The premise that runs underneath all of it is that infectious disease is the default. If humans do nothing, infectious diseases spread. They emerge. They increase. Risk communication, vaccine acceptance, functioning public health institutions, even something as unglamorous as cooling tower maintenance, all of that is part of holding the line. When those systems hold, humans win and civilization wins. Where they fray, the pathogens are already there, waiting to come back.

Ebola in the DRC: no longer just an outbreak

The Ebola outbreak in the Democratic Republic of the Congo is now the third largest on record, and it is still climbing. We are firmly in the expansion stage. This remains a game of catch up, where responders are chasing transmission rather than getting ahead of it.

Cases now sit around 1,800, with more than 600 deaths, for a case fatality ratio near 34 percent. This is an undercount. There are more cases out there than the official numbers capture, because testing still lags, even though it has improved somewhat.

We now have another infected American, a humanitarian worker with Samaritan's Purse. Some of you will remember that Samaritan's Purse was also involved in the 2014 to 2016 outbreak in West Africa, when two of their personnel were infected, including Dr. Kent Brantly, who was famously transferred to Emory for care. The open question is what happens to this patient. Do they go to Germany, as the last infected American did, or are they allowed to use the Ebola treatment centers that we built here in the United States at taxpayer expense? It appears that this patient is now in Germany.

There is also a fifth province now involved, Tshopo. At least one case there has no travel link to known cases elsewhere in the outbreak zone. That tells you there is very likely an undetected chain of transmission seeding this new province.

Healthcare workers are bearing an inordinate burden. As of now, 112 healthcare workers have been infected and 32 have died. This is precisely why personal protective equipment and safe treatment settings matter so much. Healthcare workers are canaries in the coal mine. When they start getting infected in numbers like this, it is a signal that they do not have the resources they need and that things are going wrong. Not unrelated, there is a healthcare worker strike threatening recent progress, and it could stall the clinical trials underway to evaluate a monoclonal antibody, remdesivir, and obeldesivir. All of that is up in the air while a strike continues.

There is a deeper failure here. This same region experienced an Ebola outbreak between 2018 and 2020, the second largest on record. Yet there does not appear to have been sustained risk communication in the years since. People's memory has faded, and we are seeing the same resistance and the same misinformation recur. Misinformation is the single biggest ally of this outbreak, and it has to be addressed directly.

A couple of guardrails need to stay intact. This is an area where malaria is also endemic, and you cannot let malaria services collapse. During the 2014 to 2016 outbreak, the collapse of malaria control is estimated to have caused as many deaths as Ebola itself, more than 10,000. It is critical not to forget the other infectious disease threats that already plague parts of the DRC.

For all of that, keep Ebola's limits in mind. This is not a pathogen that will go pandemic. It is very constrained in its ability to spread. The real worst-case scenario is not global spread. It is that this region becomes a place where Ebola is endemic, a frontier where Ebola is simply common. That is the outcome responders are trying to avoid.

Broken risk communication, healthcare worker strikes, transmission outrunning testing, a fifth province drawn in, the third largest outbreak on record, and regional endemicity as the worst case. Taken together, this is no longer simply an Ebola outbreak. It is a test of whether the international community remembers the lessons of the last one and chooses to act proactively.

Cyclospora: a fast outbreak with no source and no clear advice

Cyclospora is all over the headlines in the United States right now, and it is an unusual situation: a fast-growing outbreak with an unknown source, no traceback, and no clear advice to give people.

A quick primer. Cyclospora is a parasitic protozoal infection spread by produce. The produce becomes contaminated when irrigation water carries human fecal matter. It has been surging across the country this summer. Michigan is at around 2,000 cases with several dozen hospitalizations, roughly four times higher than the state reported last year. Sixteen other states are also reporting cases, and no common source has yet to be identified.

We do know that there does not seem to be an international travel link driving this major outbreak. People who travel to areas of Central and South America where cyclospora is endemic can certainly bring it home, and that appears to explain many of the California cases, but it does not explain the Michigan outbreak. We are in peak season, spring and summer, and that part is normal. What is abnormal is that no one can identify the source, which means there is no concrete "avoid this" to give the public. In past outbreaks we could point to raspberries, basil, or bagged lettuce. This time we cannot, and it is already changing behavior. I was at dinner recently with people who would not eat the lettuce on their plates because they were scared.

Part of the difficulty is technical. Unlike Salmonella or E. coli, cyclospora does not lend itself to an easy genomic traceback. One expert likened sorting its genetics to reading War and Peace versus a quick read. On top of that, our foodborne surveillance system, FoodNet, has been scaled back significantly since July 2025. It is run by the CDC, and the focus now is really on Salmonella and E. coli (it used to cover cyclospora). It is not yet clear exactly what role that scale back played in this outbreak, but it certainly did not help, and the fact that CDC reporting lags state reporting is its own problem.

On the clinical side, the treatment for cyclospora is Bactrim, but the diagnosis is often missed because clinicians do not order the right test. It requires a specific stool test. The illness can be prolonged and severe in people who are immunocompromised. This is all unfolding during the World Cup. I do not see a clear linkage between the two, and it has not meaningfully affected the tournament, but expect cyclospora to stay in the headlines until the driver is finally found.

A few other foodborne items deserve a mention. There is an E. coli outbreak traced to frozen blueberries sold at Publix. Infant botulism cases continue to occur in connection with powdered formula, with four cases reported in the latest cluster. And Fox News has reported that many US beaches are under swimming warnings because of high E. coli and coliform counts. The reporting described fecal contamination that could actually be smelled at many beaches, which puts swimmers at real risk if they enter contaminated water.

Measles: an endemic disease reestablishing itself in real time

I no longer think of measles as an outbreak. I think of it as an endemic disease reestablishing itself in real time.

We now have more than 2,200 cases in the United States, and the number is still rising. That is nearing the total for all of 2025, and we are only in July. About 6 percent of cases have been hospitalized. That is lower than last year, but it is not trivial, because this is a fully preventable disease. My home state of Pennsylvania has passed 100 cases, which is a modern record.

This is exactly where you can see that measles is the default. Do nothing, and you get what is happening in Pennsylvania. We are watching this virus reestablish endemicity in front of us.

One thing that genuinely annoyed me this week: someone offered me the population denominator, telling me Pennsylvania has roughly twelve million people and only about a hundred cases, as if that made the number small. It does not. That hundred is very high, because the relevant baseline is zero. The denominator does not matter. Every case of measles occurring in Pennsylvania, or anywhere in the United States, is essentially voluntary. It reflects people choosing a lower standard of living.

Development and disease are intertwined. We do not have a development problem in the United States, but the data are clear that when there is war or disruption, measles rises, and each standard deviation increase in development tracks with roughly a one-third standard deviation drop in measles. We are not being forced into this situation by war or collapse. We are choosing to lower ourselves toward that level in pursuit of what amounts to a nihilist ideology that refuses to recognize the value of vaccines.

People's behavior is shifting in response. Around 74,000 older adults have sought to check their measles status, spending money and effort to manage a risk that was actively brought back. That is a change in healthcare economics as much as anything else. We are also seeing outbreaks in congregate settings, including ICE facilities in Tucson, Arizona, which are fertile ground for measles, and predictably we are seeing communication problems around those outbreaks as well.

Remember that the line against measles was already built. It was built in the 1960s when the vaccine was developed. What is happening now is that people are erasing that line. When you erase the barrier of herd immunity in front of a pathogen that is simply waiting outside it, the outcome is not a mystery.

Vaccine policy and preparedness

The through line in vaccine policy this week is that the institutions built to safeguard vaccines are being remade, not to improve them, but to denigrate them, because the people doing the remaking are vaccine skeptics.

Consider the nominee for Assistant Secretary for Preparedness and Response, Sean Kaufman, who had a Senate hearing this past week. He is a vocal opponent of mRNA vaccines and of the hepatitis B vaccine. The proposal is to put this person in charge of the nation's emergency vaccine stockpiles, reporting to RFK Jr., who himself does not even accept the germ theory of disease. That is not accidental. RFK Jr. himself is moving to add many conditions to the COVID vaccine injury tables by fiat, likely insulated from judicial or legislative challenge, which opens the door to unfounded claims and makes vaccine development far more hazardous.

Leana Wen, the former Baltimore City health commissioner, published an op-ed in the Washington Post documenting how CDC leadership has meddled with the science around certain test designs. The important point is not the technical nuance of how you might tweak a trial for more statistical validity. The real aim is to erode public confidence in vaccine data altogether. When the general public sees this kind of manufactured debate, they conclude that nothing about vaccine data can be trusted, and that is exactly what the anti-vaccine movement wants.

The Advisory Committee on Immunization Practices is in shambles, and it is in shambles by design. At the same time, there is a hopeful counterweight in the courts, which appear to be separating somewhat from the administration's position. Courts are affirming that schools can maintain vaccine entry requirements and that employers can maintain vaccine requirements for employment. That is a good thing, and it is encouraging to see the judiciary defend sound vaccine policy.

The absurdity of the movement was on full display this week in its platforming of Andrea Shaw, a mother charged with murder in the deaths of her twins, who is blaming the vaccines and claiming they suffocated her children. There is no biological plausibility to that claim. It lays bare an anti-human ideology. This is a movement that is, by its own logic, avowedly anti-human.

Legionnaires' disease in New York City: a preventable failure of maintenance

New York City has a growing cluster of Legionnaires' disease on the Upper East Side. There is a grim symmetry to it, arriving 50 years after the disease was first described in Philadelphia in 1976. The latest figures I have seen are around 46 cases and 22 hospitalizations, and the cluster is still growing.

Legionnaires' is fundamentally an industrial disease. The culprit is almost always building cooling towers. Officials are now sampling those towers, running cultures and PCR, and remediating the ones that test positive. It is important to finish that work and to interpret the data carefully. Many towers may be PCR positive at low levels or with non-viable bacteria without being the actual source, so we will have to see what the full picture reveals. Legionella thrives in warm water in cooling towers, and New York has seen this before, including an outbreak in Harlem last year.

This is not a benign illness. It can cause a severe pneumonia, especially in older people and those who are immunocompromised, and patients sometimes present late enough that antibiotics can no longer help. The durable lesson for a city of apartment towers is straightforward. Cooling towers must be maintained and routinely tested. This should be standard of care, not something you investigate only after an outbreak, because Legionnaires' is among the more preventable outbreaks we face. The technology is not futuristic. It is just maintenance. And it applies beyond cooling towers to hot tubs, another known source. The natural state of the world is not disease control. Disease control is something societies actively create and maintain.

When systems fail together: congregate settings and the Eaton Fire

There is a useful reminder in data from the Eaton Fire in Los Angeles in January 2025. When large numbers of evacuees were placed into congregate settings, disease spread. Among evacuees and staff there were 104 cases of norovirus, 56 of COVID, 29 of flu, and additional cases of nonspecific respiratory illness.

The lesson is that congregate settings spread infection, and that disasters compound. You have a fire, you evacuate people, you place them together, and disease takes hold. That is the default. You have to assume it will happen and put technology and planning in place to minimize the impact.

Ticks: refusing preemptive surrender

Finally, a strong and comprehensive piece ran in the New York Times, by Jonathan Mingle, about ticks. What I appreciated most was its framing that humans are currently in a state of what it called preemptive surrender to ticks.

We do not need to be in preemptive surrender to ticks, or to anything. This is a civilizational question. Can we master the problem of tick-borne illness? The answer is yes. We will start to see Lyme disease vaccines and other countermeasures, and those will be part of how we handle the resurgence of tick-borne disease. Surrender is a choice, and it is the wrong one.

The common thread

I noticed these stories precisely because they are the exceptions. Most days, vaccines prevent outbreaks, surveillance systems detect threats, and public health infrastructure quietly and thanklessly does its job. The challenge is keeping it that way.

That is the common thread through this week. Civilization is not self-sustaining. The systems that protect us from infectious disease have to be maintained, defended, and renewed. When they are, outbreaks stop or never occur at all. When they are not, the microbes remind us why those systems existed in the first place.

Filoviruses are a family of thread-shaped RNA viruses that kill with a brutality that is almost unmatched in the natural world. Ebola Zaire, the most lethal species, has killed as many as 90% of the people it has infected in some outbreaks. Marburg, discovered in Germany and Yugoslavia in 1967 when laboratory workers were exposed to infected monkeys imported from Uganda, has hit 88% in certain outbreak settings. These are not numbers that should invite complacency.

Filoviruses are not one virus. They are a family. Building a countermeasure against Ebola Zaire does not automatically produce protection against Sudan, Bundibugyo, or Marburg because the viral glycoproteins differ substantially. The challenge is analogous to developing a highly effective key for one lock and discovering it doesn’t fit the others.

And yet, if you survey the full landscape of this viral family today, you find the following: one licensed vaccine for one species, one licensed therapeutic antibody for that same species, one approved antibody cocktail also targeting only that species, and nothing — not a single approved countermeasure — for Marburg, Ebola Sudan, Ebola Bundibugyo, or Ebola Tai Forest. Viruses capable of killing more than half the people they infect.

The 2026 DRC outbreak, now over 1,500 cases and still spreading, is caused by Bundibugyo ebolavirus — a species with no licensed countermeasures whatsoever. Uganda has confirmed Marburg cases alongside Ebola cases. These outbreaks are burning right now, in real time, with nothing purpose-built to stop them.

How did we get the tools we have, and why do we have them only for one species?

The Cold War built the first case for taking filoviruses seriously as a weapons threat

To understand where filovirus countermeasures came from, you have to start not with a public health crisis but with a military intelligence discovery.

The Soviet Union ran an enormous, secret biological weapons program called Biopreparat for most of the Cold War, in direct violation of the 1972 Biological Weapons Convention — a treaty the Soviets had signed. Defectors who came forward after the Soviet collapse described a program that, at its peak, employed tens of thousands of scientists working across dozens of facilities. They were not working on defensive measures. They were developing agents intended to kill, including, according to multiple accounts, experiments aimed at weaponizing Ebola.

The realization that state actors had been weaponizing agents like anthrax and researching filoviruses changed the strategic calculus. These were no longer theoretical public health concerns. They were national security threats.

Non-state actors were engaged too. Aum Shinrikyo, the Japanese doomsday cult that carried out the 1995 Tokyo subway sarin attack, had earlier dispatched members to active Ebola outbreaks in Africa with the explicit goal of collecting blood from infected patients for use in a weapon. They failed to turn it into a viable agent, but the attempt was real and documented.

Then came September 11, 2001, and weeks later, anthrax-laced letters were mailed through the U.S. postal system. Five people died. The government was forced to confront a national security gap it had largely not addressed: there were almost no medical countermeasures for the biological threats its own intelligence community had identified as genuine dangers. Anthrax, smallpox, plague — and Ebola.

The response was to build an infrastructure specifically designed to fill those gaps. Congress created Project BioShield. BARDA — the Biomedical Advanced Research and Development Authority — was established under the 2006 Pandemic and All Hazards Preparedness Act as an advanced development agency, its explicit purpose being to bridge the "valley of death" between early-stage research and licensed products. Pharmaceutical companies do not naturally invest in countermeasures for threats that may never materialize into commercial markets. The government needed to substitute as buyer and funder.

The ZMapp monoclonal antibody cocktail — the experimental treatment that made international news when it was administered to infected American missionaries Kent Brantly and Nancy Writebol during the 2014 West Africa outbreak — came directly out of this biodefense investment pipeline. The antiviral and antibody candidates that entered trials during 2014 to 2016 were the products of a funding stream that traced its origins to the post-9/11 bioterrorism recognition that Ebola could be used as a weapon. The market incentive that produced these medicines was, at its core, a weapons threat.

The 2014 West Africa outbreak created the pressure that produced a licensed vaccine

The 2013–2016 West Africa Ebola epidemic changed everything. More than 28,000 cases. More than 11,000 deaths. The world's attention focused on the problem in a way it never had during smaller, self-limiting outbreaks in remote Congo.

The vaccine that emerged was Merck's Ervebo — rVSV-ZEBOV-GP — a replication-competent viral-vectored vaccine that works by inserting the Ebola Zaire glycoprotein into the backbone of vesicular stomatitis virus platform.

Originally developed by the Public Health Agency of Canada, licensed to NewLink Genetics, and then sublicensed to Merck, the vaccine was tested in the remarkable ring vaccination trial in 2015. The logic of ring vaccination, which goes back to the smallpox eradication campaign which DA Henderson led, is that you identify a case, vaccinate everyone in that person's immediate network of contacts, and create a vaccine wall around cases. In the Guinea trial, rings were randomized to receive vaccine immediately or after a 21-day delay. Among those vaccinated immediately, there were zero Ebola cases after 10 days. In the delayed groups, cases continued to appear. The efficacy signal was strong enough that the trial was redesigned to eliminate the delayed arm.

The FDA approved Ervebo in December 2019. It was the first licensed Ebola vaccine in history — more than 40 years after the virus was first identified in 1976 outbreaks in what was then Zaire and South Sudan.

The vaccine was deployed at scale during the 2018–2020 North Kivu DRC outbreak, the second-largest Ebola outbreak ever recorded at the time. It delivered under extraordinarily difficult conditions: active armed conflict, deep community distrust, treatment units being burned down, healthcare workers being killed. The vaccine demonstrated effectiveness in a real-world emergency, not just a trial.

But Ervebo only works against Ebola Zaire. The glycoprotein it displays to the immune system is specific to one species. Present it with Ebola Sudan, with Bundibugyo, with Marburg — and the immunity it generates is not reliable.

The European Medicines Agency granted conditional marketing authorization in July 2020 to a second Ebola Zaire vaccine — Janssen's two-dose regimen (sold as Zabdeno and Mvabea), which uses an adenovirus vector for the prime dose followed by a modified vaccinia Ankara booster — though like Ervebo it covers only Zaire ebolavirus, and its two-dose schedule makes rapid ring-vaccination deployment more logistically demanding than the single-shot Merck product.

Ebanga, Inmazeb and the PALM trial proved that targeted antibodies could turn a death sentence into survivable disease

The second major breakthrough came not from the vaccine pipeline but from the therapeutic antibody pipeline, and it grew directly from a question that arose from the field for decades: could we find, in the immune systems of Ebola survivors, antibodies potent enough to serve as treatments?

The 1995 Kikwit outbreak in the Democratic Republic of the Congo was one of the more extensively studied Ebola events prior to 2014. Researchers collected blood samples from survivors, and those samples went into archives. Years later, NIH researchers, working with the archived samples, identified a single antibody — designated mAb114 — that bound to the Ebola Zaire glycoprotein with remarkable potency and neutralized the virus in preclinical models. This antibody was licensed by Ridgeback Biotherapeutics and eventually approved by the FDA in December 2020 under the name Ebanga.

What established it was the PALM trial conducted during the 2018–2020 DRC outbreak. PALM was a randomized controlled trial that compared four treatment arms: ZMapp (the old standard), remdesivir, mAb114 (Ebanga), and REGN-EB3 (Inmazeb, a three-antibody cocktail from Regeneron). The trial enrolled patients presenting to Ebola treatment units in North Kivu.

The result was decisive. ZMapp achieved 49% mortality at 28 days. REGN-EB3 achieved 34% and mAb114 35%. Both antibody therapies dramatically outperformed ZMapp, and both outperformed remdesivir. The PALM trial stopped the ZMapp and remdesivir arms early once the antibody superiority was established.

The FDA approved two antibody-based therapeutics for Ebola Zaire in late 2020: Inmazeb — a cocktail of three monoclonal antibodies developed by Regeneron and Ebanga, a single monoclonal antibody from Ridgeback Biotherapeutics.

Ebanga is now, alongside Inmazeb, the standard of care for Ebola Zaire. These are genuine life-saving medicines. A disease that killed 90% of patients in early outbreaks now kills closer to a third of patients who reach treatment coupled to supportive care.

But the same species-specificity problem applies here. Ebanga was derived from an Ebola Zaire survivor. Its target, the glycoprotein it binds, is specific to Zaire. It will not work for Sudan, for Bundibugyo, for Marburg. The antibodies are as species-specific as the vaccine.

For every other filovirus, we start from scratch

The current DRC outbreak is caused by Bundibugyo ebolavirus, first discovered in 2007 in western Uganda during a 149-person outbreak. Before the current crisis, the world had seen it in exactly two prior events. Its glycoprotein is genetically divergent enough from Zaire that the existing antibodies and vaccines — all designed around the Zaire surface protein — do not offer meaningful protection.

There is no Bundibugyo vaccine. There is no Bundibugyo monoclonal antibody therapy. The diagnosis itself was delayed by weeks because the standard rapid field tests are calibrated for Zaire and Sudan — the outbreak was circulating for an estimated four weeks before the causative strain was even identified.

Into this gap, several efforts are now moving. A clinical trial (Partners) has begun in the DRC enrolling patients to test remdesivir in combination with a Mapp Biopharmaceutical monoclonal antibody (MBP134) — a descendant of the ZMapp lineage — that may offer cross-reactive activity against Bundibugyo, though the data on cross-reactivity remain preliminary. An Oxford/Serum Institute of India vaccine candidate built on the same adenovirus-vector platform as the AstraZeneca COVID vaccine is advancing toward field deployment, potentially within months. There is also an mRNA vaccine in development from Moderna and another candidate similar to the Merck vaccine in development from IAVI. These vaccine candidates are receiving funding from CEPI. BARDA is developing an antibody product that may have cross-filovirus activity, exploring whether a more conserved region of the glycoprotein can serve as a target that would work across multiple species. These are promising efforts happening while an active outbreak spreads through four DRC provinces.

Marburg has no countermeasures and a confirmed 2026 case in Uganda

Marburg is worth treating separately, because it is a different genus within the Filoviridae family.

An 18-month-old child in Uganda tested positive for Marburg in July 2026. There is a possible second case. The case count is small. The concern is not the current count, but what it reveals: a toddler is almost never the index case in a Marburg outbreak. Marburg typically enters human populations through contact with infected Egyptian fruit bats, in caves or mineshafts. A child that young almost certainly didn't have that contact independently, which means there is an upstream transmission chain we have not yet traced.

