As delegates met this week in Geneva to debate pandemic preparedness at the World Health Assembly, an Ebola crisis in the Democratic Republic of the Congo and Uganda was once again testing the world’s outbreak response architecture.

On May 15, Congo formally declared a new Ebola epidemic in Ituri province, in the country’s east, after laboratory confirmation of multiple cases and dozens of suspected deaths. Spread into Uganda was confirmed soon afterward. Two days later, the director-general of the World Health Organization (WHO) declared the outbreak a public health emergency of international concern without first convening an emergency committee—an unprecedented move.

The immediate questions are familiar. How widespread is the outbreak? How quickly can cases be identified? Are vaccines available? What is the threat to Western countries? But perhaps the question people should be asking is: How can fragile health care systems withstand such crises?

The practical limitations of the response to the current Ebola outbreak are hard to ignore. The occupation of large parts of eastern Congo by M23, a Rwanda-backed paramilitary group, has fragmented authority and complicated humanitarian access in the conflict-affected region; foreign aid cuts have decimated local implementing partners. Meanwhile, public trust in national authorities, the United Nations, and international health agencies has largely dissolved.

During the last major Ebola outbreak in eastern Congo, from 2018 to 2020, screening measures repeatedly failed among populations affected by conflict and displacement. Communities living through chronic insecurity, widespread malnutrition, malaria, and violence often saw interventions such as contact tracing and “safe burial” by the police as disconnected from broader health realities. More than 400 attacks on health facilities and responders were recorded during that epidemic, fueling cycles of mistrust that shape outbreak response today.

The Bundibugyo strain responsible for the current Ebola epidemic has no approved vaccine or proven treatment—but that doesn’t mean the outbreak represents the apocalyptic scenario that has come to dominate global preparedness rhetoric.

The COVID-19 pandemic intensified a preparedness model centered on technological containment. The current Ebola outbreak underscores a flaw in this model. As negotiations over the WHO Pandemic Agreement remain focused on debates around vaccines, intellectual property, and technology transfer, less attention has been paid to the human forces that determine whether dangerous outbreaks can be contained.

---

For more than a century, outbreak control has been shaped by the intellectual legacy of tropical medicine and hygiene: a colonial framework centered on controlling specific diseases in ways that facilitated trade, military expansion, and administration. Though Western nations reduced epidemic disease at home through horizontal investments in sanitation, housing, nutrition, labor protections, and public infrastructure, global health in poorer regions tended to be organized around vertical campaigns targeting individual pathogens.

Modern pandemic preparedness, particularly after the 2003 SARS outbreak, inherited much of that logic. The approach helped produce extraordinary scientific advances, but it also narrowly focused on technological interventions while sidelining the structural conditions that determine whether outbreaks become catastrophic. Technological tools matter enormously, but fixating only on these solutions and single pathogens obscures a larger unfolding threat: the slow collapse of the human systems required to contain outbreaks once they emerge.

Ebola remains terrifying because of its lethality, but since transmission occurs through contact with infected bodily fluids, it is much harder to spread than respiratory viruses—making infection control measures highly effective. The West African Ebola epidemic in 2014-16 demonstrated the catastrophic consequences that Ebola can have for fragile regional health systems and local economies, while also revealing the comparatively limited direct threat to most Western populations.

That limited threat helps explain a political dynamic rarely acknowledged openly at pandemic summits. Though outbreaks of diseases such as Ebola and hantavirus are invoked to underscore the urgency of pandemic treaties and preparedness plans, Western governments often appear far less alarmed in practice than their rhetoric suggests.

Lasting global attention remains strikingly selective. The outbreaks that generate meaningful concern and sustained urgency in wealthy countries are generally those perceived as capable of destabilizing advanced economies and health care systems, such as COVID-19 or pandemic influenza. Ebola generated extraordinary fear during the 2014-16 West African epidemic because of its lethality and imagery. But the pathogens that ultimately provoke the greatest international response are not the most lethal, but the most transmissible.

Ebola exposes a profound fault line in the global system: inequity. Outbreaks of Ebola, mpox, anthrax, cholera, malaria, and polio emerge disproportionately in conflict-affected settings where health care systems are already weakened by violence, displacement, poverty, and underinvestment. Mpox, for example, emerged as a major sustained epidemic in eastern Congo in 2023, where insecurity, sexual violence, and weak surveillance systems created ideal conditions for prolonged transmission.

Further, the response to the recent hantavirus outbreak linked to a cruise ship originating in Argentina highlights an uncomfortable reality: Outbreak detection still depends heavily on trust, transparency, and informal professional networks rather than global surveillance systems.

In eastern Congo, that informal clinical intelligence is now under threat. Doctors and local health workers increasingly report that communications are monitored by armed groups, including M23. Sharing photographs of patients, discussing outbreaks, or transmitting clinical information can carry risks of arrest, disappearance, or even execution because armed groups view the information as politically or militarily sensitive. Under such conditions, the assumption that outbreaks will be rapidly and transparently reported is detached from reality.

