Dr. Casséus: “The First Outbreak of the Post-USAID Era”

When the Trump administration began dismantling the U.S Agency for International Development (USAID) in January 2025, it set off a chain of reactions globally, including the termination of numerous global health programs tackling malaria, HIV, tuberculosis, and polio. Organizations like PIH rushed to fill in the gaps while global health advocates and experts appealed to members of Congress to restore foreign aid funding.

When these systems of aid that had been developed over decades were destroyed, global health experts around the world knew there would be ripple effects for years to come-from individual patients not receiving lifesaving care to entire supply chains breaking down.

Now, a new Ebola Disease (EBOD) outbreak in central Africa has, as of Wednesday, resulted in more than 600 suspected cases and 139 deaths. It comes from the Bundiugyo strain, one of the least common variants of the disease that has no vaccine.

Dr. Alain Casséus, infectious diseases division chief and principal investigator for the PEPFAR Project for Zanmi Lasante, PIH's sister organization in Haiti, knows this outbreak is uncharted territory. To explain how USAID's destruction could impact Ebola response in Africa, Dr. Casséus shared his expertise on infectious disease control and supply chain impact in the following piece, originally published on Substack.

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The First Outbreak of the Post-USAID Era

On Friday, Africa CDC confirmed what health officials in eastern Congo had been quietly tracking for several weeks: a new Ebola outbreak in Ituri Province. By Saturday morning the count was 336 suspected cases and 87 deaths (Note: at the time of publication on Wednesday, suspected cases have risen to 600 with 139 deaths), with a confirmed cross-border export to Kampala. It is the seventeenth time the Democratic Republic of Congo (DRC) has faced Ebola since the virus was first identified there in 1976. In most respects, the country and the region know this script.

In one critical respect, they don't.

This is the first major filovirus outbreak since the United States dismantled the foreign assistance architecture that scaffolded every DRC Ebola response since 2014. USAID was officially closed on July 1, 2025. Roughly 80% of its global health awards were terminated, $12.7 billion in committed funding pulled. U.S. assistance to Africa fell to its lowest level in a decade. The Disaster Assistance Response Team model - the operational fulcrum of the 2018-2020 response - no longer exists in the form it did even eighteen months ago. And the cuts did not happen in isolation: the UK, Germany, France, and Canada cut their aid budgets in the same year, the first time in nearly three decades the major donors moved together in that direction.

The outbreak unfolding in Ituri is, in epidemiological terms, already among the most difficult of the past decade: a strain with no licensed vaccine, an urban index case, a mining-town geography, an active conflict overlay, and a late detection window measured in weeks rather than days. Even with a fully functioning international response, this would be a hard outbreak.

It is not getting a fully functioning international response. What it gets instead is the question this piece is built around: what does global health response actually look like when the architecture that carried it for a decade is no longer there?

What's Happening

The outbreak is centered in Mongwalu and Rwampara, two health zones in Ituri Province, with suspected cases now reported in Bunia, the provincial capital of roughly 800,000 people. The Africa CDC confirmation on May 15 reported 246 suspected cases and 65 deaths; by Saturday morning, those figures had moved to 336 and 87. Of the first twenty samples tested by DRC's Institut National de Recherche Biomédicale, thirteen returned positive for Ebola... and the strain has been confirmed as Bundibugyo, not Zaire. That single laboratory finding reshapes the entire response.

The suspected index case was a nurse who died at the Evangelical Medical Centre in Bunia after presenting with fever, bleeding, vomiting, and severe weakness. A healthcare worker as the first identified case almost always signals two things: significant prior community transmission that went unrecognized, and nosocomial amplification among other clinical staff and their contacts. Both have likely been running for several weeks. Africa CDC and DRC's health ministry believe the outbreak began in late April, which means the case count at announcement reflects transmission chains that had been propagating unobserved in two mining towns and the provincial capital.

On May 14, a 59-year-old Congolese man died of the virus in Kampala after travelling from DRC. He had been admitted to Kibuli Muslim Hospital on May 11. Uganda's Ministry of Health has classified the case as imported and has not yet confirmed local transmission. His body was returned across the border to DRC for burial. This is itself a SIGNIFICANT exposure event, given how Ebola transmits through funeral practices.

