Monday, October 20, 2014

Ebola outbreak: the deadliest in history

Celu Binani/AFP

A lethal virus has been killing hundreds in West Africa. Follow this ongoing story here.

Nina Pham, one of the two Texas nurses infected with Ebola, posted a video late Thursday night from her hospital in Dallas. Pham, who appears to be in good health in the one-minute clip, has since been transferred to the National Institute of Health for her treatment.

In the video, Pham jokes with her co-workers about accompanying her to the NIH ("Come. Come to Maryland," she says. "Party. Party in Maryland") and bids them a tearful goodbye ("No crying," one of her colleagues instructs, as Pham is given a tissue). The best news of the video is that Pham, who was diagnosed with Ebola five days ago, looks healthy.

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Earlier today, the Liberian government published a list of the supplies it has on hand to treat Ebola patients — and the supplies it thinks it will need. The data paints a dire picture of a country bracing for an outbreak that only gets worse.

The Liberian government estimates it needs an additional 84,841 body bags. It currently has 4,901 on hand.

The West African country also needs more than 2 million boxes of rubber gloves and a half-million pairs of goggles and tens of thousands more pairs of rubber boots. Right now, it has very little of any of these. You can see the gap between supplies needed and supplies on hand here:

liberia

The full list of supplies, both those on hand and those necessary, is available in the government's most recent situation report.

liberia sit rep

(Liberian Ministry of Health and Social Welfare)

Liberia has been harder hit by the Ebola outbreak than any other country. It has so far recorded 4,076 cases and 2,316 deaths. More than half of all Ebola deaths worldwide have happened in Liberia.

The country is also poor, with few resources to fight the deadly outbreak. Even before Ebola hit, Liberia had one of the world's poorest health care systems. Liberia spends an average of $66 per person per year on health care — a mere 2 percent of the OECD average.

health_spending_revised.0.png Supplies matter a lot in the Ebola outbreak. Without proper protective gear, its easier for the disease to spread — not just in Liberia, but also outside of the country, too.

If you're looking for ways to help ease the supply shortage, consider this list of non-profits currently providing aid in West Africa in the Ebola fight.

Hat tip to the Washington Post for noticing this report earlier today.

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The country's largest nursing union is considering the possibility of picketing hospitals if they do not offer more extensive training on how to treat Ebola patient.

Nurses United executive director RoseAnn DeMoro said in a conference call Wednesday that her group may take "pretty dramatic action for nurses across the country" that could "escalate into possible pickets at hospitals."

"We have heard consistently across the country that there are no protocols in place," she said.

On the same call, nurses lamented the lack of training they have so far received, arguing that few hospitals have adequately prepared them to treat Ebola patients without a risk of becoming infected.

Those who spoke cited brief trainings — sometimes 10 minutes or fewer — and two-page leaflets that hospitals have offered to their workers. Many have not received interactive demonstrations of how to put on personal protective gear, which can be complex and takes many steps to do successfully. One nurse in Washington, DC said she and her colleagues asked for better protective goggles, only to be told they weren't coming — the new goggles were too expensive.

These complaints are concerning because the Centers for Disease Control and Prevention has said that every hospital needs to prepare for the possibility of Ebola turning up in their emergency room.  "Every hospital in the country needs to be ready to diagnose Ebola," CDC director Thomas Frieden said in a Tuesday news conference.

While there are four, specialized biocontamination units in the United States — one, at Emory University, is now treating a Texas nurse infected while treating patient Eric Duncan — its unrealistic to expect possible patients to turn up at that small handful of hospitals. That means any hospital could be where an Ebola patient arrives next.

But, at least from the nurses' perspective, that preparation isn't happening — and, if the situation doesn't change, could result in the caregivers walking off the job.

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The next time you have the chance, say thank you to a nurse. He or she near certainly deserves it.

In the American health care system (any health system, really) it's nurses who are on the front lines. We are seeing that right now in the Ebola outbreak. From Liberia to the United States, the brunt of the disease has fallen hardest on nurses.

The majority of Liberian health care workers who have become infected with Ebola are nurses, the country's government found in a late September report.

infections

A Spanish nurse became infected with the disease after caring for a patient there. And, here in the United States, two nurses in Texas — Linda Pham and Amber Joy Vinson — both contracted the disease.

It's not especially hard to understand why: nurses provide much of the world's hands on care. They're the ones who are checking in with patients, taking their temperature, administering medications and delivering lots of the hands-on care that makes the health care system works.

This isn't to undercut the important work that doctors do, everyday, helping to save lives and deliver medicine. But it is to draw attention to the fact that nurses are doing equally important work, also everyday, for less recognition and lower pay.

Nurses get paid less than doctors—even when delivering the exact same care

Our health care system values nurses less than doctors. Medicare pays nurse practitioners 85 percent of what doctors make for administering the exact same services. MedPac, a federal board that advises the government on Medicare policy, found that there was "no analytical foundation for this difference."

In other words: it's not that, in the situations that MedPac looked at, nurse practitioners provide worse care than doctors. It's just that we've made a decision we should pay them less for their services. The Affordable Care Act included a pay bump for doctors who provide primary care services — but not for nurses.

The Institute of Medicine has recommended upping nurses' reimbursement rates to match those of doctors. So far, it hasn't happened.

