The board of Gavi, the international vaccine agency, meets Wednesday to debate shutting down the program, known as Covax, amid swiftly waning demand for the shots.The organization that has led the global effort to bring Covid vaccines to poor and middle-income countries will decide this week whether to shut down that project, ending a historic attempt to achieve global health equity with a tacit acknowledgment that the effort fell far short of its goal. The deliberations reflect the reality that demand for Covid vaccines is waning quickly throughout the world and is near nonexistent in countries that have some of the lowest rates of coverage. The program, known as Covax, has delivered more than a billion Covid vaccines to developing countries, in hugely challenging circumstances. But it was hobbled by fierce vaccine nationalism in wealthy nations and a series of missteps and misfortunes that undermined demand for the shots.The proposal to end Covax will be voted on by the board of directors of Gavi, a nonprofit, founded in 2000, that manages strategic stockpiles of emergency vaccines and supplies routine childhood shots to developing countries. The proposal would “sunset” Covax sometime in 2023. For 54 poor countries that traditionally receive Gavi support to deliver routine childhood immunizations, Covid shots would still be available for free. However, they would be rolled into Gavi’s standard immunization program, mostly as booster shots for the elderly and others in high-risk groups.Thirty-seven other countries — middle-income nations including Bolivia, Indonesia and Egypt — would receive a one-time cash infusion to “catalyze” the setting up of their own independent Covid vaccination programs.The proposal, which was obtained by The New York Times, comes from Gavi’s planning committee, whose recommendations are usually adopted largely as presented.The fate and performance of the global Covid vaccination program has become a heated issue among Gavi’s donors and the Covax partners ahead of the board meeting in Geneva — a gathering that is normally an unremarkable affair. Few of the players in the decision process were willing to speak about it on the record.Dr. Seth Berkley, the chief executive of Gavi, said the group’s work on Covid vaccination would not be diminished if the plan were adopted. “The plan in 2023 is to continue to work on getting primary coverage up as high as countries want it but also to really focus in on helping countries get those high-risk populations covered,” Dr. Berkley said. “The current proposal is that we integrate the Covax work into the core work of Gavi — not closing it down but integrating it. Because the belief is that, by the end of 2023, it shouldn’t be seen as an emergency program anymore.”Read More on the Coronavirus PandemicLong Covid: People who took the antiviral drug Paxlovid within a few days after being infected with the coronavirus were less likely to experience long Covid months later, a study found.Updated Boosters: New findings show that updated boosters by Pfizer and Moderna are better than their predecessors at increasing antibody levels against the most common version of the virus now circulating.Calls for a New Strategy: Covid boosters can help vulnerable Americans dodge serious illness or death, but some experts believe the shots must be improved to prevent new waves.Future Vaccines: Financial and bureaucratic barriers in the United States mean that the next generation of Covid vaccines may well be designed here, but used elsewhere.Currently, there is an average of 52 percent coverage of primary vaccination in Gavi-supported countries, but in some countries the figure is still below 20 percent.The World Health Organization continues to endorse a target goal of 70 percent Covid vaccination coverage. The W.H.O., a Covax partner, declined to comment on the proposal being considered by the Gavi board.Kate Elder, the senior vaccines policy adviser for Doctors Without Borders’ Access Campaign, said Gavi is moving too quickly to abandon Covax when countries have been led to expect that support would be there for years to come. “They don’t have enough analysis for this kind of huge policy decision,” she said. “But this move is driven by donors. When I speak to donors, they say, ‘We don’t want any more fund-raising for Covid-19 vaccines’.” The low demand for the vaccines means Covax has had to cancel and renegotiate purchase agreements — while high-income nations, with limited interest from their own populations, continue to funnel excess supply into the organization.Recipient countries are refusing and returning vaccine shipments, saying they have more urgent health priorities. One issue before the Gavi board this week is an effort to redouble efforts on catch-up campaigns for routine vaccinations, rates of which have declined sharply through the Covid pandemic.“Most African countries would much rather see increased investment in malaria vaccines,” said a board member not authorized to speak on the record about Gavi activities..css-1v2n82w{max-width:600px;width:calc(100% – 40px);margin-top:20px;margin-bottom:25px;height:auto;margin-left:auto;margin-right:auto;font-family:nyt-franklin;color:var(–color-content-secondary,#363636);}@media only screen and (max-width:480px){.css-1v2n82w{margin-left:20px;margin-right:20px;}}@media only screen and (min-width:1024px){.css-1v2n82w{width:600px;}}.css-161d8zr{width:40px;margin-bottom:18px;text-align:left;margin-left:0;color:var(–color-content-primary,#121212);border:1px solid var(–color-content-primary,#121212);}@media only screen and (max-width:480px){.css-161d8zr{width:30px;margin-bottom:15px;}}.css-tjtq43{line-height:25px;}@media only screen and (max-width:480px){.css-tjtq43{line-height:24px;}}.css-x1k33h{font-family:nyt-cheltenham;font-size:19px;font-weight:700;line-height:25px;}.css-1hvpcve{font-size:17px;font-weight:300;line-height:25px;}.css-1hvpcve em{font-style:italic;}.css-1hvpcve strong{font-weight:bold;}.css-1hvpcve a{font-weight:500;color:var(–color-content-secondary,#363636);}.css-1c013uz{margin-top:18px;margin-bottom:22px;}@media only screen and (max-width:480px){.css-1c013uz{font-size:14px;margin-top:15px;margin-bottom:20px;}}.css-1c013uz a{color:var(–color-signal-editorial,#326891);-webkit-text-decoration:underline;text-decoration:underline;font-weight:500;font-size:16px;}@media only screen and (max-width:480px){.css-1c013uz a{font-size:13px;}}.css-1c013uz a:hover{-webkit-text-decoration:none;text-decoration:none;}What we consider before using anonymous sources. Do the sources know the information? What’s their motivation for telling us? Have they proved reliable in the past? Can we corroborate the information? Even with these questions satisfied, The Times uses anonymous sources as a last resort. The reporter and at least one editor know the identity of the source.Learn more about our process.While Covid infections are rising in much of sub-Saharan Africa, the least-vaccinated region of the world, few countries there are reporting any increase in hospitalization or death rates, one factor in the declining interest in vaccination. The low rates of serious illness and death reflect the fact that the region has a young and thus less vulnerable population, that fewer people have easy access to hospital care, and that causes of death are rarely determined or registered. All those factors may contribute to a perception that Covid is not an urgent problem.A vaccine awareness campaign in Juba, South Sudan, in 2021.Lynsey Addario for The New York TimesBut accepting low Covid vaccination rates globally could allow the virus to evolve in dangerous ways, some public health experts say. “There is still the possibility of more lethal variants emerging, and that could be a disaster,” said Philip Schellekens, a health economist who maintains the data analytics resource pandem-ic.com on pandemic inequalities across countries. “Booster momentum has come to a near halt in the developing world,” he added.Covax was badly hampered from the outset. High-income nations rushed to lock up the supply of vaccines when they were still scarce, and donations were fitful. Covax had intended to rely on a supply of AstraZeneca’s vaccine made by the Serum Institute of India in order to start deliveries in mid-2021, but the Indian government blocked the export of 400 million doses in the face of a crushing Delta variant wave.When Covax finally had vaccines to distribute, it became apparent that plans to use the routine immunization systems to deliver them were inadequate, said a Gavi board member closely involved in the rollout who was not authorized to speak publicly about the organization’s performance. The Covid shots, intended for adults and requiring multiple doses and extreme refrigeration, presented new challenges that weak health systems were ill-equipped to manage.Frustrated by the erratic supply, some public health agencies did little to create demand for the vaccines, while a cresting tide of misinformation discouraged people from seeking them out. By the time supply was adequate, Omicron, which caused less severe illness, was the dominant variant. Motivation, especially for people who would need to travel long distances or invest their own scarce resources to get a shot, had fallen away.A senior official with one of the Covax partner organizations, who was not authorized to speak publicly about the group’s work, said that some who work with the organization are referring to Covax as a “zombie mechanism.”Recipient countries don’t want Covid vaccines, but Gavi needs to move doses, and the W.H.O. has doubled down on its goal of vaccinating 70 percent of the world, the official said. “And there’s interest from many of the donors who are still trying to offload their own doses through donations to Covax,” the official added.Multiple people in senior roles with Covax partners described to The Times a monthslong and souring dispute. They said that major donors, including the Bill & Melinda Gates Foundation, had warned Gavi that it was overcommitting on vaccination orders and Covid efforts, harming its reputation because of the close affiliation with Covax failures and straying too far from its mission.Doses of the Pfizer-BioNTech Covid vaccine in Kathmandu, Nepal.Narendra Shrestha/EPA, via ShutterstockIn a statement, the Gates Foundation said that it supported the work Gavi did with Covax. “As the pandemic evolved and with hundreds of millions of lives still at risk, Gavi’s board and other supporting Covax partners had to make supply and resource mobilization decisions quickly to respond to the unfolding crisis,” a foundation spokesperson said. “These decisions were not easy and involved vigorous dialogue among Gavi and its partners and supporters, including the foundation,” the spokesperson added.Covax has had to renegotiate its contracts with four suppliers of vaccines, to reduce them by between 400 and 600 million doses. Four hundred million doses from Pfizer that were coming as a donation from the United States government have been converted into future options available in 2023.“We did not massively overbuy,” Dr. Berkley said, adding that he expected the demand by countries that continue to try to do primary or booster dose delivery would largely align with the doses Gavi has available. “In a pandemic, I would want to err on the side of buying too many doses, rather than err on the side of not having enough doses, particularly given the fact that countries felt that there weren’t enough doses at the beginning,” he said. “If you want to get doses at the beginning, you’ve got to go ahead and put orders in, even if you don’t know if they’re going to work, and that’s risk. You have to have risk.”The Gavi secretariat is proposing to board members that the organization keep a pool of $1.8 billion that will allow for the acquisition of new doses as required into 2025 and support for the delivery of vaccines.Dr. Berkley said the “pandemic preparedness pool” is meant to act as insurance against another situation where Gavi needs to procure vaccines for developing countries (against a new Covid variant, for example) and is forced to compete with the deep pockets of richer nations. Some board members expressed concern at the idea of the organization sitting on these funds.“We just want to make sure the money is not used until we have a lot more conversations about where we want those funds to go,” one board member said. “We don’t have governance in place right now for how to manage that fund. The important thing is, we don’t want them to use these funds to broaden their mandate.”Dr. Orin Levine, an epidemiologist who until September 2021 represented the Gates Foundation on the Gavi board, said Covax’s fate was sealed by mid- 2021. “The fact that they were zero on the doses delivered in that period, near zero, is a fundamental blemish for us as a global community,” he said. “We couldn’t get any rich countries to slow down their individual vaccination order to help other people get started on their first ones.”

