Event Brief
The Democratic Republic of the Congo is battling what Doctors Without Borders describes as its largest and fastest-spreading Ebola outbreak ever recorded, caused by the Bundibugyo ebolavirus (BDBV) strain rather than the more familiar Zaire strain that existing licensed vaccines and treatments were designed against. As of September 23, 2026, the WHO and ECDC report 7,890 confirmed cases and 3,799 deaths in the DRC, plus two additional deaths in Uganda, for a crude case fatality ratio of roughly 48%. The outbreak, first declared in Ituri Province on May 15, 2026, and designated a Public Health Emergency of International Concern by the WHO on May 16, 2026, has now spread across 63 health zones in seven provinces, most recently reaching Bulu in South Ubangi (bordering the Central African Republic) and Dungu in Haut-Uele (bordering South Sudan).
The epidemiological picture is genuinely mixed rather than uniformly worsening. UN reporting from September 23, 2026 notes cases fell approximately 26% in Ituri and 15% in Haut-Uele over the prior 21 days, while North Kivu recorded a 73% increase over the same window, with WHO's Regional Emergency Director for Africa, Dr. Marie Roseline Belizaire, stating cases are declining in some provinces while continuing to rise in others. North Kivu has emerged as a distinct hotspot with a substantially higher case fatality rate, nearly 60%, compared to the roughly 48% national average, and treatment centers such as the Kitatumba facility in Butembo have been reported at full capacity amid community mistrust complicating case-finding and safe-burial practices.
The response is complicated by a critical countermeasure gap: neither of the two WHO-prequalified Ebola vaccines (Merck's Ervebo/rVSV-ZEBOV and the Zabdeno/Mvabea regimen) was designed against the Bundibugyo species, though Ervebo is currently the only Ebola vaccine licensed for use in Bundibugyo-virus outbreaks based on cross-reactivity data. Doctors Without Borders and its research arm Epicentre launched a study on September 19, 2026 to evaluate Ervebo's effectiveness among roughly 20,000 frontline health workers in Ituri and North Kivu over nine to twelve months, while Oxford researchers vaccinated the first volunteer in the world's first Bundibugyo-specific vaccine trial in July 2026, and Moderna announced a Phase I trial of mRNA-1469 targeting Bundibugyo virus in early August 2026. None of these next-generation candidates are positioned to affect the current outbreak's trajectory given standard vaccine development timelines.
Operational strain is acute: the DRC faces a documented shortage of health workers to staff specialized Ebola treatment centers, MSF has deployed more than 1,700 staff across nine treatment centers in five provinces, and a laboratory-confirmed mpox case was identified on September 25, 2026 in Bunia, the city at the center of the Ebola response, raising the specter of a concurrent outbreak straining the same fragile health infrastructure. Ongoing armed conflict in eastern DRC, including the M23 militia's control of Goma and Bukavu since early 2025, continues to hinder contact tracing and treatment access, and WHO leadership has explicitly linked population displacement and conflict to reduced ability to reach affected communities.
Intersection Groups (8)
Proximity: DirectImmediateFLOW D
Democratic Republic of Congo Ministry of Public Health, Hygiene, and Social Welfare
The Ministry faces a documented health worker shortage for staffing specialized Ebola treatment centers even as the epidemic has expanded to 63 health zones across seven provinces, requiring it to prioritize scarce clinical staff toward North Kivu where the case fatality rate has climbed to nearly 60% against a roughly 48% national average. The Ministry must simultaneously manage the newly confirmed mpox case in Bunia, the city at the center of the Ebola response, without diverting resources that are already stretched thin.
Strategic Options
01Reallocate treatment center staffing and ring-vaccination teams toward North Kivu, where WHO data show cases rose 73% over the last 21 days versus declines in Ituri and Haut-Uele.
02Request additional International Coordinating Group Ervebo stockpile allocations specifically for North Kivu given its elevated near-60% case fatality rate.
03Coordinate jointly with mpox surveillance teams in Bunia to avoid duplicative community engagement efforts that could deepen local mistrust documented in Butembo's Kitatumba treatment center reporting.
↳ The national case fatality ratio of roughly 48% obscures a materially worse outcome in North Kivu (near 60%), meaning aggregate WHO figures likely understate the clinical severity of the outbreak's newest and fastest-growing front.