Nurses barely get leadership positions — not in TV dramas, not in real life

Nurses don't get as much popular attention. One 2002 study of four major medical dramas, like ER, found that nurses appear in 10 percent of all dramatized health care interactions. In the real world, there are more than twice as many nurses (2.6 million) as there are doctors (893,851). In the world of television though, nurses barely exist: the same study found they make up 4 percent of all characters.

"The shows portrayed doctors as dominating discussions around health policy issues," the report concludes. "Nurses, social workers, and other members of the health care team hardly existed in policy."

Nursing isn't glamorous; the title characters and ER and Grey's Anatomy all have M.D.s behind their names. The one television show that has a nurse as its title character is a comedy: Nurse Jackie.

This isn't just a challenge in the fictional world of Seattle Grace Hospital: real-life hospitals are less likely to have nurses in positions of leadership. Surveys of hospital boards find that nurses typically represent 2-4 percent of the board positions. Doctors claim 22 percent. Again, nurses vastly outnumber doctors in the overall health care system.

This should be worrisome: fewer nurses in leadership can mean less diversity of opinion— specifically, less opinion from nurses about what makes a hospital run best. Arthur Relman, a prominent physician and former editor of the New England Journal of Medicine, learned this lesson the hard way when he broke his neck. He spent 10 weeks in rehab in the care of nurses.

"I had never before understood how much good nursing care contributes to patients' safety and comfort, especially when they are very sick or disabled," Relmand wrote in an essay about his experience. "This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good."

So thank nurses. Try and do it sometime soon. They work important, sometimes dangerous and too-frequently thankless jobs. Our health care system just wouldn't work without them.

The 90-second case for deregulating nurse practitioners.

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Ever since Thomas Duncan, the first Ebola patient diagnosed in the US, got on a plane in Monrovia and traveled to Dallas with the Ebola virus incubating in his body, there has been a lot of confusion about the risk of contracting the disease during travel. Now, with the news that the second Dallas health worker to contract Ebola flew from Cleveland the day before reporting to hospital with a fever, worry about the virus during air travel will surely peak.

So here's a refresher on how you can and can't get Ebola on a plane (or, for that matter, anywhere else):

Here are ways you could get Ebola on a plane:

1) You can get the Ebola virus if you have "direct contact" with the bodily fluids of a sick person, including blood, saliva, breast milk, stool, sweat, semen, tears, vomit, and urine. "Direct contact" means these fluids need to get into your broken skin (such as a wound) or touch your mucous membranes (mouth, nose, eyes, vagina).

2) So you could get Ebola on a plane by kissing or sharing food with someone showing symptoms of Ebola. You could get it if that symptomatic person happens to bleed or vomit on you during flight, and those viral fluids hit your mouth or eyes. You could also get it if you happen to be seated next to a sick individual, who is sweating profusely, and you touch that virulent sweat to your face. At least this last scenario is unlikely, however. One of the Ebola discoverers, Peter Piot, said, "I wouldn't be worried to sit next to someone with Ebola virus on the Tube as long as they don't vomit on you or something. This is an infection that requires very close contact."

The Ebola virus has been able to Live in semen for up to 82 days3) You can get Ebola through sex with an Ebola patient. So you could get Ebola on a plane if you join the Mile High Club with an Ebola-infected individual. The virus has been able to live in semen up to 82 days after a patient became symptomatic, which means sexual transmission — even with someone who has survived the disease for months — is possible.

4) You can get Ebola through contact with an infected surface. Though Ebola is easily killed with disinfectants like bleach, if it isn't caught, it can live outside the body on, say, an arm rest or table. In bodily fluids, like blood, the virus can survive for several days. So if someone with infectious Ebola gets his or her diseased bodily fluids on a surface that you touch — an airplane seat, for example — and then you put your hands in your mouth and eyes, you could get Ebola on an airplane.

5) This is a very unlikely situation, but: you can get the virus by eating wild animals infected with Ebola or coming into contact with their bodily fluids — on a plane. The fruit bat is believed to be the animal reservoir for Ebola, and when it's prepared for a meal or eaten raw, people get sick. So you could get Ebola in flight by bringing some under-cooked bat meat onto the aircraft and having it for supper.

ebola map

Here are ways you can't get Ebola on a plane:

1) You can't get Ebola from someone who is not already sick and showing symptoms. The virus only turns up in people's bodily fluids after a person starts to feel ill, and only then can they spread it to another person. So if you were sitting on a plane next to someone who had Ebola but wasn't yet showing symptoms or infectious, you would not get Ebola.

The second Dallas health worker to contract the virus flew the day before she reported to hospital with a fever and had a temperature of 99.5. If true, it's unlikely that she would have been infectious at the time, but health officials are taking precautions and following up with everybody on the flight.

Ebola isn't easy to transmit.2) It's very rare to transmit Ebola through coughing or sneezing. The virus isn't airborne, thankfully, and experts expect that it will never become airborne because viruses don't change the way they are transmitted.

Still, the Centers for Disease Control and Prevention
offered this cautionary note: "If a symptomatic patient with Ebola coughs or sneezes on someone, and saliva or mucus come into contact with that person's eyes, nose or mouth, these fluids may transmit the disease." This happens rarely and usually only affects health workers or those caring for the sick.

So the possibility of transmission on a plane by coughing or sneezing exists — but it is small. It would have to go something like this: An Ebola patient would have to cough on the hand of the person sitting next to them, releasing some amount of mucus or saliva. The person being coughed on would then have to (say) rub his or her eye with that hand,  allowing the disease into the body.

