The Unfinished Filovirus Countermeasure Project

One Vaccine. Two Antibodies. An Entire Viral Family Still Waiting. 

We have a licensed Ebola vaccine. We have licensed Ebola antibodies. We have shown that modern medicine can dramatically reduce mortality from one of the most feared pathogens on Earth. Yet today’s outbreaks are caused by the wrong species of filoviruses and we are largely back where we started.

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.

NETEC Was for Naught: The Kenya Ebola Debacle and the Abandonment of Our Own Readiness System

On Friday, July 10, the CDC confirmed that a second American — a humanitarian worker — has tested positive for Bundibugyo ebolavirus in the Democratic Republic of Congo. This follows Dr. Peter Stafford, the medical missionary physician who contracted Ebola in Bunia in May and was successfully treated — in Berlin. Not in Atlanta. Not in Omaha. Not in New York. In Berlin.

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.

The Platform We Are Choosing to Give Away

The FDA may approve Moderna’s mRNA flu vaccine. The larger question is whether America still intends to lead the technology that will power the next pandemic response.

On June 18, 2026, every member of the FDA's independent vaccine advisory committee — nine out of nine — voted to recommend approval of Moderna's mFlusiva, an mRNA flu vaccine for older adults. Nine voted yes, and yet the most important question isn’t whether Moderna’s flu vaccine will be approved. It’s whether the United States still intends to lead the technology that made Operation Warp Speed possible.

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.

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.

Choosing Measles

Civilizations do not lose their achievements all at once. They abandon them one decision at a time.

There is a distinction worth making right now, as the United States approaches the formal loss of its measles elimination status.

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.

The Pandemic That's Already Here

Picture this: it's Fourth of July weekend, America's 250th birthday. A patient walks into a Washington, D.C., emergency room. International traveler. Initially mild symptoms. Then, the standard medications stop working. Not because the diagnosis was wrong — but because the bacteria causing the infection have evolved past the drugs we have to fight them. A nurse mentions it to a friend who happens to be a reporter. Within hours, garbled TikTok videos are describing a mystery illness spreading from the National Aquarium to a restaurant in Old Town Alexandria.

 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.