FLOW Rationale: A national outbreak spanning seven provinces and 63 health zones with a near-60% localized case fatality rate in North Kivu constitutes population-level scale that overrides complexity considerations per the Three Rules.
Scale (Large): The outbreak spans 63 health zones across seven provinces with 7,890 confirmed cases and 3,799 deaths as of September 23, 2026, constituting population-level national health emergency scale.
Complexity (High): Divergent province-level trends, improvement in Ituri and Haut-Uele but a 73% case increase in North Kivu over the same 21-day window, mean no single national strategy applies uniformly.
Key Question
Will the Democratic Republic of Congo's Ministry of Public Health be able to reduce North Kivu province's near-60% Ebola case fatality rate, which is running above the roughly 48% national average, before the 73% 21-day case increase reported by WHO on September 23, 2026 overwhelms the Kitatumba treatment center's capacity in Butembo?
Watch Signals:- [Likely] WHO Disease Outbreak News updates (published roughly every 1-3 weeks per the pattern from May through September 2026) showing whether North Kivu's share of new cases continues rising above the roughly one-third of national new cases reported in the September 23, 2026 update.
- [Possible] ECDC's next scheduled epidemiological update on September 28, 2026 showing whether the national case fatality ratio moves materially from the 48.3% recorded as of September 7, 2026.
- [Possible] Reports of Ebola treatment center bed capacity in North Kivu exceeding documented levels, referencing the 29-bed Kitatumba facility reported at full capacity in Straits Times reporting dated September 25, 2026.
Proximity: DirectImmediateFLOW D
World Health Organization
WHO must sustain its Public Health Emergency of International Concern designation, declared May 16, 2026, while managing a genuinely mixed epidemiological trend, cases falling in Ituri and Haut-Uele but rising sharply in North Kivu, that complicates any near-term messaging about the outbreak's trajectory. Cross-border spread into health zones bordering the Central African Republic and South Sudan requires WHO to activate cross-border surveillance coordination with neighboring health ministries before further regional spread occurs.
Strategic Options
01Issue updated cross-border preparedness guidance to the Central African Republic and South Sudan given new confirmed cases in Bulu (South Ubangi) and Dungu (Haut-Uele), both reported by WHO on September 25, 2026 as bordering those countries.
02Expedite ICG Ervebo stockpile deployment specifically to North Kivu treatment centers given the province's near-60% case fatality rate.
03Publish an updated Disease Outbreak News bulletin explicitly disaggregating province-level trends to correct potential public misperception from aggregate national figures alone.
↳ WHO's own data shows the outbreak is not monolithically worsening, per-province divergence (Ituri and Haut-Uele improving, North Kivu deteriorating sharply) means a 'very high risk' national assessment is being driven disproportionately by one province's trajectory.
FLOW Rationale: A PHEIC-designated outbreak spreading across international borders with nearly 4,000 deaths constitutes population/region-wide scale that overrides complexity per the Three Rules, keeping this at D rather than C.
Scale (Large): As the convening global health authority for a PHEIC-designated outbreak with nearly 4,000 confirmed deaths and expansion into border-adjacent health zones, WHO's coordination role carries population- and region-wide significance.
Complexity (High): The outbreak's transmission profile differs meaningfully by province, per WHO Regional Emergency Director for Africa Dr. Marie Roseline Belizaire's September 23, 2026 statement that cases are declining in some provinces while rising in others, requiring province-specific rather than uniform national guidance.
Key Question
Will the World Health Organization's cross-border preparedness measures for the Central African Republic and South Sudan prevent onward spread following the confirmed new Ebola cases in Bulu (South Ubangi) and Dungu (Haut-Uele) health zones reported on September 25, 2026?
Watch Signals:- [Possible] Confirmed Ebola cases reported by health authorities in the Central African Republic or South Sudan, which as of September 25, 2026 had reported none despite bordering the newly affected Bulu and Dungu health zones.
- [Likely] WHO's next Disease Outbreak News update (following the pattern of updates roughly every 1-3 weeks since May 2026) reporting whether the total affected health zone count exceeds the 63 recorded as of September 25, 2026.
- [Possible] ECDC's scheduled September 28, 2026 threat assessment brief noting any change in the WHO risk classification from 'very high' at national level.