The bottom line: Ebola is difficult, but not impossible, to catch even in confined spaces like planes

Ebola isn't easy to transmit. The scenarios under which Ebola spreads are very specific. As the World Health Organization — which does not recommend travel bans — put it, "On the small chance that someone on the plane is sick with Ebola, the likelihood of other passengers and crew having contact with their body fluids is even smaller." They also point out that people who are sick with Ebola "are so unwell that they cannot travel."

Ebola doesn't spread quickly, either. An Ebola victim usually only infects one or two other people. Compare that with HIV, which creates four secondary infections, or measles with 17.

So far, there have been three known Ebola cases originating in the US. There are upwards of 8,000 in West Africa. That's where experts say the worry and fear about Ebola contagion should be placed.

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Nina Pham, the 26-year-old Dallas nurse who contracted Ebola while caring for a patient, has been transfused with the blood of another US citizen who survived the disease.

While this might sound like some bizarre medical experiment, the World Health Organization has called these sorts of blood therapies "a matter of priority" in this outbreak, and noted that there's been a "growth of interest in convalescent therapies as an already bad epidemic gets worse."

The idea of using survivors' blood to treat Ebola has actually been floated for decades, and it's rather simple: The blood of a person who has recovered from Ebola is thought to be rich in the antibodies needed to fight off the virus. So, the logic goes, if you give convalescent plasma to a patient struggling with the virus, it might be the boost they need to beat it.

Pham, who contracted the disease while caring for the first-ever Ebola patient diagnosed in the US, received the blood of Dr. Kent Brantly, one of the first American medical missionaries to be infected with the virus in Liberia. Brantly also received the blood of a survivor, and in turn donated his own blood to Dr. Rick Sacra, another American medical missionary who also contracted Ebola in Liberia. Sacra survived Ebola, too.

What does science say about convalescent serum?

The evidence for convalescent serum is the subject of controversy in the Ebola research community, said Dr. Thomas Geisbert, a professor or microbiology and immunology at the University of Texas Medical Branch.

brantly

Ebola patient at Emory Hospital, stands with his wife, Amber Brantly, on his release from Emory Hospital in Atlanta, Georgia. (Photo: Jessica McGowan/ Getty Images News)

"Back in 1995 during the large outbreak of Ebola Zaire virus in the Democratic Republic of the Congo, there were reports that convalescent serum was used from people who survived Ebola to treat people who were infected," he told Vox.

A report about the treatment involving eight patients was published in the Journal of Infectious Diseases. Only one of the eight people died, a fatality rate much lower than the then-outbreak, which killed some 80 percent of those infected.

Unfortunately, however, the serum theory was not supported by later studies. "When we tested that hypothesis in a lab, and took convalescent blood from animals who survived and gave it to Ebola-infected animals, they all died," said Dr. Geisbert. "There was the belief that most of those patients treated were in the process of recovering anyway."

Before that, according to the WHO, convalescent therapy was first tried in a young woman infected with Ebola during the first-recorded Ebola outbreak in 1976. "The woman was treated with plasma from a person who survived infection with the closely-related Marburg virus. She had less clinical bleeding than other Ebola patients, but died within days."

Why is the WHO backing the use of survivors' blood?

Despite the patchy scientific findings and the admission that convalescent therapies have been used in too few patients to know whether they actually work, the WHO continues to tout them as good medicine in this outbreak.

The reason they're doing that is this: serum as a treatment for Ebola is a cost-effective and potentially helpful solution at a time when there are no alternatives.

There's a chance that, even though the small, published studies were not very positive, the serum could turn out to be helpful. We can only know that by trying it in more people, and this Ebola crisis — the most desperate the world has ever known — provides a natural environment to learn about the risks and benefits, especially with no other treatment or vaccine yet on the market.

Watch the Vox.com 2-minute explainer video about how this outbreak spun out of control.

That doesn't mean using blood from Ebola survivors as a treatment doesn't come without risks. The worry that public-health officials are discussing now is mainly that you might make people even sicker with tainted blood.

As infectious diseases expert Gary Kobinger said recently, "There are important risks associated with the transfer of plasma." These include giving people blood that's infected with other pathogens, such as hepatitis or HIV. The extent of blood testing before transfusions in Africa is not at the same standard as it is in North America, which is concerning.

Still, at the population level, blood plasma as a treatment has the potential to do more good than harm, since there are no known side effects and it could save lives or at least further our understanding of whether this therapy is useful.

Even though the infected Americans — Drs. Sacra and Brantly — survived after getting the blood therapies, we won't know whether it's because of the serum or something else. Both Brantly and Sacra got experimental medications in addition to convalescent blood, and both had excellent supportive medical care, which has been shown to improve outcomes. So it will be difficult to untangle which intervention actually worked to save their lives.

To truly find out what stops Ebola, it'll be the thousands of infected Africans — who don't have access to experimental-drug alternatives — that hold the answer to the question.

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Peter Jahrling, one of the country's top scientists, has dedicated his life to studying some of the most dangerous viruses on the planet. Twenty-five years ago, he cut his teeth on Lassa hemorrhagic fever, hunting for Ebola's viral cousin in Liberia. In 1989, he helped discover Reston, a new Ebola strain, in his Virginia lab.