Marburg vaccine development has been underway for years, principally led by IAVI, using a cAd3 (chimpanzee adenovirus type 3) vector platform. Phase 1 and Phase 2 trials have been completed with promising immunogenicity data. This is the same platform used in some Ebola Sudan vaccine candidates, and the science behind it is sound. But there is no licensed Marburg vaccine. There is no licensed Marburg therapeutic. If the Uganda case is the beginning of something larger, the response toolkit is supportive care: fluids, electrolytes, oxygen, preventing secondary infections. It is not nothing — improved supportive care has meaningfully reduced filovirus mortality even without targeted agents — but it is far from what the science is capable of producing.

The pattern and the lesson

Step back and you can see the through-line clearly. Filovirus countermeasure development was kicked into motion by a Cold War weapons threat and accelerated by post-9/11 biodefense investment. The money that funded ZMapp, that funded the early vaccine candidates, that sustained the research pipelines long enough to reach the PALM trial — nearly all of it traces back to the recognition that Ebola was a potential weapon and that the United States had no way to protect against it.

It is challenging to generate the sustained investment needed to develop countermeasures against low-frequency, high-mortality pathogens with no commercial market. Biodefense funding was critical in the development of Ebola Zaire medical countermeasures.

The result is a genuine achievement: one licensed vaccine, two licensed therapeutic antibodies, all for Ebola Zaire.

The gap is everything else in the family. Ebola Sudan has killed more than half the people it has infected in every documented outbreak and has no licensed countermeasures. Ebola Bundibugyo is causing the largest active Ebola outbreak in 2026 and has no licensed countermeasures. Marburg can kill 88% of its victims and has no licensed countermeasures.

This is not a scientific mystery. The biology of filovirus glycoproteins is well understood. The antibody technology that produced Ebanga and Inmazeb is the same technology that could produce Marburg and Sudan antibodies. Platform vaccines — viral-vectored and mRNA, — can be adapted to new glycoprotein targets in months rather than years. Scientists know how to do this. The knowledge exists.

What doesn't exist, or hasn't existed consistently enough, is the sustained political will and funding infrastructure to take a known but infrequent threat all the way to licensure when the commercial market is negligible and the outbreak won't last long enough to run a Phase 3 trial. BARDA was created specifically to address that market failure, and when it has been allowed to function — the PALM trial, the 2018-2020 vaccine deployment — it has worked.

The family-wide countermeasure approach I've been arguing for for years is not radical. It is simply the application of what we learned from Ervebo and Ebanga to the rest of the Filoviridae family. Build the antibodies. Run the platform vaccine trials. Do as much as possible between outbreaks rather than during them. Civilization will be categorically safer in a world where these technologies are prioritized versus one in which they aren't.

Filoviruses are not unconquerable. The success of Ervebo and Ebanga proves the opposite. The lesson of the last twenty years is that scientific capability is no longer the limiting factor. The limiting factor is whether we choose to build the tools before the outbreak arrives. Nature will continue generating threats. The question is whether human beings will continue applying reason, resources, and foresight to meet them.

What needs to be part of this is discussion is that the United States built a system to handle exactly this situation and what it means that we are not using it.

We built the infrastructure. It is sitting idle.

In the wake of the 2014 West African Ebola epidemic — the largest in history — the United States made a serious, taxpayer-funded commitment to never again be caught flat-footed. Through the Administration for Strategic Preparedness and Response (ASPR) and the CDC, the federal government stood up the National Emerging Special Pathogen Training and Education Center, or NETEC, a coordinating body anchored at three hospitals that had proven they could do the job: Emory University Hospital in Atlanta, the University of Nebraska Medical Center/Nebraska Medicine in Omaha, and NYC Health + Hospitals/Bellevue in New York City. These institutions weren't chosen because they were prestigious (even though they are). They were chosen because they had already treated Ebola patients safely, successfully, and without a single nosocomial transmission to their communities.

NETEC coordinates a tiered national network that grew to include 13 federally designated Regional Emerging Special Pathogen Treatment Centers, or RESPTCs, spread across the country. These Level 1 centers — which include Johns Hopkins Hospital, Massachusetts General, University of Texas Medical Branch in Galveston, Denver Health, and others — are the apex of the system. They maintain dedicated biocontainment units. Their teams drill, train, and simulate special pathogen care on a continuous basis. They develop protocols. They publish findings. They build institutional memory. They exist for one purpose: so that when an American gets infected with a high-consequence pathogen — Ebola, Marburg, Lassa, whatever it might be — there is a place ready to receive them, treat them, and protect the healthcare workers doing the treating.

This network was not cheap. It was not built casually. Hundreds of millions of dollars in federal preparedness funding have flowed into it over a decade.

And right now, as a second American has tested positive for Ebola in the DRC, every one of those 13 RESPTC biocontainment units is sitting idle.

What these centers actually did in 2014 tells the whole story.

During the 2014-2016 domestic Ebola response, 11 Ebola patients were treated at five U.S. health care facilities. The three institutions that would become NETEC's founding pillars each treated patients and did so in ways that were extraordinary both clinically and in terms of infection control.

During the 2014-2016 domestic Ebola response, 11 Ebola patients were treated at U.S. health care facilities, and the record speaks for itself. Emory treated four patients — Dr. Kent Brantly and Nancy Writebol, the first two Americans evacuated from West Africa, then nurse Amber Vinson, transferred from Dallas after being infected while caring for Thomas Eric Duncan, and later Dr. Ian Crozier, a WHO physician. All four survived. NIH's Clinical Center in Bethesda received Nina Pham, the other Dallas nurse infected while caring for Duncan — she recovered fully. Nebraska Medicine treated three patients: Dr. Rick Sacra, a medical missionary who contracted Ebola while delivering babies at ELWA Hospital in Liberia; Ashoka Mukpo, the NBC News cameraman who contracted Ebola in Liberia; and Dr. Martin Salia, a Sierra Leonean surgeon who arrived too late in his disease course to survive — the one death in the domestic system, attributable to the severity of his illness on arrival, not to any failure of the unit. Bellevue treated Dr. Craig Spencer, who had returned from Guinea after working with Doctors Without Borders, and discharged him Ebola-free. Across all of these cases — different patients, different facilities, different stages of disease — not a single healthcare worker at any of these centers became infected. Zero nosocomial transmission. That is the standard these facilities set and have maintained ever since.

The one facility where an Ebola patient was treated without a specialized biocontainment unit was Texas Health Presbyterian Hospital in Dallas, where Thomas Eric Duncan presented, was initially sent home, returned, and died. Two nurses who cared for him — in an improvised isolation unit — were infected. They were transferred to Emory and NIH.

The lesson from 2014 is not subtle: specialized units staffed by experienced, prepared teams save lives and prevent nosocomial spread. Improvised isolation in unfamiliar settings, without established protocols, kills patients and infects staff.

The aggregate mortality for Ebola patients treated in U.S. and European high-consequence facilities was 18.5%, compared to 37 to 74% in West African field settings. Advanced supportive care — not magic, not exotic drugs, but the painstaking work of fluid management, electrolyte correction, and critical care that requires a real ICU and a team that has run through the scenarios — is what drove that difference. You cannot deliver that type of mastery in an adhoc facility that didn't exist six weeks ago.

What the Kenya plan actually is.

In late May, the Trump administration announced that Americans who contract Ebola in the outbreak zone would not be repatriated to the United States. Instead, they would be sent to a newly constructed facility at Laikipia Air Base near Nanyuki, Kenya — a fifty-bed unit, stood up on a military airfield, staffed by approximately 30 U.S. Public Health Service officers who received three days of specialized preparation before deployment.

Three days.

NETEC teams train continuously. They run full-scale simulations. They refine and republish PPE doffing protocols because doffing — removing your protective equipment in the right sequence without self-contamination — is itself a learned and rehearsed skill that has caused infections when done wrong. The teams at Emory, Nebraska, and Bellevue have been doing this for over a decade. They know the physical layout of their units. They know their colleagues. They have practiced every scenario that can go wrong because some of those scenarios did go wrong in 2014, and they adapted. That accumulated institutional knowledge is irreplaceable.

It is true that several of the deployed USPHS officers have previous Ebola experience from the 2014-2015 Liberia response, and that matters. Those individuals are not blank slates but the care they will be able to provide is not equivalent to what the RESPTC system provides.

The administration's framing of the facility has been confused. Senior officials have at different times described it as a quarantine-only site, a quarantine-and-treatment site, and a transit point before evacuation to a third country. Those are three very different things. If a patient develops symptoms at Laikipia and deteriorates, requiring mechanical ventilation or renal replacement therapy, where exactly does that happen? With what team? In what unit? These are not rhetorical questions. They are the questions whose answers determine whether the patient lives or dies.

The Kenyan public and legal system recognized these issues immediately. Kenyan courts temporarily blocked the facility's implementation. Kenyan protesters were shot dead by police during demonstrations against it. A Kenyan high court judge issued a temporary bar, noting the complete absence of transparency from either government. The Kenyan president ultimately struck a separate deal with the Trump administration. And the supplemental Ebola funding request the administration sent to Congress included money for this Kenya facility — taxpayer dollars to build a worse version of something the taxpayers already funded and which is sitting empty in Atlanta.

Lawrence Gostin, a Georgetown legal scholar who has tracked this carefully, put it cleanly: the CDC has no legal authority to quarantine Americans on foreign soil, and under the Constitution, a U.S. citizen has an absolute right to return home. Whatever coercive pressure the administration is applying to steer Americans toward Kenya is operating outside the law and has been applied with zero public transparency.

Dr. Stafford should have been treated in the United States.

Dr. Peter Stafford, the American missionary physician who contracted Bundibugyo ebolavirus while caring for patients at Nyankunde Hospital in Bunia, was evacuated — to Germany. He was treated at the Charité hospital in Berlin, received experimental therapeutics including the MBP134 monoclonal antibody and remdesivir, and was discharged. His family, including his wife Dr. Rebekah Stafford, who was herself exposed, has been released from quarantine. The German physicians deserve full credit for the expert level of care they provided.

But Dr. Stafford is an American. He was working in one of the most dangerous medical settings on earth. When he got sick, the United States should have brought him home. Emory could have received him. Nebraska could have received him. Johns Hopkins could have received him. These facilities are specifically designed for exactly this patient. They have treated patients at least as sick. They have the protocols, the teams, the experience, and the equipment.

Instead, the operating logic of this administration is that the risk of having an Ebola patient on U.S. soil — treated in a sealed biocontainment unit by a specialist team with a decade of preparation — is politically intolerable. So, they transported an American doctor to Berlin, and built an improvised facility in Kenya, and are calling it a response.

This is below the standard of care. Standard of care is a medical and legal concept, not a rhetorical one. The standard of care for a patient with Ebola, established by more than a decade of clinical experience and multiple peer-reviewed publications, is aggressive supportive care in a dedicated high-biocontainment unit staffed by a trained, experienced team. The Kenya facility cannot meet that standard. It was not designed to. It was not built with that goal. And the people staffing it, however dedicated and however experienced some of them may be, were given three days of preparation and sent to a hospital that didn't exist six weeks ago.

As the next American in the DRC is now sick, this is an active question.

The zero-Ebola-in-America fixation is a chilling deterrent, and it is irrational.

There is a deeper dysfunction driving all of this.

The political goal of this administration's Ebola policy is to maintain a count of zero confirmed Ebola cases on U.S. soil. That is the metric they are optimizing for. Everything else flows from that — the travel bans on DRC, Uganda, and South Sudan; the Kenya facility; the refusal to repatriate Dr. Stafford; the deliberate opacity about what the Kenya facility is actually for. The administration wants to say that Ebola hasn't touched America.

But this goal has no medical or epidemiological meaning. A patient with Ebola in a biocontainment unit at Emory poses no risk to the public. We have proven that repeatedly. There was no community transmission from any of the 2014-2016 US cases — not from Brantly, not from Writebol, not from Spencer, not from Pham or Vinson after they were transferred to specialized care. The biocontainment works. The risk to the American public of a patient at a RESPTC is, practically speaking, zero.

What the zero-cases fixation actually accomplishes is the deterrence of people willing to go fight the outbreak. Right now, there are American physicians, nurses, epidemiologists, and public health professionals who might otherwise volunteer to work in the DRC or Uganda, knowing that if they got infected, they would be brought home to state-of-the-art facilities designed for exactly this. That knowledge is part of what makes it possible to take on extraordinary risk to fight for civilization against this virus.

The current policy inverts that. It tells any American healthcare worker contemplating work in the outbreak zone: if you get infected, you will not come home. You will go to a hastily constructed facility in Kenya, staffed by people who had three days of training, in a building they've never worked in before. You will be treated there, or transferred to some unspecified third country, and the U.S. government will have maintained its clean count of zero. The administration is actively making it more difficult to recruit the fighters we need to put this outbreak out.

The Obama administration's response to the 2014 epidemic — deploying military and public health assets to West Africa, building treatment capacity at the source, and, repatriating infected Americans to specialized units in Atlanta and Nebraska — was not a risk to the American public. It was a model of exactly what works.

 In fact, in August 2014, when Kent Brantly and Nancy Writebol were being evacuated to Emory, then-private-citizen Donald Trump tweeted that "our leaders are incompetent" for allowing it, that Ebola patients must "suffer the consequences" of going to help in dangerous places, and that "the U.S. must immediately stop all flights from EBOLA infected countries or the plague will start and spread inside our borders." He was wrong then. The science was clear, the facilities were ready, and both patients survived without a single person in Atlanta becoming infected.

Now he is president, and that sentiment— keep it out, don't touch it, zero cases at any cost — has become policy. Secretary of State Marco Rubio said it plainly at a Cabinet meeting: "We cannot and will not allow any cases of Ebola to enter the United States. Just: keep it out. That is not a public health strategy. It is a political posture dressed up as one.

The irony is that the institutions that helped build this preparedness architecture have themselves been deliberately weakened. The CDC programs that supported emerging pathogen readiness have lost personnel and leadership, while expertise accumulated over years has become harder to sustain. That makes the decision to bypass the existing biocontainment network even more unjustifiable. At a moment when specialized capability is more valuable than ever, the United States is choosing not to use one of the few preparedness systems that has already demonstrated its effectiveness under real-world conditions.

The Real Question Is Why We Built the System

There is a larger question underneath all of this.

The United States did not stumble into the NETEC system. It was built deliberately after the 2014 West African Ebola epidemic exposed the consequences of being unprepared. Congress appropriated money. Hospitals invested in specialized facilities. Clinicians spent years training. Protocols were written, tested, and revised. Institutional memory was created.

Preparedness is expensive precisely because it is built for events that may not happen for years. Biocontainment units exist for the rare moments when a patient infected with a pathogen such as Ebola, Marburg, or Lassa fever needs care.

An American physician contracted Ebola while providing care in one of the most challenging medical environments in the world. A second American has now tested positive. This is not a hypothetical exercise. It is exactly the type of situation the United States spent a decade preparing for.

Yet instead of relying on the system that was built, funded, tested, and proven, policymakers have chosen an alternative that depends on newly assembled personnel, a newly established facility, and uncertain lines of authority and care.

Preparedness is not the construction of buildings. It is the accumulation of expertise. The value of the RESPTC network is not simply that it contains isolation rooms. It is that the teams staffing those rooms have spent years developing the experience, trust, and operational competence required to safely care for patients with high-consequence infectious diseases.

When a nation spends a decade building a capability and then declines to use it when the exact scenario arrives, it raises a fundamental question: what was the preparation for?

The thirteen RESPTC biocontainment centers remain ready. The clinicians who staff them remain ready. The protocols refined through years of training and real-world experience remain ready.

They should be used.

This American who tested positive for Ebola should be brought home.

But the story of mRNA and influenza in the United States right now is not primarily a story about one vaccine. It is a story about whether this country will remain a serious participant in the technology that will determine the outcome of the next pandemic.

Influenza is the pandemic pathogen

This has been my conclusion for decades.

Influenza matters because it is the pandemic pathogen we know best—and the one most likely to surprise us again. Unlike many emerging infectious disease threats, influenza is not rare or exotic. It circulates continuously in birds, pigs, and humans, mutating relentlessly and periodically acquiring the ability to spread efficiently through populations with little preexisting immunity. The 1918 influenza pandemic killed an estimated 50 million people worldwide, and subsequent pandemics in 1957, 1968, and 2009 demonstrated that influenza’s capacity for global disruption remains intact. Every year, seasonal influenza causes substantial illness, hospitalization, and death, but its greatest threat lies in its evolutionary potential. We do not know when the next influenza pandemic will occur, but history suggests that it is a matter of when, not if. That reality makes investments in adaptable vaccine platforms more than a public health decision. They are part of the civilizational infrastructure that stands between human ingenuity and one of nature’s most reliable pandemic threats.

Every year, we grow most flu vaccines inside chicken eggs, the same technology that produced flu vaccines since the 1940s. Influenza mutates when it grows in eggs — a process called egg adaptation — so the vaccine that eventually results may be subtly different from the strain it was targeted against. On top of that, the strain selection for any given flu season happens months before that season starts. When the virus drifts between selection and distribution, the vaccine's effectiveness collapses. In a bad mismatch year, we are handing people a shield that does not quite fit the threat.

It's important to note that two existing alternatives — FluBlok, which uses recombinant protein technology and inset cell lines, and Flucelvax, which grows the virus in mammalian cells rather than eggs — already sidestep the egg-adaptation problem to varying degrees, and both represent genuine improvements over the traditional process but are still tied to the egg-based timetable.

mRNA solves both of these problems. Because mRNA vaccines are manufactured synthetically — no eggs involved — there is no adaptation artifact. And because the manufacturing process is fast, the lag between strain selection and vaccine delivery can shrink dramatically. Moderna has made exactly this argument: when the flu strain mutates late, an mRNA platform can respond in a way that egg-based manufacturing simply cannot.

The Phase 3 data bears this out. In a trial of nearly 41,000 adults aged 50 and older, mFlusiva was 27 percent more effective than a standard-dose flu shot — and this result came during one of the most severe flu seasons in years, when you might have expected both vaccines to underperform relative to a milder year. In the 65-and-older cohort, the immunogenicity data compared favorably to the high-dose vaccine already recommended for that age group. The VRBPAC looked at all of this, asked hard questions about the single-season data window and the limited data in frail elderly patients, and still voted unanimously in favor.

What happened in February

So, it matters that in February 2026, Dr. Vinay Prasad — then FDA's former top vaccine official, installed under HHS Secretary Robert F. Kennedy Jr. — rejected Moderna's application. Not rejected the vaccine after review. Refused to review it at all.

His stated reason was that the trial was not "adequate and well-controlled" because Moderna used a standard-dose flu shot as the comparator in the main trial rather than the high-dose vaccine recommended for seniors. There is an obvious problem with this objection: FDA scientists and career officials had previously approved that study design. Prasad issued the refusal over their objections. Moderna published the FDA's letter alongside a statement pointing out that the agency had, in their words, backtracked on prior communications and contradicted established guidance. Within a week the FDA reversed course.

But the reversal does not undo the thing that actually matters.

 The signal is louder than the reversal

 A pharmaceutical company making a billion-dollar, decade-long investment in vaccine development does not allocate capital based on last week's FDA policy position. It allocates based on the long range. Before February 2026, a company planning an mRNA flu program could look at the regulatory pathway and see a predictable process with established rules. After February 2026, they have to include in their model the possibility that the FDA will simply decline to engage — at any stage, for reasons that contradict the FDA's own prior guidance, driven by the anti-human political ideology of RFK Jr.

The kill shot to a pipeline is not always a formal rejection. Sometimes it is just opacity. The question "will FDA review this?" should have an unequivocal, transparent, and predictable answer.

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While we were fumbling, Europe moved

 On April 20, 2026, the European Commission granted full marketing authorization for mCombriax — Moderna's combined mRNA flu and COVID-19 vaccine — valid across the European Union. The European Medicines Agency's scientific committee had recommended it in February. Europe saw the data, ran a rigorous process, and issued a decision. The first combined mRNA flu vaccine is now available in Europe.

Meanwhile the US is still awaiting an FDA decision on the flu-only version.

This is a strategic divergence.

And it sits in juxtaposition to another demonstration of the power of the mRNA platform. mRESVIA, Moderna's mRNA RSV vaccine, was FDA-approved in May 2024 — the second mRNA vaccine ever approved in humans. This path-breaking technology translates across respiratory viruses. The platform is invaluable to anyone who is not an adherent to an anti-human philosophy. Accordingly, in August 2025, HHS Secretary Kennedy canceled $500 million in mRNA vaccine research contracts.

The platform is leaving

The UK has proved more hospitable. Moderna has committed over £1 billion in R&D investment through a 10-year strategic partnership with the British government, opened a manufacturing facility in Harwell capable of producing 250 million doses annually in a pandemic, and just launched a Phase 3 trial of an mRNA H5N1 vaccine as part of that partnership. When Moderna's CEO Stéphane Bancel was asked why, he said the UK was chosen because it "still believes in vaccination" — and that if anti-vaccine sentiment continues to erode US demand, the UK investment "may pay dividends."

Sanofi, the French pharmaceutical company, has made an over €1 billion in investment to build a complete end-to-end mRNA manufacturing capability in France, from plasmid production to final vial.

 The European Commission launched a "Choose Europe for Life Sciences Strategy" in July 2025, explicitly identifying mRNA platforms as cornerstones of European health sovereignty and pandemic preparedness. The program includes €300 million from Horizon Europe, dedicated manufacturing capacity, and a goal of making the EU the most attractive destination for life sciences by 2030.

As RNA biologist Jeff Coller told BioPharma Dive, "The future is very bright for mRNA research in other countries."

Years before COVID, colleagues and I recognized that vaccine platforms should be viewed as strategic infrastructure rather than individual products. In a report I coauthored with colleagues from the Johns Hopkins Center for Health Security, I argued that mRNA platforms represent a "sustainable pluripotent infrastructure" that can be applied to emerging infectious disease vaccines with minimal added financial risk. The reason is precisely that the platform is not pathogen-specific. You do not build it for one virus. You build it, and then you aim it wherever the threat appears. Vaccine Platforms: State of the Field and Looming Challenges was written before COVID. We knew then what mRNA could become. We have now seen it perform. And the institutional response from the current US administration has been to attack it.

What we are actually giving away

The mRNA platform is not just about a new flu vaccine. It is the on ramp to the next Operation Warp Speed. When COVID-19 arrived, the reason a vaccine was in arms within a year was not luck. It was that Moderna, BioNTech, the NIH Vaccine Research Center, and BARDA had spent a decade building and funding and practicing on this platform. Barney Graham's two-proline substitution that locked the spike protein in the right shape. Katalin Karikó's pseudouridine modification that solved the immune activation problem. The lipid nanoparticle delivery system. None of that was improvised in 2020. It was accumulated, piece by piece through a multi-decade R&D investment.