Proximity: DirectNear-TermFLOW C
Merck & Co. (Ervebo vaccine program)
Ervebo (rVSV-ZEBOV) is currently the only Ebola vaccine licensed for use in Bundibugyo-virus outbreaks based on cross-reactivity data, positioning Merck as the sole near-term vaccine supplier for the ICG stockpile despite Ervebo having been developed and licensed by the FDA and EMA in 2019 against the distinct Zaire ebolavirus strain. Merck's product is now the subject of an MSF/Epicentre effectiveness study launched September 19, 2026 following roughly 20,000 frontline health workers in Ituri and North Kivu, results of which will shape whether Ervebo remains the response backbone or whether reliance narrows further pending Bundibugyo-specific candidates.
Strategic Options
01Support expanded ICG stockpile replenishment specifically earmarked for Bundibugyo-outbreak ring vaccination in North Kivu given documented cross-reactivity but unconfirmed real-world efficacy.
02Provide manufacturing and regulatory support to the MSF/Epicentre effectiveness study following roughly 20,000 frontline workers, given the study's direct bearing on continued off-label Bundibugyo use.
03Coordinate with Oxford and Moderna's Bundibugyo-specific vaccine trial teams on shared safety and immunogenicity data to avoid duplicative early-phase testing burden on DRC trial infrastructure.
↳ Ervebo's continued use rests on cross-reactivity assumptions rather than a Bundibugyo-specific efficacy trial, meaning the drug's real-world protective value in this outbreak remains an open question the MSF/Epicentre study is only now designed to answer.
FLOW Rationale: Moderate scale (one licensed product's off-label deployment) combined with high complexity (unresolved cross-strain efficacy question with results pending nine to twelve months) places this at FLOW C rather than D, since the affected population is bounded to outbreak zones rather than population-wide.
Scale (Moderate): Merck's existing licensed franchise supplies the sole outbreak-response vaccine for a PHEIC-designated epidemic, materially affecting its public health role even though this is not a new revenue-driving indication.
Complexity (High): Ervebo's efficacy against a heterologous strain (Bundibugyo vs. the Zaire strain it was designed against) is scientifically unclear, and the ongoing MSF/Epicentre real-world effectiveness study will not report for nine to twelve months from its September 19, 2026 launch.
Key Question
Will Merck's Ervebo vaccine demonstrate meaningful real-world effectiveness against Bundibugyo ebolavirus in the MSF/Epicentre study launched September 19, 2026 following approximately 20,000 frontline health workers in Ituri and North Kivu provinces?
Watch Signals:- [Possible] Interim safety or immunogenicity data releases from the MSF/Epicentre Ervebo effectiveness study ahead of its full nine-to-twelve-month follow-up period from the September 19, 2026 launch.
- [Possible] ICG stockpile drawdown reports indicating the volume of Ervebo doses specifically allocated to North Kivu ring vaccination relative to Ituri.
- [Unlikely] A change in WHO's Technical Advisory Group on candidate vaccine prioritization (TAG-CVP) recommendation away from Ervebo as the primary outbreak-response vaccine, given its current status as the only licensed option for Bundibugyo outbreaks.
Proximity: CloseMonitorFLOW C
Moderna (mRNA-1469 Bundibugyo vaccine candidate)
Moderna's mRNA-1469 Phase I trial, announced August 4, 2026, positions the company as a next-generation entrant targeting Bundibugyo ebolavirus specifically, but standard Phase I timelines mean the candidate cannot affect the current outbreak's trajectory and instead builds toward stockpile diversification for future Bundibugyo outbreaks. The DRC's status as the epidemic epicenter creates an unusual real-world testing ground, though ethical and logistical constraints of running early-phase trials during an active PHEIC-designated outbreak add development complexity beyond typical vaccine programs.
Strategic Options
01Coordinate Phase I safety data sharing with Oxford's parallel Bundibugyo-specific vaccine trial to accelerate the broader evidence base given the shared outbreak context.
02Engage WHO's Technical Advisory Group on candidate vaccine prioritization to clarify mRNA-1469's potential future stockpile role alongside Ervebo.
03Assess trial site placement outside the highest-mistrust zones documented in North Kivu to reduce enrollment and retention risk.
↳ Moderna's Bundibugyo-specific candidate cannot influence the current outbreak's outcome given Phase I timelines, meaning its strategic value lies entirely in future outbreak preparedness rather than present crisis response.