Jahrling now serves as a chief scientist at the National Institute of Allergy and Infectious Diseases, where he runs the emerging viral pathogens section. He has been watching this Ebola epidemic with a mixture of horror, concern and scientific curiosity. And there's one thing he's found particularly worrisome: the mutations of the virus that are circulating now look to be more contagious than the ones that have turned up in the past.

When his team has run tests on patients in Liberia, they seem to carry a much higher "viral load." In other words, Ebola victims today have more of the virus in their blood — and that could make them more contagious.

We spoke last week about his work studying the disease, how this Ebola virus may be more dangerous than others, and what that means for the epidemic. What follows is a transcript of our conversation, lightly edited for clarity and length.

If you want to learn more about Ebola and this epidemic, read our cardstack.

Julia Belluz: What concerns you most about the virus circulating now?

Peter Jahrling: I want to know if this virus is intrinsically different from the one we have seen before, if it is a more virulent strain. We are using tests now that weren't using in the past, but there seems to be a belief that the virus load is higher in these patients [today] than what we have seen before. If true, that's a very different bug.

One of the studies we're going to do here is to test the virulence of this new strain in experimentally infected primates and compare it with the reference strain, and look at whether it is hotter, extrapolating from monkeys to people. It may be that the virus burns hotter and quicker [meaning it's more contagious and easily spread].

JB: Yet everyone is worried about Ebola going airborne...

PJ: You're seeing all these patients getting infected, so people think there must be aerosol spread. Certainly, it's very clear that people who are in close contact with patients are getting a very high incidence of disease and not all of that can be explained by preparation of bodies for burial and all the standard stuff. But if you are to assume that the differences in virus load detected in the blood are reflected by differences in virus load spread by body secretions, then maybe it's a simple quantitative difference. There's just more virus.

JB: A higher viral load means this Ebola virus can spread faster and further?

PJ: Yes. I have a field team in Monrovia. They are running [tests]. They are telling me that viral loads are coming up very quickly and really high, higher than they are used to seeing. It turns out that in limited studies with the evacuated patients, they continued to express virus in blood and semen. What does that mean? Right now, we just don't know.

JB: Can you entertain the air-borne hypothesis. Do you think it's plausible?

PJ: You can argue that any time the virus replicates it's going to mutate. So there is a potential for the thing to acquire an aerogenic property but that would have to be a dramatic change. When scientists have done studies, playing with  influenza strains to make them more virulent, when they increase the aerosol potential of a flu strain, they also reduce its virulence. So when you start messing with viruses, you usually make them less virulent.

JB: There have been worries that Ebola can become a pandemic like HIV and spread around the world. Even Tom Frieden, director of the Centers for Disease Control and Prevention, was recently saying as much. Your thoughts?

PJ: The mode of transmission is different between the two viruses. Ebola causes an acute infection which you either die from or you're immune, you don't carry the virus for long periods of time. Whereas with AIDS, a lot of people transmitting AIDS didn't know they have it. Before we had a triple cocktail therapy, AIDS was lethal with the exception of a few people who were not susceptible. Long term AIDS was hotter than Ebola. My gut feeling is that Ebola is going to burn out in human populations.

JB: Why are you optimistic about this epidemic burning out?


PJ: In this epidemic, it would appear that there have been multiple introductions [of the virus from animals to humans]. It's not all person to person transmission. It's coming from animals again and again. [This means people need to be near potential animal hosts — believed to be fruit bats endemic to Africa — to get the virus.] Now there are all these different strains. That could also mean the virus is more mutable. We can't yet say. I think it's unlikely that this thing is going to perpetuate in humans.

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A female nurse who cared for the Liberian patient who died from Ebola in Dallas has tested positive for the virus, marking the first-ever transmission of the disease in the United States.

The nurse, who treated Ebola patient Thomas Eric Duncan at Texas Health Presbyterian Hospital, had reported a fever on Friday and was isolated and tested on Saturday. Tests from a state lab in Texas and the CDC both found her to be positive for the Ebola virus. (To learn more about this Ebola epidemic, read our cardstack.)

"We're deeply concerned by the news," CDC director Tom Frieden said in a Sunday briefing. "We don't know what occurred in the care of the index patient [Duncan] in Dallas but at some point there was a breach in protocol and that breach in protocol resulted in this infection."

The nurse had been wearing personal protective gear — gloves, gown, and a mask — while treating the Ebola patient. She had cared for Duncan on multiple occasions after his diagnosis.

When she went into isolation, her fever was low-grade, which means her infection was at an early stage and she would not have been very infectious. Ebola contagion increases as symptoms worsen and the virus builds up in the body.

getty

Texas Health Presbyterian. (Photo courtesy of Mike Stone/Getty Images News)

"We knew a second case could be a reality, and we've been preparing for this possibility," said Dr. David Lakey, commissioner of the Texas Department of State Health Services.

Duncan, the first person to be diagnosed with Ebola in the United States, died at at Texas Health Presbyterian Hospital in Dallas on October 8. He tested positive for the virus over a week after arriving in Dallas from Liberia, one of countries hardest hit by the epidemic.

A hospital misstep in failing to diagnose Duncan at an early stage might have affected his outcome, but it has also affected the lives of everyone with whom he came into contact.

Officials are still following up with 48 people who had some kind of exposure to Duncan or his family prior to Duncan's diagnosis.


The infected health worker was not one of the 48 contacts being traced.
The CDC says it is now monitoring all of the contacts who had exposure to Duncan after his diagnosis on September 28, during his hospital stay.

