This week in infectious disease: an Ebola outbreak we are playing catch-up with, a measles resurgence that is happening by choice, and the institutions meant to protect us being weakened from the inside. None of it is fate.
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.
