Increasing antibiotic resistance is one of the most important public health threats of our time. In England alone, the number of antibiotic-resistant bloodstream infections rose by 9.3% in a single year, from 18,740 cases in 2023 to 20,484 in 2024, while estimated deaths from resistant infections increased from 2,041 to 2,379 over the same period.

Those affected are often elderly, often from the most deprived communities.

The UK Health Security Agency (UKHSA) now documents close to 400 new drug-resistant infections every week in England ¹. Globally, more than one million people have died each year as a direct result of antimicrobial resistance (AMR) since 1990, and the situation is getting worse. Modelling published in The Lancet in 2024 predicts that, without intervention, AMR deaths could reach 1.91 million annually by 2050, a near 70% increase on current figures ².

And there is worse news: resistance to carbapenems, a class of antibiotics that has long served as medicine’s final line of defence, is increasing.

The Carbapenem Problem

Carbapenems - a group that includes meropenem, imipenem and ertapenem - occupy a critical position in the antibiotic arsenal. They are broad-spectrum beta-lactam antibiotics, reserved for severe or multidrug-resistant infections where other agents have failed. When a bacterium becomes resistant to carbapenems, doctors are left with very limited, often more toxic alternatives. In many cases, there is no good option at all.

Among Gram-negative bacteria, pathogens including Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa, resistance to carbapenems has increased more than any other antibiotic class between 1990 and 2021, with attributable deaths rising by 89,200 over that period ². Carbapenem-resistant A. baumannii and carbapenem-resistant Enterobacterales are classified by the World Health Organization (WHO) as critical priority 1 pathogens, the highest category of concern, reserved for organisms where new active antibiotics are most urgently needed ³.

Carbapenem resistance can arise through several mechanisms, but the most clinically and epidemiologically important involves the production of carbapenemase enzymes. These are proteins that chemically hydrolyse the carbapenem molecule, rendering it inactive. The most transferable and globally distributed carbapenemase genes include KPC (Klebsiella pneumoniae carbapenemase), NDM (New Delhi metallo-beta-lactamase), OXA-48 and VIM (Verona integron-encoding metallo-beta-lactamase). What makes these genes particularly problematic is their capacity to move between bacteria through a process known as horizontal gene transfer.

Horizontal Gene Transfer

Unlike vertical transmission, where a parent bacterium passes genes to its offspring, horizontal gene transfer (HGT) allows resistance genes to move laterally between entirely different bacterial species. The primary vehicle for carbapenemase gene transfer is the plasmid: a small, circular piece of DNA that sits in the bacterium’s cytoplasm separate from the main chromosome and can be readily copied and passed to neighbouring organisms through a process called conjugation. Plasmids are frequently mobile genetic elements; some can transfer themselves to bacteria of entirely different genera, or even different phyla.

Research published in The Lancet Microbe in 2023 demonstrated just how actively this process occurs in real-world bacterial communities within hospital sewage. Using CRISPR-tagged plasmids, the study tracked the transfer of NDM-5-positive plasmids across multiple bacterial phyla within a hospital wastewater treatment system, the first culture-independent evidence of interphylum gene transfer in such an environment ⁴.

Plasmids and transposons also carry integrons, genetic structures that can capture and accumulate multiple resistance genes, creating bacteria resistant to several antibiotic classes simultaneously.

Crucially, horizontal gene transfer does not require contact between clinical pathogens. It can occur among the broader microbial communities that inhabit wastewater, river sediments and agricultural soil. At this is point we have to consider the problem of sewage pollution.

The UK’s Sewage Problem

The United Kingdom’s waterways are in a dire state. Routine sewage overflows, inadequate wastewater treatment and agricultural runoff have created conditions in which antibiotic-resistant bacteria and resistance genes are accumulating in rivers, lakes and coastal waters. Every water body in England currently fails the Water Framework Directive standards for ecological quality - a systemic failure with direct implications for AMR.

A 2024 study led by the University of York, conducted in partnership with Surfers Against Sewage, tested 23 designated inland bathing sites across England, Wales and Scotland. Antimicrobial resistance genes were detected at all sites but one; the most heavily contaminated - the River Dart in Devon - harboured 53 of the 71 resistance genes tested for. Among those detected were genes conferring resistance to last-resort antibiotics ⁵.

In February 2026, research from Index Microbiology found that 97% of water samples taken from Oxford’s rivers tested positive for bacteria producing extended-spectrum beta-lactamases (ESBLs), a key step on the pathway towards carbapenem resistance ⁶. A 2019 analysis of the River Thames catchment found that large portions of the river system are chronically exposed to antibiotic concentrations sufficient to promote resistance gene selection, even after wastewater treatment, with 64% of the catchment at risk of selection for macrolide resistance and 74% for fluoroquinolones resistance ⁷.

Hospital effluent is a particularly concentrated source. Studies of hospital wastewater in Wales, conducted under the PATH-SAFE programme, found the ‘big five’ carbapenemase gene variants distributed across NHS sites, along with concentrations of antibiotics exceeding thresholds associated with resistance emergence ⁸. When this effluent passes through wastewater treatment plants (WWTPs), treatment reduces but does not eliminate resistance genes. The treated water, along with sewage sludge subsequently applied to agricultural land, then disperses resistant organisms and genetic material into the wider environment.

Animal Agriculture and One Health

Human sewage is not the only source of risk; animal agriculture contributes substantially to antibiotic resistance. Antibiotics used in livestock, including those related to classes used in human medicine, are excreted in manure which can then enter watercourses through runoff. A nationwide wastewater study published in Nature Communications in January 2026 found aminoglycoside resistance genes present at concentrations 50% higher in sewage than in clinical samples, a discrepancy attributed to inputs from poultry, aquaculture and other agricultural sources ⁹.

Studies of rural English rivers, including the Eden in Cumbria and the Coquet in Northumberland, have confirmed that diffuse agricultural pollution, mediated by soil saturation and surface runoff, measurably increases the abundance of resistance genes in river microbiomes¹⁰. In Northern Ireland, veterinary antibiotics have been found downstream of farm sites, consistent with farm runoff as a direct source. This runoff, along with the disposal of treated and untreated human sewage, is implicated in the heavy pollution of Lough Neagh, a water source which supplies approximately 40% of Northern Ireland’s drinking water.

This interplay between human medicine, veterinary practice and environmental contamination is why AMR is increasingly approached from a One Health perspective, recognising that human, animal and environmental health are inseparably linked. The carbapenemase genes accumulating in the rivers of the United Kingdom do not distinguish between clinical and non-clinical bacteria. Through horizontal gene transfer, antibiotic resistance can transfer from environmental organisms to pathogens that subsequently cause human infection.

The Politics of Antimicrobial Resistance

Antibiotic resistance is not a politically neutral crisis. UKHSA data consistently demonstrate that people in the most deprived communities bear a disproportionate burden. In 2022, individuals from the most deprived 10% of the population were more than twice as likely to carry carbapenemase-producing Gram-negative bacteria than those from the least deprived 10% - rates of 6.8 compared to 2.8 per 100,000 ¹¹. Resistant infections are substantially more common in areas of poverty, where overcrowding, poorer housing conditions, reduced access to timely healthcare and higher baseline rates of comorbidity combine to increase both vulnerability and exposure.

The communities most likely to swim in polluted rivers, to live near water company sewage overflow points or to work in agricultural settings with high antibiotic use are rarely those with the most political or economic power to demand regulatory action. This is an environmental justice failure as much as a scientific one.

The UK Response

The UK published a new five-year National Action Plan (NAP) for antimicrobial resistance in 2024, setting targets including a 5% reduction in total antimicrobial use in humans by 2029 relative to 2019 levels, and strengthened One Health surveillance ¹². There has been progress: overall NHS antibiotic use in 2024 was 2% below the pre-pandemic 2019 baseline. But the trend remains concerning, with resistant bloodstream infections continuing to rise and the surveillance gap between human and animal sectors still inadequately closed. The National Audit Office and Public Accounts Committee both highlighted in early 2025 that further action is urgently required.

On the environmental front, antibiotics discharged into rivers and waterways remain largely unregulated. No environmental quality standards currently exist in England for antibiotic concentrations in surface water, a gap that researchers in the field have called untenable given the evidence of resistance selection at concentrations which are routinely exceeded ⁷. Wastewater surveillance for AMR, pioneered during the COVID-19 pandemic, is now being extended; Wales is among the early adopters of national hospital wastewater screening for carbapenemase genes. But upgrading wastewater treatment infrastructure to reliably remove resistance genes remains a longer-term, expensive ambition. It is an upgrade that the water companies have not convincingly prioritised in the past.

Conclusion

The spread of carbapenem resistance represents a significant risk to medicine and to health. Procedures that depend on reliable antimicrobials, such as major surgery, cancer chemotherapy, organ transplantation, the care of premature infants, become more dangerous when bacterial infections that were once treatable can no longer be controlled.

The sewage crisis contaminating Britain’s rivers isa significant factor. Environmental reservoirs of resistance genes, amplified by HGT in microbial communities and dispersed by failing water infrastructure and agricultural runoff, represent a source of developing resistance that clinical antibiotic stewardship alone cannot address. Reducing medical use of antibiotics, though desirable, will have little effect unless all the other factors are addressed.

Tackling this will require enforced reductions in agricultural antibiotic use, no more antibiotic prescriptions for viral chest infections, the development and dissemination of vaccines for bacterial infections, enforceable regulation of antibiotic discharges into waterways, investment in wastewater treatment capable of removing resistance genes, and a recognition that the communities most harmed by environmental AMR are those already least supported by the systems meant to protect them. The science is clear. The politics is hazy. The effects of profiteering are disastrous.

References

1. UK Health Security Agency. Nearly 400 antibiotic-resistant infections each week in 2024 [Internet]. London: UKHSA; 2025 [cited 2026 Mar 14].

2. GBD 2021 Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050. Lancet. 2024;404(10459):1129–61.

3. World Health Organization. WHO Bacterial Priority Pathogens List, 2024: bacterial pathogens of public health importance to guide research, development and strategies to prevent and control antimicrobial resistance. Geneva: WHO; 2024.

4. Prof Qiu E Yang, Xiaodan Ma, Lingshuang Zeng, Qinqin Wang, Minchun Li, Lin Teng, Mingzhen He, Chen Liu, Mengshi Zhao, Mengzhu Wang, Deng Hui, Jonas Stenløkke Madsen, Hanpeng Liao , Prof Timothy R Walsh, Prof Shungui Zhou. Interphylum dissemination of NDM-5-positive plasmids in hospital wastewater from Fuzhou, China: a single-centre, culture-independent, plasmid transmission study. Lancet Microbe. 2024;5(1):e13–e23.

5. University of York. UK inland bathing sites polluted by chemicals and antibiotic-resistant genes [Internet]. York: University of York; 2024 [cited 2026 Mar 14].

6. Morley R. Antibiotic-resistant bacteria in Oxford rivers [Internet]. Oxford: Index Microbiology/Oxford Daily News; 2026 Feb [cited 2026 Mar 14].

7. Singer A, Quiying Xu, Keller VDJ. Translating antibiotic prescribing into antibiotic resistance in the environment: a hazard characterisation case study. PLoS One. 2019;14(9):e0221568.

8. Reshma Silvester, William B. Perry, Gordon Webster, Laura Rushton, Amy Baldwin, Daniel A. Pass, Neil Andrew Byrnes, Kata Farkas, Margaret Heginbothom, Noel Craine, Gareth Cross, Peter Kille, Barbara Kasprzyk-Hordern, Andrew J. Weightman, Davey L. Jones. Metagenomic profiling of hospital wastewater: a comprehensive national scale analysis of antimicrobial resistance genes and opportunistic pathogens. J Infect. June 2025.

9. Paul D, Dutta B, Gupta A, Bhattacharya S. Hospital superbugs are circulating through urban sewage. Nat Commun. 2025

10. Katie Robins, Greg O'Donnell, Anke Neumann, Wiebke Schmidt, Alwyn Hart, David W. Graham. Antimicrobial resistance in rural rivers: comparative study of the Coquet (Northumberland) and Eden (Cumbria) river catchments. Sci Total Environ. 2024;Volume 928, 10 June 2024, 172348.

11. UK Health Security Agency. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report 2022 [Internet]. London: UKHSA; 2022

12. UK Government. UK 2024 to 2029 antimicrobial resistance national action plan [Internet]. London: HM Government; 2024 [cited 2026 Mar 14].

Integrons are bacterial genetic mechanisms that enable the rapid adaptation and evolution of bacteria by capturing, storing, rearranging, and expressing gene cassettes.

Integrons are primarily found in bacteria, where they serve as genetic platforms for capturing and expressing mobile genes. Approximately 15–17% of all sequenced bacterial genomes contain these elements.

National Institutes of Health (NIH) | (.gov) +4

They are typically found in two distinct genetic contexts:

• Bacterial Chromosomes: Many integrons are sedentary components of the host chromosome. These “chromosomal integrons” (sometimes called super-integrons) can be very large, carrying hundreds of gene cassettes that contribute to general bacterial adaptation and evolution.

• Mobile Genetic Elements (MGEs): Integrons are frequently found on plasmids and transposons. These “mobile integrons” (MIs) are much smaller, typically carrying fewer than ten cassettes, and are the primary drivers for spreading antibiotic resistance in clinical settings.

• Wikipedia +4

Environmental Distribution

Beyond clinical isolates, integrons are ubiquitously distributed in diverse natural habitats, including:

• Aquatic Environments: Freshwater (rivers, lakes, and hot springs) and marine environments (deep-sea sediments and aquatic biofilms).

• Terrestrial Environments: Forest, desert, and Antarctic soils.

• Human-Impacted Sites: Wastewater treatment plants, hospital effluents, and agricultural areas treated with manure.

• Biological Surfaces: On the surfaces of plants and in the symbionts of eukaryotes

• Gene Cassettes: These are small, mobile, circular DNA elements, often carrying a single, promoterless antibiotic resistance gene.

• Transposons, or "jumping genes," are DNA sequences that move (transpose) from one location to another within a genome.

OK, no towns were actually completely depopulated but the epidemic of English sweating sickness had a significant and devastating effect upon the communities it affected. The 1551 outbreak was centred around the town of Shrewsbury from where it spread, locally at first to Oswestry, Presteigne, and, a bit further, to Chester, eventually reaching London in after about three months. T the time of the outbreak, the population of Shrewsbury is thought to have been between 3,000 and 5,000. The sickness claimed 1,000 of those lives, with many more people fleeing the area. The town population fell significantly.

This pattern was to repeat throughout England.

English sweating sickness surfaced in 1485, in the weeks around Henry VII’s seizure of the English throne, and struck in a series of epidemics before disappearing for good after 1551. In between, it left a trail of sudden death and a puzzle that medicine has never solved.

Contemporaries described a horrifyingly rapid illness. A person could feel perfectly well at dinner and be dead by morning. The symptoms began with a sense of apprehension and dread, then cold shivers, aching limbs, headache and dizziness. This gave way to the phase that named the disease: a drenching, malodorous sweat, a pounding heart, breathlessness, and collapse. Survival or death was often decided within a single day. Those who lived through twenty-four hours generally recovered; many were dead before the day was out.

The sweat had odd characteristics that still baffle historians and epidemiologists. Unlike most epidemics of the era, it seemed to prefer the young, the fit, and the affluent — striking robust men in their prime rather than the old and frail. It ravaged England while largely sparing Scotland, Wales, and Ireland. And in its final major appearance in 1528, it leapt across the Channel to sweep through the German lands, Scandinavia, and the Low Countries, while curiously bypassing France and Italy almost entirely, before receding again.

Its reach touched the highest levels of Tudor society. Anne Boleyn is said to have caught and survived it in 1528, while others in Henry VIII’s circle were not so fortunate, and the king himself fled from residence to residence in fear of it. The last outbreak, in 1551, produced the one detailed medical account we have, from the physician John Caius, who set down its symptoms and course in a short treatise.

Then the sickness simply was gone.

There are many theories. Some researchers favour a hantavirus carried by rodents, pointing to the sudden respiratory collapse that hantaviruses can cause. Others have proposed a relapsing fever spread by ticks or lice, an unknown strain of influenza, or even a form of anthrax. The trouble is that no theory accounts for all the disease’s speed, social selectivity or its limited geography and, crucially, no physical trace survives.

From a modern view, the symptoms are consistent with sepsis, but what was the cause?

The sweating sickness therefore remains a genuine cold case: a lethal illness that shaped the anxieties of Tudor England, then slipped out of the historical record just before medicine developed the tools that might have caught it.

In July 1518, a woman remembered only as Frau Troffea stepped into a lane in Strasbourg and began to dance. There was no music, no festival, no evident reason — she just danced and would not stop. She danced through the day and into the night, when at last she dropped from exhaustion. After a brief rest she got up and started dancing again. Within days a handful of others had joined her. Within a month, according to the city’s chronicles, the compulsive dancers numbered in the hundreds.

Witnesses described faces contorted with distress, bodies slick with sweat, feet bloodied and bruised. Some of the dancers reportedly collapsed and died though the true death toll is impossible to verify from the surviving records.

The response of the authorities now appears naive. Strasbourg’s physicians, working from the medical theory of the day, concluded that the dancing arose from “hot blood” and that the only cure was to let the sufferers dance it out of their system. So the city cleared two guildhalls, roped in professional pipers and drummers, and even erected a wooden stage. Predictably, the intervention made everything worse: the spectacle drew in still more dancers, and the mania fed on itself.

What actually happened is still uncertain. One long-standing theory blames ergot, a psychoactive mould that grows on damp rye and can trigger convulsions and hallucinations. But ergot poisoning causes fits and tends to constrict blood flow to the limbs, causing pain and gangrene rather than sustained, coordinated dancing.

The explanation favoured by most historians today is mass psychogenic illness: a collective stress response in a population ground down by famine, disease, and the constant dread of divine judgement. Strasbourg in 1518 was perfect for this.

Locals also feared St. Vitus, a saint believed capable of cursing sinners with compulsive dancing, a belief that may have shaped the form of the affliction, the mind reaching for a template already lodged in the culture.

The episode is among the best-documented outbreaks of its kind, preserved in physician notes and municipal records. But it was not unique: similar dancing manias had rippled through the Rhine and Mosel regions for at least a century and a half, with a notable outbreak in 1374. But Strasbourg remains the most vivid and unsettling exapmle; a case study in how the mind, under sufficient pressure and given the right cultural background, can drive the body to lethal extremes we still cannot fully explain.