T
his case of transmission to the nurse will mean that officials now need to find and follow-up with all of her contacts, too.
Frieden said the CDC knows of one other individual who definitely had contact with the nurse while she was infectious.

The CDC still says it can contain any US outbreak

"It is certainly possible that someone who had contact with [Duncan]... could develop Ebola in the coming weeks," the CDC director Tom Frieden said previously. Still, he added: "I have no doubt we will stop this in its tracks in the US. I also have no doubt as long as this continues in Africa, we need to be on guard."

That said, the failure to screen and diagnose Duncan on his first visit to hospital — and news that he transmitted Ebola to this nurse — will raise public concern about Ebola, in particular, among health-care workers and hospital staff who might come into contact with Ebola patients in the US.

Frieden said his agency will be looking at how to minimize the risk of transmission to health workers, figure out how to improve the use of personal protective equipment, and boost hospital preparedness for Ebola across the US.

This is part of a wider effort to protect Americans from Ebola. As a precautionary measure, the Department of Homeland Security announced last week that they would begin screening flight passengers coming in from West Africa for signs of infection, starting with five American airports.

For now, though, the major concern is stopping the outbreak at it's source. Ebola is currently concentrated in West Africa, in Liberia, Guinea and Sierra Leone. There, more than 8,000 people have gotten the virus, and more than 4,000 have died.

Transmission from patients to health workers has been an all-too-common feature of this outbreak. More than 230 health workers have died while caring for the sick in this epidemic — an unprecedented number, according to the World Health Organization.

Further reading: How you can and can't get Ebola, The nightmare Ebola scenario keeping scientists up at night, The lesson that should be learned from this Ebola outbreak.

WATCH: How the 2014 Ebola outbreak spiraled completely out of control

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There's something unique about the three hospitals that have so far successfully treated Ebola patients — something that's different from Texas Presbyterian Hospital in Dallas, where a patient died and one worker treating him became infected.

Emory, the University of Nebraska, and the National Institutes of Health have all received and successfully discharged Ebola patients. These three hospitals are among just four in the nation with specialized biocontamination units. These are units that have existed for years, with the sole purpose of handling patients with deadly, infectious dieases like SARS or Ebola.

While biocontamination units look similar to a standard hospital room, they usually have specialized air circulation systems to remove disease particles from the facility. And, perhaps more importantly, they're staffed by doctors who have spent years training, preparing and thinking about how to stop dangerous infections from spreading. 

"Ever since [2007] we've had a training program," says George Risi, who runs the country's fourth biocontainment unit, at St. Patrick's Hospital in Montana. His is the only unit that hasn't yet treated an Ebola patient, but his staff has spent years preparing for that moment. Every six months, they "do a workshop and also have periodic drilling."

This isn't true of Texas Presbyterian. Like most American hospitals, it doesn't have a biocontamination unit. It hasn't spent years running through the drills of how to treat an Ebola patient. It began receiving additional training from the CDC, director Tom Frieden told reporters Sunday, only this week.

"The care of Ebola can be done safely but its hard to do it safely," Frieden said in his Sunday press conference. "Even an innocent slip up can result in contamination."

What's different about biocontamination units is their training

isolation unit

One of Emory University's isolation units (Emory University)

I got to talk to Risi earlier this month, and he told me about all the things that make their biocontamination rooms different from typical hospital rooms. Some if it is technology.

"Each of those three rooms has negative pressure: the air is drawn in from the hallway and then goes out through a series of high efficiency particulate air [HEPA] filters," he says. "The HEPA filters connect to duct work that goes up to the top of the roof of the hospital and is discharged eight feet above the roof."

But more than the physical structure of the units, Risi really thinks it comes down to the extensive training. His staff has, for seven years now, run periodic drills about how they would treat these patients. The Nebraska hospital that successfully treated one Ebola patient — and is currently caring for the infected NBC cameraman — has been preparing for a patient like this since 2005.

These hospitals are in close contact with each other, sharing information about how to best handle tricky situations. Risi, for example, has talked to experts at Emory about the best way to dispose of waste from Ebola patients.

In Montana, Risi and his head nurse even went to Sierra Leone this summer to become more familiar with the disease — and shake off some of the scare factor around it. At his hospital, treating an Ebola patient is "something we've been talking about for years, how you handle this kind of patient. Its not new to us."

The CDC thinks that the problem in Texas comes down to the ability to follow protocol and better training. "There's a need to enhance the training to make sure the protocols are followed," he said. "We know the protocols work."

"The necessity of doing this right 100 percent of the time does require... a very intensive training process," Frieden continued.

CDC: All hospitals need to be prepared

Frieden fielded one question on Sunday morning: should all Ebola patients be cared for at these four, specialized biocontamination units?

He said that his agency will "absolutely be looking at" the "safest way to provide care" — and this could be one option.

But he also addressed one challenging point here: most Americans don't live near a biocontamination unit. An Ebola patient is more likely to turn up at the emergency department of a hospital without the specialized training. And, even if patients are ultimately transferred to a better-prepared facility, there is still some amount of time where patients will interact with their local providers.

"We can't let any hospital let its guard down," Frieden says. "A patient, who had exposure and maybe didn't have an awareness. We do want hospitals to have the ability to rapidly consider, isolate and diagnose someone who may have Ebola."