A record number of outbreaks has drained the cholera vaccine supply, leading the W.H.O. to ration emergency vaccinations.A record number of cholera outbreaks around the globe, driven by droughts, floods and armed conflicts, has sickened hundreds of thousands of people and so severely strained the supply of cholera vaccines that global health agencies are rationing doses.Outbreaks have been reported in the Caribbean, Africa, the Middle East and South Asia, putting the health of millions at risk and overwhelming fragile health systems. Untreated, the disease, which is commonly spread through contaminated water, can cause death by dehydration in as little as one day, as the body tries to expel a virulent bacteria in gushes of vomit and watery diarrhea.Cholera is typically fatal in about 3 percent of cases, but the World Health Organization says it is killing at an accelerated rate in recent outbreaks, even though it is relatively cheap and easy to treat. It is most often fatal in children, who progress swiftly to severe illness and organ failure. Cholera outbreaks tend to follow displacement: When droughts, floods, famines or the threat of violence force large groups of people to move, and they lose access to clean water and adequate sanitation facilities, cholera bacteria can race through a population. This year has seen cholera both in places where it is a familiar threat, and in countries that have not confronted it for decades.“The situation is very concerning, very worrying,” Dr. Philippe Barboza, who leads the World Health Organization’s cholera response, said. “We have had to worry about war and poverty and population movements, and that has not changed. But now we have climate change on top of that.” He called the profusion of cholera outbreaks “a fire that is just going to keep getting bigger.”In Nigeria, a million people have been displaced by floods in recent weeks, and there are at least 6,000 cases of cholera. The authorities in Kenya are reporting suspected cholera in people fleeing violence in Somalia and arriving at the mammoth Dadaab refugee camp, where tens of thousands of children are at risk.A recently opened medical center for cholera in the Syrian town of Darkush, on the outskirts of the rebel-held northwestern province of Idlib.Aaref Watad/Agence France-Presse — Getty ImagesIn Haiti, cholera has broken out as whole neighborhoods of people displaced by violence are packed into small open patches in Port-au-Prince, sharing a single cracked pipe of water that runs through untreated waste. Cholera is also festering in the country’s severely overcrowded prisons.In Syria, millions of people displaced by the civil war lack access to clean water, while the years of fighting have destroyed sanitation infrastructure. Raw sewage is being pumped into the Euphrates River, which hundreds of thousands of people depend on for water. The United Nations reports more than 20,000 suspected cholera cases and 75 deaths there.In Pakistan, where a third of the country is fully under water after massive monsoon flooding, and close to 10 million people have been displaced, there are reports of cholera cases in a dozen locations. These are not yet full-blown outbreaks, and vaccination could help stave off disaster.Read More About Extreme WeatherReversing Course: The Netherlands, a country long shaped by its overabundance of water, is suddenly confronting drought. Its population is hoping to engineer its way to safety.Water Crisis: A megafire in New Mexico that displaced thousands of people has set off a drinking water crisis — the latest chapter in a catastrophe created by the federal government when Forest Service employees lost control of two prescribed burns set this spring.Smoke Pollution: Smoke from wildfires has worsened over the past decade, potentially reversing decades of improvements in Western air quality made under the Clean Air Act, according to new research.But demand for vaccination is so high that the World Health Organization has suspended the recommended two-dose vaccination regimen and switched to a single dose, in an effort to stretch supply so enough is available to be able to respond to more outbreaks that could occur in the coming months.“We have never had to make a decision like this about vaccination before, that’s the severity of this crisis,” Dr. Barboza said.If enough single doses are given in a region, it should be enough to quell an outbreak, she said. But the length of the protection is significantly shorter. A single dose of the cholera vaccine gives between six months and two years of immunity, while the full regimen of two doses delivered a month apart gives adults four years of protection, she said. If a second dose can be delivered within six months, it should give three years of protection. But the evidence on the exact duration of protection is limited; it is known to be much shorter in children.A hospital worker at a disinfecting station at the cholera treatment unit of the Médecins Sans Frontières hospital in Cite Soleil, a densely populated neighborhood of Port-au-Prince.Ricardo Arduengo/ReutersSome 36 million doses of the oral cholera vaccine were expected to be produced in 2022, and of those, 24 million have been shipped for vaccination campaigns. The remaining eight million doses have already been designated for a second round of emergency vaccination in four countries — Cameroon, Malawi, Pakistan and Kenya — the W.H.O. said.That prompted the coordinating body that allocates cholera vaccines to decide to switch the vaccination regimen to a single shot until new supply is available, most likely by the end of the year. (That body is made up of the W.H.O., UNICEF and the aid organizations Médecins Sans Frontières and the International Federation of Red Cross and Red Crescent Societies, which staff cholera emergency centers around the globe.)Dr. Seth Berkley, the chief executive officer of GAVI, a nongovernmental organization that manages the global stockpile of vaccines for cholera among other pathogens, said that he believed as many as five million doses would be produced through the end of 2022 and that some existing requests would be canceled, so that 12 million doses could still be available this year.Dr. Daniela Garone, M.S.F.’s international medical coordinator, said the vaccine demand had left the agencies to make grim choices. “It leaves you sitting at a table literally having to have conversations like, well, do we send it to Haiti or do we send it to Syria?” she said. “Do we send it to Zimbabwe?”Ideally there would be regional vaccination in southern Africa right now, Dr. Garone said. For example: An outbreak in Malawi threatens neighboring countries because there is a lot of movement of people across borders with Zambia and Mozambique. But there are insufficient supplies to do that kind of preventive campaign in the region, or in India, Pakistan, Nigeria or the Democratic Republic of Congo.“There is just not enough vaccine,” she said. “And it’s the chicken or the egg: Do you prevent or you react? At the moment we are only on the reacting, trying to prevent mortality, and we cannot prevent.”A cholera vaccination campaign does not aim to cover the entire population of a country, but rather the area around a hot spot of transmission. The primary goal is to buy a country time to put sanitation measures in place, such as setting up latrines and trucking in sources of clean water, that are key to stopping transmission.A boy stands at a flooded stream following torrential rains in Sana’a, Yemen, in July 2022, that created a high-risk environment for cholera.Yahya Arhab/EPA, via ShutterstockThe bulk of the world’s cholera vaccine is made by a South Korean company called EuBiologics. Some 15 percent of the global stockpile was produced by Shantha Biotechnics, a wholly owned Indian subsidiary of the French drugmaker Sanofi, but the company decided two years ago to stop production of its cholera vaccine by the end of this year and end supply by the end of 2023. That planned exit from the market coincides with the spike in demand.Dr. Barboza said that EuBiologics was producing at capacity and working to expand its production, and that another drugmaker would soon begin to produce the vaccine.“But even a sharp increase in production will be low compared to the need,” he said.Drugmakers in high-income countries have little interest in making the vaccine, which typically sells for about $1.50 a shot, Dr. Barboza said. “It’s a marker of vulnerability and poverty and will never affect a rich country not at war.”A second problem is that the funds to buy more cholera vaccines often come out of the same limited envelope allotted for the drinking water and sanitation work that is necessary in an outbreak, said Gian Gandhi, the chief of health emergencies strategy for UNICEF’s supply division.While the global cholera case count is high, death numbers, at the moment, remain relatively low, which reflects the fact that cholera treatment is relatively cheap and simple. “Even countries that have not been exposed to cholera before, they can learn quickly,” Dr. Garone said.The International Center for Diarrheal Disease Research, Bangladesh hospital, where the cholera treatment was pioneered and which played a key role in the development of the vaccine, saw a record number of cholera patients in March and April this year. Instead of a typical 400 patients a day, the hospital treated 1,500, most of them in giant tents erected outside the facility to absorb the crowds, Dr. Ahmed said. There, the driver was not flood but heat: Extreme temperatures led to large-scale population movement, leaving people without clean water.But only a few people died, he said, because simple oral rehydration salts and antibiotics will cure most cases. Then, to help end that outbreak, more than two million people were vaccinated using contact tracing to hot spots. Bangladesh has been working toward preventive vaccination in known cholera flashpoints in an effort to keep outbreaks from starting.Dr. Berkley said that currently 85 percent of the supply was being used in emergencies. “If you could go in and do preventive vaccination in these hot spots, you could blot out these different places that are where the disease is transmitted from,” he said.Dr. Barboza said that while cholera outbreaks were difficult to predict, the W.H.O. anticipates that there will be more, because of climate change. While flooding disasters such as those in Nigeria and Pakistan right now immediately evoke fears of cholera, the risk from drought can be even greater, he said.“When water is scarce you can have people packed even more closely, perhaps all using a single spring that is not protected, and more people means more risk of contamination,” he said. “They don’t have water to wash, or to wash their vegetables, and it’s a spiraling effect.”If some of the outbreaks underway now continue past six months, the immunity of the people vaccinated with just one dose will have waned, and they will need to be revaccinated, he said. Ideally that would be with the full two-dose regimen, if supplies have been built back up. But, he added, the same factors driving outbreaks — insecurity and floods — make it hard to vaccinate.

