Mycobacterium tuberculosis is a near-perfect predator. In 1882, Robert Koch, the physician who discovered the microbe, told a room full of scientists that it caused one in seven of all deaths. In 2023, after a brief hiatus, tuberculosis regained from COVID its status as the world’s deadliest infectious disease—a title it has held for most of what we know of human history.

Some people die of TB when their lungs collapse or fill with fluid. For others, scarring leaves so little healthy lung tissue that breathing becomes impossible. Or the infection spreads to the brain or the spinal column, or they suffer a sudden, uncontrollable hemorrhage. Lack of appetite and extreme abdominal pain can fuel weight loss so severe that it whittles away muscle and bone. This is why TB was widely known as “consumption” until the 20th century—it seemed to be a disease that consumed the very body, shrinking and shriveling it. On a trip to Sierra Leone in 2019, I met a boy named Henry Reider, whose mix of shyness and enthusiasm for connection reminded me of my own son. I thought he was perhaps 9 years old. His doctors later told me that he was in fact 17, his body stunted by a combination of malnutrition and tuberculosis.

The cure for TB—roughly half a year on antibiotics—has existed since the 1950s, and works for most patients. Yet, in the decades since, more than 100 million people have died of tuberculosis because the drugs are not widely available in many parts of the world. The most proximate cause of contemporary tuberculosis deaths is not M. tuberculosis, but Homo sapiens. Now, as the Trump administration decimates foreign-aid programs, the U.S. is both making survival less likely for people with TB and risking the disease becoming far more treatment-resistant. After decades of improvement, we could return to something more like the world before the cure.

[Read: The danger of ignoring tuberculosis]

Anyone can get tuberculosis—in fact, a quarter of all humans living now, including an estimated 13 million Americans, have been infected with the bacterium, which spreads through coughs, sneezes, and breaths. Most will only ever have a latent form of the infection, in which infection-fighting white blood cells envelop the bacteria so it cannot wreak havoc on the body. But in 5 to 10 percent of infections, the immune system can’t produce enough white blood cells to surround the invader. M. tuberculosis explodes outward, and active disease begins.

Certain triggers make the disease more likely to go from latent to active, including air pollution and an immune system weakened by malnutrition, stress, or diabetes. The disease spreads especially well along the trails that poverty has blazed for it: in crowded living and working conditions such as slums and poorly ventilated factories. Left untreated, most people who develop active TB will die of the disease.

In the early 1980s, physicians and activists in Africa and Asia began sounding the alarm about an explosion of young patients dying within weeks of being infected instead of years. Hours after entering the hospital, they were choking to death on their own blood. In 1985, physicians in Zaire and Zambia noted high rates of active tuberculosis among patients who had the emerging disease now known as HIV/AIDS. TB surged globally, including in the U.S. Deaths skyrocketed. From 1985 to 2005, roughly as many people died of tuberculosis as in World War I, and many of them also had HIV. In 2000, nearly a third of the 2.3 million people who died of tuberculosis were co-infected with HIV.

[Read: Tragedy would unfold if Trump cancels Bush’s AIDS program]

By the mid-1990s, antiretroviral cocktails made HIV a treatable and survivable disease in rich communities. While a person is taking these medications, their viral levels generally become so low as to be undetectable and untransmittable; if a person with HIV becomes sick with tuberculosis, the drugs increase their odds of survival dramatically. But rich countries largely refused to spend money on HIV and TB meds in low- and middle-income countries. They cited many reasons, including that patients couldn’t be trusted to take their medication on time, and that resources would be better spent on prevention and control. In 2001, the head of the U.S. Agency for International Development had this to say when explaining to Congress why many Africans would not benefit from access to HIV medications: “People do not know what watches and clocks are. They do not use Western means for telling time. They use the sun. These drugs have to be administered during a certain sequence of time during the day and when you say take it at 10:00, people will say, ‘What do you mean by 10:00?’” A 2007 review of 58 studies on patient habits found that Africans were more likely to adhere to HIV treatment regimens than North Americans.