You cannot improvise a platform when you need it. You build it during the years when you do not need it, and then it is there. If we spend the next several years delegitimizing the technology and creating regulatory uncertainty that drives companies and scientists to Europe, we will not have a warm mRNA base when Disease X arrives. We will have a government that rejected it.

The right next step is not just approval

The VRBPAC vote matters. FDA approval by August 5th would matter. But the full picture requires more.

More fundamentally, the damage done by February 2026 is not reversed by a 9-0 VRBPAC vote. The companies planning the next generation of mRNA flu vaccines, the universal influenza programs, the Disease X response platforms — they already saw February. They are already incorporating into their investment decision making the probability that something like that happens again.

The mRNA platform is arguably the most important biomedical technology developed in the last century. It was built in the United States. It has already saved millions of lives. It is now, demonstrably, being built in Europe and elsewhere while the United States government actively undermines it.

This is not a regulatory story. This is a civilizational choice.

Science has already handed us the ability to master much of what is killing people right now. What we are failing at is something else entirely. We are failing at implementation. We have the toolbox. We are simply not opening it, or not opening it in time, or in some cases deliberately locking it shut. That single idea runs through nearly every story worth discussing this week.

Ebola in the DRC: an outbreak outrunning the science

The current Ebola outbreak in the DRC is, by most measures, the best-resourced Ebola response on record. We understand this virus better than almost any other hemorrhagic fever. We have vaccines, therapeutics, diagnostics, and decades of hard-won field experience. And the outbreak is outrunning all of it.

The counts now sit at more than 1,500 cases with 500+ deaths, and the virus has reached a fourth province. That matters geographically, because this province borders both the Central African Republic and South Sudan, which means the outbreak now carries a real risk of spilling across international lines and pulling additional countries into the response.

The most troubling signal is buried in the epidemiology. The majority of confirmed cases cannot be linked to a known contact. In outbreak terms, that is a flashing red light. It means there are chains of transmission we simply cannot see, and it means diagnosed patients have gone missing from the system entirely. Unseen transmission and vanished cases translate directly into more spread and a fire that is far harder to extinguish.

Meanwhile the people doing the most dangerous work on the planet, the burial teams, are facing violence from communities that do not want their ceremonies disrupted or their dead handled by strangers in protective gear. Bodies carry enormous viral loads around the time of death, so these rituals are genuine transmission events, and the teams trying to make them safe are being met with hostility. Ebola treatment units are being attacked. People are being killed inside them. This is no longer only a virological problem. It is a failed-state problem, unfolding in a place where the rule of law and respect for individual rights have collapsed, and the virus is exploiting that vacuum as efficiently as it exploits a susceptible host.

The damage does not stay in the health sector. Economic modeling now puts the worst-case scenario in the range of several billion dollars, with GDP losses that will push more people in an already impoverished region below the poverty line. This is what epidemics actually do. They cascade. They reach into every corner of ordinary life, because an economy, at its base, is nothing more than the sum of people's lives.

There is one genuine bright spot. A clinical trial has begun enrolling patients, testing remdesivir in combination with a monoclonal antibody from Mapp Biopharmaceutical. It will take time to get a meaningful readout, but enrollment of that first patient is a milestone in itself. Still, the bottom line is stark. We are watching an outbreak that is costing more, in both lives and dollars, than the available science should ever allow. That gap between what we know and what is happening on the ground is the implementation problem in its purest form.

The vaccine fights in Washington

If the DRC shows you implementation failure through state collapse, Washington shows you something more deliberate. Here we have a federal health department at odds with its own evidence, with the courts, with practicing physicians, and increasingly with the public, which is at least pushing back. That pushback is a good thing.

Several developments this week are worth understanding together. The Second Circuit affirmed that New York schools can require vaccination as a condition of entry. I want to be precise about what this is and is not. This is not a mandate in the coercive sense that the word is often thrown around. A public school system setting its own safety-based entry requirements is no different from a public transit system setting its own safety rules. The case will likely be appealed to the Supreme Court, and I cannot predict where it ends, but the underlying principle, that public institutions may be run safely, is sound.

On CBS's Face the Nation, Deborah Houry, a former top CDC physician who heroically resigned in protest after Susan Monarez was unjustly fired, said plainly what many of us have concluded, that RFK Jr.'s position is unmoored from science and from reality. He holds what amounts to a fixed, quasi-religious belief about vaccines. No quantity of evidence reaches him, because his conviction is not built on evidence in the first place. It rests on an emotional pull, on the myth that the unvaccinated state is somehow more natural. When a belief is not formed by evidence, it cannot be dislodged by evidence. He is, functionally, impervious to it.

Then there is Senator Cassidy, the physician who cast one of the deciding votes to advance RFK Jr.'s nomination and who now complains that RFK Jr. broke his promises. I find this difficult to take seriously. Everyone understood that these promises would be broken, because a promise requires a commitment to truth, and truth requires correspondence to reality. A man who has spent decades demonstrating his indifference to reality cannot make a meaningful promise. His words are words, no more binding than a parrot's. Cassidy's attempt to justify what was plainly a political calculation deserves no sympathy.

The news is not all grim. In Florida, a bill that would have made it easier to obtain vaccine exemptions for school, effectively loosening entry requirements, appears to be dead in the state legislature. This is encouraging, and it reflects something the noise often obscures: a large bipartisan majority of Americans continues to support vaccine entry requirements for schools.

That brings me to a group I read about this week and had not seen named so clearly before, the malleable middle. These are people who hold a few vaccine myths in their heads but remain genuinely persuadable. I do not pretend to know the perfect method for reaching them. Some suggest motivational interviewing, an effort to understand what is actually driving the hesitation. What I do know is that this is precisely the population the anti-vaccine movement targets hardest with disinformation, which means the window to reach the malleable middle may be closing.

For all the drama playing out in courtrooms and on cable news, one thing has not changed. The underlying science, that vaccines save lives, that they are among the greatest innovations the human mind has ever produced, is exactly where it was. Washington cannot move it.

Marburg, layered onto Uganda

Now to Marburg, which is a filovirus in the same family as Ebola. It has no medical countermeasures, a distinction it shares with the Bundibugyo strain of Ebola, and it is being layered onto an already active Ebola response in Uganda.

There is at least one confirmed case, in an 18-month-old child, with a possible second case that remains nebulous. The age of that first case is what concerns me most. A toddler is almost never the index case in a Marburg outbreak. Someone had to acquire the virus first, likely through contact with a bat or with bush meat, which means there is an unidentified chain of transmission somewhere upstream that we have not yet found.

The reassuring part is that Uganda is a country that has handled Marburg before and is generally well equipped for it. It has largely contained its concurrent Ebola outbreak at around 20 cases. So the questions I will be watching over the next week are straightforward. What is the true case count? How heavy will the response burden be? For now, this is one more reminder that these filoviruses keep coming at our species, and that competence in the response is the variable that determines the outcome.

Measles, from Bangladesh to Pennsylvania

Measles is where the implementation problem becomes almost mathematical. Consider Bangladesh. One year ago, in 2025, the country recorded 125 measles cases. It now has more than 100,000. Nothing about the virus changed. There was no biological shift, no new variant. What happened was an administrative collapse: a lapsed immunization program under an interim government and a breakdown in coordination with UN agencies. That is all it took to move from 125 to six figures.

The same principle operates everywhere. When population immunity drops, measles takes the opening, and it does not care whether that opening is in Dhaka or in Pennsylvania. Pennsylvania is having a banner year for measles, and in a recent interview the state's Secretary of Health wished aloud for a magic bullet. I understand the sentiment, but I want to correct the framing, because it matters. There already is a bullet. It is the vaccine. But, it is not magic. It is the product of a reasoning mind applying science to a problem. We do not need magic bullets. We need scientific ones, and they already exist.

In Delaware County, adjacent to venues hosting World Cup matches, wastewater surveillance has detected measles at least twice, even though no cases have been formally reported there. That is exactly why wastewater monitoring is so valuable. It tells you the virus is circulating before the case counts catch up, and it strongly suggests there are more infections in Pennsylvania than the official numbers show.

The deeper truth is that measles is the default. It will always reassert itself unless people take deliberate, sustained action to prevent it. Elimination, which the United States is now at real risk of losing, is not a resting state you achieve once and keep. It is a constant achievement that has to be earned every single year through active vaccination. A passive response guarantees the disease returns. Bangladesh going from 125 to more than 100,000 cases in twelve months, with hospitals inundated and parents fearing for their children, is what implementation failure looks like.

Ticks, Lyme, and a vaccine worth wanting

There is genuine promise in tick-borne disease right now, along with the usual frustrations. This has been a banner year for tick bites, with emergency department visits running very high, and much of the coverage has centered on a new Pfizer Lyme vaccine in the pipeline.

That vaccine is not yet approved. It is in late clinical development, with roughly 75 percent efficacy, and it requires multiple doses. It is not perfect, but it is meaningfully better than nothing, and it arrives in the long shadow of a first-generation Lyme vaccine that was pulled from the market years ago over lawsuit threats and low uptake. That history matters, because uptake is shaping up to be the central challenge again. A Kaiser Family Foundation piece interviewed hunters, one of the highest-risk groups for Lyme, and found real hesitancy among them. When people who understand the threat intimately are still hesitant, whether because of the multiple-dose schedule or the imperfect efficacy, it tells you how much work remains.

Encouragingly, the vaccine is not the only countermeasure in development. There are monoclonal antibodies that could be given at the start of tick season to provide a protective window, and there are pills under study that render your blood toxic to a feeding tick, killing it before it can transmit the Lyme bacterium, which typically takes a day or two of attachment to accomplish.

A few points about tick-borne disease deserve wider appreciation. First, it is a year-round threat. You are hearing about it now because cases are up, but ticks bite in winter too. A study in Illinois found tick-borne illness occurring throughout the year, with the single exception of babesiosis, which is absent in the colder months. Second, we should pay more attention to Powassan virus, a tick-borne encephalitis, meaning it inflames the brain, spread by the same ticks that carry Lyme. In 2015 there were seven cases. In 2025 there were 76. Whether that reflects more true infections or better diagnostics is unclear, but it belongs on your radar.

Finally, a word about post-treatment Lyme disorder, what many call chronic Lyme disease. It is a real symptom complex, and I do not dismiss the suffering of the people who live with it. But multiple studies show it is not caused by a persistent bacterial infection, which means prolonged courses of antibiotics will not help. Around these patients has grown a profitable, evidence-free cottage industry offering treatments like hyperbaric oxygen and radiofrequency devices meant to blast away bacteria that are not there. Now RFK Jr. has waded in with a Lyme disease initiative, and I expect he will lend legitimacy to exactly these practitioners. The reason is the same one we keep returning to. He does not care about science or about reality, because he does not know what those things are.

A game worth playing

I will end the roundup with a story I genuinely enjoyed. NPR reported on a game out of Nigeria, a takeoff on Chutes and Ladders called Schisto and Ladders. Schisto is schistosomiasis, a parasitic and badly neglected tropical disease that people acquire from contaminated water, with snails serving as the intermediate host. The game teaches children how to protect themselves: stay out of contaminated water, take antiparasitic medication when it is warranted, and clear the tall grass around water sources where those snails thrive. It is a clever piece of public health, and honestly, I would like to get my hands on a copy.

The question that remains

As I close, I want to make the common thread explicit, because it is easy to miss when each of these stories is treated in isolation. The DRC is not struggling with Ebola because no one understands Ebola. Bangladesh did not suffer a measles catastrophe because the virus changed. Uganda's Marburg response is not waiting on some elusive scientific breakthrough. And the fight over vaccines in the United States is not, at its core, a dispute about what the evidence shows.

The science exists. The technologies exist. What determines the outcome of an outbreak is whether a society can identify the threat, build the institutions, maintain the trust, deploy the resources, and apply what it already knows. That is an implementation problem, and infectious disease keeps teaching us the same lesson: knowledge alone is never enough. Human reason produces the vaccines, the diagnostics, the treatments, and the public health systems, but those tools only matter when people choose to pick them up. You can hold the finest toolbox in history, and if you do not know how to use it, or refuse to use it, or lock it away where no one can reach it, you are no better off than our ancestors who had nothing at all.

The microbes will never stop working. The only open question is whether we will.

Bangladesh is in the middle of a measles crisis. The country has reported over 100,000 suspected cases since March 2026. It had just 125 in 2025. Vaccine coverage there has fallen from around 90 percent to roughly 57 percent — well below the 95 percent threshold needed to prevent outbreaks. Children are dying. The Lancet has called it an immunization emergency.

The people of Bangladesh didn’t choose this. It is the product largely of bureaucratic missteps. Experts on the ground are rushing to get needles into arms. They know the vaccine is the unequivocal answer.

The United States is also in the middle of a measles crisis. We have crossed 2,000 cases in 2026 alone, on pace to exceed 2025's record of 2,289. A child named Kayley Fehr, six years old, died of measles in February 2025 — the first measles death in the United States in a decade. Eight-year-old Daisy Hildebrand died weeks later. Another person died later that year in New Mexico. After Kayley died, her parents said their position on vaccination had not changed.

The United States doesn't have Bangladesh's problem. We have the vaccine. It is safe, basically free, and spectacularly effective. Two doses of the MMR vaccine confer roughly 97 percent protection against a virus so contagious that a single infected person can pass it to 15 others in a room they have already left. Our problem is not access. It is choice.

That is the distinction. Bangladesh is fighting measles against its will. We are welcoming it.

Measles is not a mild illness. It has never been a mild illness.

This framing — that measles is a rite of passage, a manageable childhood experience, something that children power through and emerge from stronger — is a dangerous lie in circulation today. And it has currency in a way that would have been unthinkable to any generation that actually knew the disease.

The numbers from the 2025 Texas outbreak, published by the CDC, are not abstract. Among the early 325 cases, 60 patients — nearly one in five — required hospitalization. Among the hospitalized children, 91 percent had no underlying health conditions. These were not medically fragile children. Among those hospitalized, 72 percent developed pneumonia. Thirty-eight percent required supplemental oxygen. Four were admitted to intensive care. Two required mechanical ventilation. Children needed machines to breathe because they had measles.

The general statistics are equally clear. About one in twenty people who contract measles develops pneumonia. About one in a thousand develops encephalitis — a brain infection that can cause permanent disability. About one in a thousand dies, and in communities with limited health infrastructure, considerably more. This is not a rough cold. This is not a mild fever and a rash. This is a serious illness that our grandparents feared, and that still kills around 100,000 people globally every year.

But there is one dimension of measles that even many vaccine advocates underestimate, and it is the most important argument against the "natural immunity is better" position. Measles causes immune amnesia.

The immune system works partly by maintaining a memory — a record of every pathogen it has ever encountered. When a familiar threat returns, the immune system is ready. Measles systematically deletes that memory. A child who survives measles may survive the immediate illness. But the virus has reached into the immune system and erased months or years of learned defenses against other diseases. For a period that can last up to a year, that child is newly vulnerable to infections their immune system had already learned to manage. When the measles vaccine was introduced around the world, researchers noticed something: overall childhood deaths fell by more than you would have expected from stopping measles alone. The explanation is immune amnesia. Fewer children were getting measles, so fewer children were losing their immune memory and becoming newly vulnerable to everything else.

The people who argue that it is better for children to get measles "naturally" — who throw measles parties, who seek out "natural immunity" as though it were a superior product — are asking for something far worse than they understand. They are asking for the disease, the immediate danger, and then a prolonged immune vulnerability that follows. The vaccine delivers immunity with zero of those costs.

The Triple Denial: Deny the severity of measles, Exaggerate the Risks of Vaccination, and Deny the Benefits of the vaccine

The anti-vaccine argument around measles rests on three specific falsehoods, deployed in combination.

First: measles isn't that bad. We have dealt with this above. The data says otherwise. The children in Texas on ventilators say otherwise. The three funerals say otherwise.

Second: the vaccine risks are serious and underreported. The MMR vaccine's risk profile is among the most thoroughly documented of any medical intervention on earth, having been administered to hundreds of millions of people over six decades. Side effects are overwhelmingly mild. Serious adverse events are vanishingly rare and well understood. The autism claim — the one that launched the modern anti-vaccine movement — was fraud. Andrew Wakefield published a paper in 1998, funded by attorneys preparing litigation against vaccine manufacturers, with data he had falsified. His medical license was revoked. The paper was retracted. Twelve co-authors withdrew their names. What followed was a decade of scientific resources dedicated to disproving a manufactured claim — resources that could have gone toward actual research on autism's causes.

The claim survives anyway. That is what it means for falsehood to be entrenched in ideology rather than evidence: it does not respond to disconfirmation.

Third: the vaccine's benefits are overstated. The argument runs that measles mortality was already declining before the vaccine arrived in the 1960s, thanks to better nutrition and modern medicine. This contains a grain of truth, but it is not the full story. Yes, better care reduced measles mortality in industrialized countries before the vaccine. But mortality was not going to zero. It was never going to zero on that trajectory. One in twenty cases still produced pneumonia. One in a thousand still produced encephalitis. And the vaccine did what nutrition alone could never do: it drove transmission toward zero, which was the only way to stop children from getting sick in the first place.

You cannot reach measles elimination through improved pediatric nutrition. You can only reach it with a vaccine.

This is happening by choice

I have written before that measles is the default state of the world. For almost all of human history, every child got measles. Measles elimination is not the natural condition of humanity — it is a human achievement, requiring continuous maintenance. Civilization itself is not self-sustaining. Achievements decay when people stop defending them.

The United States is watching this achievement decay in real time, and we are not its victims. We are the authors.

Our kindergarten vaccination rate is 92.5 percent nationally, and in many individual communities it is far lower. The 95 percent threshold for herd immunity — the level at which the virus cannot find enough susceptible people to sustain transmission — is not a technicality. It is the line between control and outbreak. We are below it in enough communities that measles, when it arrives, finds fertile ground.

Bangladesh is below the herd immunity threshold because maintaining those programs in a resource-constrained country with governmental disruption is genuinely difficult. Bangladesh is fighting a circumstance.

We created ours.

The philosophical exemptions, the religious exemptions, the online misinformation ecosystems, the nihilist HHS secretary who promotes vitamin A as a response to US measles cases, the neutered advisory committees, the paralyzed CDC: all of this is the accumulation of choices. And the people who made those choices are now watching children be hospitalized at rates we have not seen in decades.

The parents whose children are getting sick did not, in most cases, ever see measles themselves. They grew up in a vaccinated world where measles had been made invisible, and they concluded from that invisibility that it was not dangerous. They heard that conclusion reinforced by a movement that has been building for decades, and they made a decision. They did not make that poor decision solely for themselves, they also made it for their children.

Choosing, on your child's behalf, a lower standard of health and safety than is freely available to them is to sacrifice them.

This is not a tragedy of ignorance. It is a tragedy of evasion. The information is available. The vaccine is ubiquitous. The record of measles' severity is documented, published, and visible to anyone willing to look. The deaths are public record.

What Comes Next: Losing Elimination Status

The Pan American Health Organization will formally review the United States' measles elimination status in November 2026. I expect us to lose it. The genetics make this clear: what we are experiencing is not a series of disconnected imported outbreaks. There exists one continuous chain of transmission tracing back to West Texas in January 2025 into the present day. By June, the outbreak had reached over 2,100 cases nationally in just 6 months. Positive measles wastewater is discovered in places with no confirmed cases, which means the real number is higher.

Losing elimination status is not just an abstraction, we don’t have to return a trophy. It signifies that measles is here, circulating, and self-sustaining. It is re-establishing endemicity. It means airports, school quarantines, and pediatric emergency department visits will become routine features of life in the US. It means infants who cannot yet receive the vaccine — the first dose is usually given at 12 to 15 months — will live in a country where they have been deliberately put at genuine risk.

This is what it looks like when a civilization decides that an achievement is not worth maintaining. The vaccine has not changed. The virus has not changed. The biology has not changed.

We have.

The fix is not complicated: get measles vaccination rates above 95 percent in every community, tighten exemption policies, and be honest about what measles is and what the vaccine does. Healthcare providers will be doing this work even as the national advisory infrastructure has been deliberately weakened. The knowledge is there. The tools are there. The question is whether the will is.

That scenario isn't fiction. It was the opening of a tabletop exercise I participated in just last week. And the reason it lands so hard in the room is that everyone in it knows: this is not a hypothetical. It is a live possibility, on any given day, in any emergency room in America. 

Antibiotic resistance isn't coming. It's here. And we are losing.

 The invisible pandemic doesn't get an outbreak photo

Part of why this crisis generates so little political urgency is structural. A respiratory virus moving between people produces dramatic images: overwhelmed hospitals, refrigerated morgue trucks, panic buying. Antibiotic resistance produces none of that. It manifests as an elderly woman with a urinary tract infection who isn't responding to the usual pills. A cancer patient whose post-chemotherapy infection won't clear. A transplant recipient dying of a bloodstream infection that, twenty years ago, would have been a footnote.

Each case looks like an individual tragedy. In aggregate, it's a catastrophe.

Drug-resistant infections kill tens of thousands of Americans every year. Globally, bacterial AMR was directly responsible for 1.27 million deaths in 2019 alone, with another 4.95 million deaths associated with it. A 2024 Lancet study projects that figure rising to 1.91 million deaths annually by 2050, with 39 million people expected to die from drug-resistant infections between 2025 and 2050.

 That is akin to a pandemic by any reasonable definition. We just haven't conceptualized it that way.

Resistance is natural. The crisis is not.

Antibiotic resistance doesn't require humans. It predates us by billions of years. Bacteria have been fighting each other with chemical weapons — and evolving defenses against those weapons — for as long as life has existed on Earth. Resistance genes have been found in underground cave-dwelling bacteria that have never once been exposed to human civilization. We didn't create the problem. We accelerated it to the point of crisis.

 When Alexander Fleming noticed that mold was killing the bacteria in his Petri dish in 1928 — and when Howard Florey and Ernst Chain turned that observation into actual medicine a decade later — they had no idea they were also starting a clock. Every antibiotic that enters the human body exerts selective pressure on bacteria: the organisms that happen to have resistance mechanisms survive; the others don't.