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Here's a disturbing fact in light of the current Ebola outbreak: the Centers for Disease Control and Prevention's emergency preparedness budget has fallen about half since 2006.

Scientific American posts this graph showing the steady decline since 2006.

public funding

(Scientific American)

The CDC's Public Health Emergency Preparedness Cooperative Agreement Funding is one of the federal government's main ways of helping local areas prepare for unexpected outbreaks. Funding for it has steadily fallen in recent years after a slight increase in 2006 (perhaps a response to the SARS outbreak a few years prior).

Emergency preparedness is an easy budget to cut when there aren't any emergencies happening. But the decision has consequences: we're learning with the current outbreak that our public health systems — both in the United States, and globally — simply are not prepared to handle an Outbreak of a dangerous disease like Ebola.

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Ebola fear and conspiracy theories are spreading faster than the disease. But even scientists — who have thought very deeply about Ebola and pandemics — are beginning to worry.

What they fear, however, is slightly different from the zombies and airborne Ebola that keeps many of us up at night. I asked them about what it would take for Ebola to spread further in America and around the world. Here's their worst-case scenario:

1) The Ebola outbreak in West Africa keeps growing

454002540.0.jpg Ebola outbreak in Sierra Leone. (Photo courtesy of Anadolu Agency)

In order for Ebola to move around the world, the outbreak needs to continue to grow in West Africa. Cases there need to keep on their exponential ascent. The more people infected with Ebola at the source, the more likely they are to infect other people, and the more likely those people are to travel and spread the disease. It's the mathematics of Ebola, and it's scary.

ebolmath

The exponential growth curve of this Ebola crisis.  (Courtesy of the journal EuroSurveillance)

For the situation to deteriorate in West Africa, efforts to address it need to fail. The unprecedented international response — led by the US — needs to be implemented too slowly, and needs to continue to lag the growth in cases.

And this is possible, at least for the foreseeable future, since the epidemic has already had such a long lead time before the international community intervened. "We have had more Ebola cases in the last two months than the entire history of the infection combined. It's still in the growth phase," says Ashish Jha, director of the Harvard Global Health Institute. "The longer it continues in West Africa, the bigger a chance it's going to get much more global."

2) The virus finds new hosts in urban areas with weak health systems

Screen_Shot_2014-10-15_at_1.25.43_PM.0.png Eighty-eight Indians return from Liberia, an Ebola hot zone. (Photo courtesy of Hindustan Times)

Traditionally, Ebola was a rare disease, relegated to remote and rural areas in Africa. It affected a couple thousand people since it was discovered in 1976. This year, there are more than 8,000 cases, and the virus has popped up in well-populated areas, which has helped it to find new hosts and move further.

For the Ebola caseload to continue to balloon, people with Ebola need to continue to turn up in densified areas, particularly with under-resourced and weak health systems.

Peter Piot, who helped to discover and name the virus, told the Guardian newspaper that he was concerned in particular about the link between West Africa and India:

...an outbreak in Europe or North America would quickly be brought under control. I am more worried about the many people from India who work in trade or industry in West Africa. It would only take one of them to become infected, travel to India to visit relatives during the virus's incubation period, and then, once he becomes sick, go to a public hospital there. Doctors and nurses in India, too, often don't wear protective gloves. They would immediately become infected and spread the virus.

West Africa also has strong links with China, where the health system can be similarly patchy.

Watch: How the Ebola outbreak spread out of control:



Epidemiologists have been preparing for this kind of nightmare for decades. "People have been talking about this for probably 20 years," said Stephen Morse, director of infectious disease epidemiology at the Columbia University Medical Center. Yet, even though there is more travel, and more people are living in cities, our global health responses still don't reflect this reality, says Morse. "I have been discouraged by the lackadaisical, the tepid, and late response by the global community."

3) Rich countries with strong health systems continue to fumble and botch their Ebola cases

eboalspain Spanish officials outside the Madrid hospital where people are in quarantine following the infection of a nurse with Ebola. (Photo by Curto de la Torre/AFP)

Since the beginning of this outbreak, one of the truisms about Ebola hitting America, or another developed country, has been that it would be detected and stamped out so fast, it wouldn't have a chance to gain a foothold. "It is not a potential of Ebola spreading widely in the US," Centers for Disease Control and Prevention director Tom Frieden told reporters in July. "We have strong systems to find people if there is anyone with Ebola in the US."

Yet, the first Ebola patient in the US — a recently deceased Liberian national who had arrived from Monrovia days before seeking care in a Dallas hospital — was misdiagnosed on his first visit. He was sent back into the community with antibiotics to fight what was believed to be a common viral infection, even though he told hospital staff about his travel history. He also made it through airport screening in Monrovia, days after caring for a woman who died from Ebola. Now, one of the health workers who cared for him has tested positive for the virus.

There was similar fumbling with Europe's first Ebola case. A Spanish nurse contracted the disease after caring for a repatriated priest from Sierra Leone who later died. While harboring the virus, she sat in on a civil service exam with 20,000 others and visited clinics to get help with her early symptoms. But her temperature was thought to be too low to sound the Ebola alarm bells.

"A few weeks ago, if you had asked me 'is Ebola a danger to the US?' I would say the conventional wisdom is 'no,'" says Morse. "I still think that is largely true but I have become a little less optimistic."

