Editor’s note March 16, 2020: This piece was originally published in February 2018 but has seen renewed attention amid the coronavirus pandemic. Read the original piece below, and find Vox’s guide to the coronavirus here.

The World Health Organization recently released a list of eight diseases most likely to spark a public health emergency. Some we know — like the hemorrhagic fevers Ebola, Lassa, and Marburg, which can cause their victims to bleed out from their gums and eyes.

But further down on the WHO list was a threat ominously described as “disease X.” The X stands for an unknown: a pathogen lurking out there, currently being harbored in animals, with the potential to make the dangerous leap into humans and spread suffering and death around the globe.

While disease X may sound like something that makes you want to run and hug a stuffed animal, it’s exactly the thing public health officials are bracing for. “We don’t know where the next threat will come from,” former Centers for Disease Control and Prevention Director Tom Frieden told Vox. “But we are certain there will be a next time.”

Related 4 reasons disease outbreaks are erupting around the world

What’s really worrying right now is that we’re not ready for the “next time.” Current proposals from the Trump White House would slash funding for foreign aid and US public health agencies. And that is expected to have a ripple effect around the world.

In the best of times, predicting the next outbreak is a fool’s game: No one could have seen H1N1, a.k.a. “swine flu,” emerging from Mexico or Ebola turning up in West Africa. But these are not the best of times.

While it’s true that America has long been underprepared for a pandemic, the risks right now appear to be especially high. Many signs point to the US retreating from supporting the global and public health efforts that can prevent epidemics of diseases like Lassa fever (which has, since January, been linked with 913 suspected cases and 73 deaths in Nigeria) or the unknown disease X. Here’s why.

America has played a major role in stopping pandemics globally — but many signs point to the US retreating

It’s not an exaggeration to say that with each passing day, the threat that one of those outbreaks turns into a pandemic increases. As humans travel and urbanize in ever greater volumes, mingling in unprecedented ways with the animals that harbor disease, we help viruses, bacteria, and fungi spread around the world with greater effectiveness and speed.

Countries can’t isolate themselves from the flow of disease across borders, and fighting and preventing pandemics requires cross-border collaboration and cooperation. Countries need to share information transparently about outbreaks within their borders. They need to agree on plans to prevent and fight those outbreaks.

Historically, America has been a global leader in this regard. The US government has the single largest footprint of any country in global health when it comes to money contributed. Poorer countries rely on the world’s wealthiest for both financial backing and technical expertise to do everything from building disease surveillance networks to identifying and containing outbreaks. This work is carried out directly by USAID, the CDC, and the Department of Defense, as well as by the WHO, to which the US is the largest country donor (and to which the CDC sends its experts), among others.

In the past decade, the WHO has declared four global health emergencies. Two of them occurred within the space of two years: the Ebola epidemic in 2014 and the Zika epidemic in 2016.

But these are far from the only threats the WHO has been dealing with. All told, the WHO’s executive director, Peter Salama, told Vox, “Over the course of the last five years, we responded to 1,000 outbreaks.”

And US government officials, many of them from the CDC, have helped the WHO fight these outbreaks — from Ebola all over Africa to plague in Madagascar. “This is a daily working together,” said Salama.

But that collaboration is under threat right now, both financially and conceptually.

Most notably, the Trump administration proposed in its fiscal year 2019 budget to cut funding for the CDC by 20 percent, from $7.2 billion to $5.7 billion. If passed by Congress, that would bring the CDC back to its lowest level of funding since 2003.

“To go back to 2003 is really quite disturbing,” said John Auerbach, president and CEO of the public health nonprofit the Trust for America’s Health. “That was before we’ve seen the likelihood of what we used to consider very unusual emergencies — like significant weather emergencies and novel viruses creating epidemics that have now become almost routine.”

There’s also no sign that the $1 billion pot of money Congress gave USAID and the CDC in 2015 to fight Ebola in West Africa — and help poorer countries around the world build up their disease detection and prevention systems — is going to be replenished after it’s slated to run out in 2019.

