Rented Immunity

What the Marketing of “Vaccine Alternatives” Reveals

In August 2021 — several months after COVID vaccines became available — Florida ran an experiment nobody quite recognized as one. Governor Ron DeSantis opened the first state-run monoclonal antibody sites in the country, pushing Regeneron's antibody cocktail through drive-through clinics and stadium parking lots. By the time the last site opened, Florida had administered more than 130,000 monoclonal treatments, and DeSantis was touring hospitals crediting the antibodies with significant drops in new admissions. This was the same governor fighting vaccine mandates and vaccine passports in court. The message, unstated but unmistakable, was that the antibody was the acceptable form of pharmaceutical intervention and the vaccine was not.

Then, on January 24, 2022, the FDA revoked the emergency authorizations for REGEN-COV and Eli Lilly's bamlanivimab-etesevimab. Omicron had mutated the spike protein enough that both drugs lost clinical value. They still bound the old virus and no longer touched the one circulating. Every Florida monoclonal site went dark. DeSantis called the decision reckless and said the FDA had acted "without a shred of clinical data," and threatened to sue.

While the FDA officially revoked those authorizations it was Omicron that rendered those monoclonal antibodies obsolete. The vaccines, meanwhile, built through a different mechanism — a broad, evolving immune response with T cells and memory B cells, not a single locked-in antibody shape — kept doing what they'd been doing all along: keeping vaccinated people out of the hospital, even against omicron, even without an update. That's the whole story of monoclonal antibodies versus vaccines compressed into one news cycle, and almost nobody draws the right lesson from it.

The lesson matters now because the same dynamic is back, dressed differently — and this time it isn't a governor improvising. It is federal policy.

Most of the current wave of drug-based prevention is a genuine advance and the products are true values. XOCOVA (ensitrelvir), which I've consulted on for its maker Shionogi, is the first drug approved specifically for post-exposure prevention of COVID — take it within 72 hours of a known exposure and trials showed a 67% reduction in symptomatic infection. That's a real tool for a real window: the days between exposure and infection when vaccination, already administered or not, can't retroactively do anything. DoxyPEP — a dose of doxycycline after sex — is now genuine standard of care for preventing bacterial STIs in high-risk populations, though it's a strategy that consumes its own advantage: gonococcal resistance to tetracycline is climbing as uptake rises, with models projecting meaningful efficacy loss within five to twelve years. And lenacapavir as HIV pre-exposure prophylaxis is close to invaluable, because after forty years of trying, there is still no HIV vaccine. Nobody markets doxyPEP as a substitute for a syphilis vaccine, because there is no syphilis vaccine and post-exposure prophylaxis was never trying to do a vaccine's job in the first place. Similarly, travelers have taken malaria chemoprophylaxis for generations; nobody called it a vaccine alternative, because no malaria vaccine existed for it to replace. These tools fill actual voids.

The distinguishing question isn't whether something comes from a needle or a pill or an IV bag. It's whether the product is filling a genuine immunological gap — a hole no vaccine can plug — or an ideological one, giving people a way to look like they're doing something about a preventable disease without doing the one thing that actually prevents it durably.

What's changed is that the federal government is now working both sides of that question at once.

BARDA's mRNA vaccine portfolio, roughly half a billion dollars of it, was cancelled outright; ARPA-H's own chief data officer resigned over the decision. Several vaccines were struck from the CDC's childhood recommendation list. An executive order took aim at MMR. Whatever one thinks of any individual decision, the aggregate effect is not in dispute: a population now exists that wants protection against infectious disease and either cannot get vaccinated or has been told by its own government that it probably shouldn't bother.

That population is not a clinical category. It is a market. And the same government that manufactured it is now funding the supply.

Consider the current director of ARPA-H.

Alicia Jackson, sworn in last October after six years at DARPA, told Fierce Biotech in January that her agency can help make the vaccine controversy a thing of the past — by rendering vaccines obsolete. "It's funny how we always talk about vaccines," she said. "There's actually a multitude of other technologies that you can use to protect people against infectious disease." Her agency has put up to $30 million behind an antibody-generating AI platform at Vanderbilt, part of a broader $204 million effort.

Read as pure biotechnology optimism, none of that is remarkable. Monoclonals are a marvel, longer-acting antibodies are a worthy research goal. Read in context — an administration that has spent a year denigrating vaccines and dismantling the infrastructure that produces them — it is something else. It reframes vaccines as one option among many for which there are alternatives, rather than the platform every other option is usually a narrower complement to. When a private company says that, it's marketing. When the federal research agency says it, it's industrial policy.