The Bundibugyo Ebola outbreak in the Democratic Republic of the Congo and Uganda continues to escalate. As of 25 June, the DRC Ministry of Health had confirmed 1,155 cases and 304 deaths, with Uganda reporting no new cases since 5 June. The outbreak has now reached Europe. France confirmed its first case on 24 June in a healthcare worker who had been deployed to the DRC, joining an earlier case medically evacuated to Germany in May. However, The European Centre for Disease Prevention and Control (ECDC) assesses the risk to the EU/EEA general population as very low.

The response to the outbreak is hampered by the absence of an approved vaccine or treatment for the Bundibugyo strain; the existing Ervebo vaccine, effective against the more common Zaire species, has been judged by WHO to lack sufficient evidence of cross-protection. Three vaccine candidates (from IAVI, Moderna, and Oxford) are being fast-tracked through CEPI funding, alongside trials of remdesivir and two monoclonal antibody therapies.

The Ebolaviruses are reverse RNA viruses and are subject to a high rate of mutation - and the emergence of different strains.

Hantavirus: Nebraska Quarantine Concludes After Six Weeks

The hantavirus story linked to the cruise ship MV Hondius has reached its resolution. The last eight American passengers completed their 42-day quarantine at the National Quarantine Unit in Omaha, Nebraska, on 22 June, bringing to a close what HHS (US Department of Health and Human Services) described as a successful response. The global cluster ultimately comprised 11 confirmed and probable cases and three deaths, with a delayed case also confirmed in a Spanish evacuee weeks after disembarkation.

The Andes virus strain involved is unusual among hantaviruses in its capacity, in rare cases, for limited person-to-person transmission via prolonged close contact, the reason for the unusually long and cautious monitoring period. However, compared to other viruses, human-to-human transmission is extremely low and required prolonged close contact (R0 ~ 1, barely enough to sustain an epidemic, compared to measles virus R0 >12 and seasonal flu R0 ~ 1.5).

AI-Designed Pan-Coronavirus Vaccine: Cambridge Team Sets Sights on Phase II

Cambridge spin-out DIOSynVax’s pEVAC-PS, the first vaccine whose active component was designed entirely by AI to pass human testing, remains safe and well-tolerated across all four Phase I dose levels, with cross-reactive antibodies detected against SARS-CoV-2, SARS, and related bat sarbecoviruses. Professor Jonathan Heeney has confirmed the team is now adapting the same AI antigen-design pipeline for influenza and Ebola-family vaccines. Published pre-clinical work already shows a pan-H5 avian influenza candidate generating neutralising antibodies against all 12 tested clades (distinct viral evolutionary branches) in mice.

The platform’s thermostability and needle-free delivery offer genuine advantages for low-resource deployment, but pEVAC-PS remains a commercially structured product of a UK university spin-out, funded through Innovate UK. No access framework has yet been described for Phase II or beyond.

UK Healthy Life Expectancy Falls to Lowest on Record — and the UK Now Trails Most Peer Nations

The Health Foundation’s briefing for the 1 June Second Reading of the Health Bill lays out the starkest picture yet of declining UK population health. Healthy life expectancy fell by roughly two years over the decade 2012–14 to 2022–24, to 60.7 years for men and 60.9 for women — with steep declines across England, Scotland, and Wales. As a result, the UK has fallen from 14th to 20th among 21 comparable high-income countries; only the United States now scores lower. The UK is one of just five of those 21 countries where healthy life expectancy fell at all between 2011 and 2021, and recorded the second-steepest decline of any of them.

The inequality gradient is severe and widening. The gap in healthy life expectancy between the most and least deprived deciles in England now stands at 19.4 years for men and 20.3 years for women. In Scotland, women in the least deprived areas can expect 24.2 more years of healthy life than women in the most deprived areas. The Health Foundation projects roughly 700,000 more working-age people will be living with major illness by 2040 — 80% of them in more deprived areas.

The health gap is widening and closely reflects the widening wealth inequalities. While life-expectancy might not be affected, the poor can expect to spend more of their later years in significant ill-health. The rich get richer while the poor become sicker - an effect of the World’s hideously skewed, and unfair, wealth distribution.

AMR in England: Resistant Infections Up 13% as Inequality Gap Widens

UKHSA’s ESPAUR 2024–25 report confirms that drug-resistant infections in England rose 13.1% over the five years to 2024, even as antibiotic consumption fell 2% from pre-pandemic levels. Concerning developments include continued increases in resistant E. coli, the emergence of ceftriaxone-resistant gonorrhoea, and dual-resistant Mycoplasma genitalium — both signalling the narrowing of treatment options for common infections.

This year’s report makes the social gradient explicit for the first time: the rate of resistant bacteraemia is 47% higher in the most deprived areas of England compared with the least deprived, a gap that has widened by 18% since 2019. AMR, like so much else in this newsletter, is not distributed randomly, and the UK’s own surveillance data now confirms it.

ECDC Warns of Earlier, Larger Dengue and Chikungunya Risk Across the EU

The European Centre for Disease Prevention and Control has flagged an unusually early start to this year’s chikungunya transmission season in mainland Europe, with the first locally acquired cases reported in late May/early June, weeks earlier than the typical July–August onset. ECDC attributes the early start to elevated pressure from imported cases, particularly from the Indian Ocean region, in areas where the Asian tiger mosquito (Aedes albopictus) - the vector for the chikungunya, dengue and zika viruses - is now well established.

The role of climate change

The trend reflects a broader pattern of northward arboviral expansion. A 2025 study found that recent climate change has measurably accelerated Ae. albopictus range expansion in France, with the dengue transmission risk zone extending from Mediterranean coastal regions to northern Spain and western France; researchers project that by the 2050s, arbovirus transmission could become possible as far north as Scandinavia. France recorded a record 228 locally acquired chikungunya cases in 2025 — compared with just 32 cumulative locally transmitted cases across the entire 2010–2024 period — including an unprecedented cluster in Alsace, which ECDC called “an exceptional occurrence at this latitude.” Italy recorded 213 autochthonous (indigenous, locally acquired) dengue cases in 2024 alone.

Why is the Aedes albopictus mosquito so important?

Aedes albopuctus has several biological characteristics that make it far better suited to temperate European expansion:

• Its eggs undergo diapause — a dormancy state triggered by shortening day length — allowing them to survive cold winters

• It tolerates a broader temperature range and is active at lower ambient temperatures

• It breeds readily in small artificial water containers (tyres, flower pot saucers, gutters, garden water features) — making urban environments particularly hospitable

• It is an opportunistic feeder that bites a wide range of hosts, including birds, maintaining enzootic (constantly present in a locality) cycles that can amplify transmission risk

The combination of these traits — cold tolerance, urban adaptability, broad host range, and competence for multiple pathogens — is why climate-driven northward range expansion of Ae. albopictus represents a different public health challenge from most vector-borne disease risks previously encountered in northern and central Europe. It is also spreading northwards in the United States.

Vector-borne disease expansion driven by climate change does not respect borders, but its public health burden falls hardest on regions with the weakest mosquito surveillance and vector control infrastructure — often the same lower-income municipalities least equipped to fund proactive Aedes control programmes.

Further Reading

1. WHO. Ebola disease caused by Bundibugyo virus, Democratic Republic of the Congo & Uganda. 19 June 2026.

2. ECDC. Ebola disease outbreak in the Democratic Republic of the Congo and Uganda. 26 June 2026.

3. CDC. Ebola Outbreak: Current Situation. June 2026.

4. 2026 Ebola epidemic. Wikipedia, citing WHO/CEPI/MSF reporting. June 2026.

5. Medical Daily. Americans Are Still in Nebraska Quarantine from the Cruise Ship Hantavirus Outbreak. June 2026.

6. Washington Times. Quarantine comes to an end for the last of the hantavirus ship passengers in Nebraska. June 2026.

7. TechTimes. AI-Designed Universal Coronavirus Vaccine Passes First Human Trial: Cambridge Team Eyes Phase II. June 2026.

8. University of Cambridge. New “universal vaccine” technology could protect us from future virus outbreaks. June 2026.

9. The Health Foundation. Briefing: Health Bill, Second Reading, Monday 1 June 2026.

10. The Health Foundation. Trends in life expectancy and healthy life expectancy.

11. UKHSA. English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2024 to 2025.

12. PMC. The English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2024-25.

13. ECDC. Chikungunya virus disease risk assessment for mainland EU/EEA.

14. ECDC. Dengue.

15. Radici A et al. Aedes albopictus Is Rapidly Invading Its Climatic Niche in France. Global Change Biology. 2025.

16. Science (AAAS). Mosquito-borne viruses surge in a warming Europe. September 2025.

2 July 2026

An analysis published this week in The BMJ projects that the pharmaceutical trade agreement signed by the United Kingdom and United States last December will divert approximately £44.7 billion from NHS services in England by 2036, with modelling suggesting this reallocation could result in 229,000 excess preventable deaths over the same period, so exceeding the disastrous 137,000 excess deaths recorded in the UK during the COVID-19 pandemic between March 2020 and June 2022.

The analysis, conducted by researchers at the University of York, the University of Liverpool, and Christchurch Hospital in New Zealand, is the first published attempt to quantify the population-health consequences of the deal, which the government announced on 1 December 2025 as a landmark agreement to safeguard medicines access and drive investment in UK life sciences.

The terms of the deal

Under the agreement, the United States committed to a zero tariff on UK pharmaceutical and medical device exports for three years, until January 2029, a concession secured against the implied threat of tariffs of up to 100% on medicines imported into the US. In exchange, the UK government committed to more than doubling NHS expenditure on new branded medicines, from 0.3% of GDP to at least 0.6% by 2036, with interim targets of 0.35% in 2028 and 0.4% in 2030. This shifts overall medicines spending from roughly 10% to 12% of the NHS budget.

The deal also substantially weakened the Voluntary Scheme for Branded Medicines Pricing, Access and Growth (VPAG), the rebate mechanism designed to cap growth in NHS branded-medicines expenditure. The industry rebate rate, 23% in 2025, has been cut to 14.5%, reducing one of the principal safeguards against drug-cost inflation at precisely the moment prices are set to rise.

The projected costs

Assuming the spending targets are met and the economy grows in line with Office for Budget Responsibility forecasts, the authors calculate the NHS will need to find an additional £1.3 billion per year by 2028, rising to £8.8 billion per year by 2036, cumulatively around £44.7 billion by the end of the agreement period. The government’s own public position is that the deal will cost only about £1 billion extra between 2025–26 and 2028–29; it has conceded that costs will rise thereafter but has declined to publish estimates. In February, science minister Patrick Vallance confirmed the costs would fall on the Department of Health and Social Care rather than the Treasury, without new funding they must be absorbed from within existing NHS allocations made six months before the deal was agreed.

From opportunity cost to mortality

The study treats this diverted expenditure as an effective defunding. Because NHS spending on services such as prevention, diagnostics, elective care, community services generates better health results at a lower cost per quality-adjusted outcome than new branded medicines, redirecting funds toward higher drug prices produces a net health loss.

The authors’ modelling puts the loss at 229,000 excess preventable deaths in England by 2036, concentrated among patients with cardiovascular, respiratory, and gastrointestinal disease and cancer, with broader quality-of-life effects predicted for those with neurological, endocrine, musculoskeletal, and mental health conditions - a large section of the population.

The figure rises to 291,000 when knock-on effects on publicly funded adult social care are included: modelling of English local authority data indicates that each £1 billion the NHS must divert to fund the deal increases adult social care costs by around £118 million through rising morbidity and mortality.

Co-author Samuel Cross, professor of pharmacology and therapeutics at the University of Liverpool, told Al Jazeera that the agreement’s beneficiaries are pharmaceutical companies rather than NHS patients, and that ”the numbers speak for themselves.”

Diminished economic rationale

The analysis also challenges the economic case for the concessions. A US Supreme Court ruling has since reduced the tariff exposure the deal was designed to avert from 100% to 10%, substantially shrinking the value of the exemption. The UK is a net importer of medicines, and the projected incremental costs to the NHS are expected to exceed the entire annual value of UK medical exports to the US (approximately £5 billion) before 2031.

The authors are similarly sceptical of claims that higher UK prices will stimulate domestic pharmaceutical innovation, noting that the UK represents a small share of a global R&D market and that there is little evidence domestic pricing materially shifts global investment decisions. Their assessment is that the UK already pays at or above the long-term value of most new medicines.

Calls for transparency

The Department of Health and Social Care has completed an impact assessment of the deal’s wider costs but has not published it — a point seized upon across the political spectrum. Sir Ciarán Devane, chief executive of the NHS Alliance, said the analysis raised serious questions about whether the agreement represents value for patients, and urged the government to publish the full impact assessment so the deal can receive proper scrutiny. Liberal Democrat health spokesperson Helen Morgan described the findings as alarming and called for the government’s own impact review to be released. MPs from Labour and several opposition parties have made the same demand. The campaign group Global Justice Now has previously characterised the deal as sacrificing, NHS services to satisfy US and industry pressure for higher medicine prices.

The authors conclude that the arrangement raises fundamental questions of transparency and accountability, a health system designed to deliver equitable, patient-centred care now positioned, in their words, as underwriting risk in global pharmaceutical markets.

---

Source:

Health costs of the UK-US trade deal on pharmaceuticals. BMJ 2026. doi:10.1136/bmj-2026-340588

Caveat:

The source is a BMJ Analysis piece, and the excess-deaths figure rests on assumptions about the marginal cost per QALY of displaced NHS spending, and those threshold estimates are contested.

An AI-designed vaccine targeting the entire sarbecovirus family, the coronavirus subgroup responsible for both the 2003 SARS outbreak and COVID-19, has passed its first human clinical trial, researchers at the University of Cambridge have announced.

The vaccine, pEVAC-PS, was developed by Cambridge spin-out DIOSynVax using an AI platform that analysed global genetic sequence data across all known sarbecoviruses and identified the conserved molecular features shared by the entire family. Rather than targeting a specific strain, it encodes a synthetic “super-antigen” representing a common factor of a virus group and is explicitly designed to remain effective even as new variants emerge.

In a phase I dose-escalation trial involving 39 healthy volunteers at NIHR facilities in Cambridge and Southampton, pEVAC-PS was safe and well-tolerated at all doses. The team detected cross-reactive antibody responses against multiple sarbecoviruses, including SARS-CoV-2, SARS, and related bat coronaviruses.

There are caveats: the trial was designed for safety rather than efficacy, neutralising antibody responses were not robust, and pre-existing coronavirus immunity in most participants complicates interpretation. A larger Phase II trial is planned. The same AI platform is being developed for influenza and haemorrhagic fever viruses, including Ebola, fostering hope for future vaccines.

There are further advantages over current vaccination systems. The delivery system used involves a needle-free microfluidic jet and the thermostable DNA platform requires no ultra-cold storage. The DNA vaccine’s thermostability and needle-free delivery are genuine advantages for low-resource settings. But pEVAC-PS is a commercialised spin-out product developed with UK public funding. Without explicit access commitments now, history gives us every reason to ask whether the populations most vulnerable to pandemic coronaviruses will benefit, or whether this will follow the familiar pattern of innovation for affluent markets first.

Full trial data: Munro et al., Journal of Infection, 2026

Five Alerts, One City

As a million international visitors prepare to descend on New York City for the 2026 FIFA World Cup, the city’s public health authorities are managing five concurrent Infectious threats: the ongoing hantavirus quarantine of state residents; an active measles outbreak; an Ebola preparedness posture following the WHO’s declaration of a Public Health Emergency of International Concern for the Bundibugyo strain; a new COVID-19 sub-variant; and West Nile virus. Five separate pathogen threats and a federal public health infrastructure that has been systematically stripped of a quarter of its workforce, its institutional memory, and much of its moral authority to lead.

How the United States arrived at this moment is a story of choices: about what to cut and whose lives to treat as expendable.

The CDC: A Warning System Deliberately Degraded

In February 2025, the Trump administration’s Department of Government Efficiency (DOGE) began its assault on the Centers for Disease Control and Prevention. Approximately 1,270 staff — close to 10% of the agency’s workforce — were dismissed in the initial wave. Among those let go were fellows from the Laboratory Leadership Service, the specialist corps responsible for training public health laboratory leaders and supporting outbreak response. The Epidemic Intelligence Service — the CDC’s elite “disease detective” programme, whose officers are deployed to investigate outbreaks across the US and globally — was initially threatened with the loss of its entire first-year cohort, though those officers were ultimately spared after significant public protest.

Other fellowships were not spared, and the pipeline they represented — the next generation of CDC leadership — was severed. “Even if EIS was spared, there are multiple other fellowships that were not,” one senior CDC official told reporters. “We’re being cut off at the knees. It is going to cripple public health for decades.”

The cuts did not stop there. Since January 2025, the CDC has lost close to 3,000 employees in total — nearly a quarter of its entire workforce — through layoffs, forced retirements, and resignations triggered by the chaos of political interference and leadership instability. In August 2025, HHS Secretary Robert F. Kennedy Jr. fired CDC Director Susan Monarez after she refused to accept political interference with the agency’s scientific mission, prompting multiple senior leaders to resign in protest. The agency has now operated without Senate-confirmed leadership for almost the entire period of the measles crisis. A survey of 433 current and 191 former CDC staff conducted between February and April 2026 documented the effects: communication freezes, scientific interference, and an institution whose systems and institutional memory have been hollowed out even as its remaining staff try to hold the line.

The former CDC Chief Operating Officer Robin Bailey, speaking publicly in June 2026, was measured but unambiguous: “We lost a lot of talent. Many of the things that we put in place — I’m not sure that they’re operating in the same way.” He had spent years building the operational infrastructure to deal with multi-pathogen crises like the CDC was now facing — the hantavirus cluster, the Ebola outbreak, the measles surge. The reforms have been put in place but the workforce responsible has been dismantled.

The Measles Catastrophe: Policy, Misinformation, and Preventable Deaths

Robert F. Kennedy Jr., confirmed as HHS Secretary in February 2025, is the founder of Children’s Health Defense, one of the most influential anti-vaccine organisations in the United States. His record of spreading vaccine misinformation stretches back decades: false claims linking the MMR vaccine to autism, assertions that “there is no vaccine that is safe and effective,” and sustained campaigns to erode public confidence in childhood immunisation schedules. His appointment placed the person most responsible for the ideological conditions enabling the measles resurgence in direct control of the agencies charged with stopping it. This seems to be a pattern.

