The World Cup is underway across the United States, Mexico, and Canada, with stadiums full and a record 1.3 million fans already through the gates.

Could the World Cup accelerate Ebola’s spread or carry it to new regions? No mass gathering is immune to disease threats, and the World Cup won’t be either. But Ebola isn’t the threat to worry about here.

Ebola isn’t airborne and doesn’t spread through casual contact. It requires direct contact with the body fluids of someone who is ill. In 2014, a far larger Ebola outbreak in West Africa coincided with the World Cup in Brazil. Nothing spread there. A traveler could be exposed to Ebola and infect others, but Ebola will not spread widely at the World Cup.

Diseases that pass easily between people, such as measles and influenza, pose more risk. For the first time, a non-governmental Health Security Operations Center was launched for the World Cup, pulling together wastewater surveillance, hospital data, and social monitoring across all host cities. This is the kind of work the federal government should support.

A new Resolve to Save Lives case study describes how the Caribbean Public Health Agency deployed a regional surveillance platform at the 2024 T20 Cricket World Cup that detected 146 disease cases across the tournament with no documented spread. The system worked because it was built before the event, not put together hastily during it.

When it comes to Ebola, controlling spread in the Democratic Republic of the Congo is the most pressing challenge. I wrote about the outbreak when it was first recognized and when the reported numbers hid how fast it was moving. It was found late and continues to spread faster than the response.

In late May I wrote that this outbreak would test whether the world can respond effectively to urgent health threats. It’s a stress test, and the world is failing it. We’re responding with a gutted toolkit. USAID has been dismantled. The U.S. has withdrawn from WHO. CDC has lost nearly 3,000 scientists and doctors, with more cuts proposed, including closure of most of its global outposts.

Preparedness is crucial

Outbreaks take hold where basic health care is thin or absent—a clinic with no diagnostic tests, a district with no laboratory, a community with no health worker to notice the first deaths. In those gaps, a new pathogen can spread for weeks before anyone identifies it, and by then it may have traveled far from where it began.

Preparedness has to be built everywhere. The foundation is basic health services in every community; surveillance depends on clinics people go to and health care workers they trust.

Our team has championed the 7-1-7 target: every outbreak detected within 7 days, reported within 1, and all essential control measures in place within 7. Countries that meet it find problems sooner and stop them faster. The world needs the same discipline on a far larger scale, with money behind it—rapid-response funds released in days, supplies positioned before the emergency, and responders ready to move before a local outbreak becomes a regional one.

The test that matters

While matches take place in North America, people in parts of the DRC face grave risk. The outbreak there continues to accelerate. Health workers are reporting shortages of PPE and test kits. Testing delays and roadblocks mean the official count is the floor. Conflict complicates the response, and WHO’s Director General has called on warring parties in eastern DRC to agree to a ceasefire so medical teams can reach patients.

The World Cup will end in July. Even with a much faster response, the DRC outbreak could last at least another year. The outbreak can be stopped, but it needs full funding and fast execution now. The biggest test is whether we learn from the preventable diseases we keep facing and build the community care, public health, and rapid-response capacity needed for a safer world.

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Three weeks ago I wrote that the Ebola outbreak in the DRC could be stopped. It still can, but it continues to move faster than the response, and the numbers understate how fast it’s moving.

Confirmed cases in the Democratic Republic of the Congo nearly doubled in a week, from 344 on June 3 to 635 on June 10, and confirmed deaths passed 100. June 8 brought 48 new cases and 14 deaths, the worst single day so far. Almost all the new cases came from three zones in Ituri—Bunia, Rwampara, and Mongbwalu—where the virus is now entrenched. In Mongbwalu, a gold-mining town, more than a third of confirmed patients have died.

Even these numbers don’t tell the whole story. North Kivu reported almost no new confirmed cases last week—not because transmission stopped, but because more than 180 samples were sitting untested. The province ran short of reagents for testing; every specimen had to travel nearly 1,000 miles across the country to Kinshasa. When testing caught up on June 10, twelve cases were confirmed in North Kivu in a single day, with more to come as the backlog clears. Contact tracing was reaching fewer than six in ten contacts nationally and almost none in parts of North Kivu, and burial teams have been attacked and driven away. The official count is a floor—and it’s rising fast.

A case count that looks like it is leveling off can lull a response into easing, when the flattening only means that case identification, contact testing, and laboratory work has fallen behind. There’s a large gap between the actual number of cases and the number of confirmed cases. One critically important indicator to track is the proportion of new cases that arise from named and tracked contacts. As control progresses, this number should approach 100%.

A deadly gap is the one between what has been promised and what has reached the ground. The world has pledged more than $550 million. Reagents, test kits, and protective equipment are in short supply, and the money to pay many of the people doing the most dangerous work hasn’t reached them. Funds committed in capitals do nothing until they become a tested sample or a nurse’s hazard pay in Ituri.

The task now is to close those gaps at the pace the virus is setting. Send reagents, test kits, and protective equipment to North Kivu and set up a lab there so samples no longer need to travel across the country to be tested. Release the pledged money and resources to the groups and staff working in the affected zones, to the communities that need services in these areas, and to the public health teams that need it this week. One of the most searing memories I have is of a dedicated contact tracer in Guinea in Guinea quietly and respectfully telling me that he didn’t mind working 7 days a week and risking his life for $4 a day, but he hadn’t been paid in 4 months and could we please sure that he gets paid so that his family could eat. Pay frontline workers on time, every time.

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We first discussed the Ebola outbreak unfolding in the Democratic Republic of Congo, which Sandro called a “paradigmatic example” of what many of us in public health have feared given recent, dramatic shifts in global health. The outbreak has become the third largest in history, spreading faster than the response, at a time when the systems meant to contain it have been weakened. As I wrote recently in STAT, the response to this outbreak must be massive, immediate, and meticulous.

From global, we turned to local. We discussed how the COVID-19 pandemic broke people’s trust in public health and drove people apart. We’re still dealing with what feels like an unresolved hangover from the pandemic. A proper accounting of what went right and wrong, broken down by phase of the pandemic and the evolution of our knowledge and of the virus, is needed but hasn’t happened. Rebuilding trust, Sandro noted, starts not by asking people to trust us, but by listening better and being honest about both failures and successes.

Sandro and I grappled with another vexing question: How do we balance public health reasoning with personal wellness preferences? Sandro pushed back thoughtfully on The Formula for Better Health’s application of the See-Believe-Create framework to individual health—noting that although public health can reliably predict and shift what populations do, there are too many variables to easily do the same for individuals. We’ve seen that small shifts across millions of people save enormous numbers of lives, but no formula can guarantee long-term health for any individual. With that said, I’ve highlighted six points backed by data that are strongly linked to a longer life.

We closed on hope. For Sandro, history is a source of optimism, as health has improved decade after decade. Progress is certainly possible, but it isn’t inevitable. It requires strategy, coalition-building, and the willingness to keep working even despite setbacks.

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“Sugar, rum, and tobacco are commodities which are nowhere necessaries of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation.”

—Adam Smith, The Wealth of Nations, 1776

Soda isn’t food. It delivers no protein, no fiber, no vitamins, none of the nutrients the body needs—only sugar. A single 20-ounce bottle of cola carries about 16 teaspoons of it. Although a bottle may not cost much money, these aren’t cheap calories. Sodas are empty, harmful calories, and around the world they help drive obesity, type 2 diabetes, and heart disease, as well as liver disease, dental decay, and many other health harms.

The burden doesn’t fall mainly on wealthy countries. More than three-quarters of deaths from chronic diseases such as heart disease now occur in low- and middle-income countries, where sugary-drink consumption is climbing fast and health systems can least afford the cost.

As the United States and other countries cut health and development aid, governments face widening budget gaps. Health taxes—on tobacco, alcohol, and sugary drinks—offer a rare triple win: better health, lower health-care costs, and more money.

The evidence for health taxes is strong, and it comes from countries at every income level. Mexico’s national soda tax cut purchases by 5.5% in the first year and nearly 10% in the second, with the steepest drops among the poorest households. South Africa taxed drinks according to their sugar content and cut the sugar people purchased from taxed beverages by 35%. Rwanda’s tobacco tax pushed smoking down from 13% to 7%. Colombia’s tax on junk food raised more than $750 million in 2025. Ethiopia cut harmful alcohol use in half with taxation and a ban on advertising. Ghana channels tobacco-tax revenue into national health insurance.