FLOW Rationale: Low current scale (early-stage trial with no bearing on the active outbreak) combined with high execution complexity (trial conduct amid active PHEIC conditions) places this at FLOW C.
Scale (Low): A single Phase I trial announced August 4, 2026 represents an early-stage pipeline program with no near-term bearing on the current outbreak's case counts.
Complexity (High): Conducting early-phase trial enrollment and safety monitoring amid an active PHEIC-designated Ebola epidemic with documented community mistrust (per Straits Times reporting on Butembo's Kitatumba treatment center) creates execution challenges beyond standard Phase I logistics.
Key Question
Will Moderna's Phase I trial of mRNA-1469, announced August 4, 2026 as a vaccine candidate against Bundibugyo ebolavirus, generate safety and immunogenicity data sufficient to support advancement to later-phase testing before the current DRC outbreak is declared over?
Watch Signals:- [Possible] Moderna 8-K or press release disclosing Phase I enrollment completion or interim safety data for mRNA-1469.
- [Unlikely] WHO TAG-CVP meeting report referencing mRNA-1469 for prioritized stockpile consideration ahead of the current outbreak's resolution, given the candidate's early-stage status.
Proximity: DirectImmediateFLOW C
Doctors Without Borders / Médecins Sans Frontières (MSF)
MSF has deployed more than 1,700 staff running nine Ebola treatment centers across five provinces, with more than 2,770 patients admitted to these facilities since May, and now faces expanding demand as the outbreak reaches a seventh province and North Kivu case counts rise 73% over the most recent 21-day period. The organization's newly launched Ervebo effectiveness study (with Epicentre, beginning September 19, 2026) adds a research operations burden atop its direct care mission at a moment when treatment center capacity, exemplified by the fully-occupied 29-bed Kitatumba facility in Butembo, is already strained.
Strategic Options
01Prioritize additional treatment center capacity expansion in North Kivu given the province's near-60% case fatality rate and the 29-bed Kitatumba facility's full occupancy reported in Straits Times coverage dated September 25, 2026.
02Expand community engagement teams specifically in Butembo to address the documented mistrust complicating case-finding and safe burial practices.
03Scale the Ervebo effectiveness study's frontline worker enrollment pace to ensure vaccination protection reaches North Kivu health workers facing the highest local exposure risk.
↳ MSF's treatment center capacity data (nine centers, five provinces) already lags the outbreak's geographic footprint (63 health zones, seven provinces), indicating the response infrastructure has not kept pace with the epidemic's spread into a seventh province.
FLOW Rationale: Moderate scale bounded to MSF's specific operational footprint combined with high complexity from simultaneous capacity strain and community trust challenges in North Kivu places this at FLOW C.
Scale (Moderate): MSF's role covers nine treatment centers across five of the seven affected provinces with over 2,770 admitted patients, a substantial but bounded share of total response capacity rather than the entire national response.
Complexity (High): Community mistrust documented in North Kivu's Butembo, where surging cases have overwhelmed facilities even as the outbreak eases elsewhere, requires MSF to navigate both clinical capacity constraints and community engagement challenges simultaneously.
Key Question
Can Doctors Without Borders expand Ebola treatment center capacity in North Kivu province fast enough to relieve the fully-occupied 29-bed Kitatumba facility in Butembo, given WHO's September 23, 2026 report of a 73% case increase in the province over the prior 21 days?
Watch Signals:- [Likely] MSF situation reports or press releases announcing new treatment center openings or bed capacity expansions in North Kivu, given the organization's active nine-center, five-province deployment.
- [Possible] Straits Times or comparable on-the-ground reporting documenting bed occupancy rates at Ebola treatment centers in Butembo or other North Kivu localities.
Proximity: CloseNear-TermFLOW C
Central African Republic and South Sudan health ministries
New confirmed Ebola cases in Bulu (South Ubangi, bordering the Central African Republic) and Dungu (Haut-Uele, bordering South Sudan), both reported by WHO on September 25, 2026, place these neighboring countries at elevated cross-border transmission risk despite neither having reported confirmed cases as of that date. Both health systems, already resource-constrained, must now activate or intensify border surveillance and contact-tracing protocols without the treatment infrastructure the DRC has built over more than four months of active outbreak response.