The results were immediate. On 26 February 2025 — the day after Kennedy was confirmed — the first measles death in the United States in more than a decade was reported in Texas: an unvaccinated eight-year-old girl. Kennedy’s response was to tell the White House Cabinet meeting that measles outbreaks were “not unusual.” A fortnight later, a second child died. Kennedy told Fox News that the MMR vaccine “kills people every year,” causes “the same symptoms as measles,” and “does not appear to provide maternal immunity.” Texas state health officials confirmed both deaths were caused by measles, Kennedy falsely implied otherwise.

By March 2026, more than 3,800 measles cases had been reported across US states since January 2025 — the largest sustained outbreak in a generation. The Americas as a whole recorded over 21,000 confirmed cases in the first five months of 2026, a 234% increase on the same period in 2025. In January 2026, the CDC reduced its childhood immunisation schedule from 17 recommended vaccines to 11, removing six from universal recommendation at the direction of President Trump and Kennedy. Legal experts questioned the administration’s authority to implement this change without Senate approval. Public health experts warned it would further erode vaccine uptake at the worst possible moment.

The United States has held measles elimination status since 2000 (no sustained domestic transmission for twelve consecutive months). PAHO’s Regional Monitoring Commission has now invited both the US and Mexico to review their elimination status. If the US loses it, the achievement of a generation of public health work will have been undone in under two years.

USAID and the Global Retreat

On 20 January 2025, President Trump signed an executive order initiating the United States’ withdrawal from the WHO and imposing a 90-day freeze on all USAID activities globally. Within weeks, DOGE had effectively dismantled USAID as an operational agency, absorbing its remnants into the State Department. By March 2025, 83% of USAID’s approximately 6,200 global programmes had been permanently terminated.

HIV clinics across sub-Saharan Africa received immediate “work stop” letters and closed within days, cutting approximately 20 million people supported by PEPFAR off from antiretroviral medicine. Measles mass vaccination campaigns, running in regions already experiencing surging outbreaks, were halted without notice. Malaria vaccine rollouts were disrupted. Nutrition programmes ended. The WHO, which had received approximately 18% of its funding from the United States, was forced to begin cutting staff and programmes to close a 25% budget shortfall that it has not yet recovered.

Conservative academic estimates calculated that USAID programme cancellations could contribute to 500,000 to 700,000 additional deaths annually. A year on from the cuts, a whistle-blower writing in the Boston Globe placed the confirmed toll at 750,000 additional deaths in 2025, and noted that for the first time in a generation, more children died in a single year than in the year before. The same article observed that the Bundibugyo Ebola outbreak, now a PHEIC (Public Health Emergency of International Concern), took far longer to identify than previous outbreaks because the US retreat from the global health stage had removed critical early warning and surveillance infrastructure from the region where the outbreak began.

The US withdrawal also directly undermined the outbreak response tools available for Bundibugyo. DOGE’s cuts included the NIH Vaccine Research Centre, the institution responsible for discovering the Ebola vaccines now deployed against the more common Zaire strain. Bundibugyo has no approved vaccine or treatment. The US was the world’s largest source of funding for the global health architecture that might have accelerated countermeasure development. That architecture has been dismantled.

The World Cup as Diagnostic

New York’s five concurrent public health alerts, viewed in context, are diagnostic: an example of what happens when you systematically degrade public health surveillance, outbreak response capacity, vaccine confidence, and global early-warning systems simultaneously, and then host a mass gathering of one million international visitors.

The pathogens themselves (measles, hantavirus, Ebola, West Nile, COVID) are not novel. What is new is the environment in which they are now operating. Measles has an R0 of 12–18; in a population where vaccination coverage has been eroded by eighteen months of mixed and misleading messaging from the country’s most senior health official, a mass gathering is not a contained risk. Hantavirus is normally a sporadic zoonosis; the quarantine management of the cruise ship cluster has been competent, but the outbreak response capacity that would normally back this up has been thinned. Ebola preparedness is only as reliable as the surveillance systems and those systems have been cut.

Public health infrastructure is not visible until it fails. It does not appear on a balance sheet as an asset. Its value is measured in the crises that do not happen, the outbreaks that are caught early, the deaths that are prevented rather than mourned. DOGE’s idiotic logic was that you could measure government efficiency by counting headcount and cutting it. The logic of infectious disease is different: the cost of dismantling a warning system is paid later, by people who had no say in the decision.

In the US, the measles outbreak has fallen hardest on unvaccinated children in low-income and marginalised communities where vaccine access was already uneven and misinformation spread readily. Globally, the populations most affected by USAID terminations were those already carrying the greatest burden of preventable disease: sub-Saharan Africa, South and Southeast Asia, conflict-affected, and poor, regions where US-funded health infrastructure was often the only infrastructure available.

The fiscal justification for DOGE’s cuts rested upon treating global health spending as discretionary foreign largesse. What it actually was, and what the past eighteen months have demonstrated, is a form of collective insurance: investment in outbreak detection and containment in regions far from the US border that directly protects the US from the pathogens those regions would otherwise export. Cutting it did not eliminate the risk. It transferred the cost — from the federal balance sheet to the children in Texas, patients in African HIV clinics, and a global surveillance system now operating with a structural gap where the world’s largest contributor used to be.

The World Cup will pass. The five alerts will be managed, one way or another. But the institutional damage to the CDC, the erasure of a generation’s worth of global health infrastructure, and the active promotion of vaccine misinformation from within the US government will outlast any tournament. The question for the next administration is how long it takes to rebuild what has been destroyed by the Trump administration, and how many preventable deaths will occur between now and the return of a sensible health policy.

Further Reading.

1. KFF. Measles Elimination Status: What It Is and How the U.S. Could Lose It. April 2026.

2. Fortune. We lost a lot of talent: The man who overhauled the CDC before the DOGE cuts. June 2026.

3. The Conversation. How cuts to CDC are dismantling its capacity to protect Americans’ health. June 2026.

4. BTOL. Trump Administration Cuts Nearly 10% of CDC Workforce, Eliminates Half of Disease Intelligence Officers. February 2025.

5. STAT News. Federal health officials slash recommended childhood vaccinations. January 2026.

6. FactCheck.org. A Timeline of RFK Jr.’s Mixed Messaging on the Measles Vaccine. May 2026.

7. Offit P. Another Child Dies from Measles. Substack. April 2025.

8. Contagion Live. Public Health Wake-Up Call: Will the US Lose Measles Elimination Status? 2025/2026.

9. STAT News. WHO issues starkest warning yet on fallout from U.S. withdrawal of aid for global health. March 2025.

10. Health Policy Watch. One Year Later: The Effect of US “Chainsaw” on Global Health. January 2026.

11. Center for Global Development. Update on Lives Lost from USAID Cuts. December 2025.

12. Boston Globe. I blew the whistle on DOGE’s dismantling of USAID. June 2026. (Paywall)

13. PMC. USA’s exit from the WHO and freeze on USAID funds globally. Frontiers in Public Health. 2025.

14. The Lancet. The perils of RFK Junior’s anti-vaccine leadership for public health. December 2024.

Since its discovery in 1976, Ebola virus has caused more than 40 confirmed outbreaks across sub-Saharan Africa, sixteen of them in the Democratic Republic of Congo (DRC). Health systems in the region have developed protocols, trained responders, and, since 2019, relied on a licensed vaccine to reduce transmission among those most at risk. That vaccine, rVSV-ZEBOV (Ervebo), has been a critical tool. It works against the Zaire strain, which has driven virtually every major DRC outbreak. But the 2026 outbreak is different.

On 15 May 2026, the DRC Ministry of Health declared an Ebola outbreak in Ituri Province in the north-eastern part of the country. The causative agent is Bundibugyo virus (BDBV), a rare Ebola species for which there is no approved vaccine and no approved treatment. Within 24 hours, cases had crossed the border into Uganda. Within 48 hours, a confirmed case was identified in Kinshasa, the DRC’s capital, some 1,700 kilometres from the epicentre. On 17 May 2026, the World Health Organisation (WHO) declared the outbreak a Public Health Emergency of International Concern (PHEIC).

As of 16 May, there were 246 suspected cases and 80 suspected deaths across at least three health zones in Ituri, alongside three laboratory-confirmed cases in Uganda and Kinshasa. These numbers almost certainly understate the true incidence. A high positivity rate in initial testing, eight confirmed positives from just thirteen samples, points to a much larger undetected outbreak.

What is Bundibugyo virus?

The genus Orthoebolavirus contains six recognised species. Four are known to cause disease in humans: Zaire, Sudan, Tai Forest, and Bundibugyo. Zaire has been responsible for the most catastrophic outbreaks, including the 2013–2016 West African epidemic that infected nearly 30,000 people and killed over 11,000. Sudan has caused nine outbreaks since 1976, most recently in Uganda in January 2025. Tai Forest has infected only a single confirmed human case, in 1994.

Bundibugyo virus was first characterised as a distinct species in 2007–2008, when an outbreak struck Bundibugyo District in western Uganda, a region that borders the DRC. That outbreak produced 131 reported cases and 42 deaths. A second outbreak occurred in 2012, in Province Orientale in the DRC, resulting in 38 laboratory-confirmed cases and 13 deaths. Molecular analysis of the 2012 outbreak suggested the possibility of multiple independent spillover events from an animal reservoir, rather than a single introduction with subsequent human-to-human spread.

The 2026 outbreak is therefore only the third documented Bundibugyo event in human history and, by a considerable margin, the largest. It has already surpassed both previous outbreaks combined in suspected case count, and has demonstrated rapid cross-border spread within weeks of its presumed index case.

In clinical presentation, Bundibugyo infection closely resembles Ebola Zaire. Onset is typically sudden, with fever, fatigue, muscle pain, headache, and sore throat - flu-like symptoms - in the early phase, progressing to vomiting, diarrhoea, rash, and haemorrhagic features - internal and external bleeding - in severe disease. The incubation period runs from 2 to 21 days, averaging 8–10 days. One notable difference: the case fatality rate (CFR) for Bundibugyo is estimated at 30–40%, somewhat lower than the 70–90% seen in untreated Zaire outbreaks.

The diagnostic blind spot: how the outbreak grew unseen

A notable feature of this outbreak is how long the virus spread before anyone knew what it was. The earliest known case is a nurse who developed symptoms on 24 April 2026 and died at the Evangelical Medical Centre in Bunia, Ituri’s provincial capital. Yet the outbreak was not declared until 15 May - three weeks later.

The reason lies in a critical diagnostic gap. Field testing for Ebola in the DRC relies heavily on the GeneXpert platform, which is designed to detect Ebola Zaire, the strain responsible for almost all previous DRC outbreaks. When samples from the affected health zones were tested in Bunia, they returned negative. It was only when samples were sent to the National Institute of Biomedical Research (INRB) in Kinshasa, where multi-species Ebola assays are available, that the Bundibugyo strain was identified.

Decades of Zaire-centric outbreaks have shaped surveillance infrastructure, diagnostic capacity, and response protocols around a single viral species. When a different species arrives, with identical clinical features but a different genome, diagnosis can be missed. The result is unchecked community transmission during the period when containment is most achievable.

The head of epidemiology and global health at INRB, Placide Mbala, has been explicit: a rapid field-deployable test capable of detecting Bundibugyo virus is urgently needed. This is an immediate requirement for which no solution is currently available.

Why containment is especially difficult

Ebola outbreaks are always hard to contain. This one more so.

Firstly, there is no vaccine. The rVSV-ZEBOV vaccine, deployed with considerable success in the 2018–2020 DRC outbreak, is specific to Ebola Zaire. It offers no protection against Bundibugyo virus. A ring vaccination strategy, the primary tool that helped control the last major DRC outbreak, is simply not available here. The absence of both vaccine and licensed drug therapy means the entire response burden falls on isolation, contact tracing, infection prevention and control (IPC), and safe burial practices.

Ring vaccination, sometimes called reactive or targeted vaccination, is a strategy in which, rather than vaccinating entire populations, you rapidly identify and vaccinate the social and geographic ‘ring’ of people most at risk around each confirmed case: household contacts, close community contacts, and the healthcare workers who treated them. The logic is to build a protective barrier around the virus before it can reach the wider population, cutting off transmission chains at source.

This strategy, deployed with rVSV-ZEBOV, proved effective during the 2018–2020 North Kivu and Ituri epidemic, which, despite lasting nearly two years in a conflict zone, was ultimately contained without becoming a global catastrophe. By the end of that outbreak, more than 303,000 doses had been administered. Clinical evidence from Guinea’s 2015 Ebola Ça Suffit! trial demonstrated that rVSV-ZEBOV achieved approximately 100% efficacy in vaccinated contacts, giving responders a genuinely powerful and precisely targeted tool.

None of that is available now. With no licensed vaccine for Bundibugyo virus, outbreak control reverts entirely to the pre-vaccine toolkit: early detection, isolation of cases, exhaustive contact tracing, rigorous infection prevention and control (IPC) in health facilities, and safe and dignified burial practices to prevent transmission from deceased individuals. Each of these interventions is demanding under ideal circumstances; in a conflict-affected, resource-constrained setting with a three-week diagnostic delay already embedded, the challenge is huge.

Secondly, the outbreak is occurring in a highly insecure environment. Ituri Province has been the scene of sustained inter-communal violence and militia activity for years. Armed groups, including those affiliated with the Islamic State, operate in and around the affected health zones.

This directly impedes response efforts: it restricts the movement of health workers, disrupts community engagement, damages trust in health authorities, and can render entire areas inaccessible. The 2018–2020 DRC Ebola outbreak in North Kivu and Ituri - also complicated by conflict - ultimately lasted nearly two years and became the second-largest Ebola outbreak in history.

Thirdly, population mobility in the region is high. Ituri shares porous borders with Uganda and South Sudan. Mining activity in Mongwalu creates significant cross-border movement of workers. Urban centres such as Bunia serve as transit hubs. These are precisely the conditions under which outbreaks amplify geographically. Confirmed cases in Kampala, Uganda’s capital, and in Kinshasa demonstrate that the virus is already using established mobility networks to spread.

Fourth, healthcare-associated transmission appears to be occurring. At least four of the eight laboratory-confirmed cases in DRC are healthcare workers, suggesting nosocomial spread. At least four healthcare worker deaths compatible with viral haemorrhagic fever have been reported from affected areas. This pattern, seen repeatedly in Ebola outbreaks, reflects the extreme IPC demands of managing viral haemorrhagic fever patients and the catastrophic consequences of inadequate protective equipment or training.

The WHO declaration and the global response

On 17 May 2026, WHO Director-General Tedros Adhanom Ghebreyesus declared the outbreak a Public Health Emergency of International Concern under the International Health Regulations (2005). The PHEIC designation, the WHO’s highest alert level, indicates that the event is extraordinary, constitutes a public health risk through international spread, and requires coordinated global action.

WHO explicitly noted that the outbreak does not meet the criteria for a ‘pandemic emergency’ but that countries sharing land borders with the DRC are at high risk of further spread. States have been advised to activate national emergency management mechanisms, strengthen cross-border surveillance, implement screening at major transit points, and prepare health facility IPC capacity.

Africa CDC convened an urgent high-level regional coordination meeting on 15–16 May, bringing together health authorities from DRC, Uganda, and South Sudan alongside WHO, UNICEF, Médecins Sans Frontières (MSF), the Gates Foundation, the Wellcome Trust, pharmaceutical partners including Gilead Sciences, Merck, Regeneron, BioNTech, and Moderna, and multilateral funders including the World Bank and the African Development Bank. MSF has announced preparations for a large-scale operational response in Ituri.

The involvement of vaccine and therapeutics manufacturers at this early stage reflects both the urgency of the situation and the current void: no approved product exists for Bundibugyo virus, and there is the question of how rapidly candidate interventions might be evaluated and deployed.

An outbreak that was always going to hit hardest here

The communities bearing the burden of this outbreak, in one of the world’s poorest and most conflict-affected regions, have been rendered vulnerable by forces that long predate this virus. Decades of extractive colonialism, post-independence political instability, and ongoing conflict over the region’s mineral wealth have left Ituri’s health infrastructure chronically underfunded and repeatedly disrupted.

The informal health facilities and gaps in IPC capacity that WHO identifies as outbreak amplifiers are not accidents; they are the product of sustained underinvestment and institutional neglect.

The diagnostic blind spot described above, Zaire-centric surveillance infrastructure failing to detect a different species, is also, in part, a resource allocation story. Comprehensive multi-species diagnostic capacity requires sustained funding that has not been consistently available. The same applies to research pipelines for Bundibugyo-specific vaccines and therapeutics; because previous Bundibugyo outbreaks were small and geographically contained, they generated insufficient commercial interest to drive product development.

It is also worth noting the timing. The outbreak is unfolding against the backdrop of significant reductions in global health funding, including cuts to USAID programming, which have reduced both surveillance capacity and community health infrastructure across Central and East Africa. A global health security architecture already under financial strain is being tested at a time when the potential consequences are most severe.

What does this mean for the UK?

The direct risk to the UK from this outbreak, based on current evidence, remains low. Ebola is not airborne. It spreads through direct contact with the bodily fluids of symptomatic individuals. There is no documented sustained transmission of any Ebola species outside Africa; even during the 2013–2016 West African epidemic only a handful of cases were exported to Europe, almost all among repatriated healthcare workers.

The UK Health Security Agency (UKHSA) maintains standing protocols for viral haemorrhagic fever (VHF) in returning travellers. NHS England High Consequence Infectious Disease (HCID) units — currently designated at Royal Free London, Royal Victoria Infirmary Newcastle, and Sheffield Teaching Hospitals — are equipped and staffed to manage suspected Ebola cases under negative-pressure isolation with full barrier precautions.

However, the absence of a Bundibugyo-specific vaccine or antiviral introduces an additional dimension of clinical uncertainty. In the event of an imported case, the two licensed Ebola therapeutics, atoltivimab/maftivimab/odesivimab (Inmazeb) and ansuvimab (Ebanga) - monoclonal antibodies which target Ebola Zaire glycoprotein used to gain access to target cells, are unlikely to be effective against Bundibugyo virus. Treatment would necessarily be supportive, as in the affected DRC communities. Clinicians should be aware of this in the unlikely event that a returning traveller from eastern DRC or Uganda presents with a febrile illness and relevant exposure history.

The probability of such an event remains very low. Nonetheless, this outbreak is a reminder that the UK’s imported VHF preparedness must account not only for the most common Ebola strain, but for the full range of viral haemorrhagic fever pathogens - a lesson that was underlined, but not fully implemented, after previous Sudan virus and Marburg alerts.