Anna Durbin, who directs the Johns Hopkins Center for Immunization Research, put it plainly in the same article: monoclonals have a role, especially for people who cannot receive vaccinations, but they don't trigger immune memory the way vaccines do, so they must be given again and again and again, each time you want protection. For flu, where we vaccinate annually anyway, an antibody may be fine. For measles, mumps, rubella, varicella, polio, vaccination provides long-lived protection that monoclonal antibodies cannot. They are given by infusion. They cost far more.

Add to that what Florida already demonstrated: Evusheld, a pre-exposure monoclonal antibody for the immunocompromised who have suboptimal vaccine responses, was withdrawn in January 2023 when omicron subvariants mutated past its binding site — the exact mechanism that killed the Regeneron and Lilly drugs a year earlier. AstraZeneca's successor, sipavibart, was discontinued after resistance emerged in late-stage trials. Invivyd, another company I have consulted and done press for, took the financial risk of developing and fielding Pemgarda when no other company was willing to chase a shrinking, high-cost, high-liability niche, and Pemgarda is the reason that population has any pre-exposure option at all. They deserve praise and accolades for the successful development of this product. However, an antibody is leased protection: recurring cost, recurring appointment, recurring vulnerability to the virus simply changing shape. Active immunity from a vaccine is a trained capability your own immune system owns outright.

There's an irony worth thinking through. The movement that built its identity on distrust of pharmaceutical dependency is being offered, as its flagship alternative, more highly pharma-dependent products. And the administration promoting antibodies as the way past the vaccine debate has simultaneously put Beyfortus and Enflonsia under FDA scrutiny for perceived safety concerns. Neither is a vaccine. Both, similar to vaccines, are available to be given to healthy infants on a schedule — which appears to be the operative quality that draws fire.

None of this means the products shouldn't exist, or that companies are wrong to build them. A firm facing a regulator that keeps closing its narrower, more defensible lanes is going to find the lane that achieves a return on investment. That's not a scandal; it's what companies do, and I don't fault them for it. Aiming a product at people who "can't, or won't, get vaccinated" is nonetheless fraught, and the two halves of that phrase are not alike. "Can't" is a real population — infants too young for MMR, transplant recipients, patients on B-cell-depleting therapy, people for whom vaccination genuinely doesn't take. "Won't" is not an immunological category. What separates an eligible, unvaccinated child from immunity is a choice, not a biological hole.

The scandal, if there is one, sits upstream. An HHS leadership that spends a year making the word "vaccine" radioactive should expect the market to route around it, and monoclonal antibodies marketed as vaccine alternatives are exactly the kind of routing that predictable policy failure produces. The people who created that arbitrage bear more responsibility for it than the companies cashing it in.

The question to keep asking isn't whether antibody therapies should exist. Of course they should — they're a marvel, and in the populations they were built for, they save real lives. The question is whether we're going to keep letting a preference masquerade as an indication.

Ten Years Gone

A decade of asking questions nobody has answered

Ten years ago today, D.A. Henderson died. I have written to him every year since — a list of questions I would have walked down the hall to ask him if he were still in his office. His absence is a standing deficit, a chair at the table nobody has filled. Ten years of these letters has produced a ledger, and this year's ledger is worse than last year's, which was worse than the year before that.

Here is some of what I would ask him.

Ebola Unchained

DRC declared its seventeenth Ebola outbreak on May 15, in Ituri Province, not long after the previous one ended. The virus is Bundibugyo, not Zaire, and there is no licensed vaccine and no approved treatment for it. It is the deadliest outbreak in DRC's history, the fastest-spreading ever recorded, and second in the world only to West Africa in 2014–16 which it is projected to eclipse. Most cases emanate from unknown chains of transmission, most deaths (which number over 2300) occur outside Ebola treatment units, and the population has not accepted the need for safe burial practices and other standard public health interventions. There has been real consideration of the idea of this area of the DRC becoming endemic with Ebola — a frontier of Ebola necessitating neighboring areas remaining eternally vigilant.

During the largest Ebola outbreak in 2014 you and I once argued that the fastest way to stop an outbreak like this is to concentrate everything on the small number of people doing most of the transmitting rather than chasing every contact evenly.

How would you do that in this context? Use the Merck Zaire strain vaccine — which has some anecdotal evidence of cross protection against Bundibugyo — in rings? What are the top three things you think need to be done to gain some semblance of control of the outbreak? What is the realistic time frame for control (1 year, 2 years)? How was neighboring Uganda able to act so decisively and delimit their 20 cases?