 Do that across billions of courses of antibiotics, billions of animals in agriculture, and decades of sloppy stewardship, and you predictably accelerate what was always going to happen eventually.

At first glance, antibiotic resistance can seem like an inevitable story of decline.

None of this means antibiotics were a failure. Quite the opposite. Resistance is the expected consequence of evolution acting on bacterial populations. The remarkable achievement was never that penicillin worked forever. The achievement was that human beings discovered penicillin in the first place. The same capacity for reason that uncovered the antibiotic era can build whatever comes next. The danger is not that bacteria adapt. The danger is that our institutions, incentives, and investments stop adapting faster than they do.

What makes this crisis acute right now: the resistance is (predictably) winning, and the pipeline of new antibiotics has nearly run dry.

One data point that should give you pause: NDM — New Delhi metallo-beta-lactamase, a resistance enzyme that makes bacteria nearly impervious to our most powerful class of antibiotics — used to be rare in the U.S., found in just 5.4% of resistant E. coli cases. That number is now 39.3%. It moved from "rare import" to "common problem" in a generation. And it's being driven by factors we're not fully controlling: over-the-counter antibiotics freely available in much of the world, antibiotics prescribed for viral sinusitis, for herniated discs (which are not bacterial infections), for asthmatic children whose flares are almost always viral. Environmental factors — rainfall, temperature — even appear to correlate with resistance rates. Many forces are pushing in the same direction at once.

 Modern medicine depends on antibiotics the way a building depends on its foundation

 The thing people miss when they think about antibiotic resistance is this: it isn't just about infections. It's about the entire architecture of modern medicine.

 A hip replacement, a coronary bypass, an appendectomy — every one of these routine procedures requires antibiotic prophylaxis to prevent infection during and after surgery. When you give a cancer patient chemotherapy, you deliberately suppress their immune system to kill tumors, and then you rely on antibiotics to protect them from infections their body can no longer fight. Organ transplantation requires immune suppression for life. Neonatal intensive care, premature birth management, burn treatment — all of it rests on the assumption that if a bacterial infection arises, it can be beaten.

 Remove that calculus, and you lose more than the ability to treat infections. Much of what we call modern civilization depends on a medical system that assumes bacterial infections remain controllable. You lose the ability to do most of modern medicine. You are returned, in the most important functional sense, to the pre-penicillin world — where a simple laceration could mean death and the operations we now perform routinely were the stuff of science fiction.

Market disincentives broke antibiotics before resistance could

 The antibiotic pipeline isn't primarily empty because scientists stopped trying. It's empty because of a market dynamic so structurally strange that it's almost elegant in how badly it's constructed.

 Every other drug that gets developed follows a simple enough commercial logic: you discover a molecule that treats a disease, get it approved, and sell it. The more patients who need it, the more revenue you generate. That logic completely breaks down for antibiotics.

 First, antibiotic courses are short — days to weeks, not lifetime prescriptions. Less time on therapy means less revenue per patient. Second, resistance makes new antibiotics obsolete over time, eroding whatever market you've built. Third — and this is the truly unique part — the pharmaceutical company is actively punished for successful adoption of their drug. The more widely a new antibiotic is used, the faster resistance develops, and the sooner it stops working. So responsible doctors and health systems try to steward the use of the best new antibiotics, reserving them as drugs of last resort. That means the drugs that work best and are most valuable are the ones you sell the fewest of — the exact opposite of every other product in medicine.

These market factors have produced predictable consequences: major antibiotic manufacturers like Melinta and Achaogen have gone bankrupt in recent years. In 2025, there were only 90 antibiotic candidates in development globally — compared to over 2500 in oncology. Companies have simply stopped trying.

The fix exists. It's called the PASTEUR Act. It keeps dying in committee.

 The solution to this situation has been identified. It is not complicated in concept, even if it's politically hard to pass.

 The logic is simple: decouple how much a pharmaceutical company is paid from how much of their antibiotic is actually used. Instead of revenue tied to volume — which punishes responsible stewardship — the government would pay a subscription fee for access to a portfolio of antibiotics targeting the most dangerous resistant pathogens. Think of it like a Netflix model: you pay for the service regardless of how many episodes you watch. The antibiotic company gets a predictable revenue stream that doesn't collapse just because doctors are correctly reserving their drug for the worst cases.

 This is what the PASTEUR Act — the Pioneering Antimicrobial Subscriptions To End Upsurging Resistance Act — is designed to do. It has been introduced, reintroduced, and reintroduced again. First introduced it in 2020, a new version was reintroduced in the Senate on June 24th of this year, with bipartisan co-sponsors.

 And there it sits. Again.

 The reason this keeps stalling is a separate cultural problem worth naming directly: as a society, we have somehow decided that antibiotics should be cheap. This is a historical accident. Antibiotics were first developed in an era when drug discovery was cheap and drug pricing was in its infancy. That pricing norm got locked in, and it's never been seriously revisited. Nobody protests when we spend $475,000 on a course of CAR-T therapy to treat leukemia. But the moment a new antibiotic carries a price tag that reflects its actual development cost, the political instinct is to accuse the manufacturer of price gouging. Ezekiel Emanuel put it plainly: "As a society, we seem willing to pay $100,000 or more for cancer drugs that cure no one and, at best, add weeks or a few months to life. So why won't we pay $10,000 for a lifesaving antibiotic?"

The answer is cultural, not scientific. And until we fix the culture, the PASTEUR Act will keep getting reintroduced and keep stalling.

The DISARM Act targets the other end of the same problem. Under Medicare's current bundled payment system, hospitals actually lose money when they use newer, more expensive antibiotics — so the financial incentive is to keep reaching for older, cheaper drugs even when resistance has made those drugs less effective. DISARM would carve out a separate reimbursement track for qualifying antibiotics, so hospitals aren't penalized for doing the right clinical thing.

Beyond conventional antibiotics

 Even if we pass the PASTEUR and DISARM Acts tomorrow — and we should — conventional antibiotics alone cannot win this war in the long run. The resistance genes are older than civilization. They will always exist somewhere in the environment, waiting to be selected for. An arms race built entirely on finding new versions of existing weapons is a race we can never win outright.

 That's why the most exciting work in this space isn't happening in traditional antibiotic discovery. It's happening in adjacent technologies: monoclonal antibodies that target specific bacteria or their toxins without touching the microbiome; bacteriophages — viruses that naturally hunt and kill specific strains of bacteria, deployed therapeutically against infections that no antibiotic can clear; microbiome-based therapies that restructure the bacterial ecosystem in a way that crowds out dangerous pathogens; CRISPR-based tools that could theoretically delete resistance genes from bacteria directly. None of these are fully ready for prime time.

This is the real moonshot. Not finding one more antibiotic that buys us another decade. Building a fundamentally different toolkit that doesn't depend on a chemical arms race we are structurally losing.

 What the tabletop exercise taught me

Back to that Washington emergency room. In the scenario, the question that got the sharpest debate wasn't the clinical one — what drug do you try? It was the cascade question: when does an individual patient become a public health emergency? When does a public health emergency become a national security threat? 

The answer I kept coming back to: antibiotic resistance is already a national security threat. It threatens far more than individual patients. Modern military medicine depends on effective antibiotics to treat combat wounds, burns, and trauma-related infections. Disaster response systems assume that bacterial infections can be controlled after hurricanes, earthquakes, and mass casualty events. Preparedness plans for biological attacks rely on antibiotics as a core layer of defense. A future in which common pathogens routinely outpace available treatments is not simply a public health problem; it is a direct challenge to national resilience and national security.

It just doesn't look like a national security threat because there's no single outbreak photo, no patient zero tracked across continents, no dramatic escalation moment. It's the slow erosion of the foundation that everything else stands on — surgery, chemotherapy, transplantation, neonatal care — happening in every hospital, in every country, simultaneously, without anyone formally declaring an emergency.

The technology to reverse this trajectory and master this problem exists. The scientific problem is difficult but solvable. The political problem is deciding that it matters.

The legislation to fix the pipeline has been written, rewritten, and introduced. What's missing is the sustained political will to treat this as the crisis it is — not a wonky reimbursement problem to be handled in committee, but the slow-motion unraveling of the medical gains that define the difference between the world we live in and the world that Fleming found when he went to work in the morning.

 We have the toolbox. We are choosing not to use it. That is a decision we are making, not a fate being visited upon us.

People keep telling me the Ebola outbreak in the Democratic Republic of the Congo is small. There are roughly eleven hundred cases, they say. Look how many people live on the continent of Africa. Tens of thousands died in West Africa a decade ago, and this is a fraction of that.

We can argue about why the whole continent is the wrong denominator, but set that aside. The comparison itself is the problem. It is exactly why people are underreacting.

With Ebola, the absolute size is not what should prompt you to act. The speed is. And this week, the speed is the real story. Not just with Ebola, either. Three of the biggest stories this week share the same shape: an outbreak outrunning the response because the people who would have caught it early were cut, a disease returning not by any act of nature but by bad human choices, and public health institutions being rebuilt in a way that will make the next outbreak harder to handle.

That is the through line. None of this is written. Let me walk you through it.

Ebola: watch the trajectory, not the count

As of Friday we had more than eleven hundred cases and three hundred and four deaths in the DRC, plus twenty cases and two deaths in Uganda. But the headline number is the least useful way to look at this. What matters is how fast it is moving. Around Monday, of last week, we were at a thousand cases. Then a thousand and ninety-four. Then eleven eighteen, then eleven fifty-five, and it is going to keep climbing. The deaths are following the same curve.

That is why "it's smaller than West Africa" is the wrong lens. If you look at the one-month total, this is the highest of any Ebola outbreak we have on record. That is why the WHO is alarmed. It is the speed coupled with the resource limits, not the raw count.

Consider what those resource limits actually mean on the ground. The Ebola treatment units are about ninety-five percent full. When the beds are full, people stop coming in, because they do not believe there is room for them. So, they stay home, where there is no protective equipment and plenty of exposure to blood and body fluids, and they infect the people caring for them. The capacity problem is not a side effect. It is an engine of transmission.

Reflecting all of this, the CDC has moved to a level one activation, its highest. That tells you the agency takes this seriously and considers it worth extinguishing. There are already cases in Uganda, and some modeling suggests this could eventually reach South Sudan, one of the bordering countries. There was also a case in France, in a healthcare worker who developed a headache on a flight out of Kinshasa. He was isolated, considered stable, and five contacts are being monitored. It is the first case ever diagnosed in France, but it is not a surprise. Healthcare workers get exposed and sometimes infected. That is precisely why they need to be well resourced and well equipped.

The strain this time is Bundibugyo, which is milder and produces fewer hemorrhagic cases. Ebola is a viral hemorrhagic fever, but even in a typical outbreak only about half of patients have bleeding manifestations. With this species it looks closer to ten percent. That is part of why it was harder to recognize, although there were also testing failures. It also raises an uncomfortable possibility: that earlier clusters came and went unrecognized, because they did not look like classic Ebola and were not deadly enough to force the question.

So, what actually fixes this? Not, in the first instance, anything exotic. Centralized testing cannot be the standard when a sample has to travel for hours and a result takes days. You need decentralized testing, ideally at the point of care, so you know who is infected and can start tracing contacts immediately. And the contact tracing right now is dismal. Tens of thousands of contacts have not been traced, which means chains of transmission are running unobserved. Community engagement matters too, especially around safe burial. The New York Times ran a strong series on the Red Cross burial teams, who hold one of the most dangerous jobs in the response, and not only because of violence. A body carries its highest viral load around the time of death, which makes handling the deceased one of the highest-contagion moments there is.

The newer countermeasures are genuinely encouraging. Monoclonal antibodies are in clinical trials, including the MappBio product used in earlier outbreaks. Gilead's remdesivir is in play, and there is an effort to bring in Merck's molnupiravir, another antiviral repurposed from COVID. That innovation is real and worth celebrating. But it does not replace the bread and butter: testing, tracing, and safe burial still have to happen.

A few open problems are worth flagging. There is a brewing issue around viral sovereignty. To understand this particular Bundibugyo lineage, researchers need to sequence samples from DRC and Ugandan patients, and there are questions about who owns those samples and whether they can be exported for study. Investigators are working with Bundibugyo material from prior outbreaks, but you want the strain that is actually circulating now. And we still do not know the natural reservoir for this species. Filoviruses as a family tend to live in bats, but the specific host here is unknown, which makes it harder to predict why these spillovers erupt when they do.

Here is the part that should bother us most, because it was avoidable. The USAID cuts slowed the on-the-ground response. Not because those teams were standing by for Ebola specifically, but because they were the eyes and ears that catch something like this early. There was a delay in even recognizing that this was Ebola, a point Samantha Power, the former USAID administrator, made in a Bloomberg interview. Then there is the Kenya center still in the news, reportedly staffed by Public Health Service Corps personnel with a three-day training program. That makes no sense to me. We have thirteen Ebola treatment units across the United States staffed by people who do this work routinely and have cared for Ebola patients. Standing up an ad hoc facility instead is hard to justify.

Both the Africa CDC and the Trump administration are asking for more funding to handle this, and they should. The outbreak will keep outpacing the response until the resources catch up. But the larger point is that the trajectory is not destiny. There are things that can be done.

Measles: endemicity by choice

The same is true for measles, where we are running down the clock on elimination. I think it is a foregone conclusion that the United States loses elimination status, probably formally in November. What we are watching is endemicity returning, and not because the virus changed. By choice.

I have written before that measles endemicity is the default state of the world. It takes deliberate work to eliminate the disease and continuous work to keep it eliminated. The thing that maintains elimination is not luck. It is human minds using a human tool, the vaccine. Take that away and you get exactly what we are seeing now.

We are at roughly twenty-one hundred cases nationally, eighty-four of them in Pennsylvania, my home state. That is nearly the entire 2025 total reached in about half a year, so we are on track for a record. The genomics tell us this is essentially one continuous outbreak, traceable to the West Texas outbreak that began in 2025, and sustained transmission of a single chain for twelve months is the criterion for losing elimination. The genetics are telling the story plainly.

What does endemicity look like in practice? It looks like airport exposures, like the one at O'Hare on June seventeenth. It looks like wastewater turning up positive in places with no diagnosed cases, because we are not good at catching every infection. Delaware County in Pennsylvania has positive wastewater and no confirmed cases, which tells you that twenty-one hundred is an undercount. Pennsylvania is now recommending the first vaccine dose at six months to protect infants, who normally are not vaccinated until around their first birthday. That gap is a long window of real vulnerability for the highest-risk group we have.

The state's Secretary of Health, Dr. Debra Bogen, has said the department will not sit by and let the virus spread, and I am glad they are being proactive. But in another interview she said she wished there were a magic bullet to end this. There is one. It is the vaccine. And it is not magic. It is the result of scientists applying logic and reason to a human problem. I do not think the "magic bullet" framing helps, especially when we have a working vaccine and yet people in Pennsylvania are out buying vitamin A. The vaccine is the answer. Vitamin A is not.

South Carolina offers a preview of what living with this looks like. Thirteen of thirty-two affected schools had to repeat quarantines because the outbreak kept reigniting. That is endemicity. And the single variable that changed is vaccination rates. Measles has always existed outside our borders. The reason it is hitting us this hard is that we lowered our force field, and the force field is the vaccine. The fix is unglamorous and well understood: get childhood immunization rates back up so the country is resilient again. This is happening by choice, and that is the most important thing to remember.

The institutions: process integrity, not partisanship

The worry here is not partisan. It is institutional. The concern is that the bodies we rely on to make sound, evidence-based decisions are being eroded by design.

Start with ACIP, the Advisory Committee on Immunization Practices. It has been reconfigured so that it cannot do its job, reformulated in RFK Jr.'s anti-human image. The concrete cost is immediate: we do not yet have a fall COVID recommendation for high-risk people, because the committee cannot meet. It is tangled in court cases and rechartering. RFK Jr. wanted to dismantle ACIP, and functionally he has.

Then there is politics reaching into study design. The CDC's acting leadership blocked publication of an article in the Morbidity and Mortality Weekly Report, objecting to a methodology that has been standard across many vaccine studies. It was published anyway, in JAMA Network Open, using that same standard method, and it found that COVID vaccines reduced urgent care and emergency department visits in the short term. Which we already knew. So it is hard to see what the controversy was about, except as another instance of politics polluting a scientific process. The New York Times released emails from when RFK Jr. took over HHS showing staff struggling to accommodate his ideas. I think the incompatibility is fundamental. You cannot implement anti-human premises and expect anything other than what we have now, which is a largely paralyzed CDC.

There is also a proposal for a new "science office" inside the CDC. That is code for politics. In practice it means the secretary vetting what comes out of the agency, which is already happening, only more formally. Demetre Daskalakis, who resigned from the CDC in protest over RFK Jr.'s actions, called it an anti-science office, and that is exactly right. The CDC can already do science. An office like this is not there to do science. It is there to distort it to fit a warped worldview.

Which brings me to the nominee for CDC director, Dr. Erica Schwartz. She is very qualified. My question is simply how a director squares that role with what is happening at HHS headquarters. How do you not sanction it? I would be genuinely curious to see how that gets reconciled, because the conflicts are going to be major and the chasm does not look bridgeable.

On a lighter note, the WHO is running a contest for eighteen-to-thirty-five-year-olds to make pro-vaccine videos. People will call it propaganda. It will be interesting to see how it turns out.

The standing threat: avian influenza

I have always considered avian influenza the biggest pandemic threat, and it remains a standing one. We still have far too much uncertainty at the human-animal interface. China reported its fifteenth case of H9N2 in six months, this time a child. H9N2 does not spread efficiently between people, but fifteen cases in half a year tells you there is a great deal of human-animal contact going on.

H5N1, meanwhile, hit a milestone I did not want to see. It is now on all seven continents. Australia had been the holdout, and now a skua, a type of bird, has been found infected there. So H5N1 has effectively encircled the globe, and on the human side we are flying blind, especially in the United States, where it is not clear how much human testing is even happening.

Antibiotic resistance and the pipeline

Drug resistance does not move at outbreak speed, but it is relentless, and agriculture is a major driver. Thirty-four million pounds of antibiotics go into livestock, where they make animals reach market weight faster. There are petitions asking the FDA to curb this misuse, and they are right to. The economic logic is real but short-term. People are not weighing it against the long-term cost of drug-resistant bacteria that infect animals and then infect us.

The pipeline has bright spots. There is a newly described Streptomyces gene cluster producing proteins that target the biotin, or vitamin B7, pathway, which could become a genuinely novel class of antibiotics. And in one of the more fascinating developments, researchers using AI have found prions in nature with antimicrobial activity. Prions are usually villains, the cause of chronic wasting disease, mad cow, and Creutzfeldt-Jakob disease. Prions as a therapeutic is a striking idea.

There is also a large neonatal sepsis trial underway in Africa and Asia. Neonatal sepsis kills a great many newborns, and the treatment algorithms in low- and middle-income countries often rely on obsolete antibiotics. The trial is testing newer agents. This matters because new antibiotics only help if we actually use them. They cannot sit on a shelf. That is what judicious use really means. Not simply avoiding antibiotics, but using the right one, appropriately, when it is indicated, and not defaulting to drugs that no longer work.

Around the dial

A few stories that did not lead the week but are worth your attention.

Screwworm is a slow burn that is climbing and almost certainly undercounted. We are up to about twenty-five cases in the United States across two states, Texas and New Mexico, in cows, goats, and other animals, and the true number is likely higher because it can be hard to diagnose. Pennsylvania has responded by requiring that any pet that traveled through an outbreak zone be examined by a veterinarian, a sensible attempt at prevention.

We are in peak tick season, and emergency rooms are seeing a lot of tick bites. NPR ran a KFF piece on the Lyme disease vaccine in development that interviewed hunters, who turn out to be vaccine-hesitant despite being among the highest-risk and best-informed about Lyme. The vaccine has real limitations: it requires yearly boosters and runs around seventy-five percent efficacy, so it is cumbersome. But for high-risk populations it will still be valuable.

On HIV, a couple of things stood out. Antiretrovirals are lifesaving, and they do modestly raise the risk of diabetes, on the order of 0.35 cases per patient-year, though HIV itself raises that risk too. There was also an interesting finding on the synergy between HIV and filariasis, the tropical disease that causes elephantiasis. Filariasis drives chronic immune activation, which makes people more susceptible to HIV. So treating a neglected tropical disease carries a second benefit: preventing HIV infections.

Closer to home, my own Allegheny County in Pittsburgh recorded fifty-three HIV cases, a thirty-one percent drop. But the Pittsburgh Post-Gazette noted that funding cuts are coming, and much HIV funding flows from taxpayer sources. There is a legitimate policy debate to be had about that. What does not make sense is cutting abruptly without a plan. You have to phase these things down, not slam them off, because disrupting HIV care interrupts medication access, which undermines viral load suppression, which increases transmission. It is never a contained, single-effect decision. Disrupt care for a communicable disease and you put other people at risk. If you are going to do it, do it mindfully.

The same paper ran a piece on Pittsburgh as a hub of innovation, a point I make often. Jonas Salk developed the Salk polio vaccine there, a win for Salk, for Pittsburgh, and for the species. And the Salk vaccine is the answer to the vaccine-derived poliovirus cases we keep seeing, more of which were reported in Africa and Asia this week. Those cases are a side effect of the Sabin oral vaccine. As long as Sabin is in use, they will keep occurring, which is why I think the focus belongs on wild poliovirus, until someone decides to make the switch.

The case for getting ahead of it

Here is where the through line resolves. Preparedness is a bargain, and Ebola is teaching that lesson live. From 2000 to 2022, even a relatively mild pandemic like H1N1 cost trillions. COVID was off the scale. Dengue and cholera have run into the trillions too. Against those numbers, preparedness is a rounding error. It makes economic sense the moment you think long-term instead of short. The trouble is that many people in this field, and in politics, do not think long-term, because by the time the bill comes due they are out of office.

So what does proactive work look like? ARPA-H is developing what amounts to an immune system for a building: sensors that trigger UV and filtration, profiled in a recent New York Times piece. We know it can be built and deployed. The open questions are cost-effectiveness and clinical benefit. I think we are heading toward a world where we sample building air the way we now sample wastewater, in hospitals, schools, and offices. There is also a roughly five-hundred-million-dollar effort to blunt respiratory viruses, including common cold viruses, using UV light and interferon-type boosters you could squirt into your nose to make yourself temporarily resistant. If it works, it would matter for pandemic preparedness too, because in my analysis the next pandemic virus is likely to emerge from the common respiratory viruses.