Conclusion

The 2026 Bundibugyo Ebola outbreak in the DRC is the most significant Ebola event since the 2018–2020 North Kivu epidemic. It is the first WHO PHEIC for Ebola in six years, the largest documented Bundibugyo outbreak on record, and the first to demonstrate rapid multi-country spread within days of its identification. The outbreak exposes critical gaps: diagnostic infrastructure calibrated for a single strain, a vaccine availability that does not cover rare Ebola species, and a global response system under growing resource pressure.

The communities at the centre of this outbreak are once again facing the severest consequences. The international response, now formalised under PHEIC, must be sustained, well-resourced, and attentive to the structural conditions that made this crisis possible. For the global health community, this outbreak is both a test and a reckoning.

References

1. World Health Organization. Epidemic of Ebola Disease caused by Bundibugyo virus in the Democratic Republic of the Congo and Uganda determined a public health emergency of international concern. WHO statement, 17 May 2026.. Available at: https://www.who.int/news/item/17-05-2026-epidemic-of-ebola-disease-in-the-democratic-republic-of-the-congo-and-uganda-determined-a-public-health-emergency-of-international-concern

2. CNN. Latest Ebola outbreak an emergency of international concern, WHO declares. CNN, 17 May 2026.. Available at: https://www.cnn.com/2026/05/16/africa/congo-uganda-ebola-international-concern-intl-hnk

3. Imperial College London School of Public Health. Ebola outbreak 2026: Q&A with experts. Imperial News, 15 May 2026.. Available at: https://www.imperial.ac.uk/news/articles/2026/ebola-outbreak-2026-qa-with-experts/

4. Africa CDC. Africa CDC calls for urgent regional coordination following Ebola Virus Disease outbreak in Ituri Province, DRC, and imported Ebola Bundibugyo case reported by Uganda. Africa CDC statement, 15 May 2026.. Available at: https://africacdc.org/news-item/africa-cdc-calls-for-urgent-regional-coordination-following-ebola-virus-disease-outbreak-in-ituri-province-drc-and-imported-ebola-bundibugyo-case-reported-by-uganda/

5. Kupferschmidt K. Major outbreak of rare Ebola virus species in northern Congo alarms scientists. Science, 17 May 2026.. Available at: https://www.science.org/content/article/major-outbreak-rare-ebola-virus-species-northern-congo-alarms-scientists

6. Médecins Sans Frontières. MSF preparing large-scale response to Ebola outbreak in Ituri province. MSF, 16 May 2026.. Available at: https://www.msf.org/msf-preparing-large-scale-response-ebola-outbreak-ituri-province

7. MacNeil A, Farnon EC, Wamala J, et al. Proportion of deaths and clinical features in Bundibugyo Ebola virus infection, Uganda. Emerg Infect Dis. 2010;16(12):1969–72.. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC3294552/

8. Albariño CG, Shoemaker T, Khristova ML, et al. Molecular analysis of the 2012 Bundibugyo virus disease outbreak. PLOS Neglected Tropical Diseases, 2013.. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC8385243/

9. Centers for Disease Control and Prevention. Ebola outbreak history. CDC, 2026.. Available at: https://www.cdc.gov/ebola/outbreaks/index.html

10. Al Jazeera. Health officials raise alarm over new Ebola outbreak in DR Congo. Al Jazeera, 15 May 2026.. Available at: https://www.aljazeera.com/news/2026/5/15/health-officials-raise-alarm-over-new-ebola-outbreak-in-dr-congo

Ebola Declared a Public Health Emergency of International Concern

The World Health Organization (WHO) declared a public health emergency of international concern on 17 May 2026 following a rapidly expanding Ebola outbreak in the Democratic Republic of Congo’s eastern Ituri province.

The outbreak, caused by the Bundibugyo strain of Ebola virus, had already recorded 336 suspected cases and at least 87 deaths by the time of the declaration, making it the largest documented Bundibugyo outbreak in history. The index case is believed to have been a nurse who died at the Evangelical Medical Centre in Bunia.

Cases have been concentrated around two mining towns, Mongwalu and Rwampara, where high population mobility has accelerated transmission. The outbreak has crossed borders: two laboratory-confirmed cases, including one death, have been reported in Uganda’s capital Kampala, and a further case has been identified in Kinshasa.

The Bundibugyo strain presents a particular challenge because, unlike the better-known Zaire strain, there are no approved vaccines or therapeutics.

The WHO has stressed this does not constitute a pandemic emergency, but has urged border nations to strengthen surveillance and activate emergency preparedness systems.

Hantavirus Outbreak Linked to Atlantic Cruise Ship

An unusual hantavirus cluster linked to the cruise ship MV Hondius has been reported by the WHO and is under active monitoring by the UKHSA.

As of 13 May 2026, 11 cases (8 confirmed, 2 probable, 1 inconclusive) and 3 deaths had been identified among passengers and crew, all linked to the Andes hantavirus strain. Human-to-human transmission of Andes virus, while extremely rare, is known to occur with prolonged and close contact, such as within a cruise ship environment.

Separately, Argentina has recorded 101 confirmed hantavirus cases this season, with 32 deaths. The UKHSA assesses the risk to the UK public as very low: rodents in the UK carry Seoul hantavirus, not the Andes strain, and human-to-human transmission has not been documented for any European or Asian hantavirus strains. Estimates vary, but there are thought to be between 10,000 and 100,000 cases every year, mainly in Europe and Asia.

There is currently no specific antiviral treatment or licensed vaccine for hantavirus. Management is supportive. Healthcare workers should be aware that occupational groups such as forestry workers, farmers and military personnel face elevated exposure risk in endemic regions.

Palantir and the NHS: A Contract Under Pressure

The UK government is actively weighing whether to invoke a break clause in its £330 million contract with US data analytics firm Palantir Technologies for the NHS Federated Data Platform (FDP), a centralised data hub drawing on NHS staff and patient records.

Health Minister Zubir Ahmed has indicated the contract could be terminated early if rival providers can deliver equivalent outcomes, with a formal break clause review expected in spring 2027. Opposition to Palantir has been substantial: over 50,000 patients have written to local trust boards urging rejection of the FDP; the British Medical Association passed a motion opposing the rollout in 2025 and has since advised doctors to limit engagement; and civil society organisations including Amnesty International and the Good Law Project have called for termination.

Critics point to unresolved concerns around data privacy, the absence of a patient opt-out, Palantir’s links to military surveillance and border enforcement, and a contractual structure that leaves all intellectual property and software with the supplier.

NHS users have also reported the platform as difficult to use.

Palantir has contested these characterisations, arguing that NHS data remains under NHS control and that the FDP delivers clinical value.

UK Healthy Life Expectancy Falls — and the Inequality Gap Widens

New analysis from the Health Foundation, drawing on ONS data for 2022–2024, reveals that healthy life expectancy in England has declined by approximately two years over the past decade.

The UK is now among only five of the world’s 21 wealthiest nations to record a fall in healthy life expectancy, with the second steepest decline overall.

The differences are concerning: people in the most affluent areas can expect around 19 more years in good health than those in the poorest communities. Men in Blackpool and women in Hartlepool have a healthy life expectancy of just 51 years, compared with 69–70 years in Richmond upon Thames.

The inequality gap has widened by 22% for men and 17% for women between 2011–2013 and 2021–2023. The BMA estimates health inequalities now cost the UK economy approximately £82 billion annually in 2025–26 prices. Contributing factors include poverty, poor housing, obesity, and the enduring legacy of COVID-19.

The government has committed to halving the healthy life expectancy gap and adding five years to healthy life expectancy by 2035, but experts warn that without structural investment in the social determinants of health, those targets will prove difficult to achieve.

Vaping and Cancer: The Evidence Strengthens?

A major scientific review published in Carcinogenesis in March 2026 concluded that nicotine-based e-cigarettes likely cause cancers of the lung and oral cavity, representing what the authors describe as the most definitive assessment to date that vaping increases cancer risk.

The multidisciplinary Australian analysis, led by UNSW Sydney, identified a consistent pattern of DNA damage, oxidative stress and carcinogenic signalling pathways in vaping users, alongside known carcinogens, including nitrosamines and toxic metals, in e-cigarette aerosol. Dual users of cigarettes and e-cigarettes face compounded rather than reduced risk.

The findings have prompted debate: some experts caution that the conclusions may overstate the evidence, noting that e-cigarettes lack the combustion products responsible for most smoking-related carcinogenicity, and that vaping retains value as a harm-reduction tool for established smokers.

Cancer Research UK maintains that no good evidence yet establishes that legal UK e-cigarettes cause cancer. Clinicians are nonetheless advised to counsel patients, particularly young people who have never smoked, that vaping is not risk-free, and that the long-term cancer burden of the vaping generation will not be fully apparent for years.

One-Minute Cancer Injection Rolled Out Across the NHS

NHS England has begun rolling out a subcutaneous formulation of pembrolizumab (Keytruda, MSD) that reduces treatment time by up to 90%, replacing an intravenous infusion that could take up to two hours with a subcutaneous injection administered in as little as 60 seconds.

The innovation covers 14 cancer types, including lung, breast, head and neck, and cervical cancers, and is expected to benefit around 14,000 patients annually in England. Phase 3 trial data confirmed comparable pharmacokinetics, efficacy and safety between subcutaneous and intravenous delivery.

Beyond patient convenience, the change carries significant implications: eliminating the need for specialist sterile IV preparation frees up pharmacy and oncology capacity, and NHS England projects savings of over 100,000 hours of preparation and treatment time annually.

Health Secretary, at the time, Wes Streeting welcomed the rollout as part of the government’s National Cancer Plan.

For health equity, the shift merits attention: shorter, simpler appointments may improve attendance and completion rates in communities with transport barriers or caring responsibilities, groups that have historically faced poorer cancer outcomes.

Editorial note

This newsletter was compiled with AI-assisted research support. All content has been reviewed editorially.

In late April 2026, passengers and crew aboard the MV Hondius, a Dutch-flagged expedition cruise ship returning from Antarctica and remote South Atlantic islands, began to fall gravely ill. Fever, pneumonia, and acute respiratory distress syndrome progressed rapidly. Three people died. Further confirmed or suspected cases of hantavirus infection were identified, with the Andes strain confirmed by PCR.

The ship, carrying 147 people from 23 countries, found itself marooned: Cape Verde lacked the capacity to manage an evacuation, and the president of the Canary Islands refused to allow the vessel to dock, citing fears of a local outbreak and the scarring memory of COVID-19. Spain’s central government eventually overruled him.

The Hondius saga is now, simultaneously, a clinical story, a public health story, and a story about how disease and inequality are inseparable — even at sea.

The leading investigative hypothesis is that the index cases, a Dutch couple, were exposed to infected rodent material during a birdwatching excursion to a landfill in Ushuaia, southern Argentina, before the voyage departed on 1 April 2026.

What is hantavirus, and why does the Andes strain matter?

Hantaviruses are a genus of single-stranded RNA viruses with a particular tropism for vascular endothelium. They are carried principally by rodents, which act as lifelong reservoirs without themselves becoming ill. Human infection is almost always acquired by inhaling aerosolised particles from infected rodent excreta. Most hantaviruses cause dead-end infections in humans: an individual gets sick, but the chain of transmission stops there. There is no person-to-person transmission.

The Andes virus, found predominantly in southern South America and carried by the long-tailed colilargo mouse (Oligoryzomys longicaudatus), is the single known exception. It is the only hantavirus strain for which human-to-human transmission has been documented. Transmission requires close, prolonged contact - household members, intimate partners, healthcare workers without adequate protection - and appears most likely during the early prodromal phase of illness.

Two principal disease syndromes result from hantavirus infection. Hantavirus Pulmonary Syndrome (HPS), the dominant pattern in the Americas, causes massive capillary leak into the pulmonary vasculature, producing non-cardiogenic pulmonary oedema and cardiogenic shock, with case fatality rates of 35–50% for the Andes strain. Haemorrhagic Fever with Renal Syndrome (HFRS), more common in Europe and Asia and caused by strains such as Puumala and Hantaan, primarily targets the kidney and carries lower but still significant mortality.

The pathophysiology: an immune system that becomes the enemy

Hantavirus pathology is immunopathological in nature. The virus does not destroy the endothelial cells it infects. Instead, it replicates within them while suppressing the early interferon response, buying time for widespread vascular spread before adaptive immunity can respond. When the immune response does engage, it is excessive and poorly regulated. A dense infiltrate of CD8+ cytotoxic T lymphocytes accumulates in affected tissues; the vigour of this response correlates with disease severity.

The result is a dysregulated cytokine storm — high TNF-α, IL-6, and interferon-γ — which destabilises the vascular endothelium through VE-cadherin disassembly (loosening the grip between endothelial cells and threatening barrier continuity) and elevated Vascular Endothelial Growth Factor (VEGF) signalling (increases vascular permeability). Capillary leak follows, flooding the lungs in HPS and the renal interstitium in HFRS. As the subsequent pulmonary oedema is due to increased capillary permeability, attempts to treat using a diuretic will not provide any benefit and can only decrease an already compromised circulating fluid volume.

Thrombocytopenia is almost universal, driven by platelet consumption, immune-mediated destruction, and direct viral binding via β3 integrin receptors, the receptors that hantavirus binds to to gain cellular access, and the occupation of which by the virus enhances the VEGF effect and further forces capillary leaking. Compensated disseminated intravascular coagulation can also emerge, with petechiae, haematuria, and occasionally more serious haemorrhagic complications.

In HPS specifically, a distinctive haemodynamic profile with low cardiac output, high systemic vascular resistance and relative bradycardia reflects direct cytokine-mediated myocardial depression rather than distributive shock. This pattern can mislead clinicians unfamiliar with the syndrome.

Could this become the next pandemic?

The question has circulated widely since the Hondius outbreak broke in early May 2026. The WHO has assessed the global public health risk as low, and epidemiologists are not anticipating a COVID-like scenario.

SARS-CoV-2 achieved global reach because it spread efficiently in the presymptomatic and asymptomatic phases: infected individuals who felt entirely well were seeding communities for days before their illness was apparent. Hantavirus does not do this. Individuals are not infectious before symptoms appear, and symptoms are severe enough to incapacitate quickly. The virus’s lethality constrains its spread.

Even in the Hondius outbreak, a confined ship with over 150 people in sustained close contact, an almost ideal scenario for respiratory pathogen spread, transmission remained limited to individuals with the most direct exposure. The R value estimated during the 2018–2019 Epuyen outbreak in Argentina, the largest documented Andes outbreak, was 2.12 before control measures, falling to 0.96 after their implementation. These figures reflect superspreader-driven dynamics in a tightly clustered community context, not a baseline biological constant, and should not be extrapolated to general population settings.

Continued vigilance, however, is necessary because of gaps in knowledge. Hantaviruses have been comparatively under-studied compared to other viruses. The mechanism by which the Andes virus acquired human-to-human transmissibility is not fully understood. No approved vaccine exists for any Americas-affecting hantavirus strain. And rising rodent populations in endemic regions, potentially linked to climate-driven shifts in habitat and food availability, may increase the frequency of zoonotic spillover events that could, in theory, provide further opportunities for adaptive evolution - and for human-to-human transmission.

At present, there is no specific treatment for hantavirus infection though access to intensive care does improve outcomes.

Who bears the burden?

The Hondius outbreak occurred aboard a luxury expedition cruise ship carrying passengers from wealthy nations on a voyage to Antarctica, but hantavirus is fundamentally a disease of poverty and marginalisation.

In endemic regions of South America, hantavirus disproportionately affects agricultural workers, forestry workers, and those living in rural housing with inadequate rodent exclusion. In Argentina, where the Andes strain is most prevalent, cases cluster among low-income rural communities with limited access to healthcare, poor housing stock, and occupational exposures that cannot be easily avoided. The 25.7% case fatality rate recorded across the Americas in 2025 reflects, in part, the absence of ECMO infrastructure in communities where cases actually occur. Survival from severe HPS in a well-resourced intensive care unit is better than survival in a rural district hospital.

In the UK context, hantavirus remains rare but is present. The predominant strains are Seoul virus (carried by brown rats) and Puumala virus (carried by bank voles). Cases are most commonly associated with occupational exposure - agricultural workers, sewer workers, laboratory staff, and increasingly, pet rat owners and hobbyist rat breeders. The UKHSA monitors cases and issues guidance on safe handling of potentially contaminated environments. Critically, rodent infestation in substandard housing represents a structural exposure risk that no amount of individual health messaging can adequately address without improvement in housing conditions.

For healthcare workers, awareness of hantavirus is important because of the importance in avoiding diagnostic delay. The prodromal syndrome is non-specific - fever, myalgia, headache, nausea, abdominal pain, very much like a flu or Covid presentation - and in the UK context, a clinician who has not considered hantavirus may pursue an extensive differential workup before the diagnosis is made. Occupational and exposure history, including contact with rodents or rodent-contaminated environments, should be routine.

Clinical and public health takeaways

• Consider the exposure history. In any febrile illness with rapid respiratory deterioration, ask about rodent contact, rural environments, or travel to South America.

• Thrombocytopenia plus haemoconcentration is a useful early marker of capillary leak syndrome; combined with an appropriate exposure history, it should prompt hantavirus testing.

• The haemodynamic profile of HPS - low output, high resistance, relative bradycardia - is distinct from septic shock and requires a different management approach.

• ECMO capability. Referral to an ECMO-capable centre for severe HPS should be considered early.

• Infection control in suspected cases should include respiratory precautions given the theoretical risk of aerosol transmission, particularly for the Andes strain.

• Housing and occupational policy are hantavirus prevention. Individual advice is necessary but insufficient without structural intervention in the conditions that drive rodent exposure.

Key references

WHO Disease Outbreak News — Hantavirus cluster linked to cruise ship travel, Multi-country (May 2026)

Superspreaders and person-to-person transmission of Andes virus in Argentina — NEJM (2020)

Person-to-person transmission of Andes virus — NCBI PMC

Human-to-human transmission of Andes virus modelled in Syrian hamsters — Emerging Infectious Diseases (2023)

WHO Hantavirus Fact Sheet

MV Hondius hantavirus outbreak — Wikipedia (live updates)

UKHSA guidance on hantavirus in the UK

The United Kingdom likes to think of itself as a nation of animal lovers. Yet behind the conveniently pastoral imagery of rolling fields and free-range animals, a very different reality exists. Over the past decade, the number of industrial-scale livestock facilities, the factory farms or mega-farms, has been increasing, driven by consumer demand for low-cost meat and - profit. The consequences are now becoming apparent: a toxic gas is drifting from those sheds across some of England’s most biodiverse landscapes, into the lungs of rural communities, and into rivers already under severe ecological stress. That gas is ammonia. And the communities bearing the greatest burden are, predictably, those with the least power to push back. And those most affected have no rights at all.