Critics call these taxes a burden on the poor. They have it backwards. Low-income families suffer the most disease, face the most aggressive marketing, and cut their consumption of unhealthy foods the most when prices rise. They have the most to gain—in health, and in money freed for real food, school, and care.

The fiercest resistance comes from multinational corporations headquartered far from the countries that bear the harm. Coca-Cola, PepsiCo, and the big tobacco and alcohol companies fight these taxes with the same tools, including lobbying finance ministries, funding front groups, bankrolling friendly research, and threatening lawsuits. Big Soda copied the playbook of Big Tobacco. Sweet and Deadly, a book by journalist Murray Carpenter, shows how Coca-Cola spent decades funding research built to reach the right answer and recruiting scientists-for-hire to sow doubt where no reasonable doubt exists.

The Task Force on Fiscal Policies for Health estimates that a 50% price increase on tobacco, alcohol, and sugary drinks, achieved through taxes, would prevent more than 50 million premature deaths over the next fifty years and generate $20 trillion in revenue.

That outcome depends on three things: the right tax, the right enforcement, and relentless advocacy. It’s harder than it might seem. As New York City health commissioner and CDC director, I documented the supporting evidence and advocated for a soda tax but was unsuccessful.

The right tax. The most effective health tax is a specific excise—a fixed amount per unit, per cigarette, per gram of alcohol, per ounce of sugar—not a share of the price, which lets companies escape it by cutting prices or pushing larger packs. The rate must be high enough to change behavior and must be indexed to inflation, as South Africa and Mozambique have done. And because the opposition is organized and well funded, governments must be ready for the fight. This means modeling the revenue and the lives saved, mapping the politics, and pre-empting industry’s myths before they spread.

The right enforcement. A tax is only as good as its collection. Secure tax stamps with track-and-trace, run by an independent, effective entity selected by the government and not by the industry, curb smuggling and protect revenue; Kenya’s system helped cut the share of illicit cigarettes from 15% to 5%.

Advocacy. Health taxes need advocates including researchers, journalists, and citizens to support effective government action, expose disinformation and keep pushing. Support increases when people see the money return as services. The Philippines turned taxes on tobacco and alcohol into health coverage for millions.

At Resolve to Save Lives, we work with finance ministries and partners to support optimal policies, effective implementation, and the determination to face down an industry that profits from doubt and hype.

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Ebola is back, and so far, the pace of spread of the virus is far exceeding the speed of the response.

The Democratic Republic of the Congo is confronting an outbreak that has already become the third largest in history. There have been more than 1,000 suspected and confirmed cases and at least 230 deaths, and the numbers are climbing fast. The virus is moving across cities and porous borders. This will not become a global pandemic—Ebola doesn’t spread that way. But it could devastate multiple African countries, shut health systems, kill thousands of people, and ripple through travel, trade, and supply chains. It will also test whether the world can address urgent health threats and prepare for whatever nature, human error, or human intent throws at us next.

Here is what’s working against the Ebola response, and what’s working for it.

Working against us

The outbreak was found late, and it’s already large. By the time the response began, there were already 400 to 500 cases — nearly 10 times the number we faced at the analogous time in West Africa in 2014. Late detection had several causes. The Bundibugyo strain^* is rare, and the standard rapid tests for Ebola miss it. Whether dismantling of U.S. global health programs also contributed to the late response is a question for later. The focus now must be on stopping the outbreak as quickly as possible.

There is no proven vaccine and no proven treatment for this strain. The strain is genetically distant enough from the Zaire strain that existing Ebola vaccines are unlikely to work. A new vaccine is at best months away. Candidate treatments are under study. But no vaccine or specific treatments existed in 2014 either, and the response stopped that epidemic. Supportive care—fluids, electrolytes, meticulous clinical management—saves lives. The absence of a vaccine and proven treatment isn’t a reason to lose hope, it’s a reason to do everything else right, right now.

Eastern DRC is among the hardest places in the world for outbreak control. It contains remote terrain, fragile health infrastructure, more than 100,000 newly displaced people, and active armed conflict. Ebola is hard to control in the best of conditions. It’s close to impossible to control when people are shooting at you.

The U.S. has dismantled much of its own response capacity, which has been crucial in past outbreaks. The CDC has lost close to 3,000 staff in the past 18 months. Most center and unit directors are acting, part-time, or absent. The acting director runs CDC part-time while also leading NIH; running CDC during an Ebola outbreak is more than a full-time job. The U.S. has withdrawn from WHO, stopped paying dues, and pulled out dozens of American specialists who had worked side by side with WHO staff for years. Key U.S. researchers are being shut out of the global response discussions. USAID has been dismantled. On May 5, the State Department froze the funds needed to extend 105 CDC cooperative agreements through the Presidents Emergency Plan for AIDS Relief (PEPFAR) that support laboratories and surveillance systems that detect outbreaks. Seven former CDC directors and I made the case in STAT that we need to chart a stable transition for PEPFAR rather than dismantling a successful life-saving program that also supports our frontline defenses against disease.

Working for us

The most experienced Ebola responders in the world are in DRC and Uganda. Doctors, nurses, epidemiologists, contact tracers, laboratory staff, and community health workers in the area have stopped Ebola before. In West Africa in 2014, 90 percent of the responders came from the affected communities themselves. That will be true here too. The world’s job now is to give them what they need…IMMEDIATELY!

We know how to stop Ebola. The playbook works: rapid isolation, supportive care, meticulous contact tracing, supportive community services including quarantine, twenty-one-day follow-up of every contact, safe and dignified burial, and community engagement that listens well and engages community leaders to carry essential messages in ways that will be accepted. None of this requires a vaccine.

Containment is still possible. Despite late detection of the outbreak, the response appears to be ramping up. Every dollar spent now on surge support—clinicians, laboratory capacity, treatment unit construction, logistics, and payment systems that get cash to frontline workers on time—will prevent thousands of dollars that will not have to be spent later on business closures, cancelled flights, and emergency federal spending. Funds should flow to organizations with a footprint and existing operations in the area and to reliable public sector entities. Early containment is far cheaper than late response.

WHO is stronger than it was a decade ago. In 2014, WHO was slow off the mark. Since then, the organization has greatly strengthened its outbreak response capacity. Although American withdrawal has weakened it, it is still much more capable than it used to be.

This outbreak can be stopped. It will take a response that matches the speed of the virus, not the molasses of bureaucracy. The people who know how to do the work are in place elsewhere. It’s up to the rest of the world to give them the support they need, right now.

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*The name should be changed to not refer to any geographic location, but since this hasn’t happened yet, I’m using that name in this column.

Most disease outbreaks never make the news because front line health and public health workers caught them before they spiraled into major health emergencies.

A health worker notices something wrong. A surveillance system flags an unusual cluster. A response team moves fast, and a crisis that could have spiraled into tragedy...doesn’t. These quiet victories are invisible, but they carry lessons we can’t afford to ignore.

This week, as an alarming Ebola outbreak in the Democratic Republic of the Congo spreads, Resolve to Save Lives released our latest Epidemics That Didn’t Happen report.

The Ebola outbreak is a devastating illustration of the cost of delayed detection. The virus likely spread undetected for months, and by the time it was confirmed and response activities began, the virus had a running start. There were nearly 10 times this many cases in this outbreak as there were at the same time of the catastrophic 2014 West Africa epidemic. It is spreading in a region where healthcare is already stretched and underfunded. The WHO has declared a Public Health Emergency of International Concern. There’s no approved vaccine and no proven antiviral treatment, although supportive medical care can greatly increase the likelihood that patients survive.

Every day of delay increases the risk to lives and livelihoods. That’s why the stories in this year’s Epidemics That Didn’t Happen report matter. They show what happens when countries get detection and response right—and why the world, including the United States, must stay engaged in building and maintaining the systems that make it possible.

