Ebola, TB, and the Cost of Walking Away from Global Health

On April 24, 2026, a nurse in Ituri Province in the Democratic Republic of the Congo (DRC) developed a fever. She died three days later. Her samples were tested locally and returned negative, because the standard field assays in country were designed to detect the Zaire strain of Ebola, not the rare Bundibugyo variant she was carrying. The specific test required to identify her infection was not part of the standard panel. The samples had to travel more than a thousand miles to a lab in Kinshasa, where the Bundibugyo strain was confirmed on May 14. Three days later, the World Health Organization (WHO) declared a Public Health Emergency of International Concern. By May 25, the U.S. Centers for Disease Control and Prevention (CDC) was reporting 906 suspected cases, 105 confirmed cases, and 234 deaths in the DRC, with confirmed cross-border transmission into Uganda. There is no approved vaccine and no targeted antiviral for the Bundibugyo strain. The DRC is now responding to its seventeenth Ebola outbreak since the virus was identified there in 1976. It is also the first one happening without the global health architecture the United States built to fight it.

How an Outbreak Stays Hidden for Weeks

The detection delay is the through-line of this story. U.S. Agency for International Development (USAID) officially closed on July 1, 2025, with roughly 80% of its global health awards terminated and $12.7 billion in committed funding pulled. The U.S. withdrew from the WHO effective at the start of 2026. By the time the index case in Ituri developed symptoms, the community health workers, contact tracers, and laboratory logistics networks that had carried every prior DRC Ebola response had already been defunded for months.

The financial collapse is documented. U.S. foreign assistance to the DRC dropped from $1.4 billion in 2024 to $431 million in 2025 and to roughly $21 million so far in 2026. Department of Health and Human Services aid to the country fell from about $33 million in FY2024 to under $10 million in FY2025. The WHO's Contingency Fund for Emergencies, created after the 2014-2015 West African Ebola epidemic and historically backed in significant part by the United States, has received only $5.4 million in total donor contributions for 2026 and is close to exhaustion.

The operational consequence is the part that matters for patient care. As Matthew Kavanagh of Georgetown's Center for Global Health Policy and Politics told The Guardian, the hundreds of health workers conducting active spillover surveillance in eastern DRC and Uganda, along with the thousands working on HIV, tuberculosis (TB), malaria, and maternal and child health, "are always the ones that detect outbreaks early." A CDC source told CNN the same thing more plainly: "The same staff and systems that help stop HIV epidemics are also those that often halt other epidemics." When those positions disappeared, so did the surveillance net.

The America First Strategy Meets Its First Real Test

The Trump administration's America First Global Health Strategy (AFGHS), unveiled in September 2025, reframes global health assistance as a tool of national security and economic return. It pivots from multilateral cooperation to bilateral memoranda of understanding (MOUs), one signed with Uganda in December 2025 and another with the DRC in February 2026. The DRC agreement pledges roughly $900 million over five years, which represents a 27% reduction compared to the prior five-year period. The new State Department Bureau of Global Health Security and Diplomacy inherited USAID's portfolio with fewer personnel and limited prior operational experience running an outbreak response.

A fair reading of the new approach has to include the genuine access wins. Former USAID Administrator Mark Green has pointed to the State Department's partnership with Gilead to scale up lenacapavir for HIV prevention and a pay-for-results award of up to $150 million to Zipline for medical drone deliveries in Africa. President's Emergency Plan for AIDS Relief (PEPFAR) was never perfect; its reliance on parallel non-governmental organization (NGO) systems instead of building government delivery capacity is a critique Eric Goosby, who led the program, has raised himself. It is also the most successful global health campaign in history, credited with saving 26 million lives since 2003. Trading the surveillance and workforce infrastructure built around that program for a leaner, transactional model is the bet AFGHS is making. The Ituri outbreak is the first place that bet is being tested in real time, and the early returns are not encouraging. Africa CDC Director General Jean Kaseya flagged a personal protective equipment shortfall at a press conference two days into the response. In every prior DRC Ebola response of the past decade, that supply question was already answered before reporters were in the room.

The Quieter Crisis: TB, HIV, and Drug Resistance

The Ebola outbreak draws the headlines. The slower damage is happening to people with TB and people living with HIV (PLWH), and it is the part that should worry CANN readers most. USAID was the largest bilateral donor to global TB programs, investing over $4.7 billion since 2000 and accounting for roughly half of all international donor funding for TB between 2015 and 2024. A survey of 180 affected organizations across 31 countries found that a quarter had closed in the weeks following the U.S. funding cuts, 78% had laid off staff, and 46% had stopped TB screening and outreach. The WHO's 2025 Global TB Report documents a 14% reduction in TB case notifications in Uganda in the first six months of 2025 compared to the same period in 2024.