Industrial Livestock Farming in the UK

Factory farming, defined as intensive, largely indoor systems that maximise animal output while minimising cost, has grown substantially across the UK. A 2024 report by World Animal Protection found that the number of registered factory farms rose by 13% in just five years, reaching a total of 1,821, a net increase of 209 facilities since 2017. It is estimated that over 1,000,000,000 land animals suffer in factory farms every year - and this is likely to be an under-estimate.

Lincolnshire tops the national table, with nearly 200 factory farms “processing” over 231 million animals annually, representing more than 10% of all UK factory farms in a single county. Norfolk and Herefordshire are not far behind. In order to maximise profit, the factory farms are clustered around major abattoirs and processing plants, increasing local environmental stress.

Around 80% of broiler chickens in England are now reared in fully enclosed intensive factory buildings. More than 100,000 smaller livestock and poultry farms disappeared between 1990 and 2016, to be replaced by larger and larger operations. Meanwhile, Freedom of Information data shows that, in England, the Environment Agency blocked only 57 out of approximately 2,000 applications for new intensive farming permits since 2017.

Ammonia: The Chemistry of a Rural Pollutant

Ammonia is produced in vast quantities wherever large numbers of livestock are housed in confined conditions. Manure and urine decompose to release ammonia gas which evaporates from open slurry pits, dung heaps, and shed floors into the surrounding air. Once in the atmosphere, it undergoes a series of chemical reactions with sulphur dioxide and nitrogen oxides to form fine particulate matter, specifically PM2.5, particles smaller than 2.5 micrometres in diameter.

Agriculture accounts for approximately 89% of all UK ammonia emissions, making it by far the dominant source. A new interactive map, published in April 2026 by Compassion in World Farming (CiWF) and Sustain, identified the three worst hotspots as Lincolnshire, Herefordshire, and Norfolk, areas with the densest concentrations of intensive poultry and pig units. The Waveney Valley, straddling Norfolk and Suffolk, was identified as producing the highest single regional output, estimated at up to 3,000 tonnes per year.

These figures are almost certainly underestimates. Regulatory loopholes mean that farms housing fewer than 40,000 birds have no legal obligation to report ammonia emissions. Figures suggest that close to 20 million birds are currently reared on farms that fall below this reporting threshold, so a substantial fraction of total agricultural ammonia production goes completely unmonitored.

Human Health Consequences

Directly breathing in ammonia can be fatal, and is a particular danger for those with chronic lung diseases (particularly asthma) or heart disease.

However, the main health threats from ammonia pollution occur through its conversion to PM2.5. Fine particulate matter penetrates deep into the respiratory tract, crosses into the bloodstream, and triggers systemic inflammatory responses. The Committee on the Medical Effects of Air Pollutants (COMEAP) has estimated that exposure to man-made PM2.5 in the UK is associated with tens of thousands of premature deaths annually.

Long-term PM2.5 exposure is causally associated with cardiovascular disease, stroke, COPD, asthma, and lung cancer. Emerging evidence also links it to type 2 diabetes and dementia. Nationally, agriculture is estimated to contribute up to 39% of urban fine particulate pollution through ammonia-derived secondary particles. This is a substantial proportion of the total PM2.5 burden that the Committee on the Medical Effects of Air Pollutants (COMEAP) has found to be responsible for tens of thousands of premature deaths in the UK each year.

Residents in Whaplode Drove, Lincolnshire, have described chest tightness, eye irritation, and breathing difficulties triggered by cleaning operations at nearby poultry sheds - episodes that can last for up to five days. In the Wye Valley, residents have reported having to keep windows permanently closed during warmer months and having to restrict outdoor activity. One account described preventing an asthmatic child from visiting because the ammonia from a nearby chicken shed made breathing impossible.

Professor Frank Kelly of the Environmental Research Group at Imperial College London has described agricultural ammonia as a major source of particulate pollution across Europe, calling for further restrictions, particularly on poultry farms, given what he characterised as a very strong link between PM exposure and chronic disease.

Environmental Consequences: Soils, Rivers, and Ecosystems

Ammonia does not only harm lungs. When it deposits onto soils and water bodies, it introduces reactive nitrogen into ecosystems that are frequently nitrogen-limited. The resulting eutrophication - the excessive enrichment of aquatic environments with nutrients, which leads ultimately to destruction of aquatic systems, contamination of drinking water, and the production of toxins and hypoxic conditions and the death of water life - has devastated some of England’s most important waterways.

Industrial farms along the catchment area of the once beautiful River Wye, an area spanning Herefordshire, Powys, Monmouthshire, and Gloucestershire, produce an estimated 2,500 tonnes of manure every single day, generating over 13,000 tonnes of nitrogen and 4,400 tonnes of phosphates. The phosphorus loading has fuelled toxic algal blooms that have transformed stretches of the Wye into what observers describe as an ecologically barren green sewer. Natural England has formally downgraded the river’s condition status to ‘unfavourable, declining.’

Between 2010 and 2020, aquatic plants including the characteristic river crowfoot (Ranunculus), which provides a critical spawning habitat for fish and invertebrates, were replaced across multiple reaches by dense mats of green algae. The process of eutrophication depresses dissolved oxygen levels, creating ecological dead zones. Even with this obvious environmental damage, the number of poultry birds in the Wye catchment alone rose from 23 million in 2017 to 32 million by 2024.

Beyond watercourses, atmospheric ammonia deposition acidifies soils, through the actions of nitrifying bacteria, and shifts the competitive balance in plant communities. Species-rich habitats, such as calcareous grasslands, heathlands, bogs, and ancient woodlands, are particularly sensitive because they are adapted to low-nutrient conditions. When nitrogen deposition exceeds what these ecosystems can absorb, nitrogen-tolerant grasses and rank vegetation out-compete the mosses, lichens, and specialist wildflowers, destroying these delicate and extremely important ecosystems.

In 42 areas across the UK, nitrogen pollution from agriculture has become so acute that planning authorities have been prevented from approving new housing developments for fear of adding further nitrogen load to already-saturated sensitive habitats, a development with profound implications for housing supply in some of the most economically deprived parts of rural England.

Animal Welfare: The Cost Carried by the Animals Themselves

Any honest account of factory farming must reckon with the suffering endured by the animals at its centre. In 2022, the UK passed the Animal Welfare (Sentience) Act, legally enshrining recognition that vertebrates experience pain, pleasure, fear, and distress. That same year, over a billion animals were reared annually under factory farming conditions in the UK - conditions that routinely deny the expression of natural behaviours, and inflict pain, fear and distress.

Broiler chickens, the primary drivers of ammonia pollution in the UK, are selectively bred for abnormally rapid growth, reaching slaughter weight in six weeks. The speed of muscle accumulation regularly exceeds the capacity of skeletal and cardiovascular systems to keep pace, resulting in widespread lameness, skeletal deformities, cardiac failure, and ascites. Around 90% of broilers sold to UK supermarkets belong to fast-growing breeds of this kind.

Pigs are equally affected. Farrowing crates - narrow metal cages that prevent sows from turning around or reaching their piglets - remain legal in the UK despite the European Union moving to restrict them. Piglet tail docking, carried out without anaesthetic to prevent tail-biting behaviour, that is itself a product of overcrowding and environmental stress, is practised on 72% of UK piglets.

In the UK it remains legal to keep laying hens in enriched cages in which they cannot perform most natural behaviours. Millions of birds are currently held in such conditions.

Freedom of Information requests submitted to the Environment Agency revealed that industrial farms in England breached regulations more than 7,000 times in the past decade. Yet enforcement action was taken in only a small fraction of these cases. In one documented case, a large corporate farm was found to be housing over 400,000 animals, more than 40,000 above its permitted capacity. The regulatory system, in the words of one MP, is ‘completely toothless.’

Public opinion is at odds with policy. Polling by World Animal Protection found that more than 70% of UK consumers report prioritising animal welfare when purchasing meat or dairy. Over two-thirds of people expressed the view that confinement in farrowing crates and tail docking without anaesthesia were cruel practices. The divergence between public sentiment and regulatory reality is simply due to the commercial and political influence that large food corporations exercise over agricultural policy.

The Inequity Dimension: Who Bears the Burden?

The Chief Medical Officer has described what has become known as the ‘triple jeopardy’ of air pollution inequality: the most deprived communities face higher levels of air pollution exposure, carry a greater pre-existing burden of ill-health, and - because of the compounding effects of deprivation on respiratory and cardiovascular reserve - are more biologically susceptible to the harms of pollution. The UK government’s Environmental Improvement Plan acknowledges explicitly that low-income communities disproportionately bear the health impacts of air pollution, exacerbating existing health and social inequalities.

Rural deprivation, characterised by low wages, limited public transport, poor access to health services, and high housing costs relative to local incomes, is systematically underweighted in national deprivation indices that privilege urban indicators such as proximity to roads. The communities of Herefordshire, Lincolnshire, and mid-Norfolk that are most exposed to farm ammonia are often also those least equipped to bear its health consequences and least able to relocate.

There is also a corporate dimension to this inequality. The profits generated by industrial livestock operations flow to shareholders, processing companies, and supermarkets whose headquarters are far removed from the affected communities. Avara Foods, which controls approximately 16 million of the chickens raised in the Wye catchment, posted £23 million in profits in 2020/21 while the river that runs through its supply chain deteriorated to unfavourable ecological status. This is textbook environmental injustice: costs externalised to communities and ecosystems, profits privatised.

Regulation, Loopholes, and the Planning System

The UK’s regulatory framework for agricultural ammonia has a central structural weakness: it is designed around individual farm units rather than cumulative regional emissions. An environmental regulator quoted anonymously by the Bureau of Investigative Journalism captured the problem precisely: adding farms to an area increases total ammonia output, but there is no single collective emission limit that applies to the region as a whole.

The reporting threshold of 40,000 birds, below which farms have no obligation to report emissions, creates a further gap. In practice, operators wishing to avoid scrutiny may configure facilities to remain below this threshold. National-level ammonia figures show a modest overall decline since 2017, but this masks sharp increases in key farming regions - a 40% rise in poultry ammonia emissions in Wales, and significant increases in Lincolnshire and Norfolk.

A 2026 proposed revision to the National Planning Policy Framework, which could make it easier to approve new intensive livestock units, has drawn significant criticism from public health and environmental organisations. CiWF and Sustain have called for an immediate moratorium on the construction of new industrial livestock facilities and a complete overhaul of the environmental permit system to ensure all polluting operations are properly controlled and monitored.

A One Health Response

The combination of human health harm, ecological damage, and animal suffering in a single system of food production makes factory farming a defining World Health Organisation One Health challenge. The CiWF report published in April 2026 titled The Ammonia Pollution Problem frames the issue in exactly these terms, arguing that ammonia pollution is not an isolated agricultural issue but a systemic challenge affecting animals, people, and the environment simultaneously.

Addressing it will require action at multiple levels. Nationally, the government should deliver on its commitment to reduce ammonia emissions by 16% from 2005 levels by 2030 - a target currently at risk. All farms, regardless of size, should be required to report emissions. Environmental permits should reflect cumulative regional load, not individual site calculations. A long-term strategy for reducing the UK’s reliance on industrial animal production, supported by investment in sustainable plant-based protein, would address the root cause of this damage, and its inherent ethical and moral iniquities, rather than managing its consequences.

For health professionals, factory farming represents an environmental determinant of health that combines air quality, food systems, occupational exposure, and animal welfare, and which falls disproportionately on the least advantaged communities. It deserves to be named clearly as a health equity issue.

Ethically, and for all of us, factory farming is a cruel and unjustifiable abuse of sentient beings and should be stopped.

Further reading:

1. World Animal Protection. Confined in Cruelty Report. 2024.

2. World Animal Protection. Lincolnshire tops UK for farmed animal cruelty. 2024.

3. UK Parliament Hansard. Animal Welfare in Farming. June 2025.

4. The Bureau of Investigative Journalism. Air pollution surging across poultry megafarming hotspots. April 2024.

5. The Bureau of Investigative Journalism. What is ammonia and how is it harmful? April 2024.

6. Air Quality News. Interactive map reveals ammonia hotspots from factory farms. April 2026.

7. The British Eye. UK Rural Areas Hit by Ammonia Emissions. April 2026.

8. Air Quality News. Interactive map reveals ammonia hotspots from factory farms. April 2026.

9. Sustain. New map exposes ammonia pollution hotspots from factory farms. April 2026.

10. Chartered Institute of Environmental Health. UK’s chicken megafarms are fuelling rise in ammonia emissions. May 2024.

11. Sustain. Alarming levels of industrial animal waste poisoning UK rivers. June 2023.

12. River Action UK. Rescue the River Wye. Accessed April 2026.

13. Animal Equality UK. Eight shocking legal farming practices. November 2024.

14. The Humane League UK. What laws protect farmed animals in the UK? September 2024.

15. Environment Agency. Regulating for people, the environment and growth. 2021.

16. DEFRA. Environmental Improvement Plan 2025.

17. Sustain. Save our Wild Isles from factory farming. March 2023.

18. The Grocer. ‘Serious concerns’ raised about factory farming as ammonia hotspots revealed. April 2026.

19. The Conservative Animal Welfare Foundation. The Hidden Harms of Factory Farms.

20. World Health Organisation. One Health.

A Contaminated World

We have, over the course of a century of industrialisation, turned the planet into an (failed) experiment. The atmosphere, the oceans, the soil, and the bodies of almost every living creature on Earth now carry chemical signatures that did not exist before the mid-twentieth century. Three categories of pollutant dominate the contemporary evidence base: per- and polyfluoroalkyl substances (PFAS), microplastics, and pesticide residues. Together, they represent what some researchers have termed a ‘slow poisoning’.

This is not a story of individuals making poor lifestyle choices. It is a story of structural decisions, about what industries are permitted to do, where they are permitted to do it, and who is left to bear the consequences.

PFAS: The Forever Chemicals That Will Outlast Us All

PFAS - per- and polyfluoroalkyl substances - is an umbrella term covering nearly 10,000 individual chemicals, united by their extraordinary chemical stability. That stability is precisely why they were so commercially attractive: they repel water, grease, and heat. Non-stick cookware, waterproof clothing, food packaging, firefighting foam, dental floss, PFAS have become the invisible backbone of modern consumer life.

They are also essentially indestructible. PFAS do not break down in the environment. They accumulate in water, soil, wildlife, and human tissue, a property that gives them their informal name: forever chemicals. Drinking water sources across England have now been found to be contaminated with PFAS, and concerns over the adequacy of UK regulatory limits have increased since a parliamentary inquiry was launched into the risks they pose.

The health implications are serious. Epidemiological studies have linked PFAS exposure to suppression of vaccine-induced immune responses in children, elevated cholesterol, changes in liver enzymes, reduced birth weight, and increased risks of kidney and testicular cancer. The Parliamentary Office of Science and Technology, in a 2025 briefing, confirmed these associations while noting that significant data gaps remain, particularly regarding the dose-response relationship for the thousands of less-studied PFAS compounds.

In the UK, the regulatory picture has become a source of concern. Since leaving the European Union, the UK has struggled to maintain the pace of chemical regulation set by its continental neighbours. A specific case in point: the herbicide Flufenacet, a known precursor to trifluoroacetic acid (TFA), itself a PFAS, remains approved for use in the UK despite having been withdrawn in the EU. Flufenacet acts as an endocrine disruptor that interferes with thyroid-stimulating hormones, creating a risk to brain development during pregnancy. It is also a skin sensitiser and has neurotoxic properties.

Meanwhile, the EU is moving toward a universal PFAS restriction across whole chemical classes; the UK has yet to match that ambition. A coalition of environmental organisations, including RSPB, the Rivers Trust, and Pesticide Action Network UK, has called for alignment with EU standards, warning that the UK’s voluntary drinking water standards are considerably weaker than the EU’s legally binding limits and even weaker still than those adopted in the United States.

The inequity of PFAS exposure is not incidental. Contamination hotspots cluster around industrial sites, military airbases, where firefighting foam was historically used, and landfill sites, facilities that, in the UK as elsewhere, have been disproportionately sited near deprived communities. A 2025 UKHSA analysis confirmed that people in the most deprived areas face disproportionate exposure to chemical and environmental hazards, with worse health outcomes as a consequence.

Microplastics: Part of Us, Whether We Like It or Not

Microplastics - particles under 5mm in size - are now ubiquitous in the environment. They have been detected in Arctic ice, deep ocean sediment, and even the summit of Everest. They have also been detected in human blood, placental tissue, lung tissue, brain and, most recently, in arterial plaques.

A landmark 2024 study published in the New England Journal of Medicine found microplastics and nanoplastics embedded in atherosclerotic plaques removed from patients undergoing carotid endarterectomy. Those with detectable particles in their arterial wall atheromatous plaques had a significantly higher risk of subsequent cardiovascular events, including heart attack and stroke. A subsequent Lancet Planetary Health review, published in late 2025, summarised a growing body of evidence linking microplastic exposure to metabolic, respiratory, cardiovascular, renal, hepatic, and neurodegenerative disorders, as well as an emerging, though not yet definitive, association with cancer.

Humans are exposed through ingestion, inhalation, and possibly dermal contact. We consume them in drinking water, seafood, beer, salt - just about anything we eat or drink. We inhale them in urban air. Most particles pass through the body without being absorbed, but a proportion, particularly the smallest nanoplastic particles, may cross biological barriers, entering the bloodstream and accumulating in tissues.

Research from the University of Birmingham published in 2024 raised another concern: when PFAS and microplastics were tested in combination, their toxic effects on aquatic life were synergistic - their combined effect is greater than the sum of the effects of each acting alone. The mixture caused developmental failure, stunted growth, and reproductive disruption in test organisms at concentrations routinely found in lakes, a finding with implications for human health, given that both pollutants are typically co-released from consumer products and travel together through water systems.

Occupationally, workers in textile manufacturing, recycling facilities, and plastic processing industries face far higher exposure than the general population, and those industries employ a workforce that is disproportionately drawn from lower-income groups, migrant communities, and the Global South. At a population level, communities living near busy roads and industrial zone, again the most deprived areas, face higher concentrations of airborne plastic particles alongside other forms of particulate pollution.

Pesticides: The Price Paid by Those Who Grow Our Food

Pesticide use has become a defining feature of industrialised agriculture. These chemicals protect crops from pests, disease, and competition, but they have also become one of the most thoroughly documented examples of chemically-mediated occupational harm, harm that falls almost exclusively on some of the world’s most economically marginalised workers.