An injection every two months rather than a daily pill could shield many more women from the virus, but it is unavailable in places that need it most.SOWETO, South Africa — For seven years, a daily pill has been available in South Africa to protect people from getting H.I.V. But when Victoria Makhandule, a community health worker, counsels the young women in her township about the medication, they tell her it doesn’t work for them.These young women are among the most vulnerable in the world to H.I.V., the virus that causes AIDS, but they say the daily pills, known as PrEP, bring their own challenges. The women may spend an unexpected night away from home and miss a dose, or forget for a day or two. Or their mothers or cousins snoop through their drawers, find the pills and know their business. Or their boyfriends see them taking the drug and get suspicious: Is that really for prevention, or do you have H.I.V.?Lots of young women here start PrEP (short for pre-exposure prophylaxis). Few stay on it.So when Ms. Makhandule, who volunteers with the Treatment Action Campaign, heard a few years ago that a clinical trial in South Africa was testing PrEP as a shot delivered once every couple of months, she thought: This is the solution we need. It would be private and invisible, and a woman would need to remember it only six times a year.The clinical trial found the injectable PrEP to be a huge success, nearly eliminating women’s risk of contracting H.I.V., and to be 88 percent more effective than the daily pill. But there’s still no sign of those injections in Soweto.“It will take long because money is always the problem,” said Ms. Makhandule, a veteran of South Africans’ fight for access to H.I.V. medications.Talk of PrEP — and the promise of the long-acting, injectable version — dominated the global AIDS conference, an annual gathering of researchers, policymakers and activists, held in Montreal last month. The rate of H.I.V. infections has plateaued in recent years, at about 1.5 million new infections a year, and injectable PrEP is the first promising new H.I.V. prevention technology in a long time.“This is the best chance we’ve ever had, in probably the entire history of the AIDS pandemic, to reimagine prevention and to do it with equity and with impact,” said Mitchell Warren, executive director of the H.I.V. prevention advocacy organization AVAC. “History will judge us very harshly if in five or 10 years, we go back to AIDS conferences and report on low uptake, and if we don’t see the rate of new infections begin to truly be pulled down.”PrEP taken as a daily pill has been responsible for a decline in infection rates among men who have sex with men in high-income countries. However, the prophylactic has been slow to reach developing countries and has proved far less effective at blocking the virus in most groups, including young women, who make up a majority of new infections in sub-Saharan Africa.Educational pamphlets for PrEP at the Diepkloof Clinic in Soweto.Ihsaan Haffejee for The New York TimesThe persistent stigma surrounding H.I.V. and the visibility of the drugs are big deterrents, said Dr. Linda-Gail Bekker, director of the Desmond Tutu H.I.V. Center at the University of Cape Town.But the path to getting a more discreet, injectable PrEP to where it’s most needed is proving to be uncertain. As Ms. Makhandule noted, cost is a critical factor — as it has been through much of the global response to H.I.V. over 40 years.The drug that aced the clinical trial is called long-acting cabotegravir, or Cab-LA, and it is made by the British pharmaceutical company ViiV Healthcare. ViiV is majority owned by the pharmaceutical giant GSK, with Pfizer and the Japanese drug company Shionogi as shareholders.The only country where regulators have approved Cab-LA is the United States; the Food and Drug Administration authorized the injectable drug’s use in December. Cab-LA is priced at $22,200 per patient per year in the United States and will most likely be covered by private insurance plans and Medicaid, which already cover oral PrEP.The Fight Against H.I.V.An estimated 40 million people are living with H.I.V. worldwide. About 10 million of them do not have access to treatment.Pandemic Setbacks: Before Covid-19, the world had been making strides against global illnesses like H.I.V. The pandemic has changed that for the worse.A Visionary: Ravindra Gupta led the efforts that resulted in the second case of a patient being cured of H.I.V. Then he was drawn into Covid research.A Promising Treatment: A woman became the third person ever to be cured of H.I.V. thanks to a new transplant method that could help more people from racially diverse backgrounds.Lessons From Africa: The story of a Kenyan woman diagnosed with H.I.V. in 2001 is emblematic of how the fight against the virus has unfolded in the past two decades.In the euphoric period after the clinical trial results were announced in 2020, Viiv said that it would apply immediately to have the drug approved by regulators in all the African countries where it was tested.Dr. Kimberly Smith, ViiV’s head of research and development, said, “Given how many disappointments we’ve had, including the vaccine studies that have not been successful, we have obviously got to do something dramatic, and this is potentially that dramatic thing.” She added that ViiV would aim for a “not-for-profit, not-for-loss price.”The usual path to broaden access would be for the company to license generics makers to produce a cheaper version of the injectable for markets such as South Africa. But in March, Viiv announced that for the foreseeable future, it would not be granting licenses for generic makers, saying the company could find no partner capable of making the drug.ViiV would not tell The New York Times the price it was proposing in developing countries, but Mr. Warren of AVAC said that the company told those working on the rollout that it expected the drug would cost $250 per person per year. Although that price is far lower than that in the United States, it is not nearly low enough for a country such as South Africa, which needs to administer hundreds of thousands of doses and where oral PrEP costs about $50 per person per year.Drug access activists responded angrily to the idea that $250 a year was “accessible pricing” and demanded that ViiV commit to voluntary licensing of the drug.Two days before the AIDS conference began, ViiV announced an agreement with the Medicines Patent Pool, a United Nations-backed nonprofit that works to make medical treatment and technologies accessible. The deal permits up to three generics companies to make the drug for sale in 90 low- and middle-income countries. It will take at least three years for a generic to be available for regulatory approval. ViiV has also submitted an application to the World Health Organization for prequalification of the drug, which could help expedite those approvals.Ms. Makhandule has worked for years to expand access to H.I.V. medications. “It will take long because money is always the problem,” she said.Ihsaan Haffejee for The New York TimesDrug access activists called the limited voluntary license progress less than ideal. Leena Menghaney, who leads the South Asia access campaign of Doctors Without Borders, said the agreement was “limited and disappointing.” The organization helped pioneer AIDS treatment in sub-Saharan Africa.The deal leaves out all the countries where ViiV holds a patent on Cab-LA — including Brazil, where gay men and trans women volunteered for the trials in which the drug was tested.“ViiV has not learned the lessons of the last 40 years because right out of the gate their pricing strategy is one that obstructs rather than conveys access,” said Asia Russell, executive director of the group Health GAP, which campaigns for drug access. “This is a pandemic-altering intervention, and any day lost is measured in preventable infections. ViiV must cut the price.”AIDS researchers and activists believe that the company is worried about how much it may earn on Cab-LA because other H.I.V. prevention drugs are in trials as injectable PrEP, too. Some of these drugs have longer dosing cycles — that is, they could be injected only two or three times a year, which would probably appeal to more women, and could be synced with shots for contraception. Researchers also believe that ViiV might be concerned about what it would earn in the United States, typically a company’s most lucrative market. Cab-LA costs roughly the same as the brand-name oral PrEP drug Truvada in the United States, but a far cheaper generic oral PrEP is available.A cost-of-goods study by the Clinton Health Access Initiative compared Cab-LA with similar products and concluded that Cab-LA could profitably be produced for $16 per patient per year — one-third the cost of oral PrEP in South Africa — assuming a volume of 800,000 patients. That price is estimated for production by a generic maker, most likely in India, not at ViiV’s plant in Britain. The analysis noted that the amount of active pharmaceutical ingredient — a key cost in drug production — for six injections per year would be far lower than that in 365 pills.Dr. Smith of Viiv said that the study seriously underestimated the cost. “The complexity of cabotegravir manufacturing is significant,” she said.At the recent AIDS conference, major global health agencies announced a new collaboration with charitable agencies and advocacy groups to try to broaden access to the injectable drug. They will work first on getting ViiV’s product into low-income markets, most likely by negotiating with the company over guarantees for purchase volumes that may entice it to agree to lower prices.And in the longer term, the partners will provide funding to help makers of generic versions speed up manufacturing. The partners include the Children’s Investment Fund Foundation, which pledged $33 million to the effort this month, and the Bill & Melinda Gates Foundation.But generics makers would be watching the other drugs in the pipeline and could act accordingly. “If you’re a generic company and you know that there may be a product that supersedes this in three to five years, it’s a very real question whether you spend money to make this one now,” Mr. Warren said.Street art encouraging H.I.V. treatment on the walls of a taxi station in Kliptown, a suburb of Soweto.Ihsaan Haffejee for The New York TimesAnother obstacle is that injectable PrEP programs will need funding for more than just the cost of the drug. The shots would need to be administered by health care workers and would require syringes and other medical supplies. African governments that are considering rolling out injectable PrEP would need financial support from multilateral agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, so as not to take funds from other H.I.V. education and prevention initiatives, Ms. Russell said.Donors committed $14.3 billion to the Global Fund at a meeting in New York last week, with many countries, including the United States, significantly raising pledges over those they had made in previous years. While further commitments are expected in the coming days from Italy and Britain, the fund is still likely to fall significantly short of its funding target of $18 billion.As Ms. Makhandule, the community health worker, has found in Soweto, there is excitement all over sub-Saharan Africa about the idea of injectable PrEP. But there is also a need to prove that women will want and use it.