In the mid-2000s, programs such as PEPFAR and the Global Fund finally began distributing antiretroviral therapy to millions of people living with HIV in poor countries. PEPFAR, a U.S.-funded initiative, was especially successful, saving more than 25 million lives and preventing 7 million children from being born with HIV. These projects lowered deaths and infections while also strengthening health-care systems, allowing low-income countries to better respond to diseases as varied as malaria and diabetes. Millions of lives have been saved—and tuberculosis deaths among those living with HIV have declined dramatically in the decades since.

Still, tuberculosis is great at exploiting any advantage that humans hand it. During the coronavirus pandemic, disruptions to supply chains and TB-prevention programs led to an uptick in infections worldwide. Last year, the U.S. logged more cases of tuberculosis than it has in any year since the CDC began keeping count in the 1950s. Two people died. But in some ways, at the beginning of this year, the fight against tuberculosis had never looked more promising. High-quality vaccine candidates were in late-stage trials. In December, the World Health Organization made its first endorsement of a TB diagnostic test, and global health workers readied to deploy it.

[Read: America can’t just unpause USAID]

Now that progress is on the verge of being erased. Since Donald Trump has taken office, his administration has dismantled USAID, massively eliminating foreign-aid funding and programs. According to The New York Times, hundreds of thousands of sick patients have seen their access to medication and testing suddenly cut off. A memo released by a USAID official earlier this month estimated that cases of multidrug-resistant tuberculosis will rise by about 30 percent in the next few years, an unprecedented regression in the history of humankind’s fight against the disease. (The official was subsequently placed on administrative leave.) Research on tuberculosis tests and treatments has been terminated. Although the secretary of state and Elon Musk have assured the public that the new administration’s actions have not disrupted the distribution of life-saving medicine, that just isn’t true. A colleague in central Africa sent me a picture of TB drugs that the U.S. has already paid for sitting unused in a warehouse because of stop-work orders. (Neither the State Department nor DOGE employees responded to requests for comment.)

Last year, roughly half of all international donor funding for tuberculosis treatment came from the U.S. Now many programs are disappearing. In a recent survey on the impact of lost funding in 31 countries, one in four organizations providing TB care reported they have shut down entirely. About half have stopped screening for new cases of tuberculosis. The average untreated case of active tuberculosis will spread the infection to 10 to 15 people a year. Without treatment, or even a diagnosis, hundreds of thousands more people will die—and each of those deaths will be needless.

By revoking money from global-health efforts, the U.S. has created the conditions for the health of people around the world to deteriorate, which will give tuberculosis even more opportunities to kill. HIV clinics in many countries have started rationing pills as drug supplies run dangerously low, raising the specter of co-infection. Like HIV, insufficient nutrition weakens the immune system. It is the leading risk factor for tuberculosis. An estimated 1 million children with severe acute malnutrition will lose access to treatment because of the USAID cuts, and refugee camps across the world are slashing already meager food rations.

For billions of people, TB is already a nightmare disease, both because the bacterium is unusually powerful and because world leaders have done a poor job of distributing cures. And yet, to the extent that one hears about TB at all in the rich world, it’s usually in the context of a looming crisis: Given enough time, a strain of tuberculosis may evolve that is resistant to all available antibiotics, a superbug that is perhaps even more aggressive and deadly than previous iterations of the disease.

[Read: Resistance to the antibiotic of last resort is silently spreading]

The Trump administration’s current policies are making such a future more plausible. Even pausing TB treatment for a couple of weeks can give the bacterium a chance to evolve resistance. The world is ill-prepared to respond to drug-resistant TB, because we have shockingly few treatments for the world’s deadliest infectious disease. Between 1963 and 2012, scientists approved no new drugs to treat tuberculosis. Doing so stopped being profitable once the disease ceased to be a crisis in rich countries. Many strains of tuberculosis are already resistant to the 60-year-old drugs that are still the first line of treatment for nearly all TB patients. If a person is unlucky enough to have drug-resistant TB, the next step is costly testing to determine if their body can withstand harsh, alternative treatments. The United States helped pay for those tests in many countries, which means that now fewer people with drug-resistant TB are being diagnosed or treated. Instead, they are almost certainly getting sicker and spreading the infection.

