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.

Measles is the Default

(I’ve adapted this piece’s title from Dr. Gena Gorlin’s excellent essay arguing that for human beings, death is the default.)

Recently, I was listening to psychologist Steven Pinker discuss the Second Law of Thermodynamics on a panel. Entropy, in its broadest sense, describes the tendency of systems toward disorder. Pinker noted that human agency acts as a countervailing force, creating pockets of order in a universe that naturally trends in the opposite direction.

I’ve been thinking about that idea a great deal lately, particularly in the context of what I see as the role of infectious disease physicians, nurses, physician assistants, nurse practicioners, epidemiologists, virologists, microbiologists, infection control practitioners, as defenders of civilization.

Transposed into the realm of infectious disease, entropy means that death, disability, and disruption caused by infectious agents are the norm. Human beings altered that trajectory through reason. Germ theory, sanitation, antisepsis, vaccination, antibiotics, antiviral drugs, and modern public health infrastructure are all products of human intelligence directed toward a specific purpose: creating order where nature provided none. Left unattended, the natural trajectory is not toward health but toward recurring outbreaks, epidemics, and premature death.

Measles is the default.

For most of human history, measles infected everyone. Measles elimination was not the natural state of the world. It is an achievement.

And like all achievements, it requires maintenance.

Civilization itself is not automatic. It must be continuously maintained and advanced. Societies can and do backslide. The Dark Ages remain the most famous example. I often think of the Antikythera mechanism—a sophisticated ancient Greek device whose purpose was lost for centuries. Imagine discovering such an object in the Dark Ages, possessing the artifact but lacking the intellectual framework necessary to understand it because people jettisoned that framework.

History offers many examples of achievements that were abandoned, forgotten, or allowed to deteriorate. The Concorde disappeared. Human moon missions ceased for decades. Today, vaccines are following a similar trajectory. A nightmare scenario is some future human finding a vial of an mRNA vaccine the way we first held the Antikythera mechanism—possessing the artifact but having lost the intellectual culture that made it possible.

Human flourishing consists of creating islands of order against a backdrop of entropy.

This is why the return of measles in the United States is not primarily a biological event. It is a cultural and intellectual one.

The measles virus has not become more virulent. The vaccine has not become less effective. What has changed is humans’ willingness to support the technology that made elimination possible.

The ultimate resource is not a vaccine, an antibiotic, an antiviral, or a hospital.

It is the human mind.

The same force that drained swamps, built sewers, created vaccines, developed antibiotics, eradicated smallpox, and eliminated measles is the force that keeps entropy at bay.

Measles elimination was not humanity’s inheritance. It was humanity’s achievement.

The state of nature is not measles elimination but measles endemicity.

The Bear and The Microbe

A grizzly bear weighs more than 1,000 pounds, can run faster than a racehorse, and possesses claws and teeth that make human beings look laughably ill-equipped for survival. Yet in The Edge, it is not the bear that ultimately demonstrates superiority. It is the human mind.

This movie, made decades ago, is something that I keep coming back to. I am drawn to this movie because of its theme — the edge that humans have over other species. The edge that enables us to thrive in a natural world that is often hostile. That edge is not an opposable thumb but our specific consciousness which houses the faculty of reason. It is reason that allows humans to shape the world in a manner that is conducive to human survival, beating back lions, tigers, wolves, floods, hurricanes, and — critically — infectious diseases. It is also the case that the knowledge discovered by one human mind can be acquired by another, creating a web of information flow that serves to promote human life beyond the temporal and spatial bounds it was discovered in.

The Edge is fundamentally about thinking and using one’s mind to solve problems related to survival. In the film, a group of men are stranded in the wilderness. However, it is not the physically strongest human that flourishes but the one most committed to the use of reason. As they square off against the elements and the superior physical prowess of bears, it is the mind that triumphs.  This is not surprising. As the philosopher Ayn Rand identified, and the film dramatizes, reason is man’s means of survival.

Darwin understood that humanity’s distinctive adaptation was not speed, strength, claws, or teeth. It was intelligence. Reason, he wrote, stands “at the summit” of mankind’s mental faculties. Humans survive not by adapting themselves to every environment, but by adapting the environment to themselves.

As such, it is the human capacity to reason that stands as the ultimate resource to call upon for survival issues.

These survival issues most definitely extend beyond bears. The bear in The Edge is simply a stand-in for nature’s threats. For most of human history, those threats included yellow fever, smallpox, cholera, plague, tuberculosis, and influenza and only in recent generations have some humans secured freedom from the disruption, death, and despair that characterizes infectious disease outbreaks.

The story of infectious disease is the story of reason applied to nature. Smallpox did not disappear because nature became kinder. Cholera was not defeated because rivers became cleaner. Yellow fever did not retreat because mosquitoes became less dangerous.

Human beings identified causes, discovered mechanisms, tested hypotheses, and transformed knowledge into action. Every vaccine, antibiotic, sanitation system, intensive care unit, and genomic surveillance network is reason made tangible.

Left to her own devices, Mother Nature would kill us. Survival rdepends on the ability to think. It is not automatic; it is an achievement. The edge that separates humanity from the bear, the mosquito, and the microbe is ultimately the same edge dramatized in the film: the reasoning mind.