“We hear from many young people this would be ideal, but the proof is in the pudding,” Dr. Bekker said. It’s far from certain that healthy women will show up at a clinic every two months to get the shot, she said, and the key would be making it available in community clinics and framing it as part of a healthy sex life rather than as a medication associated with risk.Dr. Smith said ViiV was hoping to learn from the history of long-acting injectable contraception such as Depo-Provera, which is delivered in a shot four times a year and which many women in the developing world choose as their preferred method of birth control. But there is no guarantee that bimonthly PrEP shots will gain favor because H.I.V. has a unique stigma.Mr. Warren said that by the end of 2023, the new coalition hopes to have five large projects in different parts of the world. Each project would have about 50,000 participants, including sex workers and teenage girls, and would test whether they want the medication, will take it regularly or develop drug resistance.ViiV has committed to supplying the drugs for only an initial implementation study in South Africa, and no donor has yet committed to funding others.“The most important thing is to get this out there, into clinics and into people’s hands,” Dr. Bekker said.

High-income countries snapped up vaccines when the disease hit them, leaving none for countries that have battled the virus for years, in an echo of the Covid response.For the past month, a couple of patients a day have sat across from Dr. Alberto Mendoza at the H.I.V. clinic where he works in Lima, Peru, to hear him confirm what they had feared: They have monkeypox. The men are tormented by the painful lesions the virus causes. They’re also afraid, because the visible sores mark them as men who have sex with men, a dangerous identity in Peru, where there is intense discrimination against homosexuality.But Dr. Mendoza, an infectious disease specialist, has little to offer. “I have no options,” he said in an interview. Neither the antiviral drug nor the vaccine being used against monkeypox in the United States and Europe is available in Peru. “We have nothing, even though we are the country with one of the highest numbers of cases by population,” said Dr. Mendoza, who works with the medical charity Partners in Health.Neighboring Brazil, which, according to the World Health Organization, has close to 10 percent of global monkeypox cases, currently has no vaccine or treatment either. Nor do the countries in West and Central Africa that have struggled with monkeypox outbreaks for decades.The scramble for monkeypox vaccines and treatments has been centered in the United States and Europe, where supplies of shots have stretched thin or nearly run out. But more than 100 countries are now reporting monkeypox cases, and a vast majority of those have had no vaccine or treatments at all.They have been shut out by the prohibitive cost and by wealthy nations who bought up most of the available doses. The United States already controlled most of the vaccine, which was originally developed for smallpox, as part of its bioweapons strategy after the terrorist attacks of Sept. 11, 2001. Some public health groups are also criticizing the W.H.O. for not doing more to ensure swift movement on equitable access to tests, treatments and vaccines, after it declared monkeypox a public health emergency of international concern on July 23. They say the issues echo those seen with Covid, but without any of the mechanisms that were developed to try to right the balance during the coronavirus pandemic.A tent for screening monkeypox patients outside the Arzobispo Loayza Hospital in Lima.Ernesto Benavides/Agence France-Presse — Getty ImagesIt is difficult to even know the number of people who have monkeypox in developing nations because many lack capacity for diagnosing the disease, which is done with a P.C.R. test. Most of the testing in countries that have had outbreaks for years is done at the surveillance level, testing only a sampling of the population to find the overall incidence of the disease. Testing to diagnose individual patients, many of whom live in isolated rural areas, is rare or nonexistent.“We don’t have access to testing in Africa so we don’t know where cases are, so you can’t use that as a basis for decisions on the use of resources,” said Dr. Boghuma Titanji, an assistant professor of medicine at Emory University who responded to a monkeypox outbreak in 2018 in her native Cameroon.Most people who die from monkeypox are Africans. There are two different strains of the disease, a more lethal one circulating in the Democratic Republic of Congo and neighboring countries, and a less virulent version in West Africa, which is the one now being seen in high-income countries. Though deaths from monkeypox are rare, the risk of a fatal case is greatest in children and pregnant women, and the disease is excruciatingly painful for anyone infected.What to Know About the Monkeypox VirusCard 1 of 7What is monkeypox?

A city on the forefront of harm reduction has taken the concept to a new level in an effort to address the growing toxicity of street drugs.VANCOUVER, British Columbia — The place where Chris gets his fentanyl is bright and airy, all blond wood and exposed brick. The staff is friendly and knowledgeable about the potency of the pills he can crush, cook and inject.Soft pop music played, and an attendant spritzed a bit of Covid-cautious spray on his seat before he settled into a booth on a recent afternoon with a couple of red-and-yellow pills, a tourniquet, a tiny candle and a lighter. “The best thing about this is the guarantee: I can come in here four times a day and get it,” Chris said. He no longer spends all of his waking hours in a frantic scrabble of panhandling and “other stuff” to scrape up the cash to pay a dealer. He won’t get arrested — and he won’t overdose and die using a drug that is not what it is sold as.This fentanyl dispensary is legal, and Canada’s public health system finances it.It is the latest and perhaps most radical step in a city that has consistently been at the leading edge of experiments in “harm reduction,” an approach to reducing deaths and severe illness from illicit drugs by making the drugs safer for people who use them. Harm reduction, even in basic forms such as the distribution of clean needles, remains deeply controversial in the United States, although the concept has been gaining fitful support as overdoses rise, including from the Biden administration.But the breadth of Vancouver’s services and interventions are almost unimaginable in the United States, less than an hour’s drive to the south. Supervised injection sites and biometric machines that dispense prescription hydromorphone dot the city center; naloxone kits, which reverse overdoses, are available free in every pharmacy; last year, a big downtown hospital opened a safer-use site next to the cafeteria, to keep patients who are drug users from leaving in order to stave off withdrawal.And since April, Chris, a wiry, soft-spoken 30-year-old who wanted to be identified by only his first name to protect his privacy, has received pharmaceutical-grade fentanyl through the dispensary, which sells to those who can pay and provides free drugs through the program’s operational budget to those who cannot.The new program aims to provide a safer alternative to the fentanyl available on the streets, where the supply is increasingly lethal and is responsible for most of the overdose epidemic that was declared a public health emergency here six years ago.Dr. Christy Sutherland, a board-certified addiction medicine specialist who set up the program, said its goal was, first, to keep people from dying, and, second, to help bring stability to their lives so that they may think about what they might want to change.Chris started using pills recreationally in his teens, then moved to heroin. But the heroin supply in Vancouver was taken over about a decade ago by fentanyl, an opioid that is 50 to 100 times more potent and thus far more profitable for the cartels that sell it.Chris has been using illicit drugs since he was a teenager. “The best thing about this is the guarantee: I can come in here four times a day and get it,” he said.Jackie Dives for The New York TimesWistaria Burdge, right, a nurse, helped Ken Elliott apply a bandage after injecting heroin at the Crosstown Clinic. Jackie Dives for The New York TimesOverdose deaths have surged in British Columbia since the start of the Covid pandemic, as they have across the rest of North America. Some 2,200 people died of overdoses in the province last year, among the 115,000 lives lost to drugs in Canada and the United States during that time. The mounting toll has spurred communities to search for new solutions, and this city has tried more of them, faster, than anywhere else.Fentanyl Overdoses: What to KnowCard 1 of 5Devastating losses.