This is the lesson to draw through the whole week. Proactivity is what makes an out-of-control Ebola outbreak less likely in the first place.

The week's real story

Step back and the real story is the avoidable cost. An Ebola response playing catch-up because we removed the eyes on the ground. Measles returning because we lowered our force field. Institutions being weakened by design. None of it is fate. These are human choices, every one of them.

So remember the arithmetic, because it is not complicated. Preparedness is cheap. Under-reaction is not.

Recently, I was listening to psychologist Steven Pinker discuss the Second Law of Thermodynamics on a panel. Entropy, in its broadest sense, describes the tendency of systems toward disorder. Pinker noted that human agency acts as a countervailing force, creating pockets of order in a universe that naturally trends in the opposite direction.

I’ve been thinking about that idea a great deal lately, particularly in the context of what I see as the role of infectious disease physicians, nurses, physician assistants, nurse practicioners, epidemiologists, virologists, microbiologists, infection control practitioners, as defenders of civilization.

Transposed into the realm of infectious disease, entropy means that death, disability, and disruption caused by infectious agents are the norm. Human beings altered that trajectory through reason. Germ theory, sanitation, antisepsis, vaccination, antibiotics, antiviral drugs, and modern public health infrastructure are all products of human intelligence directed toward a specific purpose: creating order where nature provided none. Left unattended, the natural trajectory is not toward health but toward recurring outbreaks, epidemics, and premature death.

Measles is the default.

For most of human history, measles infected everyone. Measles elimination was not the natural state of the world. It is an achievement.

And like all achievements, it requires maintenance.

Civilization itself is not automatic. It must be continuously maintained and advanced. Societies can and do backslide. The Dark Ages remain the most famous example. I often think of the Antikythera mechanism—a sophisticated ancient Greek device whose purpose was lost for centuries. Imagine discovering such an object in the Dark Ages, possessing the artifact but lacking the intellectual framework necessary to understand it because people jettisoned that framework.

History offers many examples of achievements that were abandoned, forgotten, or allowed to deteriorate. The Concorde disappeared. Human moon missions ceased for decades. Today, vaccines are following a similar trajectory. A nightmare scenario is some future human finding a vial of an mRNA vaccine the way we first held the Antikythera mechanism—possessing the artifact but having lost the intellectual culture that made it possible.

Human flourishing consists of creating islands of order against a backdrop of entropy.

This is why the return of measles in the United States is not primarily a biological event. It is a cultural and intellectual one.

The measles virus has not become more virulent. The vaccine has not become less effective. What has changed is humans’ willingness to support the technology that made elimination possible.

The ultimate resource is not a vaccine, an antibiotic, an antiviral, or a hospital.

It is the human mind.

The same force that drained swamps, built sewers, created vaccines, developed antibiotics, eradicated smallpox, and eliminated measles is the force that keeps entropy at bay.

Measles elimination was not humanity’s inheritance. It was humanity’s achievement.

The state of nature is not measles elimination but measles endemicity.

Ebola in the DRC: When You Chase the Virus and Ignore Everything Around It

The Ebola outbreak in the Democratic Republic of the Congo remains the dominant global story, and it has been present nearly every day I have been covering the news. It has now grown into the third-largest Ebola outbreak ever recorded, a containment failure driven less by the virus itself than by the broken conditions surrounding it.

Cases climbed across the week from around 800 to close to 900, and that figure is almost certainly an undercount. There are now more than 200 confirmed deaths. Most concerning, contact tracing is failing, and contact tracing is the single most important way an outbreak like this gets extinguished. Trace rates are sitting near 56 percent, with roughly 28,000 contacts untraced. You cannot break a transmission chain with that many people unaccounted for. If you cannot see where the virus is moving, you cannot stop it, and you have no idea where it will surface next.

This is what I would call a complex, synergistic disaster, and it explains why people keep asking why the outbreak cannot simply be fixed. Where this is happening, one in five people lack clean water. It is hard to keep yourself free of blood and body fluids without clean water. Ongoing militia violence is overwhelming hospitals, and the Red Cross has noted that its surgical suites are still running because of the fighting in the provinces where the outbreak is spreading. Many people seek out traditional healers because they do not recognize Ebola as an infectious disease, so they arrive at hospitals later, sicker, more contagious, and less likely to survive. Patients are fleeing Ebola treatment units because there is no food to feed them. Ebola is only one item on a long list of things that can kill people there, and it is not at the top of that list. They know that, and if a hospital has no food, I do not see how it keeps anyone in a treatment unit. Safe burials remain a problem as well, because viral load peaks near death and a body carries a tremendous amount of infectious material.

There are some bright spots worth holding onto. Clinical trials of remdesivir, monoclonal antibodies, and vaccines are spinning up. Dr. Stafford, the American surgeon treated in Germany, is now back in the United States, and there has been advocacy to deliver the monoclonal antibody he received more broadly, provided the logistics can be put in place. Vaccines look likely to reach trials within months, which reflects a real effort to conduct real-time research during an outbreak involving a rare species of Ebola. The WHO has also released supportive care guidance on replacing IV fluids, managing electrolytes, and controlling blood pressure, all of which can meaningfully reduce mortality if patients reach treatment units that are stocked and have food.

The idea I want to push back on is that a containment response can succeed by chasing the virus alone. It cannot. If you cannot fix the food, the water, and the security in a fragile and neglected region, you get exactly what we are seeing: patients fleeing for lack of food, contact tracing collapsing, and an outbreak that has grown to the third largest in history and is now projected to burn for a year or more. Ebola is interacting with all of these other factors at once, and that is what makes it so difficult.

The Idea Installed at the Top: RFK Jr. and the Vaccine Infrastructure

The next story is one I have covered often: RFK Jr. and the dismantling of the United States vaccine infrastructure. In my view, this is an ideology installed at the very top of HHS, an anti-human ideology, and it is producing measurable damage across the entire vaccine system.

ACIP, the Advisory Committee for Immunization Practices at the CDC, has been reformulated and, as I see it, gutted. He planned this and installed people whose main qualification appeared to be agreement with his worldview, with at least one exception. A judge has blocked the move, and RFK Jr. is now trying to expedite a ruling to undo that. Senate Democrats are demanding an accounting, and Senator Schumer is calling to restore the CDC. I think all of this is insufficient. If RFK Jr. remains in charge at HHS, the politics around it do not change the outcome. He told everyone what he intended to do, so the accounting already exists.

His inconsistency is striking. He is not a physician and does not accept the germ theory of disease, yet he issued a hantavirus quarantine order, overruling the CDC's own hantavirus expert who deemed it unnecessary. I do not understand how someone who rejects the idea that microorganisms cause infection can justify a quarantine at all, and I wish someone would ask him that directly.

We are already seeing the results. Hepatitis B vaccine uptake is falling, more in females than in males, correlated with vitamin K refusal, and it traces back to the reformulated childhood immunization schedule. The University of Maryland's vaccine center has reportedly stopped working on mRNA vaccines, apparently because RFK Jr. dislikes them. It is worth noting that when a survey looked at 13 red states, the majority of respondents actually support vaccines. The loud, angry voices in the comment sections, and I would not advise reading the comments on my videos, are not a reflection of reality.

The idea here is that national vaccine policy is being bent to one official's worldview, and that comes at a cost. ACIP is dysfunctional. mRNA research, the most promising infectious disease work we have seen in a long time and a major reason the world weathered COVID, is being halted. Hepatitis B vaccine uptake is falling, even though it is one of the best vaccines we have and prevents liver cancer and cirrhosis. The entire scaffolding of vaccination is being degraded from the top down. None of this was hidden. He announced it, and people like Senator Cassidy voted to confirm him anyway.

Measles: The Consequence Arrives on the Ground

Measles is the disease on the ground, the flashpoint where anti-vaccine ideology becomes visible. Hotspots have appeared across the country: Buckingham County, Virginia; Amish and Mennonite communities in Lancaster County and Lebanon County, Pennsylvania, where some Mennonite schools report under 50 percent kindergarten vaccination; and Walla Walla County, Washington, which has seven cases this year after several years of none. Pennsylvania is now facing its largest measles outbreak since the 1990s.

Lower vaccination rates in some Amish and Mennonite communities are not new, and Americans have long traveled to measles hotspots abroad. What has changed is our resilience. The communities that traditionally surrounded these enclaves used to have higher vaccination rates, which limited spread. That buffer has now been lowered, and lowered voluntarily, so these pockets of unvaccinated individuals have become kindling for outbreaks.

In Pennsylvania, there is a bill to make vaccine exemptions harder to obtain by requiring a conversation with a physician. The state currently has one of the easiest exemption processes in the country. I think tightening it is the right move. Schools should be run competently, and competent means safe, not operating as pest houses. Utah has also become a focal point in the decision over whether the United States retains its measles elimination status, because it has been dealing with cases since June 2025 and has recorded 680 of them. Whether those represent the same strain and the same outbreak is being adjudicated now, but either way, it is clear the state cannot contain measles. One pediatrician, quoted by the Associated Press, said she was not sure they could get it to end.

That is the situation we are facing. Measles is reestablishing endemicity, not because of any failure of technology, but because people turned against the technology. The idea that vaccination is optional and that easy exemptions are harmless has a direct consequence: the largest outbreak in Pennsylvania since the early 1990s and multiple low-coverage enclaves around the country serving as kindling. We may lose elimination status, but even setting that aside, we can no longer reliably control measles in the United States. It has returned, and it is becoming more common.

Influenza: Two Ideas, Two Consequences

Influenza gave us two competing ideas this week, and each one carried its own consequence.

On the positive side, the VRBPAC committee at the FDA voted unanimously to approve Moderna's mRNA flu vaccine, a vaccine the agency declined even to review just months ago. This would be the first mRNA flu vaccine in the United States, and it matters well beyond seasonal influenza. An mRNA platform allows rapid strain changes during a pandemic or late in a season when it is too late to adjust egg-based vaccines. I think it will set a new standard for how we select strains and meaningfully improve our resilience to pandemic influenza.

It is also worth correcting the belief that the flu vaccine does little good. Even if you still get the flu, vaccination matters, because influenza is not just fever, cough, and aches. It drives inflammation throughout the body that can trigger cardiovascular events like heart attacks and strokes. Vaccinated people are considerably less likely to suffer a cardiovascular death, with a hazard ratio around 0.77, a 23 percent reduction. The COVID vaccine does something similar. For perspective on how far we have come, flu now carries a 43 percent hospitalization rate, higher than COVID, which both reflects the progress of COVID science and reminds us that influenza still takes a serious toll. Secondary bloodstream infections with flu triple the risk of death, and secondary bacterial infections were the leading cause of death in 1918. The flu vaccine also appears to lower the risk of Alzheimer's disease, with one finding of 55 percent lower risk among people who received the high-dose vaccine in the two years afterward. The downstream benefits are substantial: fewer infections, milder cases, fewer deaths, fewer cardiovascular events, and possibly less dementia.

Now the negative idea. Secretary Hegseth ended the military's flu vaccine requirement, apparently on the premise that soldiers do not need one. The consequence followed quickly. There has been a major outbreak at Lakeland Air Force Base, with only about 40 percent of recruits now vaccinated and at least one fatal case. Both ideas, the harmful one and the hopeful one, show how directly decisions translate into outcomes. One produced an outbreak on a military base. The other put an mRNA flu vaccine within reach.

Long COVID: The Cost of a Definition We Don't Have

Long COVID remains an area of unsettled science, but new findings appear constantly. It is best understood as a nebulous umbrella term that likely covers more than one distinct condition, yet it is real and it is costly, perhaps around $1,300 per year for an affected person. There may be a mortality signal suggesting men with a long COVID diagnosis are more likely to die than women, which points to some sex-based interaction, though the definitions are so loose that I would be cautious reading much into it. We also see more cardiovascular disease in people with long COVID. Preexisting mental illness such as depression and anxiety has long been a risk signal, and preexisting physical illness raises the risk as well. The underlying mechanism is still unknown.

The idea I want to challenge is the impulse to manage long COVID as a single disease when it is a poorly defined, catch-all condition. As long as we do that, the data will stay muddled and contradictory. We will not have an integrated understanding of long COVID, or of its subtypes, until we get better at defining what we are actually talking about. The science cannot deliver clean answers under those conditions, and in the meantime patients with genuine health problems are left in limbo while the definitional work remains undone.

West Nile: A Quiet Reminder

Finally, a brief word on West Nile virus, because we are now in West Nile season. A good piece from the CBC noted that Canada recorded nine deaths in 2025. People often assume these mosquitoes cannot survive the cold there, but they can. One of the deaths described in that reporting happened to be the neighbor of a friend of mine in Toronto. It is a real risk, and one you are going to hear more about.

Everything Is Downstream

The point I want to leave you with is that none of this is without consequence. Every one of these policy decisions trickles down to actual people getting actual infections: the Air Force recruits at Lakeland, the children in Utah falling ill, the physicians being harassed for opposing RFK Jr. Everything is downstream of these ideas, and the ideas have real-world consequences. It is worth sitting with that.

This movie, made decades ago, is something that I keep coming back to. I am drawn to this movie because of its theme — the edge that humans have over other species. The edge that enables us to thrive in a natural world that is often hostile. That edge is not an opposable thumb but our specific consciousness which houses the faculty of reason. It is reason that allows humans to shape the world in a manner that is conducive to human survival, beating back lions, tigers, wolves, floods, hurricanes, and — critically — infectious diseases. It is also the case that the knowledge discovered by one human mind can be acquired by another, creating a web of information flow that serves to promote human life beyond the temporal and spatial bounds it was discovered in.

The Edge is fundamentally about thinking and using one’s mind to solve problems related to survival. In the film, a group of men are stranded in the wilderness. However, it is not the physically strongest human that flourishes but the one most committed to the use of reason. As they square off against the elements and the superior physical prowess of bears, it is the mind that triumphs.  This is not surprising. As the philosopher Ayn Rand identified, and the film dramatizes, reason is man’s means of survival.

Darwin understood that humanity’s distinctive adaptation was not speed, strength, claws, or teeth. It was intelligence. Reason, he wrote, stands “at the summit” of mankind’s mental faculties. Humans survive not by adapting themselves to every environment, but by adapting the environment to themselves.

As such, it is the human capacity to reason that stands as the ultimate resource to call upon for survival issues.

These survival issues most definitely extend beyond bears. The bear in The Edge is simply a stand-in for nature’s threats. For most of human history, those threats included yellow fever, smallpox, cholera, plague, tuberculosis, and influenza and only in recent generations have some humans secured freedom from the disruption, death, and despair that characterizes infectious disease outbreaks.

The story of infectious disease is the story of reason applied to nature. Smallpox did not disappear because nature became kinder. Cholera was not defeated because rivers became cleaner. Yellow fever did not retreat because mosquitoes became less dangerous.

Human beings identified causes, discovered mechanisms, tested hypotheses, and transformed knowledge into action. Every vaccine, antibiotic, sanitation system, intensive care unit, and genomic surveillance network is reason made tangible.

Left to her own devices, Mother Nature would kill us. Survival rdepends on the ability to think. It is not automatic; it is an achievement. The edge that separates humanity from the bear, the mosquito, and the microbe is ultimately the same edge dramatized in the film: the reasoning mind.

The Ebola outbreak in the Democratic Republic of the Congo is the clearest illustration of that problem. By the time anyone noticed it, the outbreak already had enormous momentum and a massive head start.

Ebola and the price of a head start

A Reuters piece published this past week went back to try to reconstruct who the index patient was, the very first case. The official records list a healthcare worker, but we know that can't be right, because healthcare workers acquire their infections from the patients they care for. The reporting points instead to a religious figure who died of peritonitis, an inflammation of the lining of the abdomen. That can be a manifestation of Ebola, but this man was never tested.

What makes the account so striking is what happened next. On the way to his funeral, his coffin was damaged and cracked. The body had to be moved and handled, and that funeral appears to have served as a nexus point for many of the cases that followed. Was he the index patient? Was the funeral a super-spreading event? These are important questions, and the genomics suggest the virus had probably been circulating for months before anyone recognized it. That is the lesson I keep returning to: you cannot let a virus spread unchecked and then act surprised when you are handed a major, out-of-control outbreak.

Geography is key here. This is Ituri Province, North Kivu, and South Kivu, regions that are war-torn, famished, militia-run, and in places effectively anarchic. That makes it extraordinarily difficult to move resources in, to understand what is actually happening, and to earn the trust of the population. We have seen fatal cases emerging from displacement camps and cases appearing in orphanages, and all of it speaks to the same reality: this is a complex disaster, a system of interacting emergencies that an infectious disease, as they always do, is feeding on.

When Dr. Tedros, the WHO director general, spoke with STAT, he made a point worth contemplating. For people living there, Ebola sits on a long list of threats to their lives, alongside militias and famine and much else, and it may not even be the most dangerous item on that list. If you are not addressing the structural failures that have plagued these provinces, you should not expect the population to prioritize Ebola the way an outsider might. That is part of why this will take real time to bring under control.

The infrastructure problem is just as stark. This week I read that three laboratories in the DRC ran out of testing supplies. If you cannot test people, you cannot know what they have, and Ebola's early symptoms overlap with malaria, typhoid, and a host of other illnesses. Basic outbreak management requires knowing who is sick, who is infected, who is contagious, and who is not. You cannot break chains of transmission when you are running out of tests.

So how might this have been caught earlier? You keep hearing about USAID not being on the ground, and it is worth situating that claim carefully. The point is not that USAID would have been the lead responder to an Ebola outbreak. They might well have been doing other work entirely. But the more expertise you have on the ground, the more chatter you hear when an undiagnosed illness starts killing people, and that chatter is often what sounds the alarm. Earlier alarm could have meant earlier, more sophisticated testing, the kind that would have identified this rare species of Ebola sooner. So, when the acting CDC director says USAID's funding cuts didn't hamper the response, I think he is simply evading the question that matters: would assets on the ground have alerted us earlier and made this easier to extinguish?

And this is not just me. Two pieces on USAID published this past week make the same point. One was a Stat interview with a USAID worker describing the Herculean effort the agency mounted during the 2014 West African outbreak, the first Ebola outbreak it responded to. You may remember that President Obama appointed a czar for that response, Ron Klain, who later became President Biden's chief of staff. Klain wasn't a physician, but he shaped that response considerably because he was an expert at coordinating across the federal government and with international partners, and that kind of coordination may be exactly what it takes to extinguish this one. The other piece was a New York Times op-ed by Jeremy Konyndyk making essentially the same argument: this will require a major, sustained effort precisely because of all the antecedent factors I've described.

The same failure in different guises

This isn't only about Ebola. Consider a few other pathogens from the week.

With avian influenza, there were new poultry outbreaks in Indiana, Illinois, and New Jersey, but nothing in the reports about humans. Were any people tested? Did anyone test negative? We don't know. Unlike the situation in the DRC, here we actually have the ability to test humans, and yet it is: see no evil, hear no evil, until there is evil. That is a hard posture to defend.

Salmonella sounds garden-variety, but there is an outbreak of 62 cases across multiple states with no identified source and no recall. That is not how you respond to a salmonella outbreak, or to any outbreak. You need to understand the entire transmission belt. I'm confident this one will be solved, but it shows that the failure to see clearly doesn't require an exotic pathogen.

Hantavirus is stranger still. A ship was at sea for 23 days with a hantavirus death aboard without anyone realizing what they were dealing with, followed by a flat-footed CDC response and then a curiously disproportionate one: strict home monitoring and a quarantine in Nebraska that doesn't quite add up. I read in the Associated Press about an American woman who left the ship early, as many did, flew on, and ended up on the remote island of Pitcairn. At a cost of several hundred thousand dollars, the State Department is now working to move her to Easter Island, then toward Argentina, and eventually home. We are deep into the incubation period. Yes, hantavirus can have an incubation period of up to 42 days, but she isn't sick, and we have had no cases for some time. I don't understand why this warrants a $750,000 repatriation, any more than I understood the earlier proposal to post police guards outside the homes of people under monitoring. It all fits a picture of disarray in how these responses are being run.

What seeing clearly looks like

There is a counter-model, and it shows what clear vision can do.

Take the World Cup, which is underway now. A group at Georgetown has built what I would call a fusion center, pulling together genomic data from wastewater along with social media signals to understand what is circulating in World Cup host cities, across several of them at once. They have picked up rotavirus, hepatitis A, and norovirus, exactly the crowd diseases you would expect at a mass gathering, but also measles, flu, COVID, and sexually transmitted infections including mpox. When the tournament ends, it will be worth asking how valuable this center really was, because something like it might be worth running all the time, not only during mass gatherings, to give a city continuous situational awareness so that anything abnormal is caught much earlier.

In that same vein, these systems create the epidemics that didn't happen. Former CDC director Tom Frieden's group, Resolve to Save Lives, publishes a report each year on exactly those invisible wins, the outbreaks stopped before they ever became visible. That is the paradox of this work: when the systems function well, they are seamless, they sit in the background keeping civilization safe, and because they are in the background they are chronically underappreciated. Infectious disease doctors, epidemiologists, and public health workers are, in a real sense, civilization's defenders in the background. The goal was never to respond heroically to a visible outbreak with hospitals overflowing. The goal is to extinguish things before they ever get there.

The medical countermeasure response to this Ebola outbreak is another example of acting proactively. This is a rare species of Ebola without established countermeasures, and yet, as the New York Times detailed, treatments are moving quickly: monoclonal antibodies and antivirals. The piece described what Dr. Stafford, the American surgeon who was infected and treated in Berlin, actually received: Remdesivir, familiar to many from COVID, along with a monoclonal antibody. More trials like that are underway, and that only happens because people were poised to act quickly.

Vaccines as freedom: the HPV story

I want to close on something a little different, the HPV vaccine, which I think of as a vaccine that gives you freedom from certain cancers. Liz Szabo, a great science journalist at CIDRAP, published a three-part series worth discussing.

Part one framed the vaccine, correctly in my view, as freedom from cervical cancer deaths. That is the right way to think about vaccines generally. They don't restrict you; they free you. They are a positive in your life, helping you live free of a particular infectious disease, or in this case free of cervical cancer.

