Dr. Jean Kaseya has a warning for the world: "We are playing with fire."
Kaseya is director general of the Africa Centers for Disease Control and Prevention. He's talking about mpox, a virus that causes painful blisters and can be fatal.
For much of the world, mpox — formerly known as monkeypox — seems like a virus from a few years ago. There was a global outbreak in 2022 and 2023 but the virus is no longer circulating as widely in Europe and the U.S.
However, large swathes of Africa are in the midst of a major outbreak. The epicenter is in the Democratic Republic of Congo, with more than 2,000 suspected cases reported each week for months, according to Africa CDC.
There seemed to be encouraging news at the end of January, when the number of new cases dropped suddenly. But mpox trackers are not celebrating.
"This decrease in terms of cases is not the reality," says Kaseya. Instead, he says, this is a sign that the ability to monitor and tally new cases has been interrupted. He attributes this to two things: "The combination between insecurity [and] lack of funding."
The insecurity he's referring to is in eastern DRC – a hotspot in the mpox outbreak – where rebel forces have taken control of key areas. The violence has interrupted mpox control and reporting work.
The lack of funding is the result of the abrupt freeze in U.S. foreign aid instituted after President Trump took office on Jan. 20, along with the decision to fire or place on leave most of the 10,000 people working for the U.S. Agency for International Development. Almost all of the agency's work has stalled, including critical parts of the mpox response effort. Trump also ordered the U.S. to leave the World Health Organization and stop communicating with WHO officials, who have played a critical role in mpox containment.
"It's like watching a train wreck in real time – and not being able to do a thing about it," says a health worker formerly part of the U.S. response team. The worker spoke on the condition of anonymity for fear of retribution from the federal government.
The outlook before Trump's inauguration
The global community rallied after both Africa CDC and WHO declared the mpox outbreak in Africa a public health emergency in August 2024.
Over a billion dollars was pledged to the control effort by countries across Africa and Europe as well as Japan and the U.S., according to Africa CDC. President Biden promised $500 million as well as a million mpox vaccine doses.
The hope was to stop this outbreak of the virus and prevent it from spreading to other parts of the world. However, the DRC can be a challenging place to fight an infectious disease. It's an enormous country with poor road networks and a hot spot in the outbreak is in the war-torn east where overcrowded camps for displaced people are common. The mpox virus spreads through sexual contact as well as close contact, even via bed sheets.
The U.S. plays an outsized role in the public health of the DRC. Last year, the U.S. provided almost 70% of all humanitarian aid going to the country, sending $965,000,000 to the DRC according to the United Nations Office for the Coordination of Humanitarian Affairs. And when it came to mpox response, the U.S. funds have supported a wide range of efforts from training lab technicians to providing diagnostic tests to supplying gloves and gowns for health workers to working with veterinarians for disease surveillance in animal populations.
Then, in late January, the campaign to quash the virus was interrupted.
A turning point — for the worse
On January 27, M23 — a rebel group that the United Nations says is backed by Rwanda — swept into Goma, a city in the eastern DRC that has been a hub for disease response efforts. Intense fighting engulfed the city for several days and early U.N. estimates suggest a few thousand people were killed.
"From one day to another, everything just collapsed," says Paulin Nkwosseu, chief of field operations for UNICEF in the DRC. UNICEF is the humanitarian agency funded and operated by the United Nations.
Nkwosseu, who was traveling when the violence erupted, says the violence didn't just pause mpox response efforts. It likely made the outbreak significantly worse. That's because the vast majority of mpox patients in isolation wards fled to seek shelter from the fighting.
"After the fighting erupted, we managed to locate only 15 [mpox patients]. So the rest are probably living within the community with a huge, huge risk of contamination," says Nkwosseu. "This is a very big risk in terms of public health."
Africa CDC reports that at least 400 mpox patients fled.
Nkwosseu adds that the risk of spreading the virus is particularly big because the fighting meant many people lost access to clean water or electricity.