Uganda is an excellent example. In 2022, an Ebola outbreak in Uganda killed 55 people. A new outbreak last year was contained with far fewer deaths (four). What changed? Speed. Between the two outbreaks, Uganda built faster systems for detection and response, guided by the 7-1-7 target: detect within 7 days of emergence, notify public health authorities within 1 day, establish all essential control measures within 7 days of notification. The 7-1-7 approach gave Uganda the opportunity to learn from the first outbreak and close gaps in preparedness. As another ebolavirus threatens the country again, Uganda is better prepared.

The other stories in this year’s report also offer powerful lessons. South Sudan deployed a response team faster than ever and stopped a cholera outbreak before it claimed a single life. El Salvador diagnosed malaria cases early enough to protect its malaria-free status and its population. The Caribbean Public Health Agency used a new digital surveillance system during the Cricket World Cup to protect millions of residents and visitors from outbreaks that never took hold. These stories are the result of systems built before crises hit.

These successes share two things: fast detection and fast response. Finding and responding to an outbreak within the 7-1-7 window can make the difference between a small disease outbreak and an epidemic. Having response teams ready to move, without waiting weeks for approvals or resources, can break chains of transmission. Strong primary health care, real-time reporting, and cross-border coordination allow countries to see threats early.

The DRC outbreak shows what’s at stake when those systems fall short. The stories in our Epidemics That Didn’t Happen report show what’s possible when they work. The gap between those two outcomes is a choice—one that countries, donors, and global health leaders make long before any outbreak begins.

These stories deserve to be more widely known. Please read the report and share it. Epidemics aren’t inevitable. We know how to stop them. The proof is in the outbreaks you never heard about.

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In 1990, stroke killed South Koreans at a rate of 248 per 100,000. By 2023, that rate had fallen to 32. That’s an 87 percent drop. A generation ago, only about one in twenty Korean adults with high blood pressure, which is still the world’s biggest killer, had it under control. Today, six in ten do.

I’ve worked on health programs in dozens of countries over four decades, and I can’t think of a single example of more impressive progress against cardiovascular disease. Korea didn’t get lucky. It made a series of deliberate choices, sustained them across changes in government, and watched as its people stopped being hospitalized, disabled, and killed by preventable strokes and heart attacks.

The story deserves to be much better known—both because Korea has earned the credit and because every country in the world can make progress at least this fast. Here’s what happened.

Korea got there by doing something most countries still haven’t done. It made sure that every adult has a regular medical provider whose job is to keep blood pressure in check and whose performance is measured on whether they do.

That’s central to its success. Rather than launch a public awareness drive, South Korea prioritized the unglamorous, durable work of making sure the system identifies people at risk, follows up with them, and gives the professionals caring for them a real reason to do it well. The country integrated multiple public health insurance programs, which had initially been established across different sectors, into a single national health insurance system that could see who was in care and who wasn’t. It used standard medications, usually single-pill combinations of two anti-hypertensive medications, to simplify treatment. And it made these medicines free for low-income patients and deeply subsidized for older adults. When the pills cost less than a cup of coffee, people take them. When they cost a day’s wages, they don’t. This is especially important for hypertension, which is appropriately called the silent killer, since the first symptom is often a heart attack or stroke.

Then Korea did something harder. In 2012, it took on the food supply. The government implemented a National Plan to Reduce Sodium Intake and worked with manufacturers, restaurants, schools, and households to cut salt out of the Korean diet. The government funded research to help companies reformulate their products. School and worksite cafeterias rolled out lower-sodium meals. Even kimchi—the national staple and the single biggest source of dietary sodium in the country—got reformulated, with help from a kimchi refrigerator that let households use less salt to preserve it. Within a few years, Koreans were eating nearly a quarter less sodium than before.

The combined effect on blood pressure and on stroke and heart disease is what you see in the chart above. It’s progress matched by few countries, as the chart below shows.

None of this required exceptional technology, wealth, or anything specific to Korean culture. A group of dedicated advocates pushed for it and never gave up. The ingredients for success—a regular provider, consistent treatment, free medicines, and smart food policy—are possible in most countries. A recent analysis modeled what would happen if Bangladesh, Ethiopia, Nigeria, and the Philippines scaled up the WHO HEARTS hypertension package, which is built on these ideas. The result would be more than 300,000 deaths prevented in those four countries alone by 2040, at a cost that’s among the lowest of any intervention in global health.

There are at least 1.4 billion adults living with high blood pressure today. If countries follow Korea’s playbook, there would be tens of millions fewer deaths over the next two decades. That forecast is straightforward arithmetic, built on a concept that’s proven, affordable, and simple.

Korea did the hard work first. A generation ago, a Korean adult was about as likely to die of a stroke as anyone else on earth. Today, they’re among the least likely. Other countries around the world can replicate this astounding success.

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By the time disease detectives caught up with the MV Hondius, the ship was a floating outbreak.

It had left Ushuaia, at the southern tip of South America, on April 1, bound for Antarctica—about 600 miles south across the Drake Passage—and back. Ten days out, a 70-year-old Dutch passenger died on board from what looked like a respiratory illness. No specimens were taken. The body remained on board. The ship sailed on.

Two weeks after that, his widow, on her way home through Johannesburg, collapsed at the airport and died in hospital there.

On May 2, a lab at South Africa’s National Institute for Communicable Diseases identified Andes hantavirus by PCR in samples from a British passenger evacuated from Ascension Island. The same lab soon confirmed it in stored samples from the widow.

Epidemiologists are disease detectives. Investigations like this are what they live for. As I wrote in The Formula for Better Health, “A police detective can solve a murder; a disease detective can save thousands or even millions of lives by solving an epidemiologic mystery.”

The first step is to establish a case definition. A case definition has three elements: person, place, and time. Who could be infected (passengers and crew of the MV Hondius). Where (the ship and, potentially, its ports of call). When (symptom onset between specific dates). Get this wrong and you either miss cases or patterns. WHO published the Hondius case definition on May 8, with three tiers—suspected, probable, confirmed—and operational thresholds for each. That document is the spine of the response. Once there’s a case definition, detectives can do active case finding, searching for cases that might have been missed.

The next step is to talk to people. The disease detective’s most important tool is conversation. The work requires patience, empathy, and absolute confidentiality. In these types of investigations, people will tell you who they kissed, who they slept with, who they shared a needle with . . . but only if they trust you absolutely. The Hondius investigation required teams to ask elderly cruise passengers, in several languages, who they had been close to over a five-week voyage.

After that comes contact tracing. Sexually transmitted disease investigators, the most skilled interviewers in public health, can elicit the names of contacts from a rock. On the Hondius, that meant the passengers who disembarked at St. Helena, the dozens more on the Airlink flight from St. Helena to Johannesburg, and the KLM flight the widow boarded briefly and former passengers across more than twenty countries. Each gets a phone call and personal visit if possible, a temperature log, and a 42-day clock that started the moment they left the ship.

Cruise ships are basically petri dishes. People are packed together, ventilation is poor, and everyone touches the same surfaces. These are literally close quarters. Disease detectives have documented dozens of outbreaks on cruise ships over the years, from diarrheal disease, to respiratory disease, and even tuberculosis. So it’s not surprising this strain of hantavirus spread once it boarded. On a cruise ship like the Hondius, that means everyone on board is a high-risk contact.

Quarantine is what you do with people who might be infected but aren’t yet sick. It’s been a tool of public health since the Ragusan trentina of 1377—thirty days off the coast of plague-stricken ships, soon extended to the forty-day quarantena, the source of the word. Hold a possibly infected person away from others until symptoms appear and you prevent a chain from forming.

Isolation is different. It’s for people who are sick and potentially infectious. Quarantine separates the well-but-exposed; isolation separates the ill. On the Hondius, the sequence was: identify the sick, isolate them, identify the exposed, quarantine them, and care for the sick to maximize survival.

Hantavirus includes a wide range of viruses, with more than 50 species, and many subtypes within those. The 1993 Four Corners outbreak of Sin Nombre virus killed 27 Americans nationwide, more than half of those it infected. The Andes strain is different. It’s the only hantavirus we know of that’s both deadly and able to spread from one person to another. There is no antiviral treatment and no proven vaccine, but that doesn’t mean there’s nothing doctors can do. Intensive care—oxygen support, fluid management, extracorporeal membrane oxygenation (ECMO), mechanical ventilation when needed—can turn an often fatal disease into a survivable one. One British passenger, evacuated from Ascension Island to Johannesburg, is struggling in the ICU but, as of this writing, still alive.