Mathematical modeling by Mandal and colleagues, published in PLOS Global Public Health, projects that across 26 high-burden countries, sustained U.S. funding withdrawal could produce up to 10.67 million additional TB cases and 2.24 million additional TB deaths between 2025 and 2030. Those numbers describe a worst-case scenario, but they describe a credible one.

The compounding risk is drug resistance. A May 2025 correspondence in The Lancet Infectious Diseases lays out the mechanism clearly. When supply chains break and people on treatment for HIV or TB are forced to ration medications, take partial doses, or switch to lower-quality alternatives, the conditions for resistance emerge. As of 2023, 93% of PLWH in low- and middle-income countries were on tenofovir-lamivudine-dolutegravir. Dolutegravir has a high but not impermeable barrier to resistance. Widespread interruption could compromise the entire first-line regimen across former PEPFAR geographies, including the only long-acting injectable combination currently approved. The authors warn that drug resistance at scale "could irreversibly disrupt future control measures" even if funding were fully restored.

We have spent two decades building treatment regimens that work. Allowing them to fail through interrupted supply is a policy choice, not an act of nature.

Trust as Infrastructure

The connective tissue across all of these crises is trust, and trust is degrading in parallel with the funding. The Vaccine Confidence Project has documented confidence declines exceeding 20 percentage points in countries as varied as Germany, Sweden, Morocco, Tunisia, and South Korea since 2015. In January 2026, the WHO announced that six European countries had lost their measles-free status, and Canada had lost its elimination status the prior year. In the U.S., Pew Research found that 48% of Republicans express high confidence in childhood vaccines compared with 80% of Democrats. That partisan gap now shapes federal health policy directly through Health and Human Services Secretary Robert F. Kennedy Jr.

The same dynamic is visible in Ituri. Between May 21 and 25, 2026, residents attacked at least three Ebola treatment facilities. A crowd destroyed isolation tents after authorities refused to release the body of a person who had died from Ebola. Residents set fire to a Doctors Without Borders treatment center. Eighteen people with suspected Ebola fled a facility during one attack, with their whereabouts now unknown to contact tracers. The community engagement programs that built the local trust required to make safe burial protocols workable were among the first casualties of the funding cuts. Without that trust, clinical mandates enforced under armed military guard are not containment. They are accelerants.

What We Trade When We Walk Away

Stanford researchers, writing in the American Journal of Public Health, found that every additional $100 million in U.S. health aid was associated with nearly a 6-percentage-point increase in respondents holding a "very favorable" view of the United States. A Lancet study credits USAID with saving roughly 92 million lives over two decades. Dennis Carroll, the former director of USAID's Emerging Pandemic Threats program, put it to NPR: "No one has stepped in to fill the gap with the departure of the U.S. from WHO and the elimination of foreign assistance programs like USAID." Other donors have moved in the same direction. The UK, Germany, France, and Canada all cut aid budgets in 2025, the first time in nearly three decades the major donors contracted together.

The 2026 FIFA World Cup arrives in the U.S., Canada, and Mexico in June, drawing millions of international travelers across three host nations. Biological pathogens do not respect borders, and the disease surveillance funding withdrawn from Central and East Africa has not protected any host country. It has left all of them measurably more exposed.

Conclusion: Course Correction with Clear Eyes

We are past the point where the preventable loss of life from these decisions can be undone. Lives that will be lost to delayed Ebola containment in Ituri, to TB treatment interruption in Zambia and Uganda, to HIV regimen rationing across former PEPFAR geographies, and to vaccine-preventable diseases returning to communities that had eliminated them, are already encoded in choices made between January 2025 and February 2026. What remains in our hands is how much further this goes.

A course correction starts by accepting what has actually been broken. The infrastructure of global disease surveillance was not a line item. It was a workforce, a logistics chain, a network of relationships built across decades and now substantially dismantled. Restoring it requires Congress to reverse the proposed reductions to global health security funding, the State Department to formally re-engage with WHO on outbreak coordination, and PEPFAR-funded community health worker positions to be protected through FY26 because those workers are the surveillance system. None of that is sufficient on its own. All of it is necessary.

The harder problem is the one that will outlast this administration. The U.S. has lost trust with partner countries, multilateral institutions, and the global health workforce in ways that may not be recoverable in our lifetimes. Les Roberts, the Columbia researcher who has worked in the DRC for years, told STAT that his Congolese colleagues now ask him not to travel with their teams because his presence as an American puts them at risk. That is what the loss of soft power looks like in practice. We can rebuild capacity faster than we can rebuild credibility, and we cannot rebuild either by pretending the damage was somebody else's fault.