The geography compounds the epidemiology. Mongwalu is a mining town with high seasonal and inter-provincial labor mobility, the kind of population that turned earlier outbreaks regional. Rwampara and Bunia are urban centers with dense daily contact patterns. Ituri borders both Uganda and South Sudan, and the affected areas sit close enough to the frontier that cross-border movement is routine rather than exceptional. The Kampala case, the first known export, will not be the last.

Why This One is Different

Bundibugyo is the youngest of the four ebolaviruses known to infect humans, and one of the least understood. It was first identified in 2007 in the Bundibugyo District of western Uganda, with around 130 cases and 42 deaths. It surfaced once more in 2012, in DRC's Province Orientale, with under 60 cases and around 30 deaths. Then it disappeared from human populations for fourteen years. This Ituri outbreak is only the third time the strain has been identified in history, and the current case count has already exceeded the two previous outbreaks combined.

The fourteen-year absence matters. Research, vaccine development, and therapeutic platforms have concentrated almost entirely on the Zaire strain, which is the cause of every major Ebola outbreak of the past decade and the strain for which licensed vaccines and monoclonal antibody treatments now exist. There is no licensed vaccine for Bundibugyo. There is no licensed monoclonal antibody. The experimental platforms that had been developed against the strain - including some trivalent constructs that progressed through Phase I trials - were never pushed toward licensure, because there was no market and no recent outbreak to justify the investment. Africa CDC's principal advisor for program management put it plainly: the long absence of Bundibugyo outbreaks has left the research less advanced than it should be.

This is the operational consequence of that scientific gap: ring vaccination, the strategy that became central to ending the 2018-2020 outbreak in North Kivu and Ituri, is not available here. The entire protective effect of the response now rests on what epidemiologists call non-pharmaceutical interventions: case identification, contact tracing, isolation, infection prevention and control in health facilities, safe burials, and community engagement. These are the same tools that contained Ebola in the 1970s and 1980s, before any vaccine existed. They work. They are also, in a conflict zone, the hardest work in global health.

Ituri is a conflict zone. More than 920,000 people are currently displaced across the province. Fighting between the CRP militia and the Congolese armed forces resumed in late 2025, with the town of Bule, east of Fataki, at the center of repeated clashes. In the first quarter of 2026 alone, more than 100,000 people were newly displaced. The pre-existing health infrastructure that any response would have to lean on has been actively degraded for years: Fataki General Hospital suspended services in March 2025 after threats from armed groups; nearly half the health centers in Drodro health zone have been partially or fully destroyed; a patient was killed in her bed during an armed attack on Drodro's general hospital in 2024; an MSF convoy was attacked in Bambou in 2024, with activities suspended in two health zones. This is the baseline before adding Ebola.

The late detection compounds everything else. The outbreak began in late April. It was announced on May 15. That is three weeks of uncounted transmission chains in mining towns and a provincial capital, during which contacts moved, returned to villages, attended funerals, and crossed borders. Contact tracing in such a context does not start at zero; it starts in a hole that may be impossible to climb out of.

What the Response Used to Look Like

Every major DRC Ebola response of the past decade (from the 2018-2020 Kivu/Ituri outbreak that killed over 2,300 people to the 16th outbreak in Kasai that was contained quickly in September 2025) rested on the same operational architecture. It is worth describing what that architecture actually did, because the public conversation about foreign aid tends to talk about money rather than function.

At the coordination level, USAID ran a Disaster Assistance Response Team. The DART was not a single agency operation as some would think. DART was a standing mechanism that integrated USAID, CDC, the State Department, the Department of Defense, and HHS into a unified response, deployed in-country, working alongside the DRC Ministry of Health and WHO. During the 2018-2020 outbreak, the DART was operational from September 2018 onward. The United States invested over $516 million in that single response, the largest single-country donor. The money mattered. The integration of the agencies behind it mattered more.

At the supply chain level, USAID's logistics network moved PPE, lab consumables, IPC supplies, ETC construction materials, and pharmaceuticals into hot zones through a system that had been built over decades. Some of it ran through prime contractors like Chemonics, DAI Global, RTI, and Abt Global, several of which derived the majority of their revenue from USAID work. Some of it ran through pre-positioned humanitarian stockpiles. The unglamorous reality of outbreak response is that an ETC needs gloves, gowns, body bags, chlorine, fuel for generators, and reliable transport... every single day and in volumes that can only be sustained by an industrial supply chain. USAID was that supply chain.