The work of disease detectives comes down to two cardinal principles: minimize spread, maximize survival. Assess, isolate, treat intensively, and quarantine. Monitor quarantined people daily. If one falls ill, isolate, assess, and treat—fast. Patients with the Andes virus can go downhill quickly.

Disease detectives are usually invisible. It’s patient, quiet, methodical work, and it saves more lives than almost any other profession. The Hondius outbreak will end sooner because dozens of them did this work well. Disease detectives live to stop outbreaks like this one. Support them—and their institutions, including CDC—and we can all breathe more freely and live longer..

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To learn more about disease detectives, I hope you’ll read The Formula for Better Health: How to Save Millions of Lives Including Your Own.

We opened with the hantavirus outbreak unfolding on a cruise ship off West Africa. Céline provided an update about the situation: a flight attendant who had been in contact with a confirmed case tested negative, supporting the view that Andes virus may require close, prolonged contact to spread. It’s not likely that this outbreak will spiral into a pandemic. We agreed the bigger story is institutional. WHO is coordinating the response capably, while the hollowing out of CDC has left the U.S. conspicuously silent. The absence of any health alert to American physicians is a serious failure. We are less safe.

We turned to the FDA’s authorization of blueberry and mango-flavored vapes—a decision made under unusual circumstances, with tobacco industry money flowing toward political campaigns and a former tobacco executive now in a senior CDC role. In the mid-to-late 1990s, more than a third of American teens smoked; good tobacco control brought that down to the low single digits today. This decision risks rolling back hard-won progress, and it’s worth asking whether the agencies tasked with protecting our children from tobacco still have the freedom to do their jobs.

Céline emphasized that the problems that are killing Americans, from ultra-processed food, to tobacco, to inadequate primary care, are structural and they demand structural responses.

We closed on how to build forward. At least a hundred million Americans have no regular doctor. Heart attacks and strokes could be rare if we implemented what we already know. Céline invoked the late Bill Foege, architect of smallpox eradication, who counseled surrounding yourself with optimists, because optimism is the engine that gets things done. It’s crucial that we see the threats and the path forward, believe that progress is possible despite tough odds, and create effective solutions. By doing so, we can achieve the healthier future that everyone deserves.

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A small cruise ship left Argentina on April 1 with 147 passengers and crew bound for Antarctica, the South Atlantic islands, and West Africa. By early May, three of the passengers were dead and at least five more were ill. The World Health Organization confirmed the cause: Andes virus, one of the most lethal hantaviruses and the only one with documented person-to-person transmission.

Although we are learning more by the day, here is what we know so far, drawn from WHO’s Disease Outbreak News and reports from health ministries in South Africa, Switzerland, Argentina, and the United Kingdom. A 70-year-old Dutch man fell ill on April 6 on the MV Hondius cruise ship and died on board April 11 without any diagnostic workup. His 69-year-old wife disembarked at Saint Helena on April 24, deteriorated on a flight to Johannesburg, and died on April 26. South African laboratories confirmed Andes virus by PCR. A British passenger evacuated to Johannesburg is in intensive care. A Swiss man who left the ship earlier tested positive in Zurich. A German national died on board on May 2. There are at least three more suspected cases, and the ship’s doctor became infected, according to some reports. Argentine investigators believe the index couple acquired the virus during a bird-watching tour near a landfill before they boarded. WHO’s Dr. Maria Van Kerkhove has said the agency suspects limited person-to-person spread among cabin contacts. Every day brings new cases, new genome sequences, and new data across at least nine countries.

Cruise ships are floating Petri dishes for infectious disease: hundreds of people in close quarters, shared ventilation, communal dining, and constant person-to-person contact for weeks. Norovirus, influenza, COVID, and varicella outbreaks have all swept through cruises before. Whether Andes virus has done the same on the Hondius — and if so, by what route — remains an open question. Only meticulous epidemiologic investigation — symptom-onset timelines, exposure histories, and contact maps — will sort it out. Generally, spread on a cruise ship doesn’t mean that a pathogen will necessarily be highly transmissible.

Hantaviruses are diverse, with more than 50 recognized species. They are found in deer mice, shrews, moles, bats, and even fish and reptiles. The viral genome is segmented, like influenza, and can reassort when two strains meet in the same cell. Mutation rates are relatively rapid, meaning new strains can evolve and spread. Most infections never reach a clinic; Finnish serosurveys suggest doctors diagnose only about 15 percent. The case-fatality rate for hantavirus cardiopulmonary syndrome is as high as one third or more. Andes virus has documented secondary attack rates of 3.4 percent in households and 17.6 percent among sexual partners. The United States has no licensed hantavirus vaccine. No specific antiviral treatment exists.

A hantavirus pandemic is not a science-fiction scenario, it is biologically plausible. A reassortant Andes-like virus that maintains high lethality and acquires sustained respiratory transmission capacity would be catastrophic. The Epuyén outbreak in Argentina in 2018–2019, written up in the New England Journal of Medicine, was caused by sustained person-to-person transmission. Today’s cluster shows that a single tour stop can seed an outbreak that crosses four continents quickly. There’s not evidence that the current strain is highly transmissible; based on what we know now, the public’s risk remains low.

Americans should not think of this as a foreign problem. In May 1993, a young couple in the Four Corners region died of sudden respiratory failure. Working with state health departments, the Indian Health Service, and the Navajo Nation, CDC scientists identified a previously unknown hantavirus — now called Sin Nombre virus — and the deer mouse as its reservoir within three weeks. By October 1993, CDC had confirmed 42 cases in 12 states; the initial case-fatality rate exceeded 60 percent. In 2012, ten visitors to Yosemite contracted Sin Nombre virus from rodent-infested tent cabins; three died. Several hundred Americans have died of hantavirus pulmonary syndrome since. Every new documented case depends on a clinician who recognizes the syndrome and a public health laboratory that confirms it.

This is precisely the kind of threat the United States cannot handle alone. Consider what the cruise ship response required. South Africa’s reference laboratories ran the first PCR confirmation. Swiss and German hospitals identified additional cases. Argentina dispatched teams to trap rodents. The United Kingdom notified WHO under the International Health Regulations. The Netherlands coordinated repatriation. Spain prepared port reception in the Canary Islands. WHO sequenced the virus, coordinated case definitions, briefed the world, and held the response together. No single country — certainly not the United States, an ocean away — could have done this.

American clinicians who see a returning traveler with fever and pneumonia in the next seven weeks will rely on WHO’s case definition and exposure window to make the diagnosis. American laboratories will rely on WHO-shared sequences to confirm it. American public health officials will rely on WHO’s contact tracing data to identify exposed travelers who may have flown through US airports. None of this can happen without WHO.

Next week, I’ll be in Geneva for the World Health Assembly. It’s an event that doesn’t show WHO at its best; part Kabuki theatre, part mind-numbing bureaucracy. Delegates debate earnest resolutions that are unlikely to improve health. But it’s also an unparalleled opportunity to collaborate, learn from other countries, connect with inspiring leaders, and advance health security and health progress. Leaving WHO means that the U.S. cannot help fix the less functional parts of the system or benefit from the opportunities for progress.

The current administration’s disengagement from WHO makes Americans less safe. Only WHO can coordinate the early warnings, genome sequences, case definitions, and multi-country contact tracing that protect Americans. The outbreak is, at present, a small one. The next one may not be.

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The only thing predictable about influenza is that it’s unpredictable.

It’s a simple, memorable and powerful saying, often repeated by one of the world’s foremost experts in flu.

Dr. Nancy Cox died last week at 77, of brain cancer. For more than two decades, she ran the influenza division at the Centers for Disease Control and Prevention. Most Americans have never heard her name, but her work prevented catastrophes the rest of us never had to think about.

I worked with Dr. Cox during my years as CDC director. She was impressive and intimidating. Impressive, because she knew more about flu than anyone—the virology, the epidemiology, the history, the process of vaccine strain selection, the names of laboratory directors and experts in dozens of countries, and much, much more. Intimidating, because in any room where the conversation turned to flu, she clearly knew so much that it was hard to keep up.