Strategic Options
01Activate WHO-supported cross-border surveillance and contact-tracing protocols specifically along the South Ubangi/Central African Republic and Haut-Uele/South Sudan borders given the newly confirmed cases in Bulu and Dungu.
02Request ICG Ervebo stockpile pre-positioning for border health facilities as a precautionary ring-vaccination readiness measure.
03Coordinate joint risk communication campaigns with DRC health authorities to address population movement across the newly affected border health zones.
↳ The absence of confirmed cases in the Central African Republic or South Sudan as of September 25, 2026 does not indicate absence of risk, both countries border health zones (Bulu and Dungu) with newly confirmed DRC cases, and historical Ebola outbreaks in the region have shown lag time between border-zone spread and cross-border confirmation.
FLOW Rationale: Moderate scale (potential but unconfirmed cross-border spread) combined with high complexity (under-resourced health systems lacking DRC's accumulated outbreak response infrastructure) places this at FLOW C rather than D, pending confirmation of actual cross-border cases.
Scale (Moderate): The risk is currently one of potential cross-border spread into two additional countries rather than confirmed transmission, bounding scale below the DRC's national-level impact.
Complexity (High): Neither country has DRC's four-plus months of accumulated Ebola outbreak response experience or treatment center infrastructure, making any confirmed cross-border case introduce an unclear, high-stakes response scenario for under-resourced health systems.
Key Question
Will the Central African Republic or South Sudan confirm any Ebola cases following the WHO's September 25, 2026 report of new infections in the DRC's Bulu and Dungu health zones, which border those two countries respectively?
Watch Signals:- [Possible] Health ministry statements from the Central African Republic or South Sudan regarding suspected or confirmed Ebola cases near their DRC borders.
- [Possible] WHO Disease Outbreak News updates specifically noting cross-border case confirmation outside the DRC and Uganda, which as of the current outbreak have been the only two countries with confirmed cases.
Proximity: DirectImmediateFLOW D
Local communities in North Kivu and Ituri provinces (affected patient population)
Residents of North Kivu face a documented near-60% case fatality rate, significantly higher than the roughly 48% national average, compounded by ongoing armed conflict and M23 militia control of Goma and Bukavu since early 2025 that hinders health worker access and contact tracing. Community mistrust of the outbreak response, cited in Straits Times reporting on Butembo, directly affects case-finding, safe burial practice adoption, and treatment center utilization, meaning the population's own engagement with the response is itself a determinant of further mortality.
Strategic Options
01Support WHO- and MSF-led community engagement teams specifically targeting the mistrust dynamics documented in Butembo and broader North Kivu localities.
02Advocate for negotiated humanitarian access corridors with armed groups controlling Goma and Bukavu to enable contact tracing and treatment center access.
03Prioritize risk communication materials addressing both Ebola and the newly confirmed Bunia mpox case to avoid conflicting public health messaging.
↳ The near-60% case fatality rate in North Kivu, against a roughly 48% national average, suggests that conflict-driven access constraints and community mistrust are producing meaningfully worse individual outcomes than the outbreak's biology alone would predict.
FLOW Rationale: Population-level scale spanning seven provinces and nearly 4,000 deaths overrides complexity considerations per the Three Rules, placing this at FLOW D.
Scale (Large): The directly affected population spans 63 health zones across seven provinces with nearly 4,000 confirmed deaths and a near-60% localized fatality rate in North Kivu, representing population-level health impact.
Complexity (High): Community mistrust compounded by active armed conflict and displacement creates an unclear situation where standard contact-tracing and safe-burial protocols cannot be assumed to function as designed.
Key Question
Will documented community mistrust and armed conflict access constraints in North Kivu province continue to sustain a near-60% Ebola case fatality rate there, compared with the roughly 48% national average reported by WHO as of September 23, 2026?
Watch Signals:- [Possible] WHO or MSF reporting on safe burial practice adoption rates or community engagement outcomes specifically in North Kivu health zones.
- [Possible] Reports of humanitarian access negotiations with armed groups controlling Goma or Bukavu affecting Ebola response team movement.
Proximity: CloseNear-TermFLOW C
DRC mpox response (concurrent outbreak in Bunia)
A laboratory-confirmed mpox case identified in Bunia on September 25, 2026, the city at the center of the Ebola response and located in Ituri province, raises the prospect of a concurrent outbreak straining the same treatment centers, contact-tracing teams, and community engagement infrastructure already committed to Ebola response. Health officials in Bunia must now determine whether to stand up parallel mpox isolation capacity or attempt to integrate mpox case management into existing Ebola treatment center operations.