At the workforce level, CDC's DRC country office, established in 2002, had spent two decades building Congolese field epidemiology capacity. The Field Epidemiology Training Program graduated hundreds of Congolese epidemiologists who deployed to outbreaks across the country. INRB, under Jean-Jacques Muyembe, became one of the most capable filovirus diagnostic laboratories in Africa. During the 2025 Kasai outbreak, CDC deployed staff and lab equipment within 24 hours of the announcement, and the outbreak was contained in weeks. That speed was not improvised. It was the product of twenty years of investment in human and laboratory infrastructure.

At the partner level, USAID funded an ecosystem of implementing organizations (International Medical Corps, RTI, Catholic Relief Services, IRC, and dozens of smaller actors) who did the actual work in the actual places: community engagement in displacement camps, IPC training in rural health centers, contact tracing at the household level, safe burial teams in villages. This is the labor-intensive, slow, trust-dependent work that vaccines and monoclonal antibodies do not replace. It was almost entirely subsidized by US funding, even when implemented by international or local NGOs.

This is the system that responded to every prior DRC Ebola outbreak of the modern era. It was not perfect; the 2018-2020 response in particular had serious community trust failures, and the militarization of some response activities in Beni and Butembo produced backlash that cost lives. But it was an architecture. It existed. It could be activated.

What it Looks Like Now

The Africa CDC Director General, Jean Kaseya, said on Saturday that PPE supply is already a problem. "We don't have manufacturing for PPE," he told reporters, adding that his team had flagged the need for funding and was working on the issue. It was the second day of the outbreak being public. In every prior DRC Ebola response of the past decade, PPE for the first responders was not a question someone asked at a press conference on day two. It was already in country.

At the coordination level, there is no DART. As of this writing, no Disaster Assistance Response Team has been deployed, and the operational mechanism that ran the 2018-2020 response no longer exists in the form it did even eighteen months ago. The Office of Foreign Disaster Assistance was absorbed into a smaller State Department humanitarian bureau, with most of its personnel removed. The CDC Acting Director, Jay Bhattacharya, said this week that the CDC country offices in DRC and Uganda were "well-staffed and equipped" and that the agency would "absolutely mobilize there as needed." That language carries weight. It is also, notably, the language of contingent mobilization rather than active response. In previous outbreaks, the mobilization had already happened by the time the case count was at this level.

Former federal pandemic preparedness officials have been saying for months that what they're observing is not the playbook. Paul Friedrichs, the former director of the White House Office of Pandemic Preparedness and Response Policy, has listed what the federal government would normally have done by this point in an outbreak of this scale. Namely: a CDC team deployed to put eyes on the ground; State Department patient movement capability readied for transport of an infected American (especially relevant given the presence of American mining companies in eastern Congo); HHS reaching out to the pharmaceutical manufacturers of Ebola countermeasures to confirm supply. None of this appears to have happened. John Lowe, who co-leads the US system of medical facilities equipped to respond to dangerous pathogens, put it plainly: "The conversations are happening. It's just the level of structure and organization to them don't appear to be there."

At the supply chain level, the prime contractor base has collapsed. By January 2026, an estimated 258,000 jobs had been lost across the global development sector. Chemonics disclosed $103 million in outstanding invoices from terminated USAID contracts; DAI Global reported $120 million. Several of the largest contractors derived the majority of their revenue from USAID work, and many have either laid off most of their staff or exited the sector entirely. The logistics infrastructure that moved PPE and ETC supplies into Ituri during the 2018-2020 outbreak does not exist in the same form now, and there is no functional replacement for it.

At the workforce level, the picture is more nuanced. The CDC DRC country office is still operational. INRB is still operational. The Congolese FETP-trained workforce is still in place. This is the inertia of twenty years of investment, and it is real. However, the upstream supports are eroding fast. PEPFAR cuts have shrunk the HIV/TB workforce that historically doubles as the surge labor pool for outbreak response... the same nurse doing HIV testing one week is doing contact tracing the next. The Field Epidemiology Training Program continues, but the partner contractors who supported deployments have collapsed. The capacity that responded to the Kasai outbreak in September 2025 was the product of an architecture that was already being dismantled around it. The Kasai response succeeded on inertia. Unfortunately, Ituri does not have that inertia to draw on.