Even if aid workers could locate all the mpox patients who fled, Nkwosseu says, it's unclear where they would now go to be isolated and make sure they don't spread the disease to others. "Six of the seven mpox treatment centers have been looted and totally destroyed, including two supported by UNICEF," he says. "All the stocks of supplies, treatment, medicines, mattresses, tents — everything was looted."
Dr. Mike Ryan, director of the WHO's Health Emergencies Program, says the violence has been a major setback. "All of the investment we've made over the last number of months to establish mpox surveillance, mpox control, mpox vaccinations – all of that is interrupted, on hold and impossible to continue," he says.
'Flying blind'
At the same time as the security situation in eastern DRC deteriorated, President Trump froze almost all U.S. foreign assistance. While a judge has ruled that the funds should start flowing again and the administration has issued waivers for certain "lifesaving activities" — including the campaign against mpox — the aid world has faced major upheavals, with abrupt stop work orders and terminated contracts.
Public health experts say there are at least two areas where the impacts of the aid freeze are already being felt on the mpox response.
First, the vast majority of the mpox vaccines pledged by the U.S. are stuck in a warehouse. While the vaccines were donated by the U.S. Department of Health and Human Services, USAID was facilitating the transfer to the DRC. And so the stop work orders halted the process, according to an individual who was working on the process and spoke on the condition of anonymity because they were not authorized to speak publicly.
In order for the vaccine donation to continue in the DRC, this individual says, HHS needs to release the vaccines – which involves the Trump administration affirming the donation – and USAID leadership needs to approve for funds to be dispersed to partners who would then help pay for the operational costs associated with the vaccine transfer.
Second, the U.S. had been funding the secure transportation of suspected mpox samples from clinics to labs for testing — but no longer.
"We are scaling up the equipment for laboratory capacity, but the transportation of samples has become a nightmare," says Dr. Ngashi Ngongo, head of Africa CDC's incident management support team based in DRC.
Ngongo says his team has documented a steep drop in the testing rate — the portion of suspected cases where there is testing to confirm the diagnosis — even in parts of the country where violence has not disrupted mpox response efforts.
"The U.S., in particular, had been putting a lot of funding and effort into strengthening this surveillance. Without this piece, you're blind. You're flying blind in outbreak response," says an individual who had worked on the U.S. response and requested anonymity for fear of retribution.
There has been a waiver granted by the U.S. government for mpox response to continue despite the freeze in foreign aid. NPR obtained an internal memo sent to USAID staff from Mark Lloyd, who was performing the duties of assistant administrator for the USAID Bureau for Global Health. On Feb. 13, he wrote that rapid emergency response is continuing for diseases like mpox. "This includes detection, prevention, and containment efforts ... such as the following activities: risk information for affected populations, active surveillance, infection prevention and control, support for testing, case management and treatment, and supply of medical countermeasures."
However, restarting such activities has proved difficult. The payments have not resumed for mpox response, there are currently no American staff at the USAID mission in the capital of the DRC and Trump's order for the CDC officials not to communicate with WHO is still in place.
The White House did not respond to requests for comment, and the U.S. Centers for Disease Control and Prevention declined an interview request. The press line at USAID rang busy. NPR sent a request for comment to the State Department — Secretary of State Marco Rubio is acting administrator of USAID; the questions covered vaccine donations, transport of suspected mpox samples and the impact of disruptions in U.S. aid on the mpox outbreak. The request was not answered in time for our publication deadline.
It's not just mpox that is being impacted, public health experts warn, but a whole host of health threats that the DRC is confronting right now, from measles to cholera to widespread malnutrition.
Kaseya worries the deteriorating health situations could "be an entry point for a new pandemic," he says.
"DRC has a very fragile health system, and USAID is an integral part of this fabric that is already stretched very, very thin," says Anne Rimoin, a professor of epidemiology at the UCLA Fielding School of Public Health, who has worked on mpox in the DRC for decades.
Without U.S. support, there will be "disastrous setbacks" for health in the DRC and because diseases don't respect borders, she worries, those setbacks could be felt elsewhere in the world, too.
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