The soda-bottle EO

On August 10, President Trump signed an executive order instructing HHS to develop separate single-disease measles, mumps, and rubella shots, on the theory that giving three diseases' worth of vaccine at once is somehow excessive — he has compared it to pouring a bottle of soda into a child's body. The order also cuts the vaccines recommended for every child from seventeen down to eleven, shifting the rest into a vaguer shared-clinical-decision-making category. I’m glad you didn’t have to watch it.

You ran the campaign that made a human disease disappear from the planet with one shot (or scrape) per arm aimed at getting a single dose into as many arms as possible. Your method was to subtract complexity, not manufacture it.. You had no patience for controversies invented to solve problems that did not exist.

I imagine the clarity and authority of your booming voice on 60 Minutes dismantling the disinformation apparatus of RFK Jr. and his minions, reassuring the public (as you did all of us during the anthrax attacks), championing the value of vaccinations and the legacy of Jenner (which you completed). I think these minuscule gnats would shrivel just at the sight of you.

The US has confirmed 2,566 measles cases this year, the worst count in decades, and PAHO will review whether the country keeps its elimination status in November. You thought measles was a harder eradication target than smallpox, precisely because it spreads faster and more quietly, and you were skeptical of global measles eradication for that reason — but you lived to see the Americas declared measles-free in 2000 and treated it as a real accomplishment worth defending.

What do we do now? Measles is on a trajectory to become endemic in the US again and a resource consuming public health and healthcare system problem. Once our designation is gone, is there a version of elimination worth the fight to reclaim, or was 2000 a one-time achievement that doesn't come back around twice?

The platform works, the institution doesn't

The FDA approved mFlusiva on August 5 for adults fifty and older — an mRNA influenza vaccine roughly 27% more effective than the standard shot — six months after the same agency refused to review it and then reversed course. But ACIP has issued no recommendation for it. ACIP itself is littered with RFK Jr.’s acolytes and is non-functional. You judged a countermeasure by whether it worked, full stop — never by which political tribe had claimed it as a mascot.

What do you make of a government that approved the best flu vaccine in decades and embedded it in a maze that keeps it out of people's arms? How do we keep the promise of mRNA technology — so critical for pandemic preparedness against avian influenza — alive in this toxic disinformation-laden environment?

Medications favored over vaccines

Xocova was approved as the first oral pill to prevent COVID after exposure, cutting symptomatic infection by 67% when started within 72 hours of contact. DoxyPEP — a dose of doxycycline after sex to prevent bacterial STIs — is now becoming standard of care even as it consumes its own advantage: surveillance in San Francisco and King County already shows gonococcal tetracycline resistance climbing in step with doxyPEP use, and models project meaningful loss of efficacy within five to twelve years even at modest uptake. HIV PrEP, with the addition of lenacapavir, is revolutionary. Nirsevimab, the preventive antibody against RSV in infants, is changing the face of pediatric RSV while pemivibart protects the most immunocompromised against COVID-19.

I remember sitting with you in briefings about the potential smallpox antiviral tecovirimat and seeing your steadfast loyalty to the vaccine — the tool you used to beat the virus back and foreclose its ability to ever harm humans again.

Now all these medications are all genuine advances that provide valuable (or in the case of HIV PrEP, incalculably valuable) additions to the armamentarium. But, keeping on the theme of my questions, I wonder if some of them are being conceptualized not as tandem products to vaccines but as vaccine substitutes. For example, the head of HHS ARPA-H said: “There's actually a multitude of other technologies that you can use to protect people against infectious disease.” That seems to me to be coded language against vaccine technology.

So, how do we balance drug-based prevention with vaccination, knowing that there is more than a hint of irrational anti-vaccine sentiment partially driving it?

***

Better tools, weaker resolve

Every question I posed DA above has the same shape. Mastering infectious disease is no longer an exclusively scientific, technological, or medical problem. What we have is an implementation problem driven by a larger philosophical one: the return of the primitive in the form of Dark Ages’ mentalities that are openly advocating for a lower standard of living, for civilization to march backward.

DA spent his career on the inverse problem — a bifurcated needle, a jet injector, an index card, and institutions with enough authority and credibility to make those crude tools work anyway. I would love to know what he could do with the technologies we have today.

Ten years of asking DA these questions hasn't made the exercise less useful. It has made it more damning of us. I believe DA would have found this year infuriating rather than tragic. Infuriating things can still be fixed but the task is inestimably harder with his chair still empty.

I do not believe that our cause is finally lost, because it is based on truth, reality, logic and reason with an aim to improve individual human lives. But I wish DA were here to tell me how he would win because I know the nihilist forces we face would be no match for him mantled with the prowess of Jenner and Pasteur.

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.