For PLWH, for people with TB, for advocates, public health officials, and the policymakers who still have the authority to act, the work now is to name what has been lost, defend what remains, and refuse to accept that the architecture of Ending the HIV Epidemic, End TB, and global pandemic preparedness was disposable. It was not. It was infrastructure. And we are watching, in real time, what happens when we treat it as anything less.

Antibiotic Crisis: Hope Amid Institutional Decline

The fight against antimicrobial resistance (AMR) in sexually transmitted infections (STIs) stands at a critical crossroads. Despite a slight decline in U.S. STI rates in 2023, resistance to antibiotics continues to rise globally, particularly for gonorrhea. This creates a paradox: while we're seeing promising new treatments advancing toward approval, recent political decisions have dramatically weakened our ability to track resistance patterns. Meanwhile, funding and policy support for developing new antibiotics remain inadequate. This crisis demands urgent attention as resistant infections spread faster than new treatments can be developed, with serious implications for public health and patient care.

The Growing Threat of Antibiotic-Resistant STIs

For people living with chronic conditions or compromised immune systems, antibiotic-resistant STIs aren't just a public health statistic—they represent a serious and growing threat to wellbeing. While the Centers for Disease Control and Prevention (CDC) reported fewer gonorrhea cases in the U.S. last year, the global picture is far more concerning.

Gonorrhea is becoming increasingly resistant to our last effective treatments. In Southeast Asia, the World Health Organization (WHO) identified a three-fold increase in extensively drug-resistant gonorrhea strains in Cambodia between 2022 and 2023. These hard-to-treat infections now make up over 12% of cases in the region.

What does this mean for patients? When first-line treatments fail, people face longer infectious periods, more complex and expensive treatments, and greater risk of complications. For people living with HIV or hepatitis C, these resistant infections can further compromise health and complicate disease management.

Breakthrough Treatments on the Horizon

Despite the grim outlook, two novel antibiotics represent genuine breakthroughs in the fight against resistant STIs after decades without new gonorrhea treatments.

Zoliflodacin, developed through a Global Antibiotic Research & Development Partnership (GARDP) and Innoviva Specialty Therapeutics partnership, completed the largest Phase 3 trial ever conducted for gonorrhea, with promising results. While its 91% cure rate appears slightly lower than the current standard's 96%, zoliflodacin's significance lies in its novel mechanism of action against resistant strains and its oral administration route. As resistant gonorrhea increasingly requires injectable treatments, an effective oral option represents a major advance for both accessibility and patient care.

Equally promising is gepotidacin, developed by GSK and already FDA-approved for urinary tract infections as of March 2025. This novel antibiotic showed a 92.6% success rate against gonorrhea through its unique dual-targeting mechanism that inhibits two critical bacterial enzymes, making it effective against resistant strains. GSK plans to submit for the gonorrhea indication later in 2025.

These developments showcase complementary partnership models: GARDP's non-profit approach ensures zoliflodacin's availability in low-income countries, while gepotidacin demonstrates successful public-private partnership between GSK and BARDA. Despite these advances, the WHO reports the broader antibiotic pipeline remains critically thin, with only 12 truly innovative antibiotics among 32 in development, and just 4 targeting the most critical pathogens.

Political Decisions Undermining Public Health

In a dangerous contradiction, just as resistance is rising and new treatments are on the horizon, political decisions have severely weakened our ability to monitor and respond to these threats.

Since early 2025, the current administration has eliminated approximately 20,000 jobs across health agencies and proposed cutting the HHS budget by about 26% ($127 billion).

The impact on STI programs has been particularly severe. The Washington Post reported that all 27 scientists at the only U.S. facility capable of tracking hepatitis outbreaks were fired. Additionally, 77 CDC staff members working on STI prevention were let go, including 49 experts embedded in state health departments who provided critical support to local efforts.

Most alarming for people at risk of STIs is the closure of the specialized lab that tests gonorrhea samples for antibiotic resistance. This lab was our early warning system—without it, doctors and patients won't know which antibiotics still work until treatment failures start mounting.

Prevention Strategies: Interrupting Transmission Chains

While developing new antibiotics is critical, prevention remains essential. Doxycycline Post-Exposure Prophylaxis (DoxyPEP) has emerged as an effective tool for breaking transmission chains. The CDC now recommends that men who have sex with men and transgender women with a history of bacterial STIs use DoxyPEP after sexual encounters.

