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.
Focus on Hepatitis B: WHO's New Guidelines and Their Global Implications
At the 2024 Asian Pacific Conference for the Study of Liver Disease in Kyoto, the World Health Organization (WHO) introduced transformative guidelines for the prevention, diagnosis, care, and treatment of chronic Hepatitis B virus (HBV) infection. HBV is a major global health challenge affecting approximately 296 million people worldwide. If left untreated, it results in nearly 900,000 deaths annually from complications like liver disease and cancer.
The new guidelines aim to increase testing access and expand treatment eligibility, particularly in sub-Saharan Africa which accounts for 70% of all new HBV infections. They provide evidence-based recommendations based on updated scientific data about antiviral effectiveness, diagnostic test performance, and service delivery models. By simplifying testing and extending treatment eligibility, these guidelines address longstanding access barriers. They represent a significant step towards achieving the 2030 goal of eliminating HBV as a major public health threat.
Key Changes in the New Guidelines
The WHO's new guidelines focus on making HBV testing and treatment more accessible for those who need it most. Key changes include:
Simplified Testing Recommendations
The WHO's revisions highlight the importance of streamlined testing methods such as dried blood spot sampling and point-of-care viral load assessments. The goal is to expand early diagnosis. Coupled with community-based testing, these methods aim to enhance accessibility, particularly in areas with limited resources. They facilitate early intervention and aim to reduce the stigma associated with traditional diagnostic procedures.
There is also an emphasis on expanding testing among pregnant women to prevent transmission of HBV from mother to child during birth or through breastfeeding, which is the primary way the virus is transmitted.
Previous recommendations advised pregnant women with active HBV infection to receive temporary treatment until their child was fully vaccinated against the disease. The new guidelines take into account that not every health facility has the tests to determine if a woman has an active infection. They suggest that health care providers consider administering prophylaxis to pregnant women with HBV, even if they cannot determine the status of their infection.
Expanded Treatment Eligibility and Access
Nearly 300 million people currently live with HBV, and the disease causes approximately 820,000 deaths each year. Prior guidelines typically limited treatment to those with advanced liver disease or significant fibrosis, which made it challenging for patients to access care until their conditions had substantially deteriorated. The new guidelines propose a more inclusive treatment approach, expanding eligibility for antiviral therapy to millions more people. This change should increase the portion of people living with HBV eligible for treatment from the current 8% to 15% to around 50%. The World Health Organization now strongly recommends treatment for all people aged 12 and older who have chronic HBV and exhibit early signs of liver damage or other indicators, including co-infections such as HIV. The previous guidelines often recommended treatment only at more advanced disease stages and for patients above 30 years old, a significant hardship considering that 25% of infections in the region occur in people under 20.
The updated guidelines provide a more comprehensive approach to the management of hepatitis B virus (HBV) infection. These guidelines notably broaden the recommended treatments. Previously, the guidelines strongly advocated for single-drug therapies as the preferred treatment option. However, in recognition of the ongoing shortage of these single-drug therapies in some low- and middle-income countries, the updated guidelines now also endorse two dual regimens as alternate treatment options when the preferred monotherapies are not readily accessible.
This shift in treatment recommendations is a direct response to the pressing need to ensure that effective therapies are available in all regions, irrespective of their economic status. The scarcity of the preferred monotherapies in some parts of the world has necessitated the inclusion of the dual regimens in the guidelines.
Furthermore, the expansion of the recommended treatments is grounded in a growing body of scientific evidence. This evidence increasingly suggests that initiating treatment at an earlier stage of the disease can have a significant positive impact on long-term health outcomes for people living with HBV infection. Early intervention also has the potential to markedly reduce transmission rates. By taking this approach, we can address the global HBV burden more effectively and ensure a healthier future for those affected by this disease.
Improving Patient Support
Improvements in patient support mechanisms, such as the introduction of peer support and digital adherence tools, show a thorough and empathetic understanding of the many challenges faced by people living with chronic Hepatitis B virus (HBV) infection. These patient-focused initiatives, an evolution of the regulations that governed HIV testing and treatment, are based on real-world experiences and insights. They are carefully designed with two critical objectives in mind.