When Dr. Cox took over the CDC influenza division in 1992, it had 14 staff. By the time she retired in 2014, it was a powerhouse unit and was anchored to a worldwide network of laboratories that, every year, characterizes thousands of viruses to update the flu vaccine. Hundreds of millions of people worldwide benefit from this work. It’s painstaking, methodical, and largely unseen. It’s also what stands between us and the next pandemic.

Lasting accomplishments

Dr. Cox leaves a deep legacy that will carry on in communities and countries around the world. Some examples:

• A global flu surveillance network. Dr. Cox helped strengthen the WHO Global Influenza Surveillance and Response System—a worldwide network of flu laboratories that detect and characterize new strains in real time. This is the foundation that lets the world choose the best possible vaccine for each season and spot pandemic threats early.

• The seed viruses behind flu shots. Wild flu virus from a patient doesn’t grow well enough in chicken eggs to make vaccine at scale. Dr. Cox’s lab refined the reassortment techniques—pairing each year’s circulating strain with a high-yield workhorse virus first isolated in 1934—that allow manufacturers to produce hundreds of millions of doses on time.

• A pandemic head start. CDC’s library of candidate vaccine viruses against H5N1, H7N9, and other potential pandemic strains, built and maintained under her leadership, gives manufacturers a running start when a pandemic strikes.

• Tools used to judge a pandemic threat. Dr. Cox led development of the Influenza Risk Assessment Tool, which helps evaluate whether a new flu virus could become a pandemic. She also helped develop the Pandemic Severity Assessment Framework and the federal Pandemic Intervals Framework. WHO adapted her tool into its own global version. Officials rely on these tools to decide what to stockpile and how to respond.

• Mortality estimates to drive policy. She was co-author of a foundational JAMA study that provided estimates of U.S. influenza-associated deaths and hospitalizations, a crucial source for vaccination recommendations.

• A generation of public health scientists. Dr. Cox trained, mentored, and championed scientists who now lead flu surveillance and response across the United States and around the world.

In April 2009, just before I arrived as CDC director, a novel H1N1 virus emerged in Mexico and California. Dr. Cox and her team identified the virus, characterized it, and shared it with the world within days. Within two weeks, CDC distributed more than a million test kits to all 50 states and 140 countries. Compare that with the catastrophic CDC test failure at the start of Covid . The difference was decades of investment in the people, laboratories, and relationships Dr. Cox built.

That same spring in 2009, lightning struck Dr. Cox’s house and burned it to the ground. No one was hurt. She returned to the office the next day in clothes that smelled of smoke. “I flipped a switch in my mind,” she said later, “to concentrate on what we thought might turn into a pandemic.”

In 2006, the Partnership for Public Service named Dr. Cox a Federal Employee of the Year through its “Sammies”—the Samuel J. Heyman Service to America Medals, the closest thing the federal civil service has to an Oscar. Time put her on its 100 Most Influential People list the same year. Dr. Cox was the kind of public servant Michael Lewis profiles in Who Is Government?—federal civil servants whose names most Americans never hear but whose work is invaluable.

No single country can see a flu pandemic coming. Influenza begins in animals, jumps to humans, and travels around the world in days. To detect a new strain early, scientists in Beijing, Memphis, Melbourne, Cairo, and Atlanta must share samples and sequence data in real time. Dr. Cox built those relationships over years—through visits, training, and co-authorships.

The kind of trust that Dr. Cox fostered takes decades to build. It can be lost much faster. Cuts have gutted CDC. Global surveillance funding is gone. Laboratories in countries where pandemics begin no longer have American partners. WHO’s ability to coordinate global virus tracking has been disrupted. H5N1 keeps spreading in dairy cattle and other animals in the United States, and we know less about it than we should. Last year, after the virus jumped into dairy herds, Dr. Cox told STAT the virus must have “some kind of special sauce”—her dry phrase for a pathogen that keeps rewriting the textbook.

Influenza is predictably unpredictable. We are safer because of what Dr. Cox and others built. It’s also predictable that we will be less safe if we let it go.

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Before I went to medical school, I spent time doing community outreach in the Mississippi Delta. The community health center I was affiliated with was doing important work. Its staff saw all patients regardless of ability to pay and provided care otherwise not available. The staff believed that they were getting the word out about their services, but the number of patient visits was low. It was a mystery. A shiny new clinic. A community with urgent medical needs. And few people visiting the clinic.

I went door to door to survey more than 300 randomly selected households. It was intense, interesting, and revealing. Intense, because it meant traveling all over the community, in a battered old blue Chrysler the organization that hired me had provided, which broke down often. The starter motor was bad, so I had to park on a downhill, so I could roll it to start; a local mechanic was able to get it working for $20. It was interesting, in a tragic way. In the United States, I’d never seen the kind of poverty, with families living in tar shacks with dirt floors or in cabins that were for sharecropping, though not called that. And it was revealing. Half of the people didn’t know the clinic existed. Eighty percent didn’t know it had a sliding-fee scale; they could be seen for just a few dollars. And the people who knew those things? The higher-income residents, the ones who didn’t need the clinic.

I’ve thought about that survey often since. It is one of the most powerful lessons I’ve encountered in public health: Communication is never as good as you think it is.

Filling a vacuum

This pattern—reaching the already-reached while missing the most vulnerable—isn’t unique to that community in the Mississippi Delta. It’s sometimes called the inverse care law. People who need care the most, get it the least, and vice versa.

In a recent conversation about trust in public health, Dr. Noc and I discussed how for decades, public health operated on the assumption that rigorous research, clear guidelines, and official communications were enough. That assumption hasn’t held. People respond to human connection and stories. Most Americans can’t picture a single face at the CDC or NIH. The career scientists with the most expertise are invisible to the people they serve. And while public health has stayed faceless, people with names, personalities and profitable business models—but often lacking in expertise and ethics—fill that vacuum.

Take vaccines. An entire industry takes advantage of the shifting information landscape, selling products and subscriptions, and suing manufacturers, as Jessica Malaty Rivera and I discussed earlier this week. Vaccine misinformation isn’t a grassroots movement—it’s an industry driven by money. Millions of unregulated dollars, largely unaccountable. Follow the money, and it becomes clear who benefits from public distrust.

Who is hurt most by the information gap

The information gap isn’t random. It tracks along the familiar fault lines of income, education, and proximity to trusted voices.

People who navigate healthcare with confidence are more likely to find the health center, know how to make it accessible and affordable, and encounter accurate information. Those with historical reasons to distrust institutions—who also bear the heaviest burden of preventable disease—are more likely to see misinformation first.

Sometimes the barrier isn’t distrust, it’s simply that people don’t know the resource exists.

High blood pressure kills 11 million people globally each year, is the single leading driver of the survival gap between Black and White Americans, and is the leading preventable cause of death among all Americans. We know how to treat it, but we consistently fail to reach those who most need that treatment. As I describe in The Formula for Better Health, there’s a way to fix this problem: See the trends, path to progress, and status of our efforts; Believe we can improve by recognizing past progress, making phased further progress, and working together to Create a healthier future.

Reaching those left behind

Recent conversations give me more hope. People want to live longer, healthier lives, and have a genuine appetite for nuance. No one wants to be talked down to. We all want honesty, including about uncertainty.

The deeper challenge is whether large public health institutions can reach people where they are. Part of that is where they receive information, including on social media platforms. At CDC, we found career scientists from small towns across the country and got local papers to profile them and the important work they do. Many of those papers have likely shuttered since then, but at the time it was an effective strategy. We made the agency human. Connecting their stories to those places, in formats that reach people, is possible. It requires investment and leadership willing to try.

It’s up to all of us to make sure that what we’ve built doesn’t stay a secret that only the people who already know about it can access.

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Jessica opened by talking about vaccine disinformation and how the narratives circulating today aren’t actually new. The same emotional hooks—fear about fertility, genetics, and cancer—keep resurfacing, reattached to whatever vaccine or policy is in the news. Helping people recognize those recycled patterns is one of the most practical ways to build what she calls “infodemic resilience”: the stamina to navigate a constant stream of health claims without losing your footing.