Real-world data from San Francisco showed significant declines in chlamydia and syphilis among those using DoxyPEP, though gonorrhea reductions were less dramatic. While some concerns exist about the potential for DoxyPEP to contribute to broader antibiotic resistance, current evidence suggests this approach can effectively reduce STI transmission in high-risk groups—a crucial tool while we wait for new treatments.

The Funding Gap and Market Failure

The fundamental problem in antibiotic development is an economic one: the market doesn't adequately reward the creation of new antibiotics, especially those held in reserve to combat resistance.

The experiences of both zoliflodacin and gepotidacin highlight this challenge. Zoliflodacin required non-profit involvement through GARDP to advance through clinical trials, while gepotidacin needed significant government funding through BARDA. As Henry Skinner of the AMR Action Fund notes, "The funds needed to support this ecosystem, particularly in late-stage development, won't be there in a couple of years unless something unanticipated happens."

The AMR Action Fund, backed by pharmaceutical companies, aims to invest $1 billion to bring 2-4 new antibiotics to patients by 2030. The Fund has deployed over $100 million in capital to companies developing promising antimicrobials. However, experts recognize this as a stopgap measure rather than a solution to the underlying market failure.

A more sustainable approach is proposed in the PASTEUR Act, which has been introduced in multiple congressional sessions without passing. This legislation would create subscription contracts with developers of critical antimicrobials, ensuring financial returns regardless of how sparingly the drugs are used—essentially paying for access rather than volume.

This "Netflix model" for antibiotics would help align public health needs with market incentives. However, despite bipartisan support, the Act faces an uncertain future in the current political climate of budget cutting and deregulation.

Disproportionate Impact on Vulnerable Communities

Antimicrobial resistance operates within complex syndemics, where multiple health conditions interact and amplify each other within populations experiencing social inequities. People living with HIV stand at the intersection of these overlapping epidemics.

Research shows people living with HIV have higher rates of drug-resistant gonorrhea co-infection, each condition worsening the other. This syndemic intensifies with hepatitis C—a Department of Veterans Affairs study found 37% of people with HIV were also HCV-positive, with significantly higher rates of mental health issues and substance use disorders among these co-infected patients.

Among people who inject drugs with HIV, HCV rates reach up to 71% in some settings, according to a global review. These aren't coincidental occurrences—structural factors create environments where these epidemics cluster and interact.

The dismantling of surveillance infrastructure creates a dangerous blind spot in tracking these syndemics. Without specialized CDC labs monitoring resistant gonorrhea, we've lost our early warning system for emerging resistance patterns in vulnerable communities. Simultaneously, new restrictions on health equity research effectively discourage scientists from studying social factors that increase vulnerability to antimicrobial resistance.

A Patient-Centered Path Forward

From a patient and advocate perspective, five key policy areas require immediate attention:

1. Restore critical infrastructure. The dismantling of STI surveillance labs has left both patients and providers flying blind. Congress must fund restoration of these capabilities and hold administration officials accountable so we can track resistance patterns, update treatment guidelines, and support state and local health departments.

2. Support innovative development models. The GARDP partnership for zoliflodacin and the GSK-BARDA collaboration that produced gepotidacin demonstrate effective approaches to antibiotic development. These models—balancing commercial viability with public health needs—warrant expanded funding and replication.

3. Implement pull incentives. The PASTEUR Act would create a subscription-based model rewarding companies for developing critically-needed antibiotics without encouraging overuse, aligning market incentives with public health priorities.

4. Strengthen integrated care models. People at highest risk of resistant infections often face multiple health challenges. HIV, HCV, and STI services should be integrated to address overlapping needs, following the Ryan White HIV/AIDS Program's comprehensive care model.

5. Expand prevention strategies. While new treatments are essential, preventing infections reduces suffering and limits resistance. Expanded access to DoxyPEP, increased STI screening in high-risk populations, and vaccine research represent critical prevention strategies.

The antimicrobial resistance crisis in STIs reveals a stunning act of self-sabotage: just as scientific innovation finally delivers promising new treatments like zoliflodacin and gepotidacin, the misguided decimation of public health infrastructure has crippled our ability to track and respond to resistant infections. This isn't poor timing—it's the cavalier dismemberment of critical surveillance systems by ill-equipped partisans wielding policy chainsaws with no regard for consequences. The resulting wreckage threatens to undo decades of progress against STIs, particularly for communities already navigating systemic barriers to care.

The path forward demands both hope and principled outrage. Patients and advocates must forcefully reject further cuts to public health infrastructure, demand immediate restoration of STI surveillance capabilities, and hold elected officials accountable for the consequences of their decisions. We must insist on passage of the PASTEUR Act to fix the broken economics of antibiotic development while ensuring that promising science reaches those who need it most, not just those with wealth, power, and access.