Part two carried an important message: HPV is not only about cervical cancer but also about head and neck cancer, which men get. The series quotes the view that the vaccine may be even more transformational for head and neck cancer than it has been for cervical cancer. That is the real answer to the question of why we vaccinate boys. It is not merely that they can transmit HPV to women; it is that they themselves are at risk of head and neck cancer. Freeing anyone from these cancers is the point.

Part three noted that some countries, Australia among them, are on track to eliminate cervical cancer thanks to high vaccine uptake. In the US, Massachusetts is closest, while the country as a whole is not there, and Mississippi is the worst-performing state. The HPV vaccine is one of the most valuable vaccines we have, and, not so paradoxically given how nihilistic the discourse has become, it is also among the most attacked and maligned.

The whole enterprise

Situational awareness is the whole enterprise. You cannot respond to what you cannot see. Ebola got a months-long head start. With avian flu, the human side is a blank. Salmonella appears with no source. These are the same failure wearing different costumes: a lack of diagnostic testing and a lack of situational awareness, which lets problems build quietly until they bubble over, by which point they are too large for the good tools to contain.

The work at Georgetown, the epidemics that didn't happen, that is the direction we need to move: building systems that can see early. The encouraging part is that this is no longer really a technological problem. We have the pieces. What remains is the will to put them to use, and whether we choose to is the open question.

He meant it as wisdom. He was wrong, and Darwin himself would have told him so.

Darwin's most important sentence could be one you don’t know

Everyone knows Darwin for On the Origin of Species, published in 1859. But the book that reveals what he actually thought about human beings is The Descent of Man, published in 1871, where he turned his lens from finches and tortoises onto humans.

A sentence that should be far more famous than it is comes from Chapter III: "Of all the faculties of the human mind, it will, I presume, be admitted that Reason stands at the summit."

That sentence isn’t just a philosophical aside. He wrote it as an evolutionary statement. By The Descent of Man, Darwin had worked out what distinguished humans from every other species: not our size, not our strength, not our speed, not even our immune systems — but our capacity to reason. To form abstractions. To look at a pattern and induce a principle. To look at a virus and build a countermeasure. Darwin’s view of reason is that it is the means of survival for humans.

For Darwin, reason is not separate from natural selection but is natural selection's crowning project.

The Galápagos, of all places, is where this argument gets tested

I was standing in the place where Darwin assembled the observations that led him to his theory. Marine iguana, blue-footed Boobies, and the famous finches with their divergent beaks. And a guide — a naturalist, someone who had devoted his life to understanding this place — was telling me that when infectious disease shapes our species, we should let it.

I disagreed then, and I disagree now, on Darwin's own authority.

The guide's mistake was treating natural selection as something that happens to humans from the outside. But Darwin's argument was that reason itself is what natural selection built in us. When a virologist reads the genome of a novel coronavirus in January 2020 and a vaccine is in arms eleven months later, that isn't interference with Darwinian evolution. It's Darwinian evolution doing what it has been doing for millions of years: favoring the traits that help our species survive. Our trait is reason. Reasoning our way to vaccines. (Not by accident, Darwin’s view of reason was a topic I wrote a paper on in a favorite course I took in the 1990s as a post-baccalaureate student because I was so excited about the material: Jim Lennox’s Darwinism and its Critics at the University of Pittsburgh).

The anti-vaccine movement gets Darwin backwards

The "natural immunity is better" argument is an attempt at constructing a respectable-sounding voice of vaccine hesitancy. It has scientific adjacent clothing — it invokes evolution, selection pressure, immune memory and draws on real phenomenon. It sounds like Darwin.

It isn't. In fact, Darwin wrote: “There is reason to believe that vaccination has preserved thousands, who from a weak constitution would formerly have succumbed to small-pox.” Darwin recognized vaccination as a triumph of reason. Jenner looked at milkmaids and cowpox lesions and induced a principle from scattered observations. He saw a pattern in nature and converted it into a technology that liberated humanity from smallpox.

 The people who make this argument are, implicitly, asking you to treat nature as a norm-setter, something Darwin’s quote about vaccines stands in opposition to.  As if what nature does to us without our intervention is what should happen — those with “a weak constitution” succumbing to smallpox. This is the naturalistic fallacy dressed in evolutionary costume: the idea that because something is natural, it is good, or at least better than the alternative.

But Darwin didn't believe nature was a norm-setter. He described a blind, indifferent mechanism that favors whatever survives. He recognized that vaccination, a product of human reason, is a countervailing force that emanated from Edward Jenner’s faculty of reason.  Nature’s mechanism, devoid of human intervention, produces outcomes that no sane person would call a design goal: the Black Death killing a third of Europe; the 1918 influenza killing 50 to 100 million people; malaria, operating as a Darwinian selection pressure on the human genome for so long that it left permanent marks.

Which brings me to the honest face of natural immunity: it is a real phenomenon that comes at a cost.

Natural selection’s solution to malaria is a blood disorder

Of all the things I've written about infectious disease, the malaria-sickle cell story is the one that most concretely illustrates what natural selection, left to its own devices, actually produces.

It is often said that malaria has killed roughly half of all humans who ever lived. The Plasmodium parasites that cause it have been killing humans for so long, and in such numbers, that they became a selection pressure — they began to shape our genome.

The result: a mutation that, in carriers who inherit one copy, confers resistance to malaria. Natural selection preserved it because carriers survived long enough to reproduce. But inherit two copies of the mutation, and you have sickle cell anemia — a painful, debilitating, life-shortening blood disorder.

That is what natural immunity looks like when it's working as designed. Nature's answer to one of history's most lethal pathogens was to introduce blood diseases into the human population as a consolation prize. You can see the geographic overlap precisely: superimpose a map of where malaria has historically been endemic with a map of where sickle cell anemia (and the other malaria-influenced blood diseases G6PD deficiency, thalassemia, and hereditary spherocytosis) is prevalent, and the lines match almost perfectly. Natural selection did this. Over thousands of years of uncountable death.

Contrast this with what reason did to malaria: DDT eliminated it from most of the industrialized world within decades. Artemisinin-based therapies transformed treatment. Insecticide-treated bed nets keep sleeping humans safe. Vaccines decrease deaths. Modified mosquitoes will add even more. The tools built by conscious minds are doing in years what blind selection couldn't accomplish in millennia — and without the blood disorder as a byproduct. Human reason is also addressing sickle cell anemia, natural selection’s deadly byproduct, with bone marrow transplants and gene therapies.

The mRNA vaccine is what reason built

The mRNA vaccine platform is one of the clearest contemporary illustrations of this I know. For decades, scientists worked on the basic science of messenger RNA — how to stabilize it, how to deliver it, how to get cells to read it as an instruction and produce a protein. The key breakthrough on the delivery mechanism came in the 1990s. The key breakthrough on mRNA stability — a modification to the nucleoside that makes up the molecule — came from Katalin Karikó and Drew Weissman, a discovery that eventually earned the 2023 Nobel Prize in Medicine (and a Time Magazine cover that adorns my wall). None of this was done in anticipation of a specific pandemic. It was basic science, driven by curiosity and the slow accumulation of knowledge.

When SARS-CoV-2 arrived, its genome was sequenced and published in January 2020, and within 11 months, a vaccine built on that entire accumulated foundation was authorized and in arms. The speed looked miraculous. It wasn't. It was what happens when reason suddenly has a problem needing a solution at maximum urgency.

I have been calling vaccines "liberation technology" for years. When humans refuse to accept hostile nature's terms, they create the means to master these problems, winning freedom for themselves from being helpless against nature’s machinations.

The deeper point is Darwinian: we aren't refusing nature's terms. We are executing nature's terms.

Nature built a species capable of this: us. When we use that capability, we aren't defying the process that made us. We are the process that made us.

What my Galápagos guide got wrong

The guide on that boat had a philosophy that sounds like reverence for nature but is actually a form of self-abnegation. He was asking members of the most cognitively sophisticated species in the history of the planet to suppress the faculty that makes them what they are, out of deference to a blind mechanism that, left to itself, produces sickle cell anemia and the Black Death.

Darwin would have found this baffling. The man who spent his life documenting the adaptive genius of natural selection understood that what it had built in us — above all else — was reason.

The anti-vaccine movement, in all its varieties, makes the same error as my guide. It mistakes nature for a moral authority. It treats "natural" as a synonym for "correct." It advocates letting disease do what it would have done before we had the capacity to stop it, on the theory that this is somehow more authentic to who we are.

But nothing is more authentic to who we are than thinking our way to a solution.

The real Darwinists vaccinate

There is a false version of Darwinism that concludes vaccines are interference.

Darwin's version —reason standing at the summit — concludes something quite different. It concludes that the species capable of reasoning its way out of the jaws of infectious disease is doing exactly what natural selection shaped it to do. That is the mRNA vaccine, developed from a genome sequence in under a year. It stands as one of evolution's most recent and most impressive outputs.

We have had 10,000 generations of humans. Only the last four have lived in a world where we can reliably master some infectious diseases. The tools that made that possible — vaccines, antimicrobials, diagnostics, sanitation — are the products of the one trait Darwin identified as the summit of what natural selection can build.

If you want to honor Darwin, don't retreat to nature's indifference. Use your mind. That's what Darwin said it was for.

Vaccinate.

On one side, the cost of skipping the peacetime work: an Ebola outbreak caught late because it is caused by a rare species our frontline tests do not even detect; dairy herds in the United States infected with avian influenza while we fly blind on the human side, with no clear count of how many people connected to those herds were ever tested; and a domestic surveillance system being defunded at the precise moment we would want it most.

On the other side, what proactive preparation actually buys you: Ebola countermeasures that exist today only because of years of investment in vaccine and monoclonal antibody platforms, and the World Health Organization carefully building guidance to keep a brand new class of antibiotics working against highly drug-resistant gonorrhea before resistance sets in.

Same week, two completely different approaches. So let us talk about what it costs to wait for wartime.

Ebola in the DRC: the price of a head start you gave away

The outbreak in the Democratic Republic of the Congo is a clean illustration of the peacetime gap. These cases are caused by the Bundibugyo species, the third most common ebolavirus strain, and the standard rapid tests used at the frontline do not detect it. The more sophisticated assays that can identify it sit in the capital, Kinshasa, and were never forward-mobilized to the outbreak zone. That is why this was caught late, handing the virus a head start of perhaps four to six weeks.

Everything downstream flows from that lost month. There is now a massive testing backlog, which is why the case counts keep fluctuating, initially reported near a thousand and since revised down. Expect a lot of noise as responders fight to gain situational awareness. Contact tracing is the same story. You want to capture roughly 90 percent of contacts to break chains of transmission, isolate the contagious, and monitor those at risk. Right now capture is around 45 percent. The CDC modeling scenarios circulating on this are thought experiments, not prophecies, and what they show is that the size of this outbreak depends almost entirely on how much contact tracing actually gets done. More resources brought to bear, smaller outbreak. It is that direct.

We have already seen the consequences of those untraced chains. The outbreak has reached Uganda, which has on the order of 15 cases including a death and including healthcare workers. One Ugandan case was a person from the DRC who traveled through the United Arab Emirates before arriving. Whether that individual was contagious in the UAE is unclear, but this is exactly what happens when transmission chains go unidentified.

The geography is brutal. The affected areas are controlled in places by militias, anarchic and violent, and the outbreak has now reached territory controlled by ISIS, which will complicate everything further. I read about Virunga National Park, home to mountain gorillas and to people, now being set up as a makeshift testing point because it forms a natural barrier for travelers. That a national park is being pressed into service as a stopgap screening site tells you how much has to be improvised here.

This will take months. The WHO and CDC Africa are planning hundreds of millions of dollars in control activities projected through November of 2026. Bunia Airport, inside the outbreak zone, has reopened, which should let resources flow in more easily. But burial teams are still being attacked, and a great deal of anthropological work remains before responders earn the community acceptance needed to extinguish transmission. China has begun to engage, sending a team to Kinshasa, roughly a thousand miles from the outbreak. I would keep in mind that China will act in its economic interest, and it is the major consumer of the DRC's chief exports, cobalt and copper. We will see what that involvement actually amounts to.

Here is the peacetime payoff, though, and it is real. We have medical countermeasures to deploy precisely because someone invested in the platforms years ago. The pan-ebolavirus monoclonal antibody cocktail MBP134 from Mapp Biopharmaceutical is in the mix, Regeneron has a monoclonal as well, and BARDA, the U.S. agency that develops countermeasures, has played a central role. Gilead's obeldesivir, an oral antiviral in the remdesivir family, is being trialed for post-exposure prophylaxis. CEPI has invested in three vaccine platforms, from Moderna, IAVI, and Oxford. Richard Hatchett, CEPI's CEO, has said he does not think this ends without vaccines or treatments, and the point is that those are not in the infinitely distant future. Even against a rare species of Ebola, we are seeing real movement in the countermeasure space, and that movement is a dividend on proactive investment.

The Kenya plan: a wartime scramble beside an idle peacetime asset

Set against that is the Kenya plan, which has to be understood as a wartime scramble taking place right next to an idle peacetime asset. The idle asset is the set of taxpayer-funded U.S. Ebola treatment units scattered across this country. They safely cared for Ebola patients over a decade ago. Their teams drill on this, train on this, and know how to do it safely, with established protocols for personal protective equipment and waste management. Those units are sitting idle while 20 flights of equipment arrive in Kenya to stand up an ad hoc facility whose purpose remains genuinely murky.

Is it quarantine only? Some say so. Is it quarantine and treatment? Unclear. U.S. officials keep contradicting one another. What we do know is that it cannot come anywhere near the standard of care. The plan reportedly relies on U.S. Public Health Service personnel who may have had something like three days of training, working in a hospital that is still being constructed, that no one has ever worked in because it did not exist until now. I cannot make that make sense. If I were one of those Public Health Service officers, handed a few days of training and sent to treat Ebola patients in an unfamiliar improvised facility, I would be deeply uneasy.

My colleague Alex Phelan made an important point in an op-ed in The Hill: Americans have a constitutional right of return. It cannot be stopped. That reality is being evaded in this planning, and much of the social media commentary that fixates on treating these patients outside the United States seems unaware that the patients in question are Americans.

This boils down to what kind of system we want. Do we want a proactive, state-of-the-art global health security apparatus, including the Ebola treatment units the public already paid for, or do we want this scrambly improvisation built for reasons no one will state plainly? We already have a recovered case to point to. Dr. Stafford, a physician who was infected, was treated in Berlin with experimental therapeutics and has been discharged, and his family, including his physician wife, has been released from quarantine. That is a real success. But the Kenya episode is political theater, not epidemiology. These decisions are not being driven by epidemiological science or the medical standard of care. They are posturing dressed up as response.

Dismantling the radar

I want to be direct about how the peacetime infrastructure we will need next time is being taken apart right now. The CDC's wastewater surveillance system is effectively being zeroed out, stripped of the assets and resources it needs. Wastewater and genomic surveillance are our radar. They give early situational awareness, and they generate the epidemiological data that lets us aim countermeasures precisely, the way we matched monoclonal antibodies to circulating COVID variants. They tell us whether polio is circulating in a given area. The entire value proposition is that you build this before you need it, so that early warning lets you reach for precision tools while those tools still work, instead of being forced into blunt instruments later.

The American Society for Microbiology has sent a letter to Congress urging a fix. The NIH-funded CREID centers, emerging infectious disease research hubs across Africa and elsewhere, are the peacetime listening posts that catch outbreaks wherever they start, and they are being defunded as well. If you want a country that is resilient against infectious disease threats, this is precisely what you do not do. My colleagues and I released a genomics report last. O week making the same argument: build it in peacetime, so that the next encounter stays a skirmish rather than a war.

Vaccine policy and the manufacture of doubt

On the anti-vaccine front, the President signed an executive order codifying changes to the childhood immunization schedule pushed by RFK Jr. This is the move that cherry-picked Denmark's schedule, which does not even make sense as applied to Denmark, and then copied it here. The courts have been rebuffing RFK Jr., and this order looks like an attempt to get around that. A recent CIDRAP op-ed by Jess Steier made the point cleanly: this is political strategy, an effort to preserve irrational schedule changes by other means.

RFK Jr. is also seeking access to personal health records to pursue his debunked vaccine-autism claim, which raises serious privacy concerns and will almost certainly draw lawsuits, as reported by KFF News. He continues to fixate on an idea that has no basis in reality. In the same vein, a STAT podcast documented a growing demand for so-called unvaccinated blood, meaning blood from donors who never received a COVID vaccine. This is not only irrational, it is dangerous, because chasing down such donors delays transfusions for people with severe anemia and other urgent needs. It is more Dark Ages thinking, of a piece with the renewed promotion of vitamin A and cod liver oil. Recall the West Texas measles outbreak, when RFK Jr. publicly touted vitamin A. Internet searches for it spiked, pulling attention away from the thing that actually works, which is the vaccine.

I will be candid about one development that strikes me as a paradox. Timothy Mellon, an heir to the Mellon banking family from the Pittsburgh area where I live, is reportedly directing assets to RFK Jr.'s anti-vaccine groups. The Mellon family helped build this country. Routine childhood immunization is one of the great achievements of that country, and funding its dismantling is hard to reconcile with that legacy. On the more encouraging side, Marco Rubio appears to be sidelining RFK Jr. on Gavi, taking the lead on global vaccination, where RFK Jr. has held irrational positions. That is good to see. I would go further and urge Secretary Rubio to repudiate RFK Jr. outright, to state plainly that if RFK Jr. claimed something about Gavi, it should be presumed wrong.

Measles: defenses we lowered on purpose

Measles is where we have let our peacetime defenses down voluntarily. As I have said repeatedly, our elimination status is on the line, and we are not likely to keep it. That outcome is not being dictated by the biology of the virus. It is a choice we are making.

We have already reached 2,000 cases by June. Last year it took until Christmas to hit that number, so we are on pace for one of the worst years in recent history. An article in the Pittsburgh Post Gazette immunization requirements. My response is simple: if you can opt out of a requirement at will, it is not a requirement, so stop calling it one. Pennsylvania has around 60 cases across six counties right now, the highest since 1991, and that is embarrassing for my home state. The school districts are complicit through weak policy and lax enforcement. Either enforce the requirements or take them off the books, because keeping unenforced rules on paper accomplishes nothing.

Regionally the picture is no better. The Pan American Health Organization ranks the United States third worst among 16 countries, behind only Mexico and Guatemala, against a backdrop of roughly 20,000 cases and 25 deaths in the region. It is worth remembering that the Mexican outbreak was seeded by the United States; it was not indigenous to Mexico. One thing I would like to see more of is reporting that goes beyond cases and deaths to include hospitalizations, encephalitis, and pneumonia. Utah is reporting hospitalizations and encephalitis. Texas has noted that many of its hospitalized patients had no underlying conditions. That kind of reporting matters because it concretizes the threat. It makes it harder to wave measles away and harder to deny the benefit of the vaccine.

Antibiotic resistance: preparedness done right

Antibiotic resistance is the slow-moving crisis, and it is the one place this week where I think preparedness is being done correctly. We are seeing new tools against the hardest-to-treat organisms. Agents such as aztreonam-avibactam and cefepime-taniborbactam are active against metallo-beta-lactamase producers, among the most difficult resistant bacteria to treat. We have two new oral drugs for gonorrhea, zoliflodacin and gepotidacin, both approved late last year, and the WHO is now convening experts to optimize how they are used so we preserve them before resistance sets in. There is additional safety data on imipenem-relebactam, and I read about a fascinating compound in early development that attacks a unique site on the bacterial ribosome, the E site, a genuinely novel mechanism.

The connective tissue here is policy. Consider livestock antibiotics, where producers dose animals to fatten them faster and get them to market sooner. That practice drives resistance in animal populations, which then spills into human populations. It persists because the incentives are short term. A farmer is not thinking about a harder-to-treat infection down the line, so we need to recenter that thinking toward judicious agricultural use. Put it all together, stewardship, a real pipeline, and careful guidance, and you have the template. We are already in the antibiotic resistance crisis, but because it is slow rather than acute, we can actually get ahead of it. There is far more to do, but this is what doing it right looks like.

A vaccine designed by a machine

I want to end on a hopeful note. A group at Cambridge has been using AI, trained across a wide range of coronaviruses, to find a conserved region that could anchor a universal coronavirus vaccine. The approach has produced candidates that have now been put into humans. It is a fitting place to close, because it shows the genuine promise of AI in medical countermeasure development, technology bent toward improving human life.

Why this field matters

Step back and the week tells a single story. Ebola, Kenya, vaccine policy, measles, antibiotics, an AI-designed vaccine. In every case, the outcome was being decided long before the headline, by whether the work had been done in peacetime. The systems that actually protect us, surveillance that spots an outbreak early, vaccination coverage that holds the line, treatment capacity that is ready when needed, careful guidance that keeps an antibiotic optimally used, none of it can be built in the middle of an emergency. It gets built in the quiet years beforehand, or it simply is not there when the emergency arrives.

That is why this field matters. When we do the peacetime work, infectious disease control lets everything else flourish. It is what allows a society to get on with being a society. It is why I say that infectious disease physicians are defenders of civilization. But we have to be empowered to do that work during peacetime.

Ebola: The Biggest Emergency on the Board

The Ebola outbreak in the Democratic Republic of the Congo is the largest global health emergency we are facing right now. The case count is hovering around 1,000 in the DRC, and that number is going to keep moving as testing comes online. We know the outbreak had four to six weeks of momentum before it was even noticed, and it's going to take time to get full situational awareness. So I'd assume the current count is an underestimate.

The epicenter is in Ituri Province, in a city called Mongbwalu, which the New York Times profiled in detail. This appears to be one of the hotspots where cases began, and it's a telling location. Fruit bats — the natural reservoir of Ebola — roost in the town. It's a gold-mining hub with a large, transient population moving in and out constantly. In other words, it's a place that's almost purpose-built for an outbreak to take hold.

We've since seen secondary spread into other provinces of the DRC and into Uganda, which has around nine cases, including in healthcare workers and including deaths. There's real risk of further spread into neighboring countries like South Sudan.

Why the Response Is Failing

So why is this getting away from us? It comes down to multiple compounding factors, and most of them are not about the virus.