A systematic review published in Environmental Research and Public Health in 2024 looked at decades of evidence and found consistent associations between chronic pesticide exposure and cancer, neurological disorders, endocrine disruption, and respiratory disease. Farmworkers with prolonged, high-intensity exposure had a 32% higher risk of developing COPD compared to unexposed individuals. Organochlorine metabolite levels, chemicals with at least one carbon-chlorine bond and a marked propensity towards bio-accumulation, were found to be nearly four times higher in patients with Alzheimer’s disease than in controls, a finding that echoes mounting concern about the neurotoxic effects of long-term low-level exposure. Reproductive harm, including impaired sperm quality and increased risk of birth defects, has also been documented across multiple studies.

This health risk does not fall on those who profit from these products; it falls on the seasonal workers who apply them, often without adequate protective equipment or meaningful safety training. In the Global South, where international regulatory frameworks are weakest and enforcement patchiest, the problem is severe. An estimated 385 million cases of acute pesticide poisoning occur globally each year, affecting approximately 44% of the world’s agricultural workforce.

Even for those who never set foot on a farm, exposure is still a fact of life. Pesticide residues persist in food, enter waterways, and, as research now demonstrates, include PFAS-based herbicides and fungicides that contribute directly to the broader forever chemicals crisis. In the UK, the pesticide Flufenacet continues to be applied to millions of hectares of arable land each year, generating PFAS contamination that the Environment Agency is now scrambling to map and monitor.

What We Are Doing to the Rest of Life?

The evidence from wildlife populations now tells a story that is in many respects further advanced than the human health data; animals have been accumulating these exposures for longer and in less regulated conditions.

The picture from UK freshwater and marine ecosystems is especially concerning. PFAS have now been detected in every otter liver sampled across England and Wales, a finding with profound implications, since otters sit at the apex of the river food chain and absorb concentrated chemical burdens from the fish, amphibians, and crustaceans they eat.

Harbour seals and grey seals around the British coast show elevated levels of PFAS and flame-retardant chemicals; these compounds affect hormonal regulation and can be passed to offspring through maternal milk, compromising the reproductive viability of future generations. Marine fish species including herring, cod, and mackerel have been found to contain PFAS, as have the freshwater fish that populate many of Britain’s rivers and reservoirs, frequently in association with pharmaceutical residues, bisphenols, and pesticides.

Bisphenols in particular have been shown to disrupt endocrine function in fish, including altering sex determination, a phenomenon that has even been documented in rivers receiving treated effluent across the UK. Wildlife biology is being changed by human activity.

In our seas, the microplastics crisis has become an existential one for many species. A 2019 study examining marine mammals stranded around the British coastline found microplastics in every single animal tested. A 2025 study published in the Proceedings of the National Academy of Sciences established lethal dose thresholds for plastics ingestion across marine animal groups: for seabirds such as the Atlantic puffin, consuming less than three sugar cubes’ worth of plastic carries a 90% probability of death. One in twenty sea turtles studied in that research died directly from plastic ingestion. Seabirds are now being found to develop ‘plasticosis’ - a newly described condition in which plastic particles cause structural scarring of the stomach lining - and toxic pollutants, carried by the plastics, are transferring from mother birds to their eggs. Around the World, plastic debris causes the deaths of over a million seabirds each year.

Recently, monitors documented the demise of a pod of Orcas off the north coast of Scotland - evidence suggested that microplastics, and the endocrine disrupting chemicals they contain, played a major role.

The food web ensures no organism, including humans, is insulated from these harms. Microplastics ingested by zooplankton pass to the small fish that eat them, and upward to larger predators, concentrating at each step. In a 2025 review of over 500 fish species, more than two thirds had consumed plastic. Coral reefs, which support approximately a quarter of all marine biodiversity, show evidence of microplastic-induced gut blockages and reduced feeding. Microplastic particles have been found to interfere with phytoplankton growth and photosynthesis so threatening the base of the marine food chain.

The pollinators on which terrestrial food production depends are not spared either. The UK supports over 270 bee species and many are already in steep decline from habitat loss. Research has now confirmed that bees contain both PFAS and multiple pesticide residues, and that these can cause the death of whole colonies. The herbicide and insecticide compounds found in bee bodies include chemicals approved for continued use in the UK despite being linked to neurological disruption and reproductive failure in pollinating insects. Hedgehogs, who are insectivorous, have been found to carry persistent flame retardants and pesticide residues at levels capable of compromising their survival and fitness.

We share food webs, water systems, and air with the species whose bodies now function as involuntary monitors of our own contamination. Their decline is not a separate crisis.

A Crisis of Structural Inequality

The distribution of chemical harm in the UK (and globally) follows the contours of poverty, race, and class with striking consistency. UKHSA’s 2025 health inequalities report found that people in the most deprived areas of England experience higher levels of air pollution than less deprived and less ethnically diverse areas, and that this gap extends to radiation, chemical, and environmental hazards more broadly. Research from the University of York confirmed that deprivation-based inequality in air pollution emissions persists across every major source category: transport, domestic heating, industry, and power generation.

In London, 46% of the most deprived neighbourhoods exceed EU nitrogen dioxide limits, compared to just 2% of the least deprived. Regions with the poorest physical environments have 18% more deaths than expected compared to less environmentally deprived regions, a figure drawn from WHO Europe’s own analysis of UK data.

In the Global South, the situation is worse. Communities in low-income countries bear a grossly disproportionate share of chemical harm as a direct consequence of decisions made by wealthy nations and multinational corporations. Electronic waste from Europe and North America is shipped to informal recycling sites in Ghana, Nigeria, and Bangladesh, where workers, often children, are exposed to toxic metals and flame retardants without protection. Pesticides withdrawn from sale in the EU on safety grounds continue to be exported to countries with less stringent regulations. The chemical burden of affluent consumption is, in a very literal sense, exported to those least able to refuse it.

Regulatory decisions about which chemicals may be manufactured, used, and disposed of, and where, are political choices. So is the decision to underfund the Environment Agency, to leave drinking water standards on a voluntary rather than statutory footing, or to delay alignment with EU chemical regulation post-Brexit. These choices have consequences, and those consequences land hardest on people who already face the greatest health disadvantages.

What Needs to Change?

The evidence base is now substantial enough to demand action rather than further study. Several priorities emerge clearly from the literature and from recent UK policy discussions.

First, UK drinking water and food safety standards for PFAS must be placed on a statutory footing and tightened in line with EU and US standards. The current voluntary guidelines leave millions of people drinking water that may exceed safety limits applied elsewhere in the developed world.

Second, the UK should move toward class-based PFAS regulation - treating all PFAS as a group for the purposes of restriction rather than assessing each of the nearly 10,000 individual substances separately. This approach, advocated by the European Environment Agency, Chem Trust, and a coalition of UK environmental NGOs, is the only practically workable route to meaningful control.

Third, occupational protections for agricultural workers must be strengthened, with enforceable standards rather than voluntary guidance. This is particularly urgent for migrant and seasonal workers who currently have the least access to regulatory protection.

Fourth, the NHS, public health bodies, and clinicians need better data. The UK lags behind comparable European nations in large-scale human biomonitoring of chemical exposure. Without that data, the true scale of population-level harm cannot be assessed, and without that assessment, the political urgency for change is perpetually deferred.

For healthcare workers, the implications of this evidence are immediate and practical. Chemical toxicity should be considered in the differential diagnosis for a range of presentations - from unexplained cardiovascular events in younger patients, to reproductive difficulties, to neurological decline. The social and occupational history should ask about industrial proximity, agricultural work, and housing in former industrial areas. Addressing chemical pollution is, in the deepest sense, a matter of health equity and urgency.

Meanwhile, human activity - especially that of the multinational corporations and billionaires in their mad dash for profit and exploitation - is destroying the health and quality of life for all on this planet. It needs to stop.

Further Reading

1. Parliamentary Office of Science and Technology. PFAS: ‘Forever Chemicals’ — POST Note 747. UK Parliament. 2025.

2. CHEM Trust / Wildlife and Countryside Link. Regulating PFAS ‘Forever Chemicals’ in the UK: A Way Forward. CHEM Trust. 2025.

3. Fidra / Wildlife and Countryside Link. Written evidence to UK Parliament PFAS inquiry (PFAS0047). UK Parliament. 2025.

4. UK Government. PFAS Plan: Building a Safer Future Together. DEFRA / HM Government. 2026.

5. Marfella R, Prattichizzo F, Sardu C, et al. Microplastics and nanoplastics in atheromas and cardiovascular events. N Engl J Med. 2024;390(10):900–910. 2024.

6. Lancet Planetary Health. Microplastic and nanoplastic pollution and associated potential disease risks. Lancet Planet Health. 2025.

7. Orsini L, Abdallah M, et al. (University of Birmingham). Microplastics and PFAS — combined risk and greater environmental harm. Environmental Pollution. 2024.

8. Haas R, et al. Pesticide exposure, associated risks, and long-term human health impacts: a systematic review. Environmental Research and Public Health / PMC. 2024.

9. UKHSA. Health inequalities in health protection report 2025. UK Health Security Agency. 2025.

10. Gray N, Moller S, et al. (University of York). Deprived communities in England experience higher emissions of air pollution. University of York / NCAS. 2023.

11. WHO Europe. Environmental health inequalities. World Health Organization Europe. 2023.

12. Friends of the Earth. Environmental justice: protecting people and planet. Friends of the Earth UK. 2025.

13. Fidra. How does chemical pollution impact UK wildlife?. Fidra.org.uk. 2024.

14. Nelms SE, Galloway TS, Godley BJ, et al. Microplastics in marine mammals stranded around the British coast: ubiquitous but transitory?. Scientific Reports. 2019;9:1075. 2019.

15. Ocean Conservancy / Baechler B, et al. A quantitative risk assessment framework for mortality due to macroplastic ingestion in seabirds, marine mammals, and sea turtles. Proc Natl Acad Sci. 2025.

16. McGoran AR, Clark PF, Smith B, et al. Temporal variation in microplastic abundance in sediment, fish and shrimp: a case study in the Thames Estuary, UK. Philos Trans A. 2025;383(2307):20250040. 2025.

17. Marine Conservation Society. Plastic pollution impact on marine life. mcsuk.org. 2025.

On 28 February 2026, US and Israeli forces launched Operation Epic Fury — nearly 900 airstrikes in the first twelve hours targeting Iranian military infrastructure and leadership, often involving civilian areas. Supreme Leader Ali Khamenei was killed. Iran retaliated with waves of missiles and drones across the region. Within days, the world had not merely a geopolitical crisis, it had a public health emergency. And as is so often the case in times of conflict, the costs are not shared equally.

Direct Casualties and the Collapse of Healthcare in the Region

The immediate toll has been steep. According to the World Health Organization, by 11 March Iranian national health authorities had reported more than 1,300 deaths and over 9,000 injuries since the start of the conflict, with Lebanon reporting at least 570 deaths and more than 1,400 injuries. Healthcare workers have not been spared: WHO verified 18 attacks on health facilities in Iran within the first two weeks, resulting in 8 health worker deaths. In Lebanon, 49 primary healthcare centres and five hospitals have closed following military evacuation orders, and, recently, 11 healthcare workers were killed when a medical centre in Southern Lebanon was hit in an Israeli attack [1].

Each destroyed clinic represents patients with diabetes unable to collect insulin, mothers unable to access antenatal care, trauma victims dying before reaching a surgical team. The WHO’s Regional Director, Dr Hanan Balkhy, has made clear that 16 countries are now affected by the expanding crisis — and that the disruption reaches far beyond the battlefield [2].

The Dubai Bottleneck: When Global Aid Grinds to a Halt

One of the conflict’s most consequential and least-visible health impacts concerns a logistics hub in Dubai. The International Humanitarian City (IHC) in Dubai is the world’s premier disaster relief logistics centre. Last year it fulfilled over 500 emergency health orders for 75 countries across all six WHO regions [2]. On 1 March, Dubai’s Jebel Ali port - the largest container terminal in the Middle East - caught fire after debris from an intercepted Iranian missile struck it. Operations at the IHC were temporarily suspended.

The result was that $18 million in humanitarian health supplies became inaccessible, with a further $8 million in shipments unable to reach the hub at all [2]. The UN’s World Food Programme warned that shipping containers now face a $3,000 emergency surcharge, driving up the cost of life-saving operations in countries entirely uninvolved in the conflict including Sudan, Myanmar and Afghanistan [3]. The war in Iran is creating rationing of medicines thousands of miles away.

The Strait of Hormuz: A Chokepoint for Health as Well as Oil

The Strait of Hormuz carries roughly one-fifth of global petroleum and more than a quarter of global seaborne oil trade. Iran’s closure of the strait has sent oil prices surging — at one point above $120 a barrel, the highest since 2022, when Russia invaded Ukraine [4]. For wealthier nations, this means increasing petrol prices and rising energy bills. For low- and middle-income countries, it means something far more serious.

The Strait is also a major chokepoint for fertiliser exports. Around 20–30% of global fertiliser, including urea and ammonia nitrate, transits through the Hormuz strait [5]. Qatar, Saudi Arabia, Iran, and Oman together supply a large share of the world’s traded fertilisers. A blockade during key planting seasons risks devastating crop yields in countries already facing food insecurity. In addition, the UN’s International Monetary Fund has stated that every 10% increase in energy prices adds almost half a percentage point to global inflation [6] - inflation that translates directly into hunger in the world’s poorest communities.

Analysts have identified Sub-Saharan Africa as the most vulnerable region. Farmers there are heavily dependent on imported fertiliser and households spend a disproportionate share of income on food. The war’s fertiliser shock threatens both harvests and prices [7].

A Polycrisis for the World’s Most Vulnerable

The Council on Foreign Relations has described the compound effects of the conflict as a “polycrisis”: logistics gridlock, dollar appreciation, fertiliser shortages, and oil shocks converging to push the food insecure toward emergency, and those in emergency toward famine [3]. Before the conflict began, the Middle East and surrounding region was already home to 25 million displaced people [3]. That number is rising rapidly.

The conflict’s health consequences for Afghan immigrants inside Iran deserve particular attention. Iran hosts millions of Afghan migrants, documented and undocumented, who have been exposed to military strikes, economic collapse, and accelerating deportations since hostilities began. As the Lancet noted in its analysis of the conflict’s health implications, this is compounding an already fragile humanitarian situation for women and children in Afghanistan, threatening further destabilisation and cascading displacement across the region [8].

The World Food Programme, already severely weakened after losing 40% of its funding last year and shedding 6,000 staff, has warned that rising fuel and operating costs from the conflict threaten its capacity to reach children facing severe malnutrition [9].

What This Means for the UK

Britain has sought to distance itself from offensive operations, with Prime Minister Sir Keir Starmer confirming the UK will not participate in direct strikes against Iran, though limited defensive support continues [10]. But geopolitical neutrality offers no immunity from health consequences.

The UK imports roughly 40% of its oil and 60% of its gas, and although much comes from Norway rather than the Gulf, the conflict’s effects on global energy markets are already feeding through. In rural communities dependent on heating oil, Labour MPs in the Rural Research Group have reported elderly and vulnerable constituents being told their confirmed deliveries have been cancelled and re-priced - a situation one MP described as becoming “a public health issue” [11].

Food prices are also under pressure. Around 35% of key fertilisers, including urea and ammonia nitrate, come through the Strait of Hormuz [5]. British farmers are warning of severe inflationary pressures passing through the supply chain to the retail shelf. Trade experts have cautioned that food prices could rise within weeks, and the “big worry,” as one logistics specialist put it, is that they will not come back down [12].

The NHS is also vulnerable. Already affected by fragile supply chains - pharmacies reported significant difficulties sourcing even aspirin in the weeks before the conflict [13] - the disruption to global logistics adds new pressure. The Centre for Long-Term Resilience has flagged the UK’s dependence on supply chains for antibiotics, vaccines, and diagnostic equipment as “highly brittle and vulnerable” [13].

Inequality Is Not Incidental — It Is the Architecture

The health consequences of this conflict are not randomly distributed. They follow the existing architecture of global inequality. Wealthy Gulf states can fly food in by alternative routes. The United States is a net energy exporter and will benefit marginally from higher oil prices. European economies face a slowdown.

Low-income countries face famine.

In the UK, the cost of living crisis that the Iran conflict is now deepening falls most heavily on those who were already struggling. Food inflation is a regressive tax. Heating oil price spikes harm rural communities with fewer alternative energy sources. NHS supply chain fragility was already disproportionately affecting communities with least access to private healthcare alternatives.

The Lancet’s analysis of Iran’s health system noted that decades of sanctions, another form of structural violence, had already been linked to higher mortality from non-communicable diseases before a single bomb fell [8]. War does not create health inequality per se, but it amplifies it.

Conclusion

The conflict in Iran is, among other things, a public health emergency, one whose effects are radiating far beyond the Middle East. The immediate casualties are staggering. The humanitarian supply chain disruption is global. The food and energy price shocks threaten the most vulnerable communities on earth. And in the UK, a war in which we are not combatants is already threatening the food security and health of those who can least afford another crisis.

For healthcare workers, understanding these connections, between geopolitics, supply chains, food systems, and health, is not peripheral to clinical practice. It is essential to it.

It would have been better for all our sakes, except for the few already disproportionately rich who will profit financially, if this war had not started.

References

1. World Health Organization. Conflict deepens health crisis across Middle East, WHO says. 11 March 2026.

2. World Health Organization. Health impact of the escalation of conflict in the Middle East. 5 March 2026.

3. Vigersky S. The Iran War Is Breaking Global Humanitarian Aid Efforts. Council on Foreign Relations, 12 March 2026.

4. AP / Washington Times. Analysis: Iran war becomes a contest of who can take the most pain. 11 March 2026.

5. ITV News. Food prices, energy bills, mortgages and pensions: What is the broader impact of the Iran war? 9 March 2026.

6. CFR Global Conflict Tracker. Iran’s War With Israel and the United States. March 2026.

7. CNBC. A global food price shock looms as Middle East war rages on. Here’s who will be hit hardest. 12 March 2026.

8. Lankarani KB et al. Iran and beyond: perilous threats to population health. The Lancet. August 2025.

9. The National. Iran war will raise cost of food and hit struggling humanitarian groups, WFP warns. 10 March 2026.

10. Distilled Post. Britain Drawn into Conflict with Iran? The Risks and Impact on the NHS. March 2026.

11. LabourList. Think tanks and MPs call for targeted response as Iran war impacts cost of living. 13 March 2026.

12. Yahoo Finance / Logistics UK. Food prices could rise within weeks — but the ‘big worry’ is that they won’t come back down. March 2026.