An Ohio 10-year-old’s recent abortion has generated fierce debate. Doctors in countries where pregnancy is common in adolescents say the toll of childbirth on young bodies is brutal.After the account a 10-year-old Ohio girl crossing state lines to get an abortion drew national attention last week, some prominent abortion opponents suggested the child should have carried her pregnancy to term.But midwives and doctors who work in countries where pregnancy is common in young adolescent girls say those pushing for very young girls to carry pregnancies to term may not understand the brutal toll of pregnancy and delivery on the body of a child.“Their bodies are not ready for childbirth and it’s very traumatic,” said Marie Bass Gomez, a midwife and the senior nursing officer at the reproductive and child health clinic at Bundung Maternal and Child Health Hospital in Gambia.The critical issue is that the pelvis of a child is too small to allow passage of even a small fetus, said Dr. Ashok Dyalchand, who has worked with pregnant adolescent girls in low-income communities in India for more than 40 years.“They have long labor, obstructed labor, the fetus bears down on the bladder and on the urethra,” sometimes causing pelvic inflammatory disease and the rupture of tissue between the vagina and the bladder and rectum, said Dr. Dyalchand, who heads an organization called the Institute of Health Management Pachod, a public health organization serving marginalized communities in central India.“It is a pathetic state particularly for girls who are less than 15 years of age,” he added. “The complications, the morbidity and the mortality are much higher in girls under 15 than girls 16 to 19 although 16 to 19 has a mortality twice as high as women 20 and above.”The phenomenon of young girls having babies is relatively rare in the United States. In 2017, the last year for which data was available, there were 4,460 pregnancies among girls under 15, with just under half ending in abortion, according to the Guttmacher Institute, which supports abortion rights and surveys clinics regularly.But globally, complications relating to pregnancy and childbirth are the leading cause of death for girls aged 15-19, according to the World Health Organization.Young maternal age is associated with an increased risk of maternal anemia, infections, eclampsia and pre-eclampsia, emergency cesarean delivery and postpartum depression, according to a 2014 evaluation published in the Journal of Neonatal-Perinatal Medicine.Babies born to girls are more often premature and have low birth weight, said Dr. Willibald Zeck, the maternal and newborn health coordinator for the United Nations Population Fund, who frequently delivered babies for young mothers while working as a gynecologist in Tanzania and later oversaw maternal health programs in Nepal and the Philippines.While a pregnant 10-year-old in Ohio might have access to prenatal care and a cesarean section that would blunt the effects of obstructed labor, the experience of pregnancy in a young girl is the same in India as it is in the United States, Dr. Dyalchand said. “The girls would go through more or less exactly the same kind of complication: The only difference is because of access to better health care they may not have the same kind of terrible outcomes. But that doesn’t mean that the girl’s body and her life doesn’t get scarred.”Dr. Shershah Syed, a gynecologist and expert on maternal mortality in Pakistan, regularly provides care to pregnant girls as young as 11. He said good prenatal care can avert the development of a hole between the wall of the bladder or rectum and the vagina — called a fistula — which causes leaked urine or feces that is not only painful (the leaked urine causes burning sores) but also a source of enormous shame and humiliation.But even good prenatal care cannot prevent the hypertension or urinary tract infections that are common in very young mothers, he said.“In normal physiology a 10-year-old child is not supposed to be pregnant. The point is, she’s a child and the child cannot deliver a child, she’s not ready,” Dr. Syed said, adding: “And the mental torture she will go through, that is not measurable.” In the cases he has seen, early pregnancy arrests the very young mother’s physical growth, and also often her mental development because many girls leave school and lose normal social interaction with peers, he said. But while an anemic mother struggles to carry the pregnancy, fetuses appropriate nutrients and continue to grow, until they have well surpassed what a young mother’s pelvis can deliver.“They go to labor for three days, four days, five days, and after that labor, usually the baby is dead. And then when the head is collapsed, then the baby is delivered,” said Dr. Syed, who is one of South Asia’s pre-eminent experts on the repair of obstetric fistula, a common outcome of obstructed labor in pregnant girls.In nearly all these cases, the girl has developed vesicovaginal fistula, a hole between the wall of the bladder and the vagina. In a quarter of cases, the prolonged labor will also cause fistula of the rectum, so that the girl constantly leaks both urine and feces.If fistula sufferers learn that treatment is available and make their way to his clinic, Dr. Syed said he can repair the condition. But the process requires a long recovery: fistula of the bladder takes about five weeks to heal, while a rectal fistula needs four or five months.In 1978, Dr. Dyalchand began his career in public health at a small district hospital in rural Maharashtra, on the western coast of India. In his first week, two young pregnant girls bled to death — one while in labor, the other at the entrance to the hospital, before she ever made it inside. It started him on a long career of working with communities to convince them to delay the age of marriage and first conception in girls.That intervention has shown considerable success, and, Dr. Dyalchand noted, India has also been steadily expanding abortion access. The procedure is legal up to 24 weeks of pregnancy.In Gambia, Ms. Bass Gomez said that her clinic is able to offer good prenatal care to pregnant girls, but that does little to blunt the larger trauma of the experience. Her clinic is designed to serve adults, she said. “But when you have a child walk in equally pregnant it’s really traumatizing for the child,” she said. “It’s not comfortable, that environment, it’s not set for them. You can tell they are struggling. There’s a lot of shame and disgrace.”

Millions of children around the world, most of them in the poorest countries, missed some or all of their childhood vaccinations over the past two years because of a combination of conflicts, climate emergencies, misinformation campaigns, pandemic lockdowns and Covid vaccination efforts that diverted resources, according to a new analysis from Unicef, the United Nations agency that vaccinates half the world’s children.It is the largest backslide in routine immunization in 30 years, the report said. Combined with rapidly rising rates of malnutrition, it has created conditions that could threaten the lives of millions of young children.“This is an emergency for children’s health — we have to think about the immediate stakes, the number of children that are going to die because of this,” said Lily Caprani, head of advocacy for Unicef. “It’s not in a few years’ time; it’s quite soon.”The percentage of children worldwide who had received three doses of the vaccine against diphtheria, tetanus and pertussis, known as DTP3 — which Unicef uses as a benchmark for immunization coverage — fell five points between 2019 and 2021, to 81 percent. Measles vaccination rates also fell to 81 percent, and polio coverage dropped significantly, too. A vaccination coverage rate of 94 percent is necessary for herd immunity, to interrupt the chain of transmission of a disease.This translates to 25 million children who did not receive a basic intervention to protect against lethal illnesses.The number of what Unicef calls zero-dose children — those who have not received a single dose of the most basic vaccines — increased sharply during the pandemic, to 18 million from 13 million in 2019. This group includes half of all children who die before age 5.The agency had been hoping that after a sharp decline in 2020 that was driven by lockdowns, school closures and other Covid response measures, childhood vaccination coverage would rebound in 2021, said Dr. Niklas Danielsson, Unicef’s Nairobi-based senior immunization specialist.But instead, the problem got worse. DTP3 and measles coverage are at the lowest level since 2008, the report found.Anti-vaccine demonstrators in São Paulo in February.Nelson Almeida/Agence France-Presse — Getty ImagesDr. Danielsson said the rate of vaccination coverage in 2021 matched that of 2008. “But since then, the birth cohorts have increased, which means that the number of children who do not complete vaccinations, or do not even start, is the largest in the last 30 years,” he said.He and many others in the child immunization field had anticipated a recovery last year as health systems learned to adapt to the demands of the pandemic. Instead, misinformation campaigns about Covid vaccination, and broader mistrust of governments over public health measures, spilled over to deter routine immunization, he said.At the same time, health systems in the poorest countries scrambled to carry out limited Covid vaccination, diverting critical access to freezers and the health workers to put shots in arms.The world made sustained progress on childhood vaccination coverage through the 1990s and the first decade of this century. Rates then began to plateau, because the remaining children were the hardest to reach, such as those in active war zones or in nomadic communities. But before the pandemic, there had been a redoubled commitment, with support from organizations like the Bill and Melinda Gates Foundation and Gavi, the global vaccine alliance, to try to reach the remaining pockets of zero-dose children. Covid has pulled away much of that attention and investment.Over the last two years, India, Nigeria, Indonesia, Ethiopia and the Philippines recorded the highest numbers of children who had missed out on vaccines.Brazil was also on the list of the 10 most-affected countries, a harsh shift for a country once renowned for its high vaccination coverage rates. About 26 percent of Brazilian infants had received no vaccines in 2021, compared with 13 percent in 2018.“The work of 30 years has been lost overnight,” said Dr. Carla Domingues, an epidemiologist and former coordinator of Brazil’s national immunization program.Vaccination became a politicized subject in Brazil during the Covid pandemic, she said. The federal government, led by President Jair Bolsonaro, downplayed the significance of the coronavirus even as Brazil had one of the world’s highest death rates and said he would not get his own 11-year-old vaccinated against the virus.