This is unfolding in a war-torn, militia-controlled region where distrust runs extremely high. That makes it very hard to run the standard Ebola playbook — the same playbook that has shut down dozens of previous outbreaks. The numbers tell the story: only about 20% of contacts are being traced. In some places, teams don't even have motorbikes to physically reach people. Some villages have no soap; people are washing their hands with sand and oatmeal. Labs that are trying to run tests are running out of fuel, so they can't keep their generators going to power the testing.

That last point deserves emphasis as a side note: energy poverty — the lack of reliable access to power — is itself an infectious disease problem. When you can't keep the lights on, you can't keep the diagnostics running.

There's also a case under investigation in Brazil — a 37-year-old man who had been in the DRC, now febrile and isolated. It's unclear whether he has Ebola, and unclear whether he was even in the affected provinces. We'll see. But this is the kind of one-off, imported case we should expect to keep investigating in other countries. I don't suspect many of them will turn out positive, but we have to stay proactive about every one of them.

The WHO Director-General is now on the ground in the DRC and has called for a ceasefire because of the violence. As one article I read put it, you can't do contact tracing in the middle of AK-47 fire. Making sure responders can actually do their jobs is going to be critical.

Travel Bans Are the Wrong Tool

Meanwhile, travel bans keep cascading. The U.S. has one; the U.S. ban effectively begat bans in Canada and the Bahamas; Thailand has imposed a 21-day mandatory quarantine; Rwanda and Uganda have closed borders.

These are the obvious tools politicians reach for, and they feel effective. But they tend to cause paradoxical harm. People travel clandestinely. People hide symptoms. People work hard to get around the restrictions — and in the process, scarce resources get wasted. When you're in a resource-scarcity crisis, that matters enormously. What actually makes sense is targeted travel screening — funneling travelers through designated airports, as the U.S. is doing — not blunt, outright bans.

The Kenya Debacle

The other major issue is what I'll call the Kenya debacle. This was a U.S. plan to treat Americans infected in the DRC at an ad hoc hospital in Kenya, staffed by U.S. Public Health Service personnel who had never worked in an Ebola treatment unit or a biocontainment unit. At the same time, it would have left our 13 existing, fully drilled regional special-pathogen treatment centers — facilities built and paid for by taxpayers for exactly this purpose — sitting idle.

It makes zero sense. My read is that it stems from a strange political impulse to be able to claim zero Ebola infections "in the United States," even when those patients could be treated safely and easily in facilities we already built for the job.

This Kenyan plan — which has now been blocked by the Kenyan courts — would not have delivered standard medical care. You cannot expect an improvised hospital in Kenya, staffed by people who have never managed this disease, to provide the level of care a patient would get at Emory, Nebraska, Johns Hopkins, the NIH, or Boston. There's a whole roster of biocontainment units adept at this. (It's a different story when someone like Dr. Stafford, the surgeon being treated in a proper biocontainment unit in Berlin, is involved — that's a defensible arrangement. Building something de novo in Kenya and expecting equivalent care is not.)

And the failures keep stacking up. PPE is reportedly stuck in customs, which is pure bureaucratic nonsense — the DRC should be allowing the free flow of protective equipment into the outbreak zone. Case management has been described as catastrophic. The U.S. distancing itself from the WHO, and the absence of USAID on the ground, have both been counterproductive. This is simply not how we would have managed an outbreak like this in any other era.

What Could Turn the Tide

There is some forward motion on the medical side. Vaccine trials are beginning. The favored candidate is a Bundibugyo-targeted vaccine from IAVI, built on the same platform as the licensed Zaire vaccine — but it will be months before it's trial-ready. Other vaccines targeted to the relevant strain may be available sooner, along with monoclonal antibodies. Dr. Stafford, for instance, is receiving a monoclonal antibody, and those trials are accelerating. Antiviral trials are also under consideration, including remdesivir and obeldesivir.

The bottom line is hard to write cleanly, but here it is: this is going to get worse before it gets better — the WHO Director-General has said as much — and it will probably end up being at least the second-largest Ebola outbreak ever recorded. The crucial point to remember is that this is not a failure of science or medicine. It's a failure of systems. The tools to master this problem exist. They're just not being deployed efficiently.

Measles: A 30-Year High

Measles is the other story I want to dwell on. Cases in the U.S. have hit a 30-year high — roughly 2,000 in 2026.

My home state of Pennsylvania has logged more cases this year than in 1991, its previous record. Florida saw 154 cases — about twice the state's combined total from the entire preceding 25 years. Florida's outbreak seems to have quelled, and Utah's is slowing, but those are striking records.

There's a piece of Texas data I think is essential, because people keep insisting that measles is basically a head cold — "my great-grandmother had measles and she was fine." Look at the Texas outbreak: 72% of those hospitalized had pneumonia. These are the figures that need to be front and center. People routinely deny the danger of measles, exaggerate the danger of the vaccine, and dismiss the vaccine's benefits. Showing them concrete numbers — hospitalizations, pneumonia — is how you make the real cost of measles tangible, and how you make the case for controlling it.

A lot of misinformation fuels this. In Pennsylvania, 20 school districts had misinformation or disinformation on their official websites directing families to anti-vaccine sites. That underscores the need to hold school board members, administrators, and superintendents accountable when they turn their schools into modern pesthouses — usually because they're afraid to enforce their own vaccine entry requirements. They hand out provisional enrollments, herd immunity slips below the threshold, and the building becomes a tinderbox the moment a single student with measles walks in.

There was also an encouraging story from the Kaiser Family Foundation's reporting on Shasta County, California — a very low-vaccine-uptake area that nonetheless managed a measles outbreak remarkably well. They essentially applied harm-reduction principles to minimize the damage, and some are calling it a model response worldwide.

Internationally, Bangladesh is the major outbreak to watch. That one isn't the fault of the anti-vaccine movement; it's a logistical failure — an interim government that didn't order enough measles vaccine. They've seen hundreds of deaths, though their vaccine rollout does now seem to be quelling the hotspots.

The deeper point is that we shouldn't be talking about measles at all in 2026. It's preventable. What's failing is the infrastructure of trust — the same thing that's failing in the DRC, where much of the population doesn't trust the response or doesn't believe Ebola is real. We see the identical dynamic among many people in the path of measles.

A Hepatitis B Breakthrough

A genuine bright spot: a major advance in hepatitis B. Hepatitis B is a leading cause of liver cirrhosis and liver cancer. It's vaccine-preventable, but once you're infected, you can't clear it, because the virus integrates into your chromosomes. We can put people on treatment, but they have to stay on it for life, and the options aren't great.

GSK has now reported strong results for a drug nicknamed "bep" — bepirovirsen, an antisense oligonucleotide. In plain terms, it binds to the hepatitis B virus's genetic material and shuts it down, dropping the number of viral copies in the blood. It's what we'd call a functional cure: the virus is still present in the body, but it goes largely silent. This isn't 100%, but it's one of the most promising steps we've seen — because patients who respond can potentially be taken off the daily drugs they'd otherwise need forever. That's a real win.

It's also another disease we shouldn't have to discuss this much, because we have a safe, effective vaccine given as a first dose at birth — a dose the anti-vaccine movement has been pulling away from. Thankfully, people are working on additional treatment modalities, because I expect hepatitis B cases to rise as vaccination rates slide.

Antibiotic Resistance: The Slow-Motion Disaster

I keep coming back to antibiotic resistance because it's a slow-moving public health catastrophe. To understand it, you have to think at the level of genes. Multiple resistance genes can move between different species of bacteria, conferring resistance to specific antibiotics. One of the more dangerous is NDM — the New Delhi metallo-beta-lactamase, named for the enzyme it encodes and the place it was first identified.

NDM has now spread everywhere. It used to be rare in the United States — only about 5.4% of resistant E. coli cases were caused by it. That figure is now up to 39.3%. This is one of the hardest resistance mechanisms to treat, and the trajectory shows how fast these mechanisms can travel the globe, become common, and completely reshape how we approach infections.

What's driving it? Over-the-counter antibiotics are freely available in much of the world. Antibiotics get used for the wrong conditions — not just the usual suspects like sinusitis, but, astonishingly, for people with herniated discs (on the mistaken theory that a slipped disc is a bacterial problem — it isn't) and for asthmatic children, when most asthma flares are viral. Even environmental factors like rainfall and temperature appear to correlate with resistance. There are many forces pushing in the same direction. The real question is whether we'll take the actions needed to get ahead of it.

And here's what makes antibiotics unlike any other drug class: whether you use them inappropriately or appropriately, bacteria will develop resistance. That's not true of, say, a cholesterol drug — misusing a statin doesn't degrade how well statins work for everyone else. With antibiotics, it does. That's why this demands real policy solutions, like the PASTEUR Act, which would decouple a pharmaceutical company's revenue from the volume of antibiotics it sells — the so-called "Netflix model" I've mentioned before. This is a problem that bears a lot more watching.

AI Enters the Fight

The last major thread this week is artificial intelligence entering the battle against infectious disease — and I think it has real potential to change how we approach these problems.

A few stories caught my eye. There's a Toronto company called BlueDot that runs an AI platform mining open-source data to detect outbreaks. Plenty of groups are doing this now, but BlueDot is a notable example, and Wired ran a piece this week about its work around the World Cup. The World Cup is a mass-gathering event, and people keep fixating on exotic threats like Ebola or hantavirus. That's not what you need to worry about at a stadium. The real risk is crowd diseases — measles, influenza, COVID, RSV, norovirus, sexually transmitted infections. Those are what tick upward. Interestingly, BlueDot's data-mining in Argentina had flagged a rise in Andes hantavirus before the ship outbreak there, meaning the signal was building in the community first. So these tools genuinely add value, and they're using AI to do it.

Staying with the World Cup: there was a good story out of Seattle, one of the host cities, where hospitals are cooperating as a coalition. That's notoriously hard to pull off, because these institutions are usually competitors that don't want to work together. But Seattle's coalition reportedly includes load balancing — making sure no single hospital absorbs the bulk of patients. That's not an AI story, but it's a smart, system-level move worth highlighting.

On the AI side proper, OpenAI has released a model called Rosalind — almost certainly named for Rosalind Franklin, one of the underappreciated figures behind the discovery of DNA's structure. It's a dedicated biosecurity and biodefense model built end to end, from epidemiology all the way through medical countermeasure development. I think this is genuinely exciting. I've written about the use of AI in medical countermeasures, and I'm a big believer; a purpose-built biodefense model could meaningfully accelerate our ability to respond to bio-threats.

A few other AI uses crossed my desk this week. The Brigham used AI to comb electronic medical records for long COVID symptoms and arrived at a striking figure — one in six. I think that's an overestimate, but it's not the AI's fault; the real problem is that we still lack an objective definition of long COVID. Even so, it's a powerful demonstration of what these tools can do. AI sepsis-prediction tools also continue to evolve and remain a major investment for hospitals. That matters: Kyle Busch recently died after pneumonia progressed to sepsis, and being able to predict who's headed for severe sepsis is an important task.

If you had to sum it up, AI is the mirror image of this week's failures — technology stepping in precisely where human systems are breaking down. I think this is the future of outbreak detection and response.

Two More Wins Worth Noting

Two final items, both encouraging.

First, a drug from Shionogi — ensitrelvir, brand name Xocova — was approved by the FDA for post-exposure prophylaxis of COVID-19. This is the first such drug: get exposed to COVID, take ensitrelvir, and your chance of developing symptomatic infection drops by 67%. That's a meaningful new tool — for nursing homes, for someone with an important event in the next few days they can't afford to be sick for, or for anyone living with a high-risk person who gets exposed. A welcome addition to the armamentarium.

Second, mpox cases are picking up in Boston, and officials are encouraging vaccination. Mpox never went away. It's still circulating within sexual networks of men who have sex with men, and many people in that risk group still haven't been vaccinated — which is exactly why we keep seeing cases. This is another problem that policy can solve, by optimizing implementation to get the at-risk population the two doses they need.

The Lesson Underneath All of It

Every story here carries the same lesson. The pathogens themselves are old news — Ebola, measles, antibiotic-resistant bacteria have all been with us for decades. What's different is whether the systems around them are working. This week, a lot of them weren't.

But the hepatitis B functional cure, AI-driven outbreak surveillance, lenacapavir for HIV (a twice-yearly injectable pre-exposure prophylaxis I didn't get to above), and ensitrelvir for COVID post-exposure prophylaxis are all proof that the systems can work — that human beings can build scientific and technological solutions equal to these threats.

The only real question is whether we choose to build more of them, or keep dismantling the ones we have and walking ourselves back toward the dark ages instead of forward into the next technological one.

Long before microbes were understood, people often explained epidemics through monsters. Vampires, witches, curses, and demons were attempts to impose agency on otherwise mysterious illness.

The vampire is often associated with disease causing rats and bats. His Transylvanian soil required for travel can be “sterilized” with Eucharist wafers to force him to flee back to his home. Vampirism was also thought to be related to tuberculosis as individuals consumed by the disease were thought to be being consumed by vampires rising from coffins.

I’ve written about how I liken being an infectious disease physician to being akin to a Ghostbuster, Indiana Jones, a Man in Black, and an exorcist but it is also like being a vampire slayer.

When it comes to vampire slayers, there is only Buffy — and Faith. I absolutely relished the Romanticism of the movie Buffy the Vampire Slayer but the series starring Sarah Michelle Gellar was really where the parallel with infectious disease was most apparent. Not only did Buffy and her clan have to battle myriad monsters (i.e., different pathogens), they consulted librarian Giles to research what they were up against (i.e., made diagnoses). Different countermeasures were directed at different creatures, just like in infectious disease.

There’s another really poignant scene I’ve been thinking about from that series that concretizes an important point about infectious disease control. When infectious disease control systems are working, they’re invisible. Unbeknownst to the individuals being protected, it is keeping people safe. The “it” here are the epidemiologists, the public health department personnel, the microbiologists, and the infectious disease physicians. To paraphrase Men in Black: they go to places you need not go, see things you need not see.  Rarely do they get thanks — infectious disease is one of the least financially lucrative areas of medicine.

This invisibility can also work against them as people are unaware of what is keeping the demons at bay, beating the devil back; the victories are largely invisible to the people they protect. When the outbreak doesn't happen, nobody cheers. When the pandemic doesn't spread past its index case because someone in a state health department noticed a cluster and made the right calls in the first seventy-two hours, nobody hands out awards. When vaccination programs keep measles from circulating in a school, the kids who didn't get encephalitis don't know they didn't get encephalitis. The Ghostbusters don't get a parade after defeating Gozer. They get their funding cut and their lab shut down by an EPA regulator.

Similarly, public health agencies are subject to neglect and cuts in funding, vaccines are devalued and smeared, infectious disease expertise is attacked. We see the results plainly with measles re-establishing endemicity, Ebola outbreaks festering for over a month unnoticed, and minimal situational awareness of avian influenza.

Buffy has spent three years defending Sunnydale High from a parade of horrors — demons, zombies, hyena-possessed students, a principal who turned out to be a robot, and vampires. Nobody talks about it. Nobody acknowledges it. The monsters are fought mostly in the dark, largely alone, and when it's over, the next day proceeds as though none of it happened. The ordinary life of ordinary people continues precisely because someone was doing extraordinary work they couldn't see.

Then, at the prom, a student named Jonathan takes the microphone and reads from a card:

"We're not good friends. Most of us never found the time to get to know you. But that doesn't mean we haven't noticed you. We don't talk about it much, but it's no secret that Sunnydale High isn't really like other high schools. A lot of weird stuff happens here. But whenever there was a problem, or something creepy happened, you seemed to show up and stop it. Most of the people here have been saved by you, or helped by you, at one time or another. We're proud to say that the Class of '99 has the lowest mortality rate of any graduating class in Sunnydale history."

Buffy is named “class protector”.

That’s the closest most people ever get to understanding what public health actually does — not a press briefing, not a policy paper, but a kid at a microphone trying to put words to something he can’t quite name.

That's how infectious disease preparedness and public health work.

The people who keep pathogens from killing you are working with the same energy whether you're paying attention or not.

Prior to this scene Buffy states that she just wants her classmates to have a normal prom, no matter how many people she has to kill.

That’s what the entire infectious disease apparatus is doing as well — trying to give everyone a normal life where they can pursue their values and achieve, free from the dread and disruption of infectious disease.

That is the mission of infectious disease control.

Not to dominate people’s lives. Not to control society. Not to make itself visible.

The goal is to make normal life possible.

But civilization is full of unseen guardians.

Some carry stakes. Some carry microscopes.

Class protector — civilization protector —infectious disease physician.

What is it that an infectious disease physician does, what is their aim, what does the diagnosis and treatment of infections on a planet teeming with microbial life amount to?

First, every infectious disease physician stands as an intellectual descendent of a great lineage stretching back to Jenner, Pasteur, Koch, and Fleming and to D.A. Henderson. Those epoch-making minds were trying to solve real human problems that diminished the ability of humans to flourish. Their solutions — which include the germ theory of disease, vaccinology, and antibiotics—unequivocally augmented the length of human lifespans, diminished infant mortality, and facilitated much of modern medicine from chemotherapy to organ transplants to joint replacements.

As such, they advanced civilization. Every infectious disease physician, in their taming of even the most mundane of infections, is doing the same.

For much of human history, infectious diseases were a rate limiting check on human societies. A society might become too populous and invite crowd diseases such as measles, smallpox, and diphtheria to spread and cull the population. A society might become geographically tied to malarious areas or committed to cultural or gastronomical practices that increased interactions with specific animals, mosquitoes, and other vector species.

There have been 10,000 generations of humans and it is only the last 3-4 generations that humans have had some level of control and mastery of infectious diseases. What has transpired in that short period of time is arguably one of the most profound transformations in human history: a partial liberation from the microbial forces that shaped every preceding generation. In fact, it probably wasn’t actually dread as those humans were acclimatized to that baseline level of suffering, death, disruption, suboptimal lifespan, and atrocious level of infant and childhood mortality that throttled their individual achievements and ability to reach the full potential of human life. That acclimatization still exists today in malaria endemic areas as Botswana’s President Boko recently argued).

Yet describing infectious disease as a constraint on human societies only raises a deeper question. Why does it matter that we have gained some measure of mastery over microbes? What is the purpose of that mastery? Is the goal of infectious disease

medicine simply the prevention of illness and death, or is it directed toward some higher end?

Aristotle, in the Nicomachean Ethics, argued that every craft, discipline, and human endeavor aims at some good, a telos or goal. Behind all of the intermediate or instrumental goals that people pursue lies an ultimate end: eudaimonia—human flourishing or living well.

If Aristotle is right then infectious disease medicine must also have a telos. That telos cannot simply be the eradication of pathogens any more than the purpose of architecture is the production of bricks. Pathogens are the obstacle. The end is something larger than being a pathogen hunter: preserving the conditions under which human beings and human societies can flourish.

An infectious disease physician, in my view, is a guardian of the conditions that allow civilization to flourish in the presence of pathogens. We are, to borrow the title of science writer Maryn McKenna’s excellent book on the CDC’s Epidemic Intelligence Service (EIS), “beating back the devil” in order to advance human civilization. During the COVID-19 pandemic, this role became explicit. Infectious disease physicians were called upon not merely to treat patients, but to help societies reopen schools, workplaces, hospitals, and public life itself, in effect being relied upon to bring civilization back in the wake of the pandemic.

There’s a scene in the movie Ghostbusters: Afterlife (I know, I try to tie this movie franchise to everything), where the teenage granddaughter of Dr. Egon Spengler, Phoebe Spengler, is asked to explain what she’s doing — battling ghosts and investigating the paranormal—she replies simply “I am a scientist”. That scene encapsulates everything of what it is, to me, to be an infectious disease physician.

In that sense, I believe highest achievement of infectious disease medicine is not the conquest of microbes themselves, but the expansion of human freedom, civilization, and possibility through mastery of the microbial world. The late Jonathan Mann, the iconic former chief of the UNAIDS precursor agency at WHO, former state epidemiologist of New Mexico, and CDC leader once said what I deem as one of the greatest ways to describe the field of infectious disease. Writing about HIV/AIDS—but it applies to all infectious diseases—Dr. Mann said, “When the history of AIDS and the global response is written, our most precious contribution may well be that, at a time of plague, we did not flee, we did not hide, we did not separate ourselves.”

That, ultimately, is what infectious disease medicine is.

Kenya’s doctors’ union called the country a “dumping ground.” The Law Society of Kenya pointed out the obvious: Secretary of State Marco Rubio had just told a Cabinet meeting that the United States “cannot and will not allow any cases of Ebola to enter the United States.” If America, a first-world country, won’t accept that risk, why should Kenya?

Rubio’s line is telling. It is not an epidemiological or a medically-grounded statement. It is a political one — and it is the same political statement that has driven American infectious disease policy toward foreigners, immigrants, and “outsider” populations for decades, from both parties. It is almost always wrong. It is almost always damaging. And it never seems to go away.

The country that built 13 Ebola centers and then refused to use them

After the 2014 West Africa Ebola outbreak, the United States created something remarkable: a network of 13 specialized Ebola treatment centers with high-level biocontainment capacity. These are facilities designed specifically for this scenario — a highly lethal virus, limited natural contagiousness, spread through direct contact with blood and body fluids. They are the right tool for exactly this moment.

Instead of using them, the administration flew Dr. Peter Stafford — a 39-year-old American surgeon and medical missionary who was infected with Bundibugyo Ebola in DRC while treating patients — to Charité University Hospital in Berlin, Germany. His wife, Dr. Rebekah Stafford, and their four children were evacuated there too for monitoring. A second missionary doctor potentially exposed, Dr. Patrick LaRochelle, was quarantined at Bulovka Hospital in Prague, Czech Republic.

Two American physicians. Eight family members. Four countries. Zero American Ebola treatment centers used.

On May 18, the CDC (acting director Jay Bhattacharya signing the order) invoked Title 42 of the Public Health Service Act to bar non-citizens who had been in DRC, Uganda, or South Sudan from entering the United States. Four days later, the administration extended this authority to cover green card holders — lawful permanent residents — something the COVID-era Title 42 did not do, something none of Trump’s prior travel bans had done.

This is not a public health measure. It is the same ancient reflex, dressed in modern legal architecture.

The 1987 original sin

We have been here before.