Drug-resistant TB is harder to cure in individual patients, and so the aid freeze will directly lead to many deaths. But giving the bacteria so many new opportunities to develop drug resistance is also a threat to all of humanity. We now risk the emergence of TB strains that can’t be cured with our existing tools. The millennia-long history of humans’ fight against TB has seen many vicious cycles. I fear we are watching the dawn of another.

This article has been adapted from John Green’s forthcoming book, Everything Is Tuberculosis.

At Donald Trump’s first Cabinet meeting, late last month, Elon Musk sheepishly admitted that DOGE had “accidentally canceled very briefly” Ebola-prevention programs. After a nervous chuckle, he claimed that the oversight had been swiftly corrected. But it wasn’t. The truth is far more disturbing—this administration didn’t just pause a line item; it has actively dismantled the infrastructure the country relies on to detect and confront deadly pathogens.

For more than a decade, I have worked as a physician and public-health expert responding to infectious diseases around the world. In 2014, while treating Ebola patients in Guinea, I contracted and survived Ebola myself. I know how lethal Donald Trump’s assault on America’s outbreak preparedness could be. We are sure to regret it.

DOGE’s slash-and-burn campaign has hit everything from the NIH to the National Weather Service. The cuts to global health, however, are especially alarming. It’s unclear what Musk thought would happen when he fed the U.S. Agency for International Development “into the wood chipper,” as he proclaimed with gleeful indifference on X, the social-media megaphone he owns. Ditto what Trump thought when he withdrew the United States from the World Health Organization and effectively muzzled the CDC. But the result has been that, in little more than a month, America has transformed itself from a preeminent global-health leader into an untrustworthy has-been. Undermining even one of these institutions would have posed a serious threat; gutting them all at once is an invitation for future outbreaks.

The fallout from these sweeping cuts is particularly evident when examining USAID, or what’s left of it. The agency’s tagline was “From the American people,” and perhaps the American people didn’t understand that it was also for them. Musk disparaged the agency outright—declaring it a “criminal organization.” The White House pointed to alleged wasteful spending, including funding for a “DEI musical” in Ireland (which wasn’t even funded by USAID, it turned out). In decrying the agency’s downfall, many Democrats focused more on the importance of “soft power” foreign policy than on-the-ground impact. Yet much of USAID’s budget was devoted to addressing humanitarian and health crises abroad with the implicit goal of preventing these emergencies from reaching our own shores. (Explicitly, the goal was to “advance American security and prosperity.”) Americans are safer when instability and infectious threats are effectively managed on foreign lands.

[Donald Moynihan: The DOGE project will backfire]

USAID was also the primary funder of the President’s Emergency Plan for AIDS Relief, established in 2003 under George W. Bush. PEPFAR has saved more than 25 million lives and helped smother the global HIV pandemic. More than 20 million people—500,000 of them children—were receiving HIV treatment through the program when Trump signed an executive order on his first day back in office pausing all foreign aid for 90 days. Secretary of State Marco Rubio promised that waivers would allow the life-saving work to continue, but few have materialized. Meanwhile, USAID staff who were placed on administrative leave can’t distribute medicines or cover costs for transport and personnel. After this dismantling, PEPFAR’s activities in hundreds of places around the world remain restricted at best, and fully paused at worst. Without the support long provided by the program, thousands of people will likely die far younger than they would have with proper medical care. PEPFAR’s current authorization ends later this month; its future after that is unclear.