Strategic Options
01Establish separate mpox isolation protocols distinct from Ebola treatment center operations to avoid nosocomial transmission risk between the two pathogens.
02Conduct expanded mpox surveillance testing in Bunia and surrounding Ituri health zones to determine whether additional cases exist.
03Coordinate messaging with Ebola community engagement teams to avoid public confusion between the two concurrent disease threats.
↳ A concurrent mpox case emerging in the same city driving the Ebola response indicates the DRC's health system is being tested by simultaneous outbreak threats rather than a single linear crisis, a scenario requiring surge capacity beyond what has been built for Ebola alone.
FLOW Rationale: Low current scale (single confirmed case) combined with high complexity (unclear whether this signals broader resurgence, compounded by concurrent Ebola strain on the same infrastructure) places this at FLOW C.
Scale (Low): A single confirmed mpox case as of September 25, 2026 represents an early-stage signal rather than a confirmed outbreak, bounding current scale.
Complexity (High): The situation is genuinely unclear, whether this represents an isolated case or the start of a broader mpox resurgence, and any response must be coordinated without diverting resources from the ongoing Ebola epidemic.
Key Question
Will additional mpox cases be confirmed in Bunia or surrounding Ituri province health zones following the single laboratory-confirmed case reported on September 25, 2026, and will this compound the resource strain on DRC's Ebola treatment center network?
Watch Signals:- [Possible] Additional mpox case confirmations reported by Bunia hospital officials or DRC health authorities following the initial September 25, 2026 confirmation.
- [Possible] WHO situation reports referencing dual mpox-Ebola resource allocation challenges in Ituri province.
The claims behind this analysis, each with its verification status — including what is contested, unverified, or could not be established.
What each grade meansAs of September 23, 2026, the DRC has reported 7,890 confirmed Ebola cases and 3,799 deaths, a crude case fatality ratio of roughly 48%, per WHO data cited by Al Jazeera and ECDC.
This figure anchors the scale assessment for every DRC-facing intersection and establishes the national fatality baseline against which North Kivu's elevated rate is compared.
The outbreak is caused by the Bundibugyo ebolavirus (BDBV) strain, distinct from the Zaire strain that existing licensed vaccines (Ervebo, Zabdeno/Mvabea) were originally developed against.
This drives the entire vaccine-gap intersection set (Merck, Moderna, Oxford) and explains why standard outbreak-response tools face efficacy uncertainty.
North Kivu province recorded a 73% increase in Ebola cases over the 21 days preceding September 23, 2026, while Ituri fell approximately 26% and Haut-Uele fell approximately 15% over the same period, per WHO data reported by UN News.
This establishes that the outbreak is not uniformly worsening, requiring province-specific rather than national-aggregate response prioritization and directly shaping the North Kivu-focused intersections.
New confirmed Ebola cases were identified in Bulu (South Ubangi province, bordering the Central African Republic) and Dungu (Haut-Uele province, bordering South Sudan), bringing the total affected health zones to 63 across seven provinces, per WHO reporting on September 25, 2026.
This is the direct basis for the cross-border risk intersection involving the Central African Republic and South Sudan health ministries.
MSF and its research arm Epicentre launched a study on September 19, 2026 to evaluate Ervebo vaccine effectiveness among approximately 20,000 frontline health workers in Ituri and North Kivu provinces over nine to twelve months.
This anchors the Merck/Ervebo intersection's complexity rationale and timeline for resolving the vaccine's cross-strain efficacy question.
Nearly 60 percent of people diagnosed with Ebola in North Kivu have died, significantly higher than the national average of 48 percent, per WHO data reported by Al Jazeera on September 25, 2026.
This specific comparative fatality-rate gap is the core evidentiary basis for flagging North Kivu as the outbreak's most severe front across multiple intersections.
A laboratory-confirmed mpox case was identified in Bunia, the northeastern Congolese city at the center of the Ebola outbreak, according to a local hospital director and two health officials cited by the Straits Times on September 25, 2026.
This establishes the concurrent-outbreak strain intersection and the basis for concern about compounding demands on the same health infrastructure.