Inside the conversation:

We also discussed how money drives misinformation. Jessica made the case that when you follow the dollars, the picture is surprisingly clear. The unregulated wellness industry, which uses pseudoscience and fear-based tactics to sell everything from supplements to IV therapy to injectable peptides, dwarfs pharmaceutical profits, yet faces almost no scrutiny. She’s also started referring to the “anti-vaccine industry,” rather than the “anti-vaccine movement,” because that’s what it is—a business model built on selling distrust.

I raised how challenging it can be to discuss scientific uncertainty honestly and proposed communicating the level of certainty as a range—from things we know with near-certainty, to things that current evidence supports but could shift, to things that we don’t know much about at all. Jessica connected that directly to what went wrong during the Covid pandemic, when public health leaders didn’t effectively communicate scientific uncertainty in real time.

We closed on what communicators, researchers, and career scientists can do when institutions fall short and why exposing the “selling, subscribing, and suing” business model of those purveying health disinformation may be one of the most powerful tools we have right now.

I hope you’ll find this as refreshing and energizing a conversation as I did.

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The largest review of hypertension studies ever conducted tracked 6.1 million people across 119 countries and 287 surveys over two decades. Its findings are stark: the number of people with high blood pressure has nearly doubled since 2000, the burden has shifted sharply toward the world’s poorest countries, and the vast majority aren’t being treated effectively.

The core findings:

In high-income countries, the proportion of people with hypertension decreased from 32.8% in 2000 to 30.1% in 2020 and control rates more than doubled, to 40%. That control rate is still far too low, but it’s real progress. Low- and middle-income countries moved the other way. Prevalence rose. Control improved, but from a desperately low base. The gap with wealthier countries widened. Today, just one in ten men with hypertension in low- and middle-income countries has it under control.

One in ten.

High blood pressure kills more people than any other condition—more than 10 million deaths a year. More than HIV, tuberculosis, and malaria put together. More than all infectious diseases combined.

The medicines cost pennies, the protocols fit on a single page, and the science has been settled for half a century. Yet more than a billion people in low- and middle-income countries live with uncontrolled blood pressure today, most unaware of the damage accumulating silently in their hearts, brains, and kidneys.

That is a moral and practical failure. And it doesn’t have to be this way.

One reason for the high number of people with high blood pressure is our food. As a society, we eat too much sodium and too little potassium. This combination drives blood pressure up and causes millions of premature deaths every year. Government action can save lives: Mandatory sodium limits in packaged food and front-of-pack warning labels on high-sodium products are policies proven to reduce sodium intake. On the other hand, voluntary industry pledges don’t work and they never have. Switching from ordinary table salt to potassium-enriched salt could prevent hundreds of thousands of strokes and heart attacks annually at very low cost.

The health care indicator that matters most is the number of people on treatment with their blood pressure controlled. That number reflects protection from strokes, heart attacks, kidney failure and dementia. Every health system and clinic program should track it—patient by patient, month by month.

The path to moving that number is clear. The WHO HEARTS technical package lays out exactly what to do.

• A simple protocol of three medicines

• Reliable supply of quality-assured generic medications and validated digital blood pressure monitors

• Team-based care in which nurses and community health workers manage patients

• Treatment that’s free and convenient for the patient

• A tracking system that asks the fundamental question: Is a patient’s blood pressure controlled?

Resolve to Save Lives partners with governments in more than 40 countries to adapt and implement HEARTS. We embed technical staff, support workforce training, and help secure reliable supply chains. We support government-led programs that will expand and sustain themselves long after our role ends. In our partner countries, governments have been able to purchase quality-assured medications for less than $5 per patient per year. That’s what stands between someone with hypertension and the stroke that should never have happened.

Our approach is catalytic and time-limited: we invest for five to ten years, partner with governments that build the system, and exit. Each philanthropic dollar leverages, on average, eight dollars of government spending. The protocols, the supply chains, the trained staff stay in place. Few investments in global health deliver more per dollar.

By 2030, if current trends hold, more than 2 billion people worldwide will have hypertension. Every second of every day, those whose blood pressures are not controlled will have preventable damage to the hearts, brains, and kidneys. Every day, the risk of preventable tragedy, lost productivity, and avoidable health care costs compounds. Unless we act now, most people with hypertension will live in countries where the health system is not yet ready to treat them effectively. We can change that trajectory. The medicines, protocols and evidence exist. What’s missing is focused action and investment to address what has quietly become the world’s deadliest and most neglected condition.

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The doctor faced a terrible choice. Her patient had sleeping sickness, or human African trypanosomiasis, and the parasite had crossed into his brain. Without treatment, he would almost certainly die. The only available treatment might kill him.

That treatment was melarsoprol. It was literally arsenic—poison—dissolved in propylene glycol, essentially antifreeze, because arsenic doesn’t dissolve in water. Clinicians called it “arsenic in antifreeze,” and the name fit. The injections were painful. The drug attacked the parasite, but it also attacked the patient. In 5 to 15 percent of cases, melarsoprol triggered a severe brain reaction and of those patients, approximately half died. Overall, about one in twenty people treated with melarsoprol died from the drug itself. Doctors gave it anyway, because sleeping sickness, left untreated, is almost always fatal.

For decades, this was the best medicine had to offer for one of Africa’s most feared diseases.

Last month, the European Medicines Agency approved acoziborole—three tablets, taken once, with a 96 percent success rate. No injections. No hospitalization. No arsenic or antifreeze.

How that happened tells us what kind of organizations save lives.

Sleeping sickness is a parasitic disease (trypanosomiasis) transmitted by the tsetse fly, endemic across 36 sub-Saharan African countries. In its early stage, patients have fever and headache. In the late stage, the parasite crosses the blood-brain barrier causing seizures, confusion, behavioral changes and, without treatment, death. In 1998, nearly 40,000 cases were reported, with an estimated 300,000 more undiagnosed. In some villages in Angola, the Democratic Republic of Congo, and South Sudan, sleeping sickness was a leading cause of death.

The disease is a “neglected tropical disease,” meaning it kills people who lack political power and offers no profit for pharmaceutical companies. The market for melarsoprol was always poor Africans in remote villages. No drug company would invest to replace it.

So who does?

In my book The Formula for Better Health, I describe what makes organizations succeed at the hardest part of the See/Believe/Create formula for health progress: Create, where knowledge becomes action and action leads to lives saved. My experience suggests that effective organizations demonstrate three characteristics: A focus on mission, pragmatism, and use of data to improve performance. I write about the Drugs for Neglected Diseases initiative (DNDi) as a model of an organization with a crystal-clear mission: the best science for the most neglected diseases. Since 2003, DNDi has developed 14 treatments for six deadly infections—malaria, leishmaniasis, Chagas disease, sleeping sickness, and others—giving millions of people longer, healthier lives. The organization stays focused on rigorous science, turning down funding that would pull it off mission. That discipline is rare, and it matters enormously.

The arc of progress against sleeping sickness illustrates why organizations like DNDi exist. In 2009, DNDi and Sanofi developed NECT, a combination therapy that was safer and more effective than melarsoprol. In 2018, they developed fexinidazole, the first all-oral treatment, a 10-day course that replaced injections for most patients. Cases fell 98 percent over two decades, from nearly 40,000 reported in 1998 to 546 in 2024, through sustained surveillance, vector control, and better treatments.

Now comes acoziborole: three tablets, taken once, free of charge to patients through a donation from Sanofi. The clinical trial showed 96 percent success at 18 months. It was conducted by African doctors and researchers in some of the most remote areas of the DRC and Guinea, working alongside national sleeping sickness control programs. As Dr. Erick Miaka, director of the DRC’s national program, put it, this is a victory for Africa-led science.

Twenty years ago, a doctor choosing between arsenic and death had no better options. Doctors now have a safe and effective oral treatment.

When public health works, it becomes invisible. Nobody celebrates the encephalopathy that didn’t happen, the patient who didn’t die from the treatment meant to save them. The work of organizations like DNDi rarely makes headlines. But the prevention of suffering and death is the true measure of success.

The challenge now is the final mile—ensuring that acoziborole reaches every patient who needs it in villages that are hard to reach. That is where implementation catalysts matter: organizations that partner with national programs to close the gap between an approved drug and a cured patient. Resolve to Save Lives does this kind of work, partnering with local organizations in more than 60 countries to turn proven tools into functioning programs.