Similarly, USAID’s efforts to stop Ebola at its source are also now gone. USAID’s role in Ebola containment has long been essential. During the 2014 West Africa outbreak—during which more than 11,000 people died—USAID oversaw training of local health-care workers, the building of Ebola treatment centers, and passenger screening at the borders and airports. A decade later and just days into Trump’s second term, Uganda reported another Ebola outbreak. This time, though, the foreign-aid freeze Trump had put in place meant that USAID was unable to supply the usual resources for transporting lab specimens or implementing airport screening. The day after Musk reassured the Cabinet that Ebola prevention had been swiftly restored, the State Department canceled crucial contact tracing and surveillance efforts for Uganda’s outbreak. With USAID nowhere to be found, the WHO scaled up its own response. That’s something, for now, but America’s absence is shameful.

Moreover, the WHO may not have the capacity to do so for much longer. On his first day in office, Trump signed an executive order moving to withdraw from the WHO, accusing it of demanding “onerous payments from the United States.” In 2023, the U.S. contributed $481 million—an eighth of what Americans spend on professional dog-training services every year—to WHO’s operating budget. Admittedly, many Americans—fueled by Trump’s denigration of the organization—developed a deep distrust of the WHO following perceived missteps during the coronavirus pandemic. Even its supporters can see the organization’s flaws—it’s bureaucratic, sclerotic, and overdue for reform. Despite these shortcomings, it is an organization we desperately need, and no real alternative exists.

WHO is the only international organization that can identify and respond to emerging threats early on, such as flare-ups of unidentified outbreaks like the one currently circulating in northwestern Democratic Republic of the Congo. Its global network of laboratories to detect infectious threats—known as the Gremlin—relies heavily on U.S. support and is now at risk of closure. And even as its partnerships alongside U.S. colleagues have strengthened surveillance, containment, and readiness abroad, the WHO also helps us here at home. On the same day as Musk’s Ebola comments, the FDA canceled the meeting where experts decide next season’s flu-vaccine composition. Going forward, the U.S. will have to wait on WHO guidance for that crucial decision and download the recipe for next year’s flu shot. If America keeps abdicating its leadership, it will be forced to rely on an organization whose funding it is slashing and whose collaboration it is severing. Although the WHO might still scrape together funds and staff, that’s not guaranteed—especially if other nations follow Trump’s example and cut ties or funding.

[Katherine J. Wu: Inside the collapse at the NIH]

With USAID and WHO under siege, more responsibility for global disease detection and response would fall on the CDC. But the future of the world’s preeminent “disease detectives” is at risk as well. The plan to slash the next cohort of CDC Epidemic Intelligence Service officers—think Kate Winslet’s character in Contagion—was thankfully stopped at the 11th hour, but about 750 CDC staff were still let go in recent cuts, including many stationed on outbreak front lines across the country and around the globe (about 180 of those terminated were later reinstated). Certain pages on the CDC website were deleted, and when a judge ordered them restored, many had been dramatically altered. CDC communications such as the Morbidity and Mortality Weekly Report—which providers rely on to track health threats—were abruptly paused for the first time in more than 60 years. CDC staff were also ordered to stop communicating with, and to take their names off any scientific papers written with, anyone from the WHO, further weakening the CDC’s reach and insight into what’s happening around the world. Whether the issue is cuts to USAID, defunding the WHO, or hobbling the CDC, the end result is the same: America is walking away from global health leadership, making the entire world less safe—including us.

Understand how this will work at a practical level: Until recently, countries had compelling reasons to report outbreaks, even if such transparency sometimes came with travel bans or other stigmatizing restrictions. Those sticks were often worth the carrots, namely USAID funding and CDC expertise that would appear and help quickly end outbreaks. Now, with no carrots on offer, why would any country submit to the stick? Future outbreaks may be reported too late or not at all—leaving America oblivious to emerging health crises. Since 2014, seven public-health emergencies of international concern (PHEICs) have been declared by the WHO. The number of Ebola outbreaks is escalating, and climate change will intensify the emergence and spread of known and potentially unknown microbes.