At the partner level, the ecosystem of implementing organizations has been hollowed out. KFF documented that 80% of 770 USAID global health awards were terminated, with $12.7 billion in funding pulled. Physicians for Human Rights reported that the cuts in DRC specifically left "no time to develop alternative plans to ensure continuity of services." International Medical Corps withdrew from Nundu Health Zone in South Kivu. Oxfam warned that the health of up to one million people in DRC was at risk from the funding cuts alone. The organizations that would normally surge into Ituri to support a response are, in many cases, no longer in the country, or are operating at a fraction of their prior capacity.

The simultaneous European withdrawal compounds the gap. The UK, Germany, France, and Canada all cut aid budgets in 2025; the first time in nearly three decades the major donors moved together in that direction. The obvious counter-argument to the US cuts has been that other donors would step in. They have not. They could not, even if they wanted to. The math does not work without the US share, which historically accounted for roughly 40% of UN-tracked humanitarian aid globally.

Direct Relief has offered $40 million in medical aid and is monitoring the situation. Africa CDC has activated a 72-hour Incident Action Plan and deployed surge teams to DRC and Uganda. INRB has the strain identified. The Congolese MOH has activated its public health emergency operations center. The response is not nothing. It is, however, structurally different from every response that came before it, and not in a way that helps the patients in Bunia.

What Carries Weight Now

The architecture that the United States built and led for two decades is not the only architecture in the field. A second one has been growing alongside it, and it is the one carrying most of the operational weight on this outbreak.

Africa CDC, established in 2017, is substantially more capable than it was during the 2014-2016 West African Ebola response - when, it is worth remembering, it did not yet exist as a continental coordinating body. Its activation of the regional Incident Management Support Team within 72 hours of the May 15 announcement, the deployment of surge teams to DRC and Uganda, and the convening of a tri-country response across DRC, Uganda, and South Sudan reflect institutional maturity that did not exist a decade ago. Jean Kaseya's public-facing role this week, including the press conference flagging the PPE shortfall on day two, is itself a sign of a continental health agency willing to speak operationally and publicly about what it needs. It is also, frankly, one major outbreak away from being overwhelmed.

INRB, the DRC's National Institute of Biomedical Research, is one of the most capable filovirus diagnostic laboratories in Africa. Jean-Jacques Muyembe, who co-discovered Ebola in 1976, runs it. The fact that the Bundibugyo strain was identified within days of the first suspected cases reaching the lab is a function of two decades of accumulated capacity that did not evaporate when its funding sources did. The same is true of the Congolese FETP graduates, the provincial laboratory network, and the MOH's public health emergency operations infrastructure. This is institutional weight that belongs to DRC, not to any donor.

The MOH itself has now coordinated seventeen Ebola responses. The muscle memory matters. Health Minister Roger Kamba's response architecture activated within hours of laboratory confirmation. That is what twenty years of repeated outbreaks builds, and it is not something a funding cut can immediately take away.

What this implies for the decade ahead is worth naming plainly. The model that responded to every prior DRC outbreak (Western donor architecture providing the financial, logistical, and coordination layer, while Congolese institutions provided the clinical and epidemiological labor) is gone. What replaces it is a leaner, more Africa-led model, with significantly less margin for error, fewer surge resources, and a greater dependence on private and philanthropic donors who cannot match the scale of what was lost. Primarily African institutions, with constrained support from Western governments and patchwork support from private actors, will manage the outbreaks of the next decade.

Whether that is sufficient is what the Ituri outbreak will tell us.

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Dr. Alain Casséus currently serves as Infectious Diseases Division Chief and Principal Investigator for the PEPFAR Project at Zanmi Lasante, PIH's sister organization in Haiti. Dr. Casséus has worked with ZL since 2007, with a primary focus on HIV/TB and improving care through research. In his nearly two decades working in Haiti, he has led massive vaccination campaigns, conducted cross-organizational research, and ensured thousands of HIV patients have received care - by his hand and others.