Health care workers tend to be the earliest recognized victims of Ebola outbreaks, as hospitals are epidemiologic hotspots that amplify transmission. The first clusters usually involve nurses or doctors, while patients often avoid seeking care for fear of contracting Ebola or dying alone in isolation units. (Of course, COVID-19 exposed a similar global dynamic. In China, physicians who attempted to warn colleagues about the emergence of a dangerous new respiratory outbreak at the end of 2019 were silenced by authorities.)

Long before governments built elaborate pandemic preparedness architectures, doctors built their own. The Program for Monitoring Emerging Diseases (ProMED), founded in 1994, became one of the world’s most trusted outbreak intelligence systems, surfacing early warnings from SARS, MERS, and COVID-19—often weeks before governments publicly acknowledged what was unfolding.

Still, surveillance systems are only as effective as the political environments in which they operate. Governments still suppress or politically manage outbreaks when economic or political interests are perceived to be at stake. During COVID-19, the world learned that transparency and public trust may matter as much as sequencing capacity and vaccine development when it comes to fighting disease spread.

Now, even these physician-led systems have become increasingly fragile. Since 2022, a change in leadership and paywall at ProMED have raised concerns among outbreak scientists that one of the world’s most important independent epidemic intelligence networks is no longer reliable—at precisely the moment trusted transnational surveillance has become most necessary.

Meanwhile, global preparedness has increasingly drifted toward a technologically seductive vision of pandemic prevention centered on pathogen discovery. Beginning in 2009, the United States invested heavily in the U.S. Agency for International Development (USAID) Emerging Pandemic Threats (EPT) program—including PREDICT, a system that sought to identify viruses with pandemic potential circulating in wildlife populations.

In 2018, an independent evaluation of the EPT program commissioned by USAID—which is no longer available online—found that PREDICT had failed to anticipate any of the four major epidemics that defined the late 2000s and 2010s: the H1N1 influenza pandemic, MERS, Ebola, or congenital Zika syndrome.

The problem was never simply scientific. Governments poured billions of dollars into pathogen-specific countermeasures, vaccine platforms, and biodefense programs while paying far less attention to airborne and asymptomatic transmission, risk communication, and the structural fragilities that transform a virus into a global disaster: overcrowded hospitals, workforce shortages, unequal health care access, fragile supply chains, political mistrust, and underfunded public health systems.

---

Nowhere is this narrow, technocratic approach to preparedness more dangerous than in conflict settings. Siege tactics now exploit dependence on the health care system. In eastern Congo, Gaza, Myanmar, Sudan, Ukraine, and beyond, hospitals, water systems, convoys, and physicians—especially surgeons—have increasingly become targets. Under these conditions, vaccination falters, outbreak detection weakens, resistant organisms flourish, and disease spreads through overcrowding, displacement, and failing sanitation systems.

These are not separate humanitarian crises existing alongside pandemic risk—they are the risk. Yet global preparedness frameworks continue to treat outbreaks largely as discrete biological events requiring technical containment rather than as symptoms of instability. The danger is not simply that surveillance systems may fail to predict the next pandemic. It is that the world risks building a more sophisticated architecture of pathogen discovery and biodefense competition while neglecting more immediate drivers of biological volatility.

Biomedical innovation remains essential, but vaccines and experimental treatments cannot substitute for functioning health care systems or the political strategies capable of protecting them. They cannot heal the distrust and stigma that deters patients and the practice of paying informants to report them. The best biomedical tools still require functioning systems and social traction to achieve meaningful uptake.

Nor should preparedness continue to rely on performative measures that fail under real-world conditions. Thermal screening at airports did little to stop Ebola during past epidemics or COVID-19, particularly once outbreaks had already spread through highly mobile populations with limited health care access. More effective approaches may lie in less visible but more scalable systems, including wastewater surveillance, decentralized laboratory capacity, and community-based clinical intelligence, that detect outbreaks before hospitals are overwhelmed.

Pandemic preparedness is not simply a scientific and biomedical challenge. It is fundamentally political. That reality is already visible in the world’s ongoing public health emergencies of international concern. These still include polio, on the list for the last 12 years; and Ebola, which repeatedly reemerges in conflict-affected regions of Congo and now Uganda.

These emergencies persist not because the world lacks scientific knowledge, but because conflict, inequity, collapsing vaccination systems, and political fragility continue to erode the foundations of public health.

The next global biological crisis may not come from a lab or a wet market. Instead, it may emerge from any number of contemporary conflict zones after incubating in the biomilieu created by the attrition of health care workers, destruction of health care systems, degradation of infrastructure, and accelerating antimicrobial resistance. Under such conditions, the weaponization of public health increasingly functions as a form of biological warfare.

The warning signs have long been visible. The question is whether the world is prepared to recognize them before the next pandemic arrives.