“For the first time, the federal government was not recommending a vaccine, and it created a whole environment of doubt that had never existed in Brazil, where vaccination was totally accepted,” Dr. Domingues said.At the same time, anti-vaccination groups that had not had much purchase in Brazil moved into the country during the pandemic, she said, and began circulating misinformation in Portuguese on social media.And all of this was happening, Dr. Domingues said, at a time when Brazilians were a generation removed from the serious illnesses they were being urged to vaccinate their children against, leading them to question the necessity.“Parents don’t know the impact of measles, or of polio, so they start to pick and choose vaccinations,” she said. Data showing that acceptance of the pneumonia vaccine is higher than that for polio makes that clear. “Parents are choosing not to do polio. They say, ‘It’s been 30 years with no polio, so do I need to do this?’”And yet they have a clear sign of the risk, she said: A handful of measles cases were found earlier this year in São Paulo, six years after Brazil had reported eradicating the disease. “Measles is now circulating — that gives us a concrete example of what could happen with diphtheria, meningitis and so many other diseases,” she said.Administering a polio vaccine in Manila in 2019. Forty-three percent of infants in the country had had no vaccinations last year.Eloisa Lopez/ReutersIn the Philippines, 43 percent of infants had not had any vaccinations last year. There, the problem lies partly in tough Covid public health measures, including lockdowns. “If you are not allowed to take your children out apart from certain hours of the day, if they can’t go to school, if living costs are increasing, going to a health enter to have your child vaccinated drops down on your priorities,” Dr. Danielsson said.But the Philippines’ situation is also complicated by lingering mistrust of vaccination after a wide rollout of a dengue vaccine in 2016 that later proved to have caused more severe cases of the disease in some who had received it.Ms. Caprani of Unicef said an extraordinary amount of resources and commitment would be needed to bring vaccine levels back up to where they had been.“It’s not going to be enough to just go back to business as usual and restore ordinary, routine immunization,” she said. “We’re going to need really concerted investment and catch-up campaigns, because there’s a growing cohort of millions of children who are completely unimmunized living in countries that have high levels of malnutrition and other stresses.”In Zimbabwe, for example, there is currently a measles outbreak in which one in 10 children hospitalized with the illness is dying. (The typical mortality rates are one in 100 in low-income countries and below one in 1,000 in high-income nations.)Dr. Fabien Diomande, a polio eradication expert with the Task Force for Global Health who worked for years on polio campaigns in West and Central Africa, said reversing the decline in childhood immunization would require new nimbleness, innovation and resources.“It’s like we’re in a new world — those emergencies not going to disappear,” he said. “We will still have Covid. We will still have climate crises. We have to learn how to work in the context of multiple public health emergencies.”Dr. Domingues in Brazil said that Covid vaccination efforts could offer some lessons for how to catch up. Brazil achieved high vaccination coverage by providing pop-up vaccination posts and making shots available at night and on weekends.Ms. Caprani said that while there was a heartening renewed interest in global health cooperation because of Covid, investment in new surveillance measures and other novelties risked distracting from the simple intervention needed to address the child immunization crisis: deployment of thousands of community health workers.“We aren’t going to solve this with poster campaigns or social media posts,” she said. “You need outreach by reliable, well-trained, properly compensated community health workers who are out there day in, day out, building trust — the kind of trust that means you listen to them about vaccines. And there simply aren’t enough of them.”Jason Gutierrez

With Roe v. Wade overturned, states banning abortion are looking to prevent the distribution of abortion medication. Brazil shows the possible consequences.RIO DE JANEIRO — Last November, Xaiana, a 23-year-old college student in northern Brazil, began exchanging text messages with a drug dealer in the south of the country. Following the dealer’s instructions, she transferred 1,500 reais ($285), her living expenses for several months. Then, she waited three agonizing weeks for the arrival in the mail of a blister pack of eight unmarked white pills.When she took them, they had the effect she was hoping for: She underwent a medication abortion at home with her boyfriend, ending an eight-week pregnancy.But Xaiana kept bleeding for weeks, an unusual but not rare complication. “It was like a murder scene every time I had a shower,” she said. She was afraid to get help because it is illegal for a woman in Brazil to use the drug, misoprostol, to trigger an abortion. If she went to a clinic, she feared, the staff might figure out she had induced the abortion and report her. The penalty for having an abortion in Brazil is up to three years in jail.“It’s the loneliest feeling I’ve ever felt in my life,” she said, asking to be identified only by her first name out of fear of prosecution.After seven weeks, she went to a women’s clinic and admitted to having terminated a pregnancy. She was given a simple cauterization, and no one reported her.Proponents of abortion rights in the United States have suggested that a post-Roe America would differ in a key way from the era before abortion was legalized nationally. Women seeking abortions today have the option of a medical termination, using hormone pills to trigger the body to expel the fetus in private, a practice approved by the Food and Drug Administration.But the wave of state trigger laws that have begun to take effect after the Supreme Court’s ruling overturning Roe on Friday, bar all abortion, including medication abortions. To get the pills legally, women will have to travel to states where it is allowed, for a medical consultation, even if it is by video or phone, as required by the F.D.A. The trajectory of access to abortion pills in Brazil may offer insight into how medication abortion can become out of reach and what can happen when it does.While surgical abortion was the original target of Brazil’s abortion ban, the proscription expanded after medication abortion became more common, leading to the situation today where drug traffickers control most access to the pills. Women who procure them have no guarantee of the safety or authenticity of what they are taking, and if they have complications, they fear seeking help.Boxes of misoprostol were stored in a pharmacy cabinet at a university hospital in Recife, Brazil. The hospital was one of the few hospitals to perform abortions under the exceptions allowed by Brazilian legislation.Dado Galdieri for The New York TimesToday, black market misoprostol, brought in from India, Mexico and Argentina, is sold for anywhere from about $200 to $400 for the eight tablets recommended for an abortion, compared with less than $15 for a 60-pill bottle in the United States. It took a New York Times reporter under one minute of asking to find someone willing to sell eight pills for $300, in a Rio neighborhood known for the sale of black market goods.“You buy it from a dealer, you don’t know what it is, the whole process is made frightening, it’s secret, it’s not a medicine any more,” said Maira Marques, who is the director of campaigns for an abortion access advocacy organization called Milhas pelas Vidas das Mulheres. “This is supposed to be the straightforward, less complicated way to have an abortion but now instead it’s buying contraband.”It has been illegal in Brazil to have an abortion since 1890, although exceptions were added in 1940 for women who were pregnant as a result of rape or incest and in cases where a woman’s life was endangered by the pregnancy; more recently, access was added for women carrying a fetus with anencephaly (missing parts of its brain). But starting in the late 1980s, word spread a that an ulcer medication called Cytotec could “bring on a period.” In fact, it was Brazilian women’s experience with off-label use of the drug that led to research and eventual global adoption of medical abortion as a lower-cost, less invasive way to end pregnancies that could increase access, especially in developing countries.Cytotec is misoprostol, one half of the World Health Organization’s recommended combination of hormones (the other is mifepristone) to carry out a medication abortion. Mifepristone has never been approved for use in Brazil, and women, unaware of the drug, do not seek it on the black market. Misoprostol is usually enough to induce a safe abortion; a study published in The Lancet found that 8 percent of women who used misoprostol to terminate a pregnancy experienced complications, including bleeding and abdominal pain requiring medical attention.The drug was sold in pharmacies without a prescription until 1991, and then it was regulated to require prescription, although the prescription rules were lax.The availability of the pills sharply reduced the number of women turning up in hospitals with the life-threatening infections or hemorrhages from abortions they had tried to induce with the castor root or bleach or coat hangers, said Dr. Ana Teresa Derraik, an obstetrician-gynecologist in Rio. “It was a big relief for those of us who didn’t think women should be punished like this.”Brazilian President Jair Bolsonaro attending a gathering of anti-abortion demonstrators in Brasilia in 2020. Sergio Lima/Agence France-Presse — Getty ImagesBut misoprostol was becoming a focus of attention for anti-abortion campaigners in Brazil and beyond. In 1998, Brazil’s health regulatory agency, ANVISA, included misoprostol on the list of controlled drugs, alongside opiates, which meant a prison sentence of up to 15 years for anyone caught importing or buying it. International pharmaceutical companies that made misoprostol were hit with boycotts and stopped producing it; a small domestic company took over manufacturing a generic version of the drug to sell only to the Ministry of Health for hospital use.In 2006, the law prohibiting misoprostol distribution was strengthened to ban selling or publishing information about the drug on the internet.When Jair Bolsonaro was elected Brazil’s president in 2018, with the enthusiastic support of Brazil’s fast-growing evangelical Christian community, access became even more scarce.International reproductive rights organizations such as Women on Web used to mail abortion pills to Brazil, and local feminist groups used to source them and supply them, along with instructions for safe use, said Juliana Reis, director of Milhas. Now, they have almost entirely stopped.