That has already prompted these agencies to plan a retreat from 39 of the 49 foreign countries they’re working in, the Wall Street Journal and Washington Post reported. This work abroad, as Ed Yong reported at the Atlantic, has involved critical pandemic prevention efforts, like training disease detectives in Liberia, cutting outbreak response times in Cameroon, and building emergency operations centers in the Democratic Republic of the Congo.

“There is growing worry about a fiscal cliff of funding [at the CDC], with no clear signal that more will come,” said Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation. Kates noted that while the 2019 budget called for a $51 million increase to the CDC for global health security over 2017 levels, that came in the context of the overall CDC budget slashing and cuts to other global health line items. “There’s a question mark about the CDC’s ability going forward to keep the efforts up that are needed due to preparedness, let alone any [outbreak] response, around the world.”

“America First” doesn’t work during pandemics

More broadly, the Trump administration has repeatedly signaled that it’s not interested in supporting international development and foreign aid. In its most recent budget proposal, for fiscal year 2019, the administration also proposed slashing funding for the State Department and USAID by a quarter.

This “America First” worldview does not bode well for necessary international collaboration in global health, as Bill Gates wrote in his recent annual letter.

“My view is that engaging with the world has proven over time to benefit everyone, including Americans, more than withdrawing does,” Gates said. Foreign aid, he added, makes “Americans more secure by making poor countries more stable and stopping disease outbreaks before they become pandemics.”

There’s also the question of public health leadership in the US right now. With a number of embarrassing fiascos among the Trump appointees in charge of public health, the US has felt rudderless from a health leadership perspective, Donald McNeil Jr. pointed out recently at the New York Times:

[Trump’s] first secretary for Health and Human Services, Tom Price, resigned in disgrace last September after it was revealed that he spent $400,000 chartering private jets at taxpayer expense. The president’s choice for C.D.C. director, Dr. Brenda Fitzgerald, resigned in January after reports that she had recently bought stock in a tobacco company. That capped months of recusing herself from various official duties because she owned shares in biotech and health-information companies.

Frieden is bracing for what happens next. “Obviously, who they appoint as the next CDC director is an important bellwether of their commitment [to] public health,” he said. “But it’s not a good sign that they proposed [a] more than 20 percent cut to the CDC’s budget; that would bring the CDC back to the lowest level since 2003.”

The looming-health-disaster money scramble

Putting aside the Trump administration’s fumbling on public health leadership, its “America First” mentality, and its proposed funding cuts — there’s a larger structural problem that is greater than the president or any administration.

“The bigger issue is the ability of governments and organizations to put money into preparedness,” Kates summed up. And no recent administration has addressed this.

Just check out this chart from the Kaiser Family Foundation:

This shows that US funding for global health security has been flat since 2006 — with episodic funding spikes in response to outbreaks, like Ebola in 2014 and Zika in 2016 — even though the pandemic threat keeps rising.

As I’ve written before, health officials in the US are left to do “the looming-health-disaster money scramble” every time a big outbreak rears its head.

That money usually comes, but not often not fast enough. When Ebola first hit, Frieden said, “We didn’t have enough money for plane fare for our staff.”

Many global health thinkers have called for a permanent global health fund in the vein of the Federal Emergency Management Agency, which was established to respond to natural disasters. But there’s no sign of that kind of stockpile emerging. “I tried hard to get a rapid response fund,” Frieden explained. “Politically it doesn’t seem likely to happen, unfortunately. But it’s needed.”

So with Ebola faded into the background, we appear poised to return to the usual levels of global health funding if Congress approves Trump’s budget.

“Going back to ‘normal’ levels means returning to levels that were not sufficient — and certainly not able to build systems and no surge capacity,” Kates said. “Having to end programs in countries where the need still exists is risky.”

Correction: An earlier version of this article misstated that Lassa fever cases in Nigeria were counted from February. Instead, they were counted from January.