential risk for spillover ( 7 – 19 ). Although such efforts have produced findings of interest, they have not produced actionable public health data. Those approaches do not inform which pathogens are spilling over and the mechanisms driving these events.
Spillovers do provide actionable data. Once an emerging pathogen infects a human, a public health threat is actualized. Those events garner our attention and concern much more than hypothetical risk warnings. Particularly alarming is evidence of transmission of the pathogen from human to human, because this capability is necessary to cause a pandemic. For example, if there was evidence that persons infected with bovine strains of avian influenza H5 across the United States ( 20 ) were able to infect others, the risk of a pandemic from this virus would increase drastically.