“Because of the political climate, it’s much more difficult to get safe products and to get proper counseling, because the networks that used to do that are much more afraid,” said Sonia Corrêa, a researcher of reproductive health technologies in Rio.New guidelines issued by the Ministry of Health this month include the assertion that “inducing abortion by telemedicine, using drugs from the special control list, can cause irreversible damage to the woman.”Dr. Helena Paro, a gynecologist in the city of Uberlândia, who introduced telemedicine consultations for legal abortion patients during the Covid pandemic, called the guideline “completely ideological and contrary to the scientific evidence.” The W.H.O. considers the practice safe.Juliana Reis of the of the advocacy organization Milhas pelas Vidas das Mulheres, held an artwork titled “Padrão sobre Corpos,” by Agrade Camiz, prints of which were sold to raise money for safe abortions.Dado Galdieri for The New York TimesIn response to questions from The Times, the ministry said the guidelines reflect that “misoprostol is authorized only in hospital establishments, that its use outside this environment is not allowed” by law and that use of misoprostol for abortion via telemedicine meant women would not have “timely access to health services that can manage the possible clinical or surgical complications resulting from the procedure.”Dr. Derraik says she has seen an intensification of scrutiny for use of misoprostol in the hospitals where she offers abortion services to women who qualify as well as a simultaneous increase in the level of investigation of women who report miscarriages.Other women have fallen into police traps. In 2012, a Rio sociologist decided she could not continue her pregnancy — she was already struggling to parent a 12-year-old with intense special needs. The sociologist (who asked to be identified by her first initial, A., because her family does not know about her abortion) went to her gynecologist.“He said, ‘This medication exists, Cytotec, but I can’t give it to you: You’ll have to buy it from the black market’,” she recalled.She found a website, ordered the drug and paid several months’ salary for it, but the package never arrived: She was tracking it online, and watched it stall when it entered the country.She found a drug trafficking contact through a friend of a friend and bought a second batch, took the drug at home and ended the pregnancy with no complications — her only regret being that she had to be alone through a frightening process.A year later, a letter arrived summoning her to the police. She thought it was about her car, which had been stolen the year before. But when she arrived, a male officer asked her, “Do you know what Cytotec is?”She said she did. He asked if she had bought it. She could see he had her credit card information from the purchase on the paper in front of him, so she admitted she had.He asked if she had carried out the abortion. She replied, “Of course not — the medication never arrived.”The pharmacy of the university hospital in Recife. Doctors in the hospital have taken many extraneous steps when using the drug “because of the intense paranoia.”Dado Galdieri for The New York TimesIt turned out that police were monitoring the website where she bought misoprostol, traced the package and said they would charge her with unlawful purchase of a controlled substance. After several years of hearings, she entered an alternative sentencing program and performed 60 hours of community service. She continues to have to report her whereabouts to police and cannot leave her state.Women’s reliance on the black market for access to medication abortions means they may not follow best medical practice. When C., a 24-year-old teacher in Recife, bought misoprostol from a drug dealer last year, she searched Google to figure out how to take it. “Because it was illegal, there was no information about how to take it or what to take,” she said.Her search found recommendations to insert the tablets in her vagina, as a doctor would if she were in a clinic, but cautioned that traces might be left behind and give her away if she wound up in hospital; instead, she dissolved them under her tongue, a method that also works but less quickly.C., who asked to be identified only her middle initial out of fear of prosecution, bled for weeks after and wanted to ask her mother, a gynecologist, for advice. But her mother is an anti-abortion activist. Finally, C. said she thought she had miscarried, and her mother took her to see a colleague who performed a dilation-and-curettage under anesthetic.“When I was having the curettage, I had to keep saying over and over to myself, ‘Don’t say anything, you can’t say anything’ — it was torture,” she said. “Even though I was totally sure that I wanted an abortion, I had no doubts, you still feel like you’ve done something wrong because you can’t talk about it.”The restriction on misoprostol has complicated regular obstetric care, which uses on the drug for induction of labor, said Dr. Derraik. At the Rio public maternity hospital where she is medical director, a doctor must fill out a request in triplicate for the drug, have it signed by Dr. Derraik, take it to the pharmacy where the supervisor must also sign before taking it out of a locked cabinet, and then the physician must administer the drug with a witness, to ensure it is not diverted for black market sale.“Not all of these steps are officially required,” Dr. Derraik said. “But hospitals do them because of the intense paranoia around the drug.”

Sierra Leone is one of a few countries in sub-Saharan Africa that have not banned cutting. Now, young women are defying mothers and grandmothers by refusing to undergo the procedure.KAMAKWIE, Sierra Leone — When Seio Bangura’s final high school exam results arrived not long ago, she learned she had earned grades high enough to get into college. It was a thrilling moment for the daughter of farmers who never finished primary school. But Ms. Bangura is not making plans for university. Instead, she spends most days siting on a bench, watching others head to class or work.Ms. Bangura, 18, left home almost five years ago, after her parents gave her a choice: to be initiated in a ceremony centered on genital cutting, or leave. The ceremony allows entrance to bondo, or “the society,” a term for the gender-and-ethnicity-based groups that control much of life here.“My mom said, ‘If you won’t do bondo, you have to go,’” Ms. Bangura said, her voice low but her chin defiantly raised. The choice cut her off from her family’s financial support and left her unable to pay for further education or to marry.For more than two decades, there has been a push across the developing world to end female genital cutting, a centuries-old ritual tied up in ideas of sexual purity, obedience and control. Today, Sierra Leone is one of only a few countries in sub-Saharan Africa that have not banned it. Cutting is still practiced by almost every ethnic group in every region of the country. But the practice is now at the center of intense debate here.Progressive groups, many supported by international organizations, are pushing to ban cutting, while conservative forces say it is an essential part of the culture that is practiced across tribal and religious lines.As that battle plays out in the media and in parliament, growing numbers of girls and young women like Ms. Bangura are taking the matter into their own hands. It is an act of defiance almost unimaginable a generation ago: They are refusing to participate in initiation, telling their mothers and grandmothers they will not join bondo.More than 90 percent of women over 30 in Sierra Leone have undergone genital cutting, compared with just 61 percent of those ages 15 to 19, according to the most recent household survey on the subject, conducted by UNICEF in 2019. The practice is normally carried out on girls at the onset of puberty, although there are areas of the country where it is done on girls who are much younger.Refusing bondo comes at great social cost. Women who have not joined are, by custom if not by law, not permitted to marry; to represent their communities in religious or cultural events; to participate in celebrations or funerals; or to serve as chief or in parliament. A “bondo devil,” a key figure in women’s rituals, in Port Loko, Sierra Leone.Finbarr O’Reilly for The New York TimesIn most cases, the initiation involves excision of the clitoris and labia minora with a razor by a senior society member called a sowei, who has no medical training but is believed to be spiritually powerful. The ceremony is carried out in women-only encampments, which were once rural but are now sometimes in towns, known as the “bondo bush.”Laws against cutting have had uneven enforcement and mixed results. Some countries, such as Egypt and Ethiopia, have seen rates fall dramatically. But in others, such as Senegal and Somalia, the decline has been negligible. Globally, the number of girls at risk of being cut continues to grow, because countries without laws or enforcement against cutting have large and rapidly growing youth populations.The Great ReadMore fascinating tales you can’t help but read all the way to the end.Using the Vatican’s own archives, a soft-spoken scholar has become arguably the most effective excavator of the church’s hidden sins.TikTok choreography, dancing umpires, a ballet-trained first-base coach: The Savannah Bananas, a collegiate summer league baseball team, has amassed a following by leaning into entertainment.There is growing evidence that MDMA — the illegal drug known as Ecstasy or Molly — can significantly lessen or even eliminate symptoms of PTSD when the treatment is paired with talk therapy.While Sierra Leone has one of the world’s highest rates of cutting, it is also one of the few places where the practice seems to be showing a sustained decline, as more and more young women resist.Every morning as she gets ready for school, Isha Kamara and her grandmother, Hawa, debate bondo. Hawa Kamara says it is high time for Ms. Kamara to be initiated. Ms. Kamara, 20, who is in her last year of high school and wants to manage a bank one day, says she’s not interestedAll her life, Ms. Kamara, who has lived with her grandmother since she was orphaned as a small child, has