First, they aim to significantly enhance treatment adherence. This is crucial, as consistent adherence to prescribed treatment regimens is a key factor in the success of long-term antiviral therapy. Without proper adherence, the effectiveness of the treatment is compromised, potentially leading to less than optimal health outcomes for the people affected.
Second, these initiatives also aim to reduce the risk of drug resistance. Drug resistance is a major concern in managing chronic diseases like HBV, as it can make first-line treatments less effective over time. This can complicate the disease management process and potentially lead to worse health outcomes.
By addressing the dual challenges of treatment adherence and drug resistance, these improved patient support mechanisms represent a significant step forward in the comprehensive and patient-centered management of chronic HBV.
Integrating HBV into Existing Services
The guidelines suggest integrating existing HIV, tuberculosis, and primary care programs to offer streamlined services for Hepatitis B Virus (HBV). This leverages the existing infrastructures, resources, and patient engagement strategies of these programs, potentially resulting in early detection and effective management of HBV.
By making use of these existing programs, healthcare systems can effectively expand HBV services. This method ensures patients receive coordinated care for their various health needs, fostering a more holistic patient care approach. Not only does this integration yield immediate patient benefits, but it also presents long-term advantages for the entire healthcare system, aiding healthcare providers in efficient resource allocation and reducing overall costs. Additionally, the improved patient outcomes resulting from this integration could decrease the long-term expenses associated with managing chronic conditions.
Potential Impact of the Guidelines
The global impact of these guidelines could be transformative. By simplifying the diagnostic process and expanding treatment access, the WHO aims to significantly increase the rate of early HBV diagnoses. This method aims to improve health outcomes for people living with HBV, reducing liver cancer, cirrhosis, and other disease-related complications. Additionally, preventing HBV progression to severe liver diseases could substantially lessen the economic burden on global healthcare systems. This aligns with the WHO's goal of eliminating HBV as a public health threat by 2030. Experts anticipate:
Increased Diagnosis and Treatment: Expanded eligibility and easier testing could lead to more HBV diagnoses and access to lifesaving antiviral therapy.
Improved Health Outcomes: Earlier intervention and broader treatment may reduce rates of liver cancer, cirrhosis, and HBV-related deaths.
Reduced Healthcare Costs: Preventing long-term HBV consequences could alleviate strains on healthcare systems and lower economic burdens.
Considerations for the United States
The WHO's new Hepatitis B guidelines could have significant implications for U.S. healthcare policy. Domestic adoption could improve HBV management in the U.S. and demonstrate the country's commitment to global health initiatives. While the WHO guidelines provide a global framework, their implementation in the U.S. requires policy-level action. Advocates could focus on:
Streamlining Screening Programs: Encouraging community-based testing and simplifying recommendations could raise diagnosis rates, particularly in underserved populations.
Expanding Access to Treatment: Prioritizing the removal of insurance-based barriers and addressing treatment access disparities.
Implementing Supportive Care Models: Exploring strategies like peer support programs to improve patient adherence and ensure everyone benefits from treatment.
Aligning with the WHO's Hepatitis B guidelines requires substantial shifts in U.S. public health policy. This includes integrating streamlined testing protocols into existing healthcare frameworks for more accessible diagnostic services. Expanding treatment eligibility may require revising healthcare policies to include a broader range of HBV-affected populations. This could mean changes in insurance coverage and healthcare provider guidelines to implement broader treatment protocols.
The U.S. can lead global efforts in adopting these guidelines through its role in global health initiatives. By advocating for and implementing these guidelines, the U.S. can demonstrate the effectiveness of simplified and accessible HBV care, encouraging other nations to follow. This leadership role can include providing technical support, sharing best practices, and offering financial assistance to resource-limited countries, thereby enhancing global health security and moving closer to eliminating HBV as a public health threat by 2030. Researchers have estimated that $6 billion annually is needed to meet the global hepatitis targets in 67 low- and middle-income countries alone.
The WHO's revised guidelines for Hepatitis B management represents a significant step towards addressing this global health challenge. They provide a plan for simple, accessible, and effective HBV care, with a focus on early diagnosis and expanded treatment eligibility to enhance patient outcomes and reduce transmission.