If you find value in this newsletter, consider a paid subscription. Every dollar goes directly to support projects and organizations that save lives in low- and middle-income countries.

The formula for progress is See, Believe, Create. DNDi saw a disease the world ignored, believed a better treatment was achievable, and created it. Twenty years. Fourteen treatments. Millions of lives.

That is what public health, done well, looks like.

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100 years ago, the United States reached a crossroads that would undermine the health of its people for the next half-century. It was a choice between public protection and industrial profit, and the government chose the latter.

Today, as the U.S. has dismantled systems that allow us to see modern health threats and the regulations to control them, we risk repeating the mistake.

The 1926 choice

In 1925, the U.S. held hearings on a tragedy that should have been a turning point. Five workers at a New Jersey refinery died and dozens became severely ill from lead poisoning while producing gasoline with a lead additive. Alice Hamilton, a brilliant physician who became the first woman appointed to Harvard’s faculty, testified with striking clarity: “You may control conditions within a factory, but how are you going to control the whole country? ... I am not one of those who believe that the use of this leaded gasoline can ever be made safe.”

Hamilton also had a genius for strategy. She advocated for government regulation and organized worker action to reduce risks. When neither regulation nor worker demands were possible, she used astonishing tact to persuade factory owners and managers to implement safety procedures. A letter she wrote to a recalcitrant factory manager is a master class in the combination of moral suasion and a velvet hammer.

Her colleague Yandell Henderson predicted, with uncanny accuracy, that the danger “would grow worse so gradually and the development of lead poisoning would come on so insidiously … that leaded gasoline would be in nearly universal use and large number of cars would have been sold … before the public and the government awaken to the situation.”

The choice the U.S. government made in 1926 despite these warnings had almost inconceivably tragic consequences. After a brief pause in production to investigate the deaths, the federal government allowed leaded gasoline back into the market. For fifty years, lead spewed from every car’s tailpipe, contaminating air, soil, and bodies. By the 1970s, the average American child had blood lead levels of 15 µg/dL, higher than what today triggers an urgent investigation. This mistake harmed the brains of generations of Americans, resulted in millions of premature deaths, and reduced the country’s GDP by hundreds of billions of dollars in lost productivity. Imagine a parallel universe in which Hamilton’s warnings were heeded: In that world, the country would be more creative, more prosperous, more harmonious, and healthier.

The Cassandra curse and the prevention paradox

This failure is a textbook case of the Cassandra curse. Cassandra, the priestess from Greek mythology, could see the future but was cursed: No one believed her warnings and therefore did not take action to prevent the disasters she predicted.

This curse is fueled, in part, by the prevention paradox, a concept coined by the brilliant public health thinker Geoffrey Rose. The prevention paradox explains that an action bringing large benefits (or harms) to a community often offers very little to each individual. Small reductions in individual risk, applied broadly across a population, yield enormous societal gains—but these gains are hard to notice. Because most people don’t feel or notice the benefits of a toxin that was removed from the environment or a heart attack that never happened, there is no natural constituency to fight for prevention.

In contrast, the financial costs of action are concentrated and highly visible. In 1926, the opponents of regulation—the gasoline and automobile companies—were organized and powerful. They paid the public health staff involved in the process to undermine evidence and block safer alternatives. In contrast, the potential winners from government action—millions of future lead poisoning victims, many not yet born—were diffuse and voiceless.

The blindness of 2026

Today, we face a new, deliberate blindness. We are witnessing systematic dismantling of the systems society requires to find today’s versions of lead. Recent turmoil at CDC, with disruptions to data-driven programs, mean our ability to track toxins such as PFAS (“forever chemicals”), microplastics, and nanoparticles is being disabled just as evidence of their harm becomes more clear.

Public health surveillance – collecting data about harms – is the superpower that allows us to see invisible threats before they become catastrophes. When we lose these systems, it’s like flying blind.

Soot (PM 2.5) already causes an estimated 100,000 U.S. deaths annually, yet industry lobbyists continue to block the phasing out of these pollutants, just as they did with lead a century ago. And the current administration has rolled back rules limiting release of toxins into the air and weakened environmental oversight of PFAS and other toxins.

Breaking the curse

To avoid another century of silence we must apply a systematic approach, which I outlined in The Formula for Better Health: See, Believe, and Create.

See the invisible: We must restore and modernize tracking systems to document silent harms. We must also reveal the self-interested industries responsible for these harms and identify the pathway to progress. And we must determine through rigorous, objective, and transparent evaluation whether our programs are actually reducing the harmful toxic exposures of today.

Believe change is possible: We must shatter the illusion of inevitability by highlighting past victories. Progress in energy production shows what’s possible: coal-fired plants have been closed and renewable energy prices have plummeted. In the past decade, solar panels have become 90% cheaper and wind turbines 40% cheaper. Showing that a sustainable, healthier future is within reach helps build the optimism needed to persist.

Create solutions at scale: Progress requires moving beyond knowledge to effective action. We must build coalitions—including businesses that benefit from healthier workers and families that avoid disease costs—strong enough to overcome the lobbying of industries that profit while harming others. Success depends on operationally straightforward solutions that can reach entire populations.

In 1926, the government made a fateful choice. In 2026, we’ve been warned. The question is whether we’ll use a proven formula to overcome the forces blocking progress … or if future generations will look back at us as the ones who ignored the Alice Hamiltons of our time.

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Most health advice you encounter on social media, the news, or elsewhere, is driven by profit, hype, or sloppy thinking. Some of it is harmless noise. Some of it is dangerous. And nearly all of it buries what matters most.

That’s why I created Proven Steps for a Long, Healthy Life, a two-page ready reference guide now available as a free download for paid subscribers of The Formula. I was surprised as I was creating this document that I couldn’t find anything like it, anywhere. That’s why I developed it.

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A pregnant waitress, Martinah Payne-Yehuda, testified to the New York City Council in 2002 and described what it was like to breathe other people’s cigarette smoke for eight hours a night. She wasn’t an epidemiologist. She didn’t cite relative risks. She told the Council what her workday felt like.

Because of her testimony and others stories like it, the Smoke-Free Air Act passed. Opponents predicted the restaurant industry would collapse. It didn’t. Restaurant business increased. During the next decade, adult smoking in New York City decreased 28% and youth smoking dropped 52%.

When the City Council speaker demanded exemptions for smoking rooms, the health department didn’t fight the exemption. Instead, they wrote engineering specifications so technically demanding that no bar could afford to build one. Two investigated and neither proceeded.

That kind of strategy is rarely taught in classrooms

The NYC Smoke-Free case is one of eleven case studies now available for free as part of the teaching materials for The Formula for Better Health. Each comes with a student handout, instructor guide, test bank, and answer key. Faculty can build a semester-long course, use individual chapter guides, or drop a single case into an existing class. An interactive version of the case studies is under construction.

Last week, I discussed how public health training can close the gap between knowing what works and making it happen. This week, I’m focusing on why specific case studies make a big difference.

What makes these cases stand out

Most case studies describe what happened. These put students at decision points and ask: What would you do? Instructor materials provide a sequence of the material so students face the same uncertainty practitioners faced. Here are a few examples, with the full set in the table below.

Alice Hamilton and the Cassandra curse. Hamilton documented lead poisoning for decades. The 1925 Surgeon General’s conference was stacked with industry-affiliated scientists. Their conclusion was that more study was needed. The case identifies six drivers that keep dangerous products on the market despite clear evidence of harm. Students map those drivers onto a contemporary problem of their choice. Which are operating? Where’s the money? Whose story gets heard?

Styblo and HEARTS. Karel Styblo’s single rule for tuberculosis control was: “No cheating. Every patient in your area, you are responsible for their outcome.” This rule transformed how programs are measured. Most programs count patients enrolled, but Styblo counted patients cured to reveal whether a program is working. Students apply Styblo’s question to a program of their own choosing and design the simplest possible monitoring system for a resource-constrained setting. The lesson: Simplicity is a design principle, not a compromise.