13. The Week. NHS vulnerable to ‘fragile’ supply chains. 23 February 2026.

The pan on your hob. The takeaway box from Friday night. Your waterproof jacket. Each of these everyday objects may share a hidden ingredient — and new research suggests it could be quietly ageing us.

The chemicals in question are PFAS: per- and polyfluoroalkyl substances. There are over 10,000 variants of PFAS, which have been manufactured since the 1940s and are useful for being heat-resistant, waterproof, and virtually indestructible. That last quality is the problem. The stability of their carbon-fluorine backbone means they’re expected to take up to a thousand years to break down, hence the nickname that has stuck: forever chemicals.

What the new science says

A study published in February in the journal Frontiers in Aging has found that two specific PFAS compounds -PFNA (Perfluorononanoic acid, used in the production of non-stick coatings and in fire-fighting foam) and PFOSA (Perfluorooctanesulfonamide, found in food packaging) - appear to speed up biological ageing in middle-aged men, but not in women. The team measured something called the epigenetic clock: an analytical method used as a biomarker of aging using chemical tags on DNA that reveal how fast the body is truly ageing, independent of how old someone looks or feels. PFNA and PFOSA appeared in the blood of 95% of participants, and higher levels of these chemicals were linked to faster biological ageing.

Why men specifically? Researchers suspect that men may be at higher risk because the ageing markers analysed are heavily influenced by lifestyle factors such as smoking, which can compound the damaging effects of these pollutants. Science Alert There’s also a biological dimension: premenopausal women appear to clear some PFAS through menstruation, a pathway men simply don’t have.

The sample in this study was was relatively small and it demonstrates an association rather than a definite cause and effect. Larger longitudinal studies are needed, but the finding arrives on top of a growing pile of evidence linking PFAS to cancers, thyroid disease, high cholesterol, infertility, and immune disruption.

The UK picture

This is not an abstract American problem. The UK faces a large scale of legacy PFAS contamination, including land contaminated from firefighting foams and from emissions from industry and landfill. In response, Britain unveiled its first-ever national plan to tackle forever chemicals in February 2026, aiming to understand where these chemicals are coming from, how they spread, and how to reduce public and environmental exposure. The full extent of PFAS in England’s estuaries and coastal waters is to be assessed for the first time.

It’s a welcome step. Critics, however, note that the plan is heavy on monitoring intentions and light on enforcement, and that meaningful bans on PFAS in consumer products remain years away.

Where the social justice lens matters

This part of the story rarely makes it into the headlines: PFAS contamination is not evenly distributed. Industrial facilities, military airfields (which used PFAS-laden firefighting foam for decades), and waste sites are disproportionately located near lower-income communities. People living near these sources face higher exposures; exposure determined by where they can afford to live, or where their work takes them.

While harmful substances do not discriminate and everybody can be exposed, the people most at risk of adverse health effects are those exposed to high levels of PFAS and vulnerable population groups, such as children and the elderly. Industrial workers in manufacturing, firefighting, and agriculture where PFAS-contaminated sewage sludge has been spread on fields carry a disproportionate risk.

For clinicians, this matters. A patient presenting with unexplained thyroid dysfunction, elevated cholesterol unresponsive to lifestyle changes, or recurrent immune issues is rarely asked about their occupational or residential history in relation to chemical exposure. Perhaps they should be.

What can people do now?

The researchers recommend looking for reasonable ways to reduce exposure - checking local drinking water reports, using certified water filters designed to reduce PFAS, and limiting the use of stain- or grease-resistant products when alternatives are available.

But individual action only goes so far when the chemicals are already in the water, the soil, and the food chain. The deeper prescription here is regulatory and political, and the UK’s new PFAS Plan, for all its limitations, is at least an acknowledgement that the problem is real, present, and overdue for a national response.

“Forever chemicals are not a forever problem,” Environment Minister Emma Hardy said at the plan’s launch. Whether that optimism proves well-founded will depend on how much pressure is maintained on government and industry in the years ahead.

Resources:

• BBC Panorama: The Truth About Forever Chemicals.

• PFAS Plan: building a safer future together.

• PFAS.

Videos:

• What are PFAS?

• Why are PFAS a health concern?

• Lowering your Exposure to PFAS in Drinking Water.

• Short Term Solutions: How to Select a POU Water Filter or Bottled Water.

• Lowering Your Exposure to PFAS in Household Products, Part 1.

• Lowering Your Exposure to PFAS in Household Products, Part 2.

• Forever chemicals.

• How One Company Secretly Poisoned The Planet

When someone hears the words “You have cancer”, it should not matter where they live. And yet, quietly and persistently, it still does. Across the UK, people in rural, coastal and more deprived communities are often diagnosed later and treated more slowly than those living near large hospitals and specialist centres. This is not because they neglect their health or wait longer to report symptoms, it is because access is harder, services are stretched and expertise is unevenly distributed.

Recent plans to train more cancer specialists outside major cities are a welcome step because they acknowledge something important: expertise should live where people are. When doctors, nurses, and diagnostic teams are trained locally, they are more likely to stay, to know their communities, and to become trusted parts of the landscape rather than distant names on a referral letter. Training posts alone are not enough. Doctors need time, teams, and tools. They need reliable diagnostics, stable multidisciplinary working, and the sense that caring for patients outside big centres is valued, supported work — not second best.

Earlier diagnosis matter just as much. Many cancers are still found late, especially in poorer communities. If attending an appointment costs time, money or fear, delay becomes understandable. Compassionate healthcare has to take these realities seriously.

At heart, this is about fairness. A health system built on care and solidarity cannot be comfortable with outcomes that depend on a postcode.

These changes will take time, patience, and sustained commitment. But they are worth making. Because cancer already takes enough from people — where they live should not take their chance as well.

Cold Homes, Cold Bodies.

Every winter, fuel poverty affects millions of UK households. It disproportionately affects older adults, single parents, and, owing to their reduced capacity to earn, people with chronic illness.

People living in cold housing are at increased risk of respiratory infections, including pneumonia, cardiovascular events, including heart failure, hypothermia and excess winter mortality. Of course, other factors, such as the winter viruses, take their toll.

In the UK, excess winter deaths (EWDs) are calculated by comparing the number of deaths in the winter months (Dec–Mar) with the average of non-winter months (Aug–Nov and Apr–Jul). Historically, England and Wales saw 20,000–50,000 excess winter deaths per year before the pandemic, rising with severe seasonal conditions. In one recent winter (2020–21), there were about 60,760 EWDs, partly due to COVID-19 alongside cold exposure.

Estimates attribute around 4,700–5,000 excess winter deaths per year directly to cold, damp homes in England, Scotland and Wales — a marker of fuel poverty and deprivation.
Previous analyses suggest about 10% of excess winter deaths are directly linked to fuel poverty and 21.5% to cold homes specifically.

A UK analysis found that in the last decade, a quarter of a million older people died from cold-related illness — roughly one older person every 7 minutes — with poor housing a key driver. A Europe-wide study estimated approximately 363,500 deaths annually from cold exposure, compared with ~43,700 from heat (baseline 1991–2020).

Winter places stresses upon healthcare systems. The sometimes critical increases in respiratory virus infections mean that the services are less able to cope with diseases associated with cold housing. There is a knock-on effect. Further, children from cold homes have higher rates of asthma exacerbations and missed school days. Winter in the Northern Hemisphere involves some of the richest countries on Earth. Still, there is fuel poverty, homelessness, suffering, morbidity and increased mortality. Resources that could help the poor and unsheltered are being hoarded by a small percentage of the population. The excess deaths seen in winter are not a meteorological or even a purely medical phenomenon. They are a social problem. Like poverty, cold is not a lifestyle choice.

Health Inequality in Cancer Care.

Every year in the UK there are an estimated 30,000 new cases of cancer which are attributable to socio-economic deprivation, with cancer of the lung the neoplasm most strongly associated with poverty.

Healthcare Inequality - defined as unfair, systematic and avoidable differences in health between groups - exists across the cancer spectrum and has become worse since the onset of the pandemic.

Poorer communities tend to have higher levels of risk factors (for example: smoking, obesity), less awareness of the consequences of poor lifestyles and of the importance of specific symptoms, greater barriers to seeking help and lower uptake of screening programmes.

The trend towards distance consultations, present before the pandemic but much increased since, is also a potential factor. Not only is the uptake of screening lower in deprived communities, the availability of technology required for teleconsultations is also less complete.

The Inverse Care Law.

Those in most need are the least likely to receive help.

The UK loses its measles elimination status.

According to the World Health Organisation, the UK has recently lost its measles elimination status, defined as “No endemic (continuous) transmission for 12 months or over, with high-quality surveillance”. Imported cases and small outbreaks can still occur.

This follows a notable recent increase in measles cases, with several thousand confirmed infections and at least one child’s death reported. Sustained transmission, and so the number of cases, is a consequence of a reduction in the coverage of the MMR vaccine, which has declined below the 95 % threshold needed for herd immunity.

Measles is one of the world’s most contagious viral diseases; outbreaks are occurring in many countries where vaccination coverage has fallen. Most high-income countries have NOT eliminated measles reliably and loss of elimination status is now common, not exceptional. The problem is not vaccine failure, but vaccine coverage and uptake.

Measles remains a reliable marker of health-system equity and trust

Measles elimination is increasingly fragile in high-income countries. Though much of this fragility can be blamed upon serious wealth inequality, much is due to the reduction in vaccine uptake - often inexplicably promoted by global interests - with a consequent overall reduction in measles immunity.

This vaccine avoidance has already led to increased numbers of children being treated in intensive care units and to avoidable deaths.

Beetroot and High Blood Pressure.

A recent study at the University of Exeter has found that beetroot can help lower blood pressure in the over 60s.

Beetroot (and other nitrate-rich vegetables) can lower blood pressure, mainly by boosting nitric oxide (NO) via the nitrate - nitrite - nitric oxide pathway, which relaxes blood vessels and improves the function of the blood vessel wall.

The study found that adding beetroot to the diet had an effect upon oral bacteria in the older person, with an increase in useful bacteria and a decrease in harmful bacteria. There was an associated, if mild, drop in blood pressure. These changes were not seen in the younger participants, who are more likely to have normal blood pressures and a healthy oral bacteria population.

Other studies have found a small reduction in both systolic and diastolic pressures associated with regular dietary beetroot, though the evidence strength is low.

It must be realised that beetroot is not a treatment for high blood pressure but can help as an adjunct to medically recommended therapy, and, for those who don’t like beetroot, other vegetables such as rocket/arugula, spinach, lettuce, Swiss chard, celery (often comparable or higher nitrate density than beetroot, depending on growing conditions) are alternatives.

The Creeping Cold has fingers.

Figures for the effects of cold weather upon mortality in the UK for the winter of 2024/5 have been released.

Over a period of 10 days, involving three cold spells, the temperature fell to less than 2 degrees Centigrade (yellow cold warning), and was associated with a total of 2544 deaths. Diseases of the heart and circulation were responsible for the majority of the deaths, with respiratory causes and infections following closely.

Cold weather increases risks by increasing the stresses on the body, affecting its ability to maintain a healthy temperature. Stress and lower body temperatures increase the susceptibility to infection while snow and ice increase the risk of falls and injuries.

Those at most risk are the elderly, the frail, those with chronic diseases, the poor, homeless and undernourished. Again, the inequalities of society in an acknowledgedly rich country put some in comfort and rude health while others suffer and die.

New Flu strain emerging.

Reports in the British Medical Journal have shown an increase in flu cases in the UK, mainly among young adults and school children. This appears to be due to a new H3N2 strain, which has mutated several times over the summer and has increased in severity.

Though this is not an entirely new strain, there are sufficient differences for it to side-step community immunity and vaccine cover. That is side-step, not dodge. Existing acquired immunity still offers some protection, and this can be ‘topped up’ by this year’s vaccine.

The advice remains as before: take sensible precautions to avoid spread, use masks in public places, wash your hands and ... get vaccinated.

Infectious diseases watch.

Two cases of Nipah virus infection have been confirmed in West Bengal, India in early 2026, both in healthcare workers. Rapid contact tracing and testing (~196 contacts) have identified no additional cases, and the World Health Organization currently assesses the risk of wider spread as low.

Nipah virus, a zoonotic pathogen carried by fruit bats, can cause severe respiratory and neurological illness with a high fatality rate (40–75%), but human-to-human transmission tends to require close, prolonged contact.

There is no vaccine or specific treatment; management is supportive. Several Asian countries have heightened traveler screening as a precautionary measure.

At present, the outbreak appears contained, and the global risk remains low, though vigilance and strong surveillance continue to be important.

Resources

Keeping people warm:

Fuel poverty is one of the most preventable winter health risks:

• National Energy Action - Advice, advocacy, and direct support for households struggling to heat their homes.

• Citizens Advice - Eligibility checks for energy grants, benefits, debt advice, and crisis support.

• GOV.UK – Winter Fuel Payment & Cold Weather Payment - Direct financial support for older people and low-income households during cold spells.

• Energy Saving Trust - Advice on insulation, heating efficiency, and grants that reduce long-term cold exposure.

Health, Aging and Vulnerability.

• Age UK - Winter warmth programmes, befriending services, benefits advice, and local outreach

• NHS - Stay Well This Winter - Vaccination, respiratory illness prevention, and advice for carers and vulnerable adults.

• Royal Voluntary Service - Volunteers delivering food, companionship, and support to isolated older people.

• Trussell - Volunteers delivering food parcels, foodbanks around the UK.
  

As understanding of post-COVID syndromes matures, clinicians increasingly encounter neurological symptoms extending beyond fatigue and cognitive dysfunction. Visual complaints are common, but most are non-specific. Diplopia is less frequent, yet it warrants careful attention because it usually indicates disturbance of ocular alignment or ocular motor control rather than primary ocular surface disease.

The published evidence to date supports a cautious position: ocular motor palsies and diplopia have been reported following SARS-CoV-2 infection, chiefly in acute and subacute settings, and their prevalence and natural history within clearly defined Long Covid cohorts remain incompletely characterised. Early in the pandemic, Neurology reports described COVID-19 presenting with ophthalmoparesis attributable to cranial nerve palsy. Subsequent literature has continued to document oculomotor, trochlear, and abducens nerve palsies temporally associated with COVID-19 infection.

Beyond discrete cranial nerve palsies, a separate strand of evidence concerns oculomotor control in post-COVID condition (PCC). Objective eye-tracking studies in PCC, particularly among individuals with cognitive complaints, have reported alterations across saccades, pursuit, fixation, vergence, and pupillary parameters. Other cohorts have reported vision-related symptoms and measurable oculomotor findings in non-hospitalised post-COVID populations. These studies support the broader proposition that ocular motor function may be affected in some PCC patients. However, it remains premature to claim that specific syndromes such as convergence insufficiency are common without stronger prevalence data.

A small but important differential is myasthenia gravis (MG). New-onset MG has been reported after SARS-CoV-2 infection, sometimes beginning with oculo-bulbar symptoms including diplopia and ptosis. While myasthenia gravis is unlikely to explain most post-COVID visual complaints, its consequences are significant enough that fluctuating diplopia or fatigable ptosis should trigger appropriate evaluation and referral.

For generalists, the practical message remains one of measured vigilance. New-onset diplopia requires structured assessment and urgent triage where red flags are present. Where investigations are unrevealing and symptoms are stable, a post-infectious mechanism may be considered---but only after exclusion of time-critical pathology.

In summary, the evidence supports that diplopia and ocular motor dysfunction can occur after SARS-CoV-2 infection, and objective studies suggest oculomotor control changes in some PCC patients. What remains uncertain is how often diplopia forms part of Long Covid, which patients are at risk, and which interventions best help. Until better cohort data emerge, clinical curiosity should be paired with careful follow-up.

Long Covid and diplopia — key clinical points

Read more

Where you live should not determine whether your cancer is caught early, treated promptly, or managed by a specialist team. And yet, in the UK, it still too often does.

Recent announcements about expanding cancer specialist training posts in rural and coastal areas are welcome — not because they are radical, but because they address a truth clinicians and patients alike have known for years: expertise is unevenly distributed, and illness exploits that inequality mercilessly.

Cancer outcomes in the UK vary markedly by geography. Survival is consistently poorer in deprived regions, coastal communities, and areas distant from major teaching hospitals. These differences are not explained by biology alone. They reflect later presentation, reduced access to diagnostics, workforce shortages, and overstretched local services. In short, they reflect systems — not patients.

The quiet geography of expertise

Specialist care tends to cluster where training, research, and prestige already exist. Large urban centres attract oncologists, radiologists, pathologists, and specialist nurses because that is where career progression is most visible and professionally supported. Meanwhile, smaller hospitals struggle to recruit and retain the same depth of expertise, even as their populations age and cancer incidence rises.

The result is a subtle but powerful “postcode lottery”:

• Delays to imaging or biopsy

• Fewer subspecialty opinions

• Longer waits for definitive treatment

• Greater reliance on patient travel or fragmented care

None of this is deliberate. It is simply what happens when workforce planning follows gravity rather than need.

Training as redistribution, not just expansion

The proposed strategy to train more cancer specialists outside traditional centres is significant because it re-frames training as a tool of redistribution, not merely workforce growth. Training doctors and allied professionals where they are needed increases the likelihood they will stay, embed, and build local expertise over time.

But training posts alone are not enough. Specialists require:

• Diagnostic infrastructure they can rely on

• Multidisciplinary teams that are stable and supported

• Protected time for learning, audit, and reflection

• A sense that practising outside a major centre is not a professional cul-de-sac

Without this, new posts risk becoming short-term rotations rather than long-term solutions.

Early diagnosis still matters most

Redistributing expertise will only translate into better outcomes if it is paired with earlier diagnosis. Many of the starkest regional differences in cancer survival reflect late presentation — often driven by deprivation, health literacy, access barriers, and competing life pressures.

For patients juggling insecure work, transport difficulties, caring responsibilities, or mistrust of institutions, “come back if it gets worse” can mean “come back too late”. Tackling the postcode lottery therefore also means investing in:

• Community diagnostics

• Primary care capacity

• Outreach and culturally competent health messaging

Cancer equity begins long before a patient meets an oncologist.

A moral, not merely managerial, challenge

At its heart, this is not a question of efficiency or targets. It is a moral challenge. A health system founded on solidarity and equity cannot accept predictable, preventable variation in outcomes simply because of geography.

The current proposals are a step in the right direction — cautious, imperfect, but necessary. Whether they succeed will depend on whether we treat cancer workforce planning as a long-term commitment to place, rather than a short-term fix to rota gaps.

Because if we truly believe that everyone deserves the same chance of survival, then expertise must travel — not just patients.