It is in America’s interest to reverse course immediately and rebuild the crucial infrastructure needed to detect and respond to outbreaks. Not only is this the right thing to do, but it also makes economic sense. In 1980, at the height of the Cold War, the WHO declared smallpox eradicated—a milestone achieved through joint U.S. and Soviet support. Americans invested about $30 million to stamp out smallpox, a fraction of what the country now saves every year by no longer needing to vaccinate against or treat smallpox—to say nothing of the lives saved.

Americans believe that about 25 percent of the country’s budget is spent on foreign aid. In reality, the figure is 1 percent, or at least it was. USAID’s entire 2023 spending was $43 billion—a 20th of the U.S. defense budget and about what Musk’s enterprises have received in government funding. The CDC’s was even less, just $9 billion.

[Nicholas Florko: Spared by DOGE—for now]

Despite his actions, Musk clearly understands that these systems are essential for America’s security. After admitting his Ebola error, he quickly clarified: “I think we all want Ebola prevention.” That would require pulling USAID’s most essential remnants out of the dustbin. The U.S. must also reengage with the WHO and negotiate the terms of its renewed support and engagement with the organization before it’s too late. And for all the distrust many Americans harbor toward the CDC post-pandemic, they must rally around it—an agency whose role will become only more indispensable as measles, bird flu, and other pathogens spread across the country.

Now, and with startling speed, the country is turning its back on global health. In doing so, it is endangering other nations, and also itself. USAID’s account on X, once a digital chronicle of its achievements, is gone. When I search for it on my phone, I get an error message: “Something went wrong. Try again.” We must heed that warning. Musk and Trump have destroyed the shield that once protected America from the next global contagion. Deadly diseases don’t bother with borders; no wall will keep them out. If America stays the course, “Something went wrong” will become the epitaph of a great country, one that once led the world in global health preparedness. It will be deeply missed.

Yesterday’s 5–4 Supreme Court decision requiring the United States Agency for International Development to start making payments that the Trump administration had frozen was immediately hailed as a signal of the justices’ discomfort with the administration’s efforts to feed “USAID into the wood chipper,” as Elon Musk colorfully put it. It was also said to suggest skepticism of President Donald Trump’s claim that he has the constitutional authority to impound federal dollars and ignore Congress’s spending commands.

Perhaps. But the optimism may be premature. The reprieve that the order offers is brief, the basis for the decision is narrow and procedural, and the eventual outcome remains uncertain.

In a dissenting opinion, four of the conservative justices said that the federal courts ought to play a highly circumscribed role in policing Trump’s efforts to dismantle agencies by preventing them from spending money. Although Chief Justice John Roberts and Justice Amy Coney Barrett sided with the liberal justices this week, that’s no guarantee of their vote when the case comes up in a different procedural posture, which it almost certainly will. The plaintiffs’ temporary victory could still curdle into defeat.

[Stephen I. Vladeck: The Supreme Court foreign-aid ruling is a bad sign for Trump]

The key to understanding how the justices will think about the case is the Administrative Procedure Act, an 80-year-old law that allows injured parties to sue federal agencies that act in an unlawful or arbitrary manner. The APA is generally solicitous of lawsuits against the government, and is said to have created a strong presumption in favor of judicial review.

The challengers—USAID contractors who haven’t been getting paid—brought their claim under the APA. That’s natural. Although there’s some confusion about the precise source of the command to stop paying out on existing contracts—an executive order? a now-withdrawn Office of Management and Budget memo? DOGE? a directive from the secretary of state?—there’s no question that a blunderbuss spending freeze has been instituted.

If that freeze is illegal or arbitrary—and there’s a good argument that it’s both—the APA empowers the courts to set it aside and, if necessary, to enjoin the federal government from freezing the funds. Seen that way, the case is a bog-standard challenge to unlawful agency action.