heard about the plans for her initiation. But after she read about cutting in a magazine and heard lectures at school — “They told us that anything God put on our bodies belongs there and should stay” — she started saying she would not join the society.Her grandmother warned she’d have no friends. Ms. Kamara said her friends were also planning to refuse initiation. Her grandmother warned that she would die single and lonely; Ms. Kamara said she expected plenty of people would want to marry a bank manager.Her grandmother tried bribery and promised new outfits. Ms. Kamara just cocked an eyebrow at that one.The nagging is most fierce on the days when the sounds of the traditional drums echo through Port Loko for an initiation. Ms. Kamara has offered to do a no-cutting bondo, a practice being promoted by some feminist groups, but her grandmother has said that is worthless.Only one counterargument has found any resonance: “It’s a lot of money,” Hawa Kamara said, referring to the cost of the ceremony. A family must pay the sowei who leads the rites, and stage a feast or contribute to a community celebration. “I suppose we could spend it on her studies rather than calling people to come for a feast that will be eaten up quickly,” she said.Isha Kamara, 20, is not interested in the ritual and wants to go to college and manage a bank.Finbarr O’Reilly for The New York TimesWhile big international organizations such as UNICEF and U.N. Women are driving the push to end cutting, the views of many girls and young women are being influenced by homegrown activism. Radio shows, billboards and traveling drama groups have spread the message that cutting is dangerous, can cause serious difficulties for women in childbirth, undermines their sexual health and violates human rights. Ms. Bangura, who has been living with the family of her friend Aminata since she left her family home, heard the message that cutting was dangerous from her pastor at church and from a teacher at school. Most of her friends were eager to join bondo, she said, but, like her, some were hesitant, and they discussed it quietly among themselves. This is a significant change from years past. Everything about the society is meant to be secret, and breaking the taboo of discussing what happens there, including the initiation rites, is said to bring the risk of a curse.The problem, Ms. Bangura discovered, is that social change does not happen fast, or neatly.Ms. Bangura, with Kai Samura and her newborn, whom she is staying with in the town of Kamakwie, after being forced from her home village.Finbarr O’Reilly for The New York TimesKai Samura, who owns the house where Ms. Bangura stays now, said she thought Ms. Bangura’s family was overreacting. “If they abandon her because she refuses, it’s unjust,” she said.Ms. Samura, 39, underwent initiation at age 8, but has told her own daughters they are free to choose, and should wait until they are 18 to decide. (Her husband is a vehement opponent of the practice, but says the affair is a woman’s domain.)She reckons she and her husband are less rigid about bondo because they live in a town and social controls are more lax, but she understands the village view:Getting a daughter initiated is crucial for the family’s social status, and for the girl’s own future.“People don’t hate their kids,” said Chernor Bah, who runs Purposeful, a feminist advocacy organization in Freetown that works to end cutting. “They are making what they perceive as a rational, best-interest decision for the lives of their children.”A proposed amendment to the Child Right Act, which has been under review by Sierra Leone’s Ministry of Gender and Children Affairs, would codify cutting as a “harmful practice” and make it illegal to perform the procedure on girls under 18. This is far less than the outright ban than many opponents want. But the path to outlawing the procedure is not a clear one. Powerful individuals and institutions continue to champion the practice — some overtly, some discreetly — on the grounds that it is a key part of Sierra Leone’s culture and values. They often bolster the claim with the assertion that the anti-cutting movement is a Western import, an attempt to erode traditional values and a push to promiscuity.Sierra Leone’s first lady, Fatima Bio, a powerful political figure with a public profile as high as her husband’s, has said publicly that she underwent cutting and that she has seen no evidence that it is harmful, but when confronted by activists she agreed to give the issue further study. Haircare in the village of Fonkoye in northern Sierra Leone.Finbarr O’Reilly for The New York TimesSierra Leone’s education minister, David Moinina Sengeh, said in an interview that he was “not aware” if education about cutting was part of the national curriculum and that he did not feel the subject should be addressed in schools.“I don’t control what people do at home,” he said.His position is emblematic of the contested ground of cutting. Mr. Moinina Sengeh, who holds a Ph.D. from the Massachusetts Institute of Technology, is known as one of the most progressive figures in Sierra Leone’s government. He is credited with ending a ban on pregnant girls attending school. On cutting, however, he will not take a position. The curriculum should not “be making a moral decision on whether something is good or right” and should not say, “Get cut or don’t get cut,” he said.Politicians seeking votes often volunteer to pay for a mass initiation in a community — even politicians who have publicly opposed cutting, said Naasu Fofanah, a prominent Freetown entrepreneur and deputy chair of the progressive Unity Party. She said that several years ago, when she was advising a former president, Ernest Bai Koroma, on the issue, she successfully convinced most sowei leaders to endorse a ban on cutting children, which, she said, would have been a major step forward. But activists seeking a full ban blocked the move, she said.Ms. Fofanah herself underwent the cutting at age 15 and remembers the pain and shock of the actual procedure (about which she had no forewarning). But she also said it was, overall, a positive and affirming ritual.Girls’ school uniforms hung to dry on a laundry line in the Congo Town area of Freetown.Finbarr O’Reilly for The New York Times“It was a beautiful experience for me,” she said, recalling her grandmother leading dancers in celebration of her transition into womanhood, and being told “that nobody’s ever going to speak down to you. You’ve now become this woman.”It wasn’t hard to reconcile what had been done to her body, because she knew her mother, her grandmother and her aunts had all been through it as well. “So you endure, and you’re just like, ‘OK, that’s done, let’s get on with it,’” she said.Still, Ms. Fofanah, who studied bondo initiation for her masters thesis at the University of Westminster in England, did not take her own daughters for initiation and talked a niece out of it, telling her she “didn’t need it” because the family had sufficient resources to open other paths for her. Yet, she felt a blanket ban was ill-conceived.“If we are saying, when it comes to this practice, women cannot express themselves and say, ‘I am 18 or I’m 21 or I’m 30, it’s my culture, I’m going to’ — where do human rights meet my rights as a woman?” she said. “Are you saying I’m not capable of making an informed decision, of saying I want to go through this practice?”UNICEF surveys have found that the proportion of women who think that cutting should stop is rising steadily; in the most recent survey it was nearly a third, and the opinion was held across education levels. But even women who said they thought cutting should end often also said they would send their own daughters to bondo; the top reason they gave was “social acceptance.” In a third of couples, women wanted the practice to continue while their husbands said it should be ended.When Sierra Leone experienced an epidemic of Ebola virus from 2014 to 2016, the government temporarily outlawed the practice, and traditional and faith leaders helped promote the ban. It has since ended, but activists said it made a space for a public conversation about bondo that had never existed before, and likely contributed to a rise in young women resisting.A number of anti-cutting groups in Sierra Leone have been trying to build support for an alternative process, what they call a “bloodless rite,” that preserves the instruction about the role and responsibility of women but does not include cutting. This approach also has the advantage of preserving an income stream, and social power, for soweis.Kadiatu Bangura, with her daughters Adama, left, and Mariama, inherited the role of sowei but was convinced by her eldest daughter, Zeinab, to quit.Finbarr O’Reilly for The New York TimesKadiatu Bangura inherited the role of sowei and estimated that she cut more than 100 girls in the town of Port Loko before her daughter Zeinab, who is now 22, asked her to quit. Zeinab heard anti-cutting messages at church and confronted her mother, shocked that this was the core of the role her mother was esteemed for holding.Kadiatu Bangura said she tried to help her daughter see the whole picture: “The bad side is the cutting — but the good side is there is dancing and celebrating and they drum for you and when you lead, they follow.” There was community and a sense of shared values in the society, and the rites without cutting did not have the same power, she said.Nankali Maksud, who leads work on the subject for UNICEF globally, said that the public conversation about cutting in Sierra Leone, and in other countries where the practice has prominent proponents, had evolved. “As people get more educated they are challenging the blanket ‘F.GM. is bad’ messaging,” she said, using an acronym, often used by opponents of the procedure, for female genital mutilation. “UNICEF has had to regroup. We’re now having to be much more clear: We mean in children. We don’t mean in women. Women should have a right to be able to do what they want to do with their bodies.”In other countries where cutting is practiced in some communities but not in others, girls can find it easier to leave home, she said. In Kenya, for example, there are shelters and organizations that support girls who resist cutting. Sierra Leone, where the hegemony of bondo is still entrenched, has nothing of the sort.That leaves young women who resist the ritual, such as Seio Bangura, reliant on charity when they find it, or, often, turning to commercial sex work as one of the few ways a woman on her own can earn a living. Ms. Bangura sometimes sells nuts and cakes in the market, trying to save enough from the dollar or two she earns every week to pay for college. She goes to church. Mostly, she sits, waiting for Sierra Leone to catch up to her.