Summary.

The RAAS is a critical hormonal cascade that helps maintain arterial blood pressure, extracellular fluid volume, and electrolyte balance. It co-ordinates renal, vascular, and adrenal functions and interfaces with the sympathetic nervous system, vasopressin release, natriuretic peptides and local tissue systems (notably in the heart, kidney, and brain). It is a finely tuned, multi-organ system that maintains cardiovascular and fluid homeostasis.

Dysregulation contributes to hypertension, heart failure, kidney disease, and inflammatory pathologies. The RAAS is a critical hormonal cascade that helps maintain arterial blood pressure, intravascular volume, and electrolyte balance. It co-ordinates renal, vascular, and adrenal functions and interfaces with the sympathetic nervous system, vasopressin release, and local tissue systems (notably in the heart, kidney, and brain).

Modern therapeutics target this system at multiple points — renin, ACE, AT₁ receptors, and aldosterone — to modulate its activity and prevent end-organ damage.

Pathway.

Renin is synthesised and stored in juxtaglomerular (JG) cells of the kidney afferent arteriole, and is released into the blood in response to reduced renal perfusion pressure (detected by juxtaglomerular baroreceptors) and to reduced sodium chloride delivery to the macula densa.

It is also released in response to sympathetic activation via β₁-adrenoceptors at the juxtaglomerular cells.

Renin, an aspartyl protease, cleaves angiotensinogen in plasma to the decapeptide angiotensin I (Ang I).

Angiotensinogen, itself, is a glycoprotein produced mainly by the liver. Its production is increased by oestrogen, corticosteroids, thyroid hormone, and inflammation (IL-6–mediated).

Circulating angiotensin I is inactive but is converted to the active angiotensin II by Angiotensin-Converting Enzyme (ACE) on the vascular endothelial cells - particularly in the pulmonary and renal circulations. Angiotensin-Converting Enzyme removes two amino acids from angiotensin I to form angiotensin II (Ang II). It also degrades bradykinin, a vasodilator peptide, adding to the vasoconstrictive effect .

Angiotensin II acts mainly on the angiotensin II receptors AT₁ and AT₂ (both G protein-coupled receptors).

AT₁R: Mediates vasoconstriction, aldosterone release, sympathetic activation, sodium retention, and cellular growth.

AT₂R: Counter-regulatory — promotes vasodilation, anti-proliferation, apoptosis, and NO release. Although angiotensin II binds both AT₁ and AT₂ receptors, many of the vasodilatory and anti-fibrotic effects classically attributed to AT₂ activation are mediated in parallel by the angiotensin-(1–7)/Mas receptor axis.

Aldosterone is synthesised in the zona glomerulosa of the adrenal cortex. It is released following Ang II stimulation, directly in hyperkalaemia and, to a lesser extent, in response to ACTH.

It binds mineralocorticoid receptors in the distal nephron (principal cells) to:

↑ Na⁺ reabsorption via the epithelial sodium channels (ENaC) channels.

↑ K⁺ secretion via the renal outer medullary potassium (ROMK) channels.

↑ water reabsorption (secondary to sodium retention).

Aldosterone activity results in expanded extracellular volume and elevated blood pressure.

The effects of RAAS activity are counterbalanced by ACE2 which converts Ang II to Ang (1–7). This acts via Mas receptors producing vasodilation, anti-fibrosis, and anti-inflammatory effects.

Natriuretic peptides (ANP, BNP) also oppose RAAS activity by promoting loss of sodium in the urine, vasodilation, and suppression of renin/aldosterone.

Physiological Effects.

Cardiovascular.

Angiotensin II acts directly upon AT₁ receptors in vascular smooth muscle producing vasospasm, so increasing systemic vascular resistance (SVR). If the cardiac output remains constant, this action will increase the blood pressure.

Direct cardiac effects include positive inotropy and myocardial hypertrophy. Chronic stimulation can lead to myocardial fibrosis.

Renal.

RAAS activity promotes efferent arteriolar constriction which maintains glomerular filtration pressure during hypotension.

At the renal tubules, aldosterone increases Na⁺ reabsorption and K⁺ secretion in the principal cells of the distal tubule and collecting duct via its effect upon the epithelial sodium channels (ENaC) and the renal outer medullary potassium channels (ROMK channels).

Neurohormonal.

The RAAS can stimulate thirst through its effects upon the hypothalamus, and increase ADH (vasopressin) release which leads to water retention.

There is also sympathetic activation via brainstem nuclei, with consequent adrenergic effects upon the heart and circulation.

Cellular Mechanisms.

• AT₁ Receptor: A G-protein–coupled receptor (GPCR) activating phospholipase C leads to IP₃ + DAG, ↑ intracellular Ca²⁺ and, consequently, vasoconstriction, aldosterone synthesis, and cellular growth.

• Aldosterone mechanism: Nuclear receptor binding leads to increased transcription of ENaC and Na⁺/K⁺-ATPase subunits so facilitating increased Na⁺ re-uptake.

Clinical Relevance.

In heart failure, chronic RAAS activation leads to vasoconstriction, sodium retention and cardiac remodelling. ACE inhibitors, ARBs, MRAs (spironolactone) can be beneficial.

Hypertension is associated with over-activity of the angiotensin II/aldosterone axis. Appropriate therapeutic options include ACE inhibitors, angiotensin receptor blockers and renin inhibitors.

Glomerular hypertension and fibrosis from persistent from persistent angiotensin II stimulus is a feature of chronic kidney disease (CKD). RAAS blockade can slow CKD progression.

In COVID-19, use of ACE2 receptor by the coronavirus disrupts balance between angiotensin II and angiotensin (1-7) and AT₁R and MasR signalling - a possible link to endothelial injury and cytokine storm; also to potential therapeutic options.

Suggested Reading.

Classical RAAS physiology

• Hall JE, Guyton AC

Textbook of Medical Physiology

Elsevier (latest ed.)

Gold-standard integrative physiology reference

Chapters on renal sodium handling, RAAS, pressure–natriuresis

Especially strong on system-level control of BP

https://www.elsevier.com/books/guyton-and-hall-textbook-of-medical-physiology/hall/978-0-323-59712-8

• Atlas SA

The renin–angiotensin aldosterone system: pathophysiological role and pharmacologic inhibition

Journal of Managed Care Pharmacy (2007)

Clear overview of classical RAAS

Good bridge between physiology and therapeutics

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8673245/

DOI: https://doi.org/10.18553/jmcp.2007.13.s8-b.9

• Peach MJ

Renin–angiotensin system: biochemistry and mechanisms of action

Physiological Reviews (1977)

Older but still authoritative

Excellent mechanistic detail on Ang II signalling

https://journals.physiology.org/doi/10.1152/physrev.1977.57.2.313

ACE2, Ang-(1–7), Mas receptor (counter-regulatory RAAS)

• Donoghue M et al.

A Novel Angiotensin-Converting Enzyme–Related Carboxypeptidase (ACE2) Converts Angiotensin I to Angiotensin 1-9

Circulation Research Volume 87, Issue 5, 1 September 2000; Pages e1-e9

Landmark paper identifying ACE2 as a functional RAAS enzyme

https://doi.org/10.1161/01.RES.87.5.e1

• Santos RAS, et al.

The ACE2/Angiotensin-(1–7)/Mas Axis of the Renin–Angiotensin System: focus on angiotensin-(1–7)

Physiological Reviews, 2018

This review highlights roles of Ang-(1–7) via the Mas receptor and describes how this axis counterbalances the “classical” RAAS (Ang II/AT$_1$) in the heart, vessels, and kidneys.

https://pubmed.ncbi.nlm.nih.gov/29351514/

DOI: https://doi.org/10.1152/physrev.00023.2016

• Patel VB, Zhong J-C, Grant MB, Oudit GY

Role of the ACE2/Ang-(1–7) Axis of the Renin-Angiotensin System in Heart Failure

Circulation Research (2016)

Clinical relevance of ACE2

Heart failure, vascular disease, remodelling

https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.116.307708

DOI: https://doi.org/10.1161/CIRCRESAHA.116.307708

RAAS, ACE2, and modern disease (HFpEF, lung, endothelium)

• Imai Y, Kuba K, Rao S et al.

Angiotensin-converting enzyme 2 protects from severe acute lung failure

Nature (2005)

Key demonstration of ACE2 as a protective enzyme

Foundational for later COVID-19 work

https://www.nature.com/articles/nature03712

DOI: https://doi.org/10.1038/nature03712

• Vaduganathan M et al.

Renin–angiotensin–aldosterone system inhibitors in patients with COVID-19

NEJM (2020)

Clinical clarification of ACEi/ARB effects on ACE2

Important for modern interpretation

https://www.nejm.org/doi/full/10.1056/NEJMsr2005760

DOI: https://doi.org/10.1056/NEJMsr2005760

As we settle into the heart of respiratory virus season, flu continues to be the most commonly detected seasonal illness in many parts of the world — including here in the UK. Recent surveillance confirms that influenza A, and in particular the H3N2 subtype, dominates this year’s circulating viruses. Of those H3N2 viruses that have been genetically characterised, the majority belong to a variant called subclade K, a slightly drifted version of the virus compared with previous seasons.

But what does this mean in everyday terms?

Viruses like influenza are constantly changing, and seasonal variants emerge as they “drift” to escape some of the immunity we’ve built up from past infections or vaccinations. The H3N2 subclade K strain has several genetic changes that differentiate it from the H3N2 components used when this season’s vaccines were selected. This partly explains why the flu season in the UK began earlier than usual — and why case numbers climbed quickly in children and young adults last autumn.

Importantly, recent evidence does not suggest that this strain causes inherently more severe disease than typical seasonal flu. Although media outlets have sometimes dubbed it “super flu”, experts stress this is misleading.

Here’s what’s relevant for the general population now:

• Flu remains circulating at moderate levels in the UK winter season, with hospital visits and laboratory diagnoses continuing to show influenza A as the main driver.

• Vaccination still matters — even with a slight genetic mismatch, early vaccine effectiveness data suggest ongoing protection against serious outcomes, including hospital attendance and admission.

• Because the virus has drifted, some people may still get mild or moderate illness despite vaccination — but vaccinated individuals are generally less likely to become severely ill than those who are unvaccinated.

The message from public health professionals remains consistent: get your flu vaccine if you haven’t already, practice good respiratory hygiene (like handwashing and masking when symptomatic), and reach out to healthcare advice lines early if you are high-risk or develop concerning symptoms.

Flu doesn’t disappear simply because it’s mid-winter — and understanding how it’s evolving helps all of us make better choices for our health.

Cold Homes, Cold Bodies

Every winter, fuel poverty affects millions of UK households. It disproportionately affects older adults, single parents, and, owing to their reduced capacity to earn, people with chronic illness.

People living in cold housing are at increased risk of respiratory infections, including pneumonia, cardiovascular events, including heart failure, hypothermia and excess winter mortality.

Of course, other factors, such as the winter viruses, take their toll.

In the UK, excess winter deaths (EWDs) are calculated by comparing the number of deaths in the winter months (Dec–Mar) with the average of non-winter months (Aug–Nov and Apr–Jul). Historically, England and Wales saw 20,000–50,000 excess winter deaths per year before the pandemic, rising with severe seasonal conditions. In one recent winter (2020–21), there were about 60,760 excess winter deaths, partly due to COVID-19 alongside cold exposure.

Estimates attribute around 4,700–5,000 excess winter deaths per year directly to cold, damp homes in England, Scotland and Wales — a marker of fuel poverty and deprivation. Previous analyses suggest about 10% of excess winter deaths are directly linked to fuel poverty and 21.5% to cold homes specifically.

A UK analysis found that in the last decade, a quarter of a million older people died from cold-related illness — roughly one older person every 7 minutes — with poor housing a key driver. A Europe-wide study estimated approximately 363,500 deaths annually from cold exposure.

Winter places stresses upon healthcare systems. The sometimes critical increases in respiratory virus infections mean that the services are less able to cope with diseases associated with cold housing. There is a knock-on effect.

Further, children from cold homes have higher rates of asthma exacerbations and missed school days.

Winter in the Northern Hemisphere involves some of the richest countries on Earth. Still, there is fuel poverty, homelessness, suffering, morbidity and increased mortality. Resources that could help the poor and unsheltered are being hoarded by a small percentage of the population.

The excess deaths seen in winter are not a meteorological or even a purely medical phenomenon. They are a social problem.

Like poverty, cold is not a lifestyle choice.

Deprivation as a Multisystem Disease

The effects of poverty upon health can be seen as poverty behaving like a chronic inflammatory state. Poverty is associated with poor nutrition and reduced access to health care. Each has drastic effects upon the well-being of the poor.

Nutritional deficiencies can lead to poor health. Calories are cheap, so obesity is more likely among the poorer population. Dietary inadequacies can lead to poor tissue repair, immune system inefficiencies and specific vitamin and amino acid deficiencies.

The everyday problems of poor accommodation, poor nutrition, inadequate clothing and fuel poverty lead to chronic stress. The consequent rises in cortisol and sympathetic tone can lead to an increased risk of cardiovascular disease and diabetes.

Reduced access to preventative care makes common diseases more likely and delayed presentation leads to more advanced disease when help is sought.

Of course, the poor are more exposed to seasonal changes.

Why are there more deaths in winter?

Cold makes things worse.

When cold exposure contributes to excess mortality, it typically does not appear on the death certificate as “cold”, but acts as a trigger or exacerbating factor for other conditions.

The main causes associated with cold exposure are increases in cardiovascular deaths, such as heart attacks and strokes, and in respiratory deaths, such as from pneumonia and COPD exacerbations (cold stress and indoor crowding in winter facilitate respiratory infection and airway strain).

Influenza and other seasonal viruses contribute significantly to winter mortality.

Lower temperatures, icy conditions, and decreased mobility increase fall risk in older, more frail adults. Falling might mean a fractured hip, and, unless help is quickly to hand, a simple fall might lead to hypothermia.

Vulnerable populations.

Cold-related mortality is heavily concentrated in groups with less capacity to adapt. By far the majority of cold victims are from the 65 and over age group. People in poor housing, with a higher indoor exposure to cold, and those with heart and lung problems are also at risk from the cold.

Homeless people and people with insecure housing living in an exposed environment without adequate protection are a further risk group (exact UK homeless cold-death statistics are sparse but clinical and shelter data indicate a very high vulnerability).

Long COVID: what we understand better now.

With greater experience of the Long COVID syndrome comes a clearer definition and a clearer sense of scale.

The WHO now frames “post-COVID-19 condition” as symptoms starting within 3 months of infection and lasting at least 2 months, and estimates about 6 in 100 infected people develop it. A key shift is accepting that “long COVID” is likely to be several overlapping conditions, not one illness.

Several clinical presentations are now recognised, such as dysfunction of the autonomic nervous system (dizziness on standing, heart-rate changes), neurocognitive impairment, and exercise intolerance.

There are several possible ways that COVID can cause long-term health problems. Damage to the immune system and a subsequent chronic inflammatory response can keep symptoms going after the initial infection has resolved. Viral persistence or antigen persistence in some tissues is another possibility under serious consideration.

Damage to the linings of, and micro clots within, small blood vessels has been suggested as one possible contributor to fatigue, breathlessness, and exercise intolerance. Disruption of the autonomic nervous system would explain dizziness, palpitations, temperature intolerance and fatigue often seen post-COVID.

Management of the various Long COVID presentations needs to be tailored not only to the presentation but also to the individual. Symptoms often improve over months, but a meaningful minority have prolonged impairment.

Antimicrobial drug resistance.

Resistance to antibiotics and similar drugs used to fight infection is growing. This puts everybody at risk.

The UK health Security Agency reports that in England 2024 there were nearly 400 antibiotic-resistant infections per week, with estimated deaths in people with a resistant infection rising from 2,041 in 2023 to 2,379 in 2024.

This is not a theoretical problem. It means longer hospital admissions, fewer oral options, more IV therapy, and “routine” infections becoming complicated and possibly fatal.

We need better antimicrobial stewardship in order to slow the development of resistant infections and to allow our current antibiotics to remain effective.

The UK’s AMR National Action Plan 2024–2029 aims to reduce the need for antibiotics, optimise their use, and support new treatments and diagnostics options.

Think of stewardship as preventing avoidable exposure and protecting future effectiveness, while still treating serious infection promptly.

This means choosing the right drug, right duration, right indication. Shorter effective courses are preferable where evidence supports their use and we must avoid “just-in-case” antibiotics for clearly viral infections.

Without these measures, currently manageable infections can become much more serious and surgical operations at present made possible by of the availability of effective antibiotics will become unsafe or impossible to undertake.

What can we all do to help?

• Don’t seek antibiotics for colds/flu-like illness unless red flags develop.

• Don’t keep leftovers.

• Don’t share antibiotics.

• Finish the prescribed course.

• Accept offered vaccinations.

• Make sure your indoor environment is well-ventilated.

New Flu strain emerging.

Reports in the British Medical Journal have shown an increase in flu cases in the UK, mainly among young adults and school children. This appears to be due to a new H3N2 strain, which has mutated several times over the summer and so increased in severity.

Though this is not an entirely new strain, there are sufficient differences for it to side-step community immunity and vaccine cover. That is side-step, not dodge. Existing acquired immunity still offers some protection, and this can be ‘topped up’ by this year’s vaccine.

The advice remains as before: take sensible precautions to avoid spread, use masks in public places, wash your hands and ... get vaccinated.

Resources:

Keeping People Warm

Fuel poverty is one of the most preventable winter health risks.

• National Energy Action - Advice, advocacy, and direct support for households struggling to heat their homes.

• Citizens Advice - Eligibility checks for energy grants, benefits, debt advice, and crisis support.

• GOV.UK – Winter Fuel Payment & Cold Weather Payment - Direct financial support for older people and low-income households during cold spells.

• Energy Saving Trust - Advice on insulation, heating efficiency, and grants that reduce long-term cold exposure.

Health, Ageing & Vulnerability

• Age UK - Winter warmth programmes, befriending services, benefits advice, and local outreach.

• NHS – Stay Well This Winter - Vaccination, respiratory illness prevention, and advice for carers and vulnerable adults.

• Royal Voluntary Service - Volunteers delivering food, companionship, and support to isolated older people.

• Trussell - Volunteers delivering food parcels, foodbanks around the UK

Small actions matter.

Keeping one home warm, reporting one person sleeping rough, or helping one older person access support does not solve poverty, but it can prevent illness, hospitalisation, or death - and it matters to that one household, that one person.

Cold is a risk factor we know how to treat.