SIDS and the best available evidence. Dr. Ed Mitchell found a pattern in infant deaths—many had been placed prone to sleep. A statistician confirmed on the back of an envelope that prone sleeping accounted for most deaths from Sudden Infant Death Syndrome (SIDS). Mitchell’s reaction: “I couldn’t believe something as simple as placing babies prone could increase the risk of sudden death substantially. Basically thought it was rubbish.” No RCT was ever done and none was needed – and none could have been done, practically and ethically. New Zealand launched a Back to Sleep campaign based on observational evidence and SIDS deaths plummeted. The case drives home a critical lesson: RCTs are not the gold standard for every question. The best decisions come from the best available evidence appropriate to the question being studied.

What students do with these cases

These cases ask students to do what practitioners do. Design a surveillance system. Apply a political strategy framework to a real policy fight. Diagnose why a program is failing. Build a monitoring system simple enough to work. Map the forces that prevent action on a problem they care about.

Every case applies to CEPH foundational competencies. The instructor guides include detailed teaching prompts. The test banks assess applied reasoning, not just recall. Several cases include slide decks.

Free and ready to use

The materials are free. Click here to access.

At a World Health Organization meeting on TB evaluation, a participant dismissed the insistence on measuring cure rates: “Oh, you’re one of those ‘outcome‘ people.” These case studies are for the outcome people — and for training the next generation to become them.

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We started with a hard question: Has the word “expert” become a pejorative? When people hear from the CDC or the FDA, most can’t picture a face behind the message. They see an institution, a press release, an ivory tower. For decades, public health operated on the assumption that rigorous studies plus compelling data plus clear guidance would move people to act. That assumption, as we’re living through right now, hasn’t held up.

Part of the problem is tone. We’ve been too prescriptive—too quick to tell people what to think rather than giving them the evidence and trusting them to decide. People are smart. The moment they sense condescension, they push back. As they should.

Dr. Noc described how he started his career making what he now calls “vaccines are safe and effective” style content—simple, slogan-driven, and easy to absorb. He moved away from it. Not because it’s false, but because it backfires. Some people hear “safe and effective” and conclude there’s no risk at all. When they later find out vaccines, like all medical interventions, can occasionally cause harm, they feel deceived. And once someone feels lied to, you’ve lost them. The answer isn’t simpler messaging, it’s honest messaging. Show people the evidence, explain the benefit-risk tradeoff, and respect their ability to sit with complexity. A detailed, nearly six-minute video Dr. Noc made on the hepatitis B vaccine got 10 million views. People are not as allergic to nuance as we assume.

That said, the information environment makes honest communication genuinely hard. It takes three seconds to absorb a scary health claim: COVID vaccines cause heart attacks. It takes five minutes to explain why that isn’t true. That asymmetry doesn’t go away. One approach is to pre-bunk — warn people ahead of time about the tactics used to mislead them. Prepare the immune system before the infection. It’s not a complete solution, but it can help.

On algorithms: Dr. Noc made a point I want more people to hear. He said he replaces the word “algorithm” with “audience.” If you say the algorithm suppresses evidence-based health content, it sounds sinister. If you say the audience doesn’t want evidence-based health content, that sounds wrong—because it is. Nobody wants bad health information for themselves or their kids. Emotionally charged content keeps people watching. The algorithm is just a mirror. We’re the ones who stop—or don’t stop—scrolling.

What actually changes behavior? I shared what we learned with anti-smoking ads. We tested different approaches and measured the response — calls to quit lines, smoking rates. The most effective ads were not about death. They showed disability and disfigurement. People don’t fear death the way they fear losing their ability to do what they love. One of the people who recorded the ads, Terry Hall, was a cheerleader from North Carolina who started smoking in high school, got cancer in her 40s, and went on camera to tell that story. She saved more lives than most doctors. When I started at CDC, a colleague’s study showed that six-year-olds were more likely to recognize Joe Camel than Mickey Mouse. Teen smoking was at 36%. Today it’s 4%. That didn’t happen by accident.

The bigger challenge: can large public health institutions—CDC, FDA, NIH—learn to communicate where people actually are? Not press releases, not cable news. Instagram. TikTok. Facebook. At CDC, we once found career scientists from small towns across the country and got local papers to profile them. People read about their neighbor’s daughter who tracked disease outbreaks in Africa, investigated a chemical spill in the U.S., or supported a cancer prevention program. That made CDC human. The same principle applies to social media—but it requires leadership, clearance reform, and a willingness to let scientists show that they are people.

Dr. Noc said he hopes someday people inside these institutions will do this work better than he can, with better resources and direct access to the science. So do I.

There’s a lot our society disagrees about right now. But everyone wants to live longer, healthier lives. That’s common ground worth building on.

Thank you to everyone who tuned in live!

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Every year, on average, we discover at least one new microbial threat—on top of the hundreds of viruses, bacteria, and fungi we already know cause disease outbreaks. We live in a world so interconnected that a new infectious disease can travel from one continent to another in less than 36 hours. And yet, when outbreaks emerge, countries routinely lose precious days before they detect what’s happening, inform the right people, and act to contain it.

That delay is not inevitable. And it’s not acceptable.

I’ve spent four decades in public health. I led CDC during the West Africa Ebola crisis and I’ve seen what happens when response systems move too slowly and what’s possible when they move quickly. Speed isn’t everything in outbreak control, but in the earliest days of an emerging threat, it’s the most important thing. Time is lives. And speed makes the difference between a cluster and an outbreak, and between an outbreak and an epidemic.

That’s why the 7-1-7 target is so important. It’s a tool our team at Resolve to Save Lives created that’s quickly been adopted by communities, countries, and institutions around the world. It has the potential to prevent the next pandemic.

What is 7-1-7?

The concept is simple. When an infectious disease outbreak or other health threat occurs, countries should:

• Detect it within 7 days of emergence

• Notify public health authorities within 1 day of detection

• Complete all essential early response actions within 7 days of notification. These include deploying an investigation team, obtaining a lab confirmation of the pathogen and taking measures to prevent spread.

Seven days, one day, seven days. Detect. Notify. Respond. Did an outbreak meet all three? Yes or no.

The simplicity is intentional. We developed this target with data from hundreds of real-world outbreaks to create a goal that was unambiguous, measurable, and achievable—something that could drive accountability the same way the UNAIDS 90-90-90 target galvanized the global health community to drive down AIDS deaths.

Why it matters

In a study our team published in The Lancet Global Health, we applied the 7-1-7 target to 41 public health events across Brazil, Ethiopia, Liberia, Nigeria, and Uganda. Only 27% met the complete target. The bottlenecks were revealing—and fixable.

The most common reason for delayed detection was low clinical suspicion. Health workers simply weren’t thinking about the possibility of a new outbreak. On the response side, the most frequent obstacle wasn’t a missing vaccine or an unknown pathogen, it was a lack of rapidly accessible emergency funds to mobilize a team.

In 2022, Uganda identified that gaps in community awareness were causing late detection of diseases such as anthrax and viral hemorrhagic fever. As a result, the public health team made educational outreach a national priority. Other countries using 7-1-7 found that establishing a revolving emergency response fund, a relatively modest fix, cut response times dramatically.

This is the power of 7-1-7. It doesn’t just tell governments whether they fell short. It tells them where they fell short and why, so they can improve. Instead of planning and more planning, it’s a “find a problem, fix a problem” solution. Blame doesn’t help. Fixing systems does.

What success looks like

Uganda is a genuine success story. When Ebola re-emerged there in recent years, response systems refined through 7-1-7 helped contain the outbreak before it spread widely. Gabon stopped a 2024 mpox outbreak with no deaths, the product of fast detection, fast notification, and coordinated early response.

The 7-1-7 Alliance, which now includes 84 countries and is backed by the WHO and the World Bank’s Pandemic Fund, supports exactly this kind of progress, providing technical assistance and a global community of practice so countries have the support they need to use 7-1-7 effectively.

The bottom line

Another pandemic is a matter of when, not if. Climate change, urbanization, and the relentless evolution of microbes guarantee that new threats will emerge. We cannot stop every pathogen, but we can build systems that help communities and countries find threats early and act decisively.

The 7-1-7 target is ambitious but countries are proving that it’s achievable. The gap between what we know and what we do costs millions of lives. 7-1-7 helps close that gap.

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