In 1987, Senator Jesse Helms successfully added HIV to the list of “dangerous contagious diseases” that rendered foreign nationals inadmissible to the United States. The scientific logic was essentially nonexistent: HIV is not transmitted through casual contact, it does not spread through air or water, and the mode of transmission (sex, needles, blood products) is identical regardless of a person’s country of origin. HIV was, for 22 years, the only disease explicitly named by Congress in the Immigration and Nationality Act as grounds for denying someone entry to the United States.

The policy did not slow HIV transmission within the US. The epidemic spread anyway — through American communities, American hospitals, American blood banks. What the ban did do: it stigmatized an already-stigmatized population, deterred disclosure and testing, and sent the message that this disease was something that came from outside, brought in by foreign others, rather than something that spreads wherever the conditions that enable it exist.

It took until 2009 — George W. Bush signing the repeal authority and Obama’s HHS formally removing HIV from the inadmissibility list — to correct a policy that was wrong from the moment it was written. Twenty-two years of political theater, dressed as public health.

Biden punished South Africa for being honest

Administrations of both parties have played this game. In November 2021, South Africa’s scientists did exactly what the global health community asks countries to do: they identified a new, potentially significant COVID-19 variant, sequenced it rapidly, and reported it immediately to the WHO. Within days, President Biden banned travel from South Africa and seven neighboring countries.

As I said at the time: “They discovered a new variant, they sequenced it, they let the world know. Shouldn’t you be praising them? What is the incentive for the next country that identifies the next important variant if their reward is what President Biden did to South Africa?”

Omicron had already been detected in Europe, Canada, Australia, and the UK before the ban was even announced. The ban didn’t prevent Omicron from arriving in the US — it arrived almost immediately. What it did accomplish was economic punishment for scientific transparency, and the establishment of a precedent that will make every future South Africa think twice before being forthcoming.

The International Health Regulations — the internationally agreed framework for pandemic response — do not recognize travel bans as an effective public health tool. That has not stopped governments from reaching for them every single time, because they are politically useful. They look decisive. They tell voters you are doing something to keep them out.

The current Ebola response is an object lesson in what this reflex costs

The 2026 DRC Ebola outbreak is caused by the Bundibugyo species — a rare variant that standard diagnostic tests initially missed. That diagnostic delay is the main reason this outbreak, which should have been caught in the 20-to-30-case range, reached over 1,000 suspected cases before the world got a clear picture of what was happening. The delay was likely compounded by USAID dismantlement and disarray at the RFK-controlled CDC.

The travel ban does not address any of these problems. It does not improve diagnostic capacity in DRC. It does not send resources to the outbreak zone — in fact, it makes it harder to get resources and personnel in, because it chills the willingness of healthcare workers to volunteer when their ability to return home is uncertain. My colleague Alex Phelan made exactly this point in The Guardian. The cascading effect on air travel to the entire region means that even countries not named in the ban face reduced access.

Meanwhile, the US has 13 world-class Ebola treatment centers sitting empty. Dr. Stafford was sent to Germany not because Germany has better biocontainment infrastructure — it doesn’t — but because “no Ebola cases on US soil” is a political goal shorn from any grounding in medicine or epidemiology.

RFK Jr. blames immigrants. Here’s what he’s evading.

At a House Energy and Commerce Committee hearing on April 21, 2026, Health Secretary RFK Jr. — facing questions about the ongoing measles outbreaks spreading across multiple US states — said this: “It has nothing to do with me. If you’re worried about polio and tuberculosis, you should look at the immigration policies in this country. ‘Cause the place where it’s occurring are the places where the immigrants are going, because they’re not vaccinated.”

This statement requires a specific kind of rebuttal, because it is not just factually wrong — it is the inversion of what actually happened.

The current US measles outbreaks are concentrated among unvaccinated American citizens. The Texas outbreak started in a Mennonite community. South Carolina. Utah among fundamentalist Latter-day Saints. Florida. These are not immigrant communities — they are communities where American parents, influenced by the anti-vaccine movement, declined to vaccinate their children. The Mexico measles outbreak was seeded from Texas, not the other way around.

But there is a more specific and damning story here. The most striking example of vaccine hesitancy in an immigrant community in recent US history is the Minnesota Somali community — which suffered a major measles outbreak in 2017 and again in 2024. MMR vaccination rates among Somali children in Hennepin County had fallen from over 90% before 2008 to just 35.6% by 2014. That didn’t happen spontaneously. It happened because anti-vaccine groups — including Robert F. Kennedy Jr. and Andrew Wakefield — specifically targeted the Somali community with the false autism-MMR link. They held meetings in the community. They distributed materials. They exploited an existing, understandable anxiety about autism rates in the Somali-American population.

RFK Jr. and his allies created the conditions for vaccine hesitancy in a specific immigrant community. Then he stood in front of Congress and blamed immigrants for vaccine-preventable disease outbreaks.

The audacity of that position deserves to be stated directly and clearly, because it is not just hypocrisy — it is a continuation of the same tactic. Point at the outsider. Direct attention away from the actual cause. Repeat.

Title 42 for measles and TB: theater, not science

Earlier this year, the Trump administration considered reinvoking Title 42 — the pandemic-era border expulsion tool — based on claims that migrants were driving measles and tuberculosis into the United States. In March 2025, immigration law expert Agustina Vergara Cid and I analyzed this in STAT News, and the conclusion was straightforward: there is no epidemiological basis for this claim.

The bulk of US tuberculosis cases occur in legal migrants from Asian countries, diagnosed decades after arrival — not in asylum seekers from the southern border. The 2024 Chicago measles outbreak linked to Venezuelan migrants at a shelter was real — but the entire Western Hemisphere had re-achieved measles elimination status by that point, and the actual vulnerability driving US measles spread is domestic vaccination refusal, not importation from the south.

Our threshold for when an infectious disease border declaration could be legitimately contemplated is: the disease must be severely serious, must lack simple countermeasures, and must pose an epidemiologically significant importation risk. Measles has a vaccine. Tuberculosis can be diagnosed and treated to render the person non-infectious. Neither condition came close to meeting that threshold.

As we wrote in STAT: “Title 42 did nothing to blunt the impact of Covid-19 either — like the current scenario, it was a brazen attempt to use a crisis to achieve a separate policy goal.”

The CDC should not be a tool for immigration enforcement. When it is, it loses the credibility it needs to do its actual job. That is the real cost of this reflex.

What actually determines whether a disease spreads

Here is the thing about infectious disease that gets lost in every iteration of this debate: the pathogen does not check passports.

What determines whether a disease spreads in a population is not the nationality of the person who carries it into the country. It is whether the population they encounter is vulnerable to it and the transmission characteristics of the pathogen (Ebola is very constrained in that regard depending on blood and body fluid emanating from symptomatic patients). That vulnerability is a function of vaccination (when available) rates, surveillance capacity, and the ability to identify and contain cases quickly. A community with 95% MMR vaccination coverage is inhospitable to measles regardless of who crosses its border. A community where MMR rates have been driven to 35% — by a deliberate disinformation campaign — is a tinderbox waiting for a spark, regardless of whether the spark is an unvaccinated American returning from Europe or an unvaccinated immigrant from a country with low coverage.

What changes is not the science. What changes is which outbreak politicians need to deflect accountability for.

The cost we keep paying

Every time the “foreigner as vector” reflex runs its course, it costs something real.

The HIV ban didn’t stop HIV. It delayed testing, delayed treatment, and drove infected people away from the healthcare system for 22 years.

Biden’s Omicron ban didn’t stop Omicron. It established that countries which report new variants honestly will be economically punished — a precedent that makes the world less transparent about the next one.

The Title 42 Ebola ban and green-card expansion is a political tool, not an outbreak management tool. The ban does not make us safer. We have thirteen cutting-edge unrivaled centers that can handle and have handled Ebola if an American healthcare worker is infected. What the ban will do is make it harder to get responders into the outbreak zone, harder to sustain the international cooperation that containment requires, and easier for an outbreak growing at 1,000+ suspected cases to escape the region entirely.

The Kenya facility — courts permitting — would have quarantined Americans in a country with no Ebola infrastructure rather than use the infrastructure we spent a decade building, all to satisfy a political calculus that says “no Ebola shall touch US soil.”

And RFK Jr.’s immigrant-blaming, delivered under oath to Congress, will go into the record as the official government explanation for why measles is spreading in communities that his own movement depopulated of vaccine confidence.

These are not separate stories. They are expressions of the same idea: that the disease comes from them, not from us. That if we can just keep them out, we will be safe.

It is an idea with a perfect record of failure and a perfect record of political utility. That combination is why it keeps coming back.

The answer is not to restrict the movement of people. The answer is to build the population resilience — vaccination coverage, surveillance, treatment access — that makes any pathogen’s arrival an inconvenience rather than a catastrophe. We know how to do that. We have the tools to master this problem. We keep choosing not to use them, and then looking for someone to blame when the outbreak comes anyway.

Infectious Disease News Briefing | Week Ending May 24, 2026

This week was a stark reminder that the greatest threat to global health security isn't always the virus itself — it's the systems we build, and then deliberately dismantle, to catch it. From a fast-moving Ebola outbreak in the Congo to a record-breaking measles year at home, the story of this week wasn't just what's happening. It was why it keeps happening.

The Ebola Outbreak: A Four-Week Head Start for the Virus

The dominant story of the week, and arguably one of the most significant infectious disease events since COVID-19, is the Ebola outbreak now burning through the Democratic Republic of Congo. The WHO Director-General took the rare step of declaring a Public Health Emergency of International Concern (PHEIC), the third such declaration for Ebola in history. Notably, he acted without convening the emergency committee first, a sign of how urgently the situation demanded a rapid response.

What We Know

The official case count stands at approximately 1,000 suspected cases, almost certainly an underestimate. Epidemiological modeling suggests the outbreak has been underway for several weeks longer than initially known, meaning the real number is likely substantially higher. This outbreak will almost certainly become the second-largest Ebola outbreak in recorded history, and may yet surpass the 2014–2016 West Africa outbreak as the largest.

The culprit is the Bundibugyo species of Ebolavirus, the third most common strain, responsible for prior outbreaks in DRC and Uganda. This matters enormously for one critical reason: Bundibugyo is not included in standard Ebola diagnostic kits. Initial testing came back negative because labs were screening for the more common Zaire and Sudan strains. The Bundibugyo sample was never rapidly processed to identify less common species, and by the time the correct diagnosis was made, the virus had been spreading, undetected and unchecked, for approximately four weeks.

Four weeks of unimpeded transmission for a virus like Ebola creates enormous momentum, and enormous catch-up work.

Geographic Spread

The outbreak has now spread across at least three provinces in DRC (Ituri, the epicenter; North Kivu; and South Kivu) and has crossed the border into Uganda, where there are already approximately five confirmed cases, including fatal cases among healthcare workers. Neighboring countries like South Sudan should be considered at risk.

Countermeasures and Complicating Factors

Contact tracing has been severely hampered by logistics: roughly one in five contacts cannot be followed up, due in part to simple shortages of motorbikes needed to reach remote communities. Authorities have banned gatherings of more than 50 people at wakes and funerals, which are historically high-transmission settings for Ebola, though compliance will likely be uneven.

Two Ebola treatment units have already been burned down by local residents resistant to outside interventions, including foreign burial practices. This is not surprising: survey data from a prior North Kivu outbreak found that 12% of the local population believed the outbreak was fabricated. Community trust is a public health resource, and it must be rebuilt painstakingly.

One infected American, Dr. Stafford, has been evacuated to Germany, where he is reportedly improving after receiving a monoclonal antibody therapy. There is hope it may offer some cross-protection, though it was originally developed against Zaire Ebolavirus. BARDA (the Biomedical Advanced Research and Development Authority) is advancing monoclonal antibodies and has issued requests for proposals to use AI to develop countermeasures against filoviruses. An Oxford-developed vaccine may be deployable within approximately three months.

In the pipeline: Gilead's antivirals remdesivir and obeldesivir are entering clinical trials as post-exposure prophylaxis. Remdesivir's prior performance against Zaire Ebola was unimpressive, but its role in post-exposure settings remains to be seen.

An important caveat worth internalizing: we have no approved countermeasures for Bundibugyo, Sudan, or Marburg viruses. All existing tools (vaccines and monoclonal antibodies) are specific to Ebolavirus Zaire.

The Real Story: Hollowed-Out Infrastructure

The Ebola outbreak is the headline. The infrastructure collapse is the story underneath it.

The four-week detection gap almost certainly wasn't inevitable. USAID had active projects in DRC before the agency was gutted. Even if those projects couldn't have prevented the outbreak entirely, they would have provided on-the-ground presence: the kind that spots an anomalous cluster of hemorrhagic fever cases weeks before it becomes a crisis. That lead time could have saved lives and blunted the outbreak's momentum.

Consider the cascade of institutional losses:

CDC: More than 700 staff and contractors have been eliminated, including the head of high-consequence infectious disease.

USAID: Dismantled. Its DRC presence is gone.

NIAID: Acting director Jeffrey Taubenberger resigned under unclear circumstances, representing yet more infectious disease leadership vanishing from the United States.

ACIP (Advisory Committee on Immunization Practices): After a federal judge ruled its dismantling illegal and a reconstitution was ordered, the recharter plan has now been withdrawn. ACIP is effectively a non-entity.

The one bright spot is BARDA, which remains functional. The DNA for Operation Warp Speed lives there, and this week's Ebola response reflects that institutional memory. Its ongoing AI-focused countermeasure work gives some cause for cautious optimism.

But the larger pattern is troubling: the tools to master these outbreaks exist. The science and technology challenges have largely been solved. What remains is the will, and the institutions, to deploy them. When those institutions are systematically stripped away, the tools sit unused.

Avian Influenza: The Threat No One Is Watching

If there is a slow-moving emergency that deserves far more attention than it receives, it is avian influenza. It may be the single greatest pandemic threat the world faces right now, and it receives a fraction of the media coverage of diseases like Ebola.

This week's developments:

H5N5, a strain of avian influenza, killed a polar bear and walruses in Svalbard, Norway. These are mammals, and mammalian infections with avian influenza are precisely the warning signal that virologists watch most closely, because humans are mammals too.

Four new poultry farm outbreaks were reported in the US this week, in Minnesota and Indiana.

The surveillance gap around infected farm workers is deeply concerning. When poultry farms report outbreaks, how much testing is happening among the humans who work there? What is the denominator of exposed individuals? The honest answer is: we largely don't know. It's a black box.

Every week, there are developments in avian influenza. Every week, most of the coverage goes elsewhere. The mismatch between the threat level and the public attention paid to it remains one of the most significant gaps in infectious disease communication.

Measles: A Record-Breaking Year With a Political Root Cause

The United States is in the midst of its worst measles year in decades, a record driven not by scientific failure but by a failure of policy and leadership.

Highlights this week:

Pennsylvania is reporting 34 cases, the highest since 1991, when a major outbreak included deaths. A multi-county cluster is active across Dauphin, Berks, and Lebanon Counties.

Investigative reporting by the Pittsburgh Post-Gazette has revealed that 20 Pennsylvania school districts have since 2018 been directing parents to anti-vaccine websites via their official school webpages. Those districts, not coincidentally, show lower vaccination rates.

The Utah outbreak remains the most active in the country.

The South Carolina outbreak, the largest of the year, has been declared over. Post-outbreak analysis points to low vaccine uptake among Russian and Ukrainian immigrant communities as a primary driver.

A massive measles outbreak in Mexico traces directly to US and Canadian Mennonite populations, with anti-vaccine propaganda in English being found door-to-door in Mennonite communities, indicating the disinformation is being exported from the United States.

The common thread across these outbreaks is tightly-knit communities with low vaccine uptake: tinderboxes waiting for a spark. Addressing these enclaves requires targeted outreach, cultural competency, and sustained trust-building. The policy apparatus that would coordinate that work, ACIP, is gone.

Professional societies including the Infectious Disease Society of America, the American Academy of Pediatrics, and the American Academy of Family Medicine will need to fill that vacuum.

RFK Jr. and the Gavi Funding Standoff

The ongoing dysfunction around vaccine policy was thrown into sharp relief this week by the news that Gavi (the global vaccine alliance responsible for immunizations in low-income countries) is having its US funding withheld by Health and Human Services Secretary Robert F. Kennedy Jr.

His objections center on two issues:

Thimerosal, a mercury-based preservative used in multi-dose vaccine vials that is essential in the developing world. Thimerosal's safety has been established by decades of evidence. Kennedy's opposition to it is a well-documented and long-disproven fixed belief.

The whole-cell pertussis vaccine used in Gavi's DTP formulation. The whole-cell vaccine is more effective than the acellular version used in the US, though more reactogenic. The acellular vaccine's adoption in the US was itself driven by an anti-vaccine documentary called Vaccine Roulette that unfairly maligned the whole-cell version decades ago, and that shift resulted in reduced effectiveness against pertussis.

Critically, Kennedy's objections are not based on foreign aid principles or fiscal concerns. They are expressions of two specific, scientifically unfounded beliefs, applied globally, at the expense of children who depend on those vaccinations in the world's most vulnerable settings. The human cost of this policy is immeasurable.

The Bigger Picture: Tools Without the Will to Use Them

The tools are extraordinary. mRNA vaccine platforms. Molecular diagnostics. Machine learning for outbreak forecasting. CRISPR-based antivirals in the pipeline. The science has outpaced what many thought possible even a decade ago. These are masterable problems — the scientific and technological barriers have largely been cleared.

What hasn't been cleared is what might be called the Dark Ages mentality: a cluster of beliefs and policy decisions that actively throttle the deployment of these tools. It is, in the clearest terms, anti-human: an agenda that prioritizes ideology over flourishing, fixed ideas over evidence, and institutional destruction over the patient, unglamorous work of building systems that keep people alive.

The question every reader, patient, clinician, and policymaker should be asking when the next outbreak appears (and there will be a next one) is this: Why did this happen? What could we have done differently? Do we have the tools, and did we choose to use them?

If that question gets asked loudly enough, and often enough, we may yet find our way back to the infrastructure that prevents a four-week detection gap from becoming a humanitarian catastrophe.

This briefing covers the week ending May 24, 2026, and is based on publicly available outbreak reports, official WHO and CDC communications, and expert clinical analysis.

By the time you read this, the official case count is approaching 1000. The real number is higher. That gap isn’t a mystery — it’s the direct consequence of a diagnostic delay that gave the virus a several week head start. Bundibugyo is a rare species of Ebola, having caused just two prior outbreaks, and initial testing, targeted to the far more common Zaire species, missed it. By the time anyone knew what they were dealing with, untraced transmission chains were already in motion. Typical Ebola outbreaks get flagged when there are 20 or 30 cases, beginning containment when cases are in the triple digits with significant momentum is a different containment problem entirely.

This is exactly the kind of failure I testified about before the House Foreign Affairs Subcommittee in 2021. I argued then that we have a “biological dark matter” problem — undiagnosed clinical syndromes circulating everywhere, containing early signals we’re not catching because our diagnostic infrastructure isn’t looking for them. Far too many unknown infectious syndromes — from Pittsburgh to Bunia — go without a specific microbiologic diagnosis. The 20,000+ case West African Ebola epidemic of 2013–2016 offered the same lesson: Ebola had been circulating for over a decade mixed in with (and likely mistaken for) Lassa Fever cases. Guinea took three months to realize it was dealing with an Ebola outbreak and not cholera. The trajectory of the current DRC outbreak echoes the past.

What made this outbreak worse is that the US surveillance infrastructure that would have sounded the alarm earlier has been dismantled. USAID, which operated in the DRC, was impacted by DOGE program. In addition, the director-less and RFK Jr-beholden CDC has lost over 700 people from its emerging-disease activities — employees and contractors — including the head of the high-consequence infectious disease group directly responsible for Ebola response. The storied agency that was once first on the ground, first to brief the world, now can’t even participate directly with the WHO without asking permission.

A major aspect of the US response to all this has been a travel ban — on DRC, Uganda, and South Sudan. It is the wrong move, for the same reasons it has always been the wrong move. Travel bans, though a favorite tool of politicians who want to appear as if doing something, impede the flow of personnel and resources into outbreak zones. Healthcare workers who might volunteer to fight this outbreak will now have to contemplate being corralled by the policy. Other countries follow suit with cascading bans. As such, the International Health Regulations oppose travel bans. They are not evidence-based and objectively harmful. Targeted travel screening is what works. Blanket restrictions have the very real potential to postpone the extinguishing of outbreaks at their source. Critically, the US has 13 NETEC biocontainment treatment centers built precisely for this, and we should be vigilant and proactive without being rattled.

There is also a countermeasure reality to face: there are no approved vaccines or specific treatments for Bundibugyo ebolavirus. The drugs that worked so well in the DRC’s 2018–2020 outbreak are specific to Zaire ebolavirus. They don’t reliably cross-protect against Bundibugyo. BARDA is advancing a monoclonal antibody that targets Ebola Sudan and may have some cross-reactivity (it is likely the treatment that Dr. Stafford has received in Germany), and Oxford and the Serum Institute of India are working on a vaccine using the AstraZeneca COVID platform that might be field-deployable within months.

This countermeasure gap extends to other filoviruses as well. Neither Ebola Sudan nor Marburg, both of which have causes recent outbreaks, have countermeasures as well. These are filoviruses with case fatality rates that routinely exceed 50 percent, and we have had no licensed tools against them. We built countermeasures for Zaire ebolavirus in response to its potential use as a bioweapon and the magnitude of the outbreak 2014. We have not applied the same urgency to the rest of the family, and every outbreak of Sudan virus or Marburg is a reminder of why a viral family approach is desperately needed.

The post-COVID media continually wants to know if this outbreak is “the next COVID” (as they did for hantavirus). The answer is no — Ebola spreads through blood and body fluids, not the respiratory route. Its transmission is constrained. Ebola is a virus that spreads through direct contact with the bodily fluids of the sick and the dead — it finds exactly what it needs in overwhelmed clinics with no PPE and burial traditions that involve touching the body, but the moment it lands somewhere with isolation rooms and infection control, it is quickly stopped in its tracks. They also mention The World Cup. Mass gathering events are perfect venues for crowd diseases such as those caused by a respiratory or gastrointestinal virus — measles, influenza, COVID, norovirus — diseases that spread through the air and via causal contact requiring little more than proximity. Ebola requires you to be in direct contact with someone who is visibly, severely ill and is not a crowd disease.

The real worry isn’t what Bundibugyo will do to the American public. It’s what our hollowed-out response infrastructure will do when the US inevitably faces a true pandemic threat.