But the APA is limited in some important respects. Of particular relevance here, a plaintiff can’t seek “money damages” under the APA. So if a government employee runs a person over and he wants damages for his injuries, or a government agency breaches a contract with a business owner, those parties can’t bring an APA suit. Instead, they have to take their case to the Court of Federal Claims, a special court that handles claims of money damages against the federal government.

The four dissenting justices, in an angry opinion by Justice Samuel Alito, insist that that’s what the plaintiffs should have done. Sure, the plaintiffs say they’re challenging a general spending freeze. But what they’re really challenging is the refusal to pay out on their contracts. The “relief” that they seek, Alito wrote, “more closely resembles a compensatory money judgment rather than an order for specific relief that might have been available in equity.”

That’s one way to understand what the plaintiffs want. After all, they do want money. Plus, the courts are generally reluctant to entertain broad-brush challenges to agency policy, especially when an agency is accused of not doing something that it’s supposed to do. Otherwise, as the Court explained back in 2004, there’s a risk of “injecting the judge into day-to-day agency management” of the agency’s affairs. The courts don’t want to be in the business of micromanaging all of USAID’s contracts.

[Read: Trump tests the courts]

So which is it? Is the lawsuit best seen as an APA challenge to an illegal funding freeze? Or as a demand for money damages arising from specific contractual breaches that should go to the Court of Federal Claims?

That question has no intrinsically correct answer. It’s a matter of emphasis and judgment. A person’s preferred characterization may depend on their sense of just how aberrant and troubling the Trump administration’s actions are. The closer the case seems to a conventional breach-of-contract dispute, albeit at scale, the more appropriate sending it to the Court of Federal Claims may seem.

That parsimonious approach has all the virtues of judicial modesty. It also has all the vices.

There’s something deeply artificial about treating the case like an everyday spat over the terms of a contract for, say, military equipment. The funding freeze reflects a comprehensive, deliberate effort to destroy an agency that Congress established and President Trump dislikes. That freeze can be appropriately viewed as a discrete agency action that’s properly subject to APA review.

Contra Alito, just because the case is about money does not make it a case about money damages. The distinction may seem fine, but it’s got a long pedigree. “The fact that a judicial remedy may require one party to pay money to another,” the Supreme Court reasoned in 1988, “is not a sufficient reason to characterize the relief as ‘money damages.’”

Money damages, the Court explained, aim to redress an injury that’s already happened. They are meant to soothe past harms, not prevent them. Most APA suits, in contrast, are anticipatory. They allow courts to prevent agencies from harming plaintiffs in the first place. That’s what the plaintiffs are seeking here—not a financial remedy for a breach of contract, but an end to a funding freeze that causes them ongoing injury.

Moreover, conceiving of the case as a routine breach-of-contract dispute would have troubling consequences. If the case is forced into the Court of Federal Claims, the plaintiffs might eventually get a money judgment against the government, perhaps a hefty one, especially if they bring a class action. But the Court of Federal Claims likely won’t enter an injunction that ends the spending freeze. That’s not what it does.

And Trump won’t care that Congress will have to shell out cash down the line. His goal is more immediate and more destructive.

The outcome of this arcane jurisdictional dispute may thus effectively determine whether Trump has the power to impound federal funds and dismantle federal agencies. If he does, expect him to exercise that power again. And again. And again.

[Adam Serwer: Why Trump thanked John Roberts]

Right now, all we know for sure is that four conservative justices are okay with that outcome, whatever the damage to Congress’s power to control federal spending. The three liberal justices probably aren’t, whatever the risks of excessive judicial interference in government administration.

That leaves Roberts and Barrett.

We don’t know what they think. The Supreme Court’s very short opinion turned on the case’s very hurried procedural posture. Once the lower court enters a more durable order, the case will likely wing its way back to the justices, probably within weeks.

At that point, we’ll find out whether the Supreme Court intends to serve as a bulwark against a president who is hell-bent on asserting the unilateral power to control federal spending. If not, yesterday’s order may come to look like a momentary, ephemeral reprieve in Trump’s ongoing assault on Congress’s power of the purse.