These errors are all very human and all too easy to make. Despite the Ebola public-health protocols sent out to doctors, hospitals, and airports, the airport screenings, the warnings to health professionals who have been exposed to quarantine themselves, the warnings to travelers to stay home if they have come into contact with an Ebola patient, Ebola managed to slip through the cracks of the best health systems in the world. These everyday mistakes need to continue to happen for the virus to move further.

4) Rising panic causes us to make irrational — and harmful — choices that exacerbate the epidemic

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A man is arrested by police officers after a dead body was found in the center of the city of Monrovia. (Pascal Guyott/AFP)

Following the announcement of increased airport screening efforts for travelers from West Africa, New Yorker writer John Cassidy lamented the political hot potato that Ebola has become:

The measures that the Obama Administration announced on Wednesday mimicked what some Republicans, including Rick Perry, the governor of Texas, had been advocating. At a press conference on Monday, where he unveiled a new task force to combat infectious diseases, Perry called on Washington to introduce "enhanced screening procedures" and create "fully staffed quarantine stations." At this stage, the only big difference between Perry and the White House is that he wants screening to be extended to "all points of entry" to the United States; the new C.D.C. policy is limited to airports in Atlanta, Chicago, New Jersey, New York, and Washington, D.C.

It doesn't matter that Ebola is currently a small threat in America, and that the real focus should be stopping the outbreak in West Africa. If this political theater devolves into, say, a travel ban in West Africa that further isolates the region, the nightmare epidemic will inch closer to reality: the economies of the affected countries will continue to crumble, getting aid to the region will be difficult or impossible, and Ebola will rage on over there, which again, means it's a threat everywhere.

5) The virus mutates to become more virulent

Every scientist worth his weight in citations has said that the chances of Ebola mutating to become airborne are slim. This is because it would require the virus to change how it is transmitted. This would be like HIV or herpes suddenly becoming airborne. It's something viruses don't do, though of course, nothing is impossible when it comes to biology.

What is more probable, however, is that the Ebola virus now circulating is more virulent than previous strains. Peter Jahrling, a chief scientist at the National Institute of Allergy and Infectious Diseases, has a field team in Monrovia, running tests on samples of Ebola from the sick in this epidemic.

"They are telling me that the viral loads are coming up very quickly and really high, higher than they are used to seeing," he says. The more concentrated the virus in people's bodily fluids, the more infectious and easily spread.

Though Jahrling and his team need to continue to study this hypothesis, he says this kind of mutation might help explain why Ebola seems to have spread so effectively this year compared to previous outbreaks. And this is saying a lot from someone who has studied Ebola and other dangerous pathogens for more than 25 years.

The good news

Ebola hasn't yet been detected in a developing country outside of West Africa. And even the botched responses in Spain and the US haven't given way to more cases. Nigeria and Senegal were also able to stop their outbreaks. What's more, the international community has underway one of the largest-ever public-health responses to address Ebola. There's potentially promising pharmaceutical solutions on the way, too. The dire scenario playing out in West Africa has spurred unprecedented Ebola treatment and vaccine development by governments and industry.

Hopefully, this worst-case scenario will never come to pass. But, as Harvard's Ashish Jha put it, "Ebola reminds us we do live in one world, and that something that happens in Africa can have a direct effect on our lives, our health, our kids' health."

Writing in JAMA, he argued that we need to strengthen weak health systems in the long term, not only because health is global but because Ebola has shown us that viruses have no political boundaries and even the most rare and obscure pathogens can turn up anywhere.

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The Ebola epidemic is horrible. But it's more than that: it's a warning that what comes next could be devastating — unless we learn its lessons now.

Ebola, while a gruesome, lethal illness, is not especially contagious. It isn't airborne. It only infects patients when it slips beneath the skin. Historically Ebola outbreaks have been small: the largest prior to this year killed 280 people. This year's outbreak has so far killed 3,865 — and it's still raging.

Ebola deaths, 2014 outbreak

The lesson here is simple, and it needs to be heeded: our international health systems are far too weak for an increasingly interconnected, urbanized world. The failures of public-health infrastructure in Liberia quickly become the problems of hospitals in Dallas. But what happens when it's not Ebola? What happens when the disease is airborne, when it travels through coughs and sneezes — and when contagion can occur before symptoms emerge?

"Germs have always traveled," Howard Merkel, a medical historian, recently told the New York Times. "The problem now is that they can travel with the speed of a jet plane."

We've known about these weaknesses for years

Ebola isn't our first warning. There was the SARS outbreak in 2003 when — much like Ebola — poor reporting and a lack of basic resources hampered the initial response. One account of how the response went wrong, published more than a decade ago in the Journal of the Royal Society of Medicine, reads as if it could be written about the current Ebola outbreak:

There was an acute shortage of masks and protective clothing for the medical and health personnel, who were hard hit by the disease. Lack of epidemiological information about the disease hampered the prompt application of effective control measures. Because of inadequate communication, panic developed in the community and weakened cooperation and support from the public.

Reflecting afterwards, top public health officials saw how it could have gone worse. "We got lucky," Centers for Disease Control and Prevention director Tom Frieden later said of the SARS outbreak, "that none of the cases in the U.S. came from a super-spreader."

There was the H1N1 influenza outbreak in 2009, which killed at least 150,000 people in dozens of countries. Five years ago, that outbreak showed that the World Health Organization, which coordinates international responses, was too cash-strapped and disorganized to contain the disease.

During that outbreak, there were 78 million vaccines sent to 77 countries — but only after it was "long after they would have done the most good," Harvey Fineberg recently wrote in a New England Journal of Medicine review of the H1N1 outbreak.

"The budget of the WHO is incommensurate with the scope of its responsibilities," Fineberg writes. "Only approximately one quarter of the budget comes from member-state assessments, and the rest depends on specific project support from countries and foundations."

Officials were surprised that, given the missteps, the outbreak wasn't even worse. And some, once again, chalked it up to good fortune: unlike many other flu vaccines, H1N1 did not mutate into a different virus as many influenza strains do. "We are just plain lucky," WHO secretary Margaret Chan said in 2010, after the pandemic ended.

Luck does not prevent world-wide pandemics

Our luck ran out with Ebola. The virus turned up in a small village in southeastern Guinea that shares a porous border with Sierra Leone and Liberia. This made it easy, even expected, that the disease would cross the border too. The virus in the outbreak is also the most deadly strain of Ebola we know, the Zaire strain, which has historically killed 80 percent of patients.

Ebola can be a difficult disease to detect, too, giving it another advantage in a highly connected world. Infected patients can be symptom-free for as long as three weeks. This helps explain how Thomas Eric Duncan, the now deceased Ebola patient treated in Texas, successfully boarded a plan from Liberia to the United States. He was asymptomatic.

We've had bad luck with Ebola, and that exposed the weakness of our public health system. Countries mobilize too slowly and are unable to get basic resources to the areas of the world that need them most. West African nations, chronically impoverished and ravaged by years of civil war, have severely underfunded health care systems.

underfunded health care

They don't have the right labs to analyze diseases and catch disease sooner — nor did wealthier nations step in to provide that.

"We need to build the capacity of countries to find, stop, and prevent global health crises," Frieden told my colleague Ezra Klein in a recent interview ."We are all vulnerable to the weakest link in the chain."

The world ignored other warning bells in the past, with SARS and H1N1 and the outbreaks before them. That's how we ended up with the weak public health system we have today, the one that has allowed Ebola to spread across oceans, traveling to eight countries in three continents.

As bad as the current Ebola outbreak is, it could be worse with another, more contagious disease. If we can't contain a disease that is difficult to transmit — one that has to make its way under each patient's skin — how will we contain a disease that spreads more swiftly, easily and discreetly?

A luck-based public health system isn't a way to prevent pandemics. There is a lesson in this Ebola outbreak, and we may not get another chance to learn it.

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The Ebola epidemic has been roaring in West Africa since March. Unfortunately, the world only seemed to wake up to this global health crisis in July, when it hit closer to home.

First, there was the news that Americans working in Liberia had become infected with the virus. They survived. But it wasn't long before a Liberian national got on a plane in Monrovia, the virus incubating in his body, and turned up in Dallas, Texas. He died on October 8, leaving behind panic, fear, and questions about the care he received and how far this epidemic could spread outside of West Africa.

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A mother and child in a classroom now used as an Ebola isolation ward in Monrovia, Liberia. (John Moore/Getty Images News)

Ebola is a violent virus with no cure, and this epidemic is already the deadliest in history. But fear and misinformation seem to be spreading faster than this disease. To help you get the facts about Ebola, here are the nine things you were too afraid to ask.

1) How worried should I be about Ebola?

The first-ever diagnosis (and ultimate death) of an Ebola patient in the United States was a frightening and unexpected event. But it doesn't signal the start of an American outbreak, nor does it give reason for Americans to panic about the possibility of contracting the disease.

It's helpful to consider the circumstances leading up to the one confirmed case of Ebola in the the US. The now-deceased patient, a Liberian man named Thomas Eric Duncan, flew to Dallas from the hot zone. He is believed to have contracted Ebola from his neighbor in Liberia, whom he helped carry to a hospital when she was most infectious, just before her death from the disease.

So Duncan was living in the area of the world where the epidemic was raging, among people who are sick. That's really different from the situation that most of us live in, thousands of miles from the Ebola outbreak's epicenter.

ebolaquiz

Ebola is a difficult disease to contract, requiring direct contact with the bodily fluids of another Ebola patient (more on this below). It cannot be contracted through more casual touch; if you ate a restaurant or shopped in a store where Duncan had been, you would not become infected. Because it's difficult to catch, Ebola is less contagious than most other infectious diseases we're familiar with, like measles or SARS. So far, all of the 48 people with whom Duncan had contact while he was contagious appear to be virus-free.

There are some people who have cause for worry: those who are living in West Africa. Those who have a fever, and who have just returned from one of the affected countries — Liberia, Sierra Leone, and Guinea. Those who feel sick after having come into close contact with a traveler from West Africa. But if you're not in one these situations then you, personally, are not at risk.

2) What happens if you get Ebola?

Most people's views of Ebola are probably informed by Hollywood — they think of it as a deadly and highly contagious virus that swirls around the world, striking everyone in its path and causing them to hemorrhage from their eyeballs, ears, and mouth until there is no more blood to spill.

outbreak

Remember this 1995 film?

In reality, Ebola is something different. About half of the people who contract Ebola die. The others return to a normal life after a months-long recovery that can include periods of hair loss, sensory changes, weakness, fatigue, headaches, and eye and liver inflammation.

As for the blood: While Ebola can cause people to hemorrhage, about half of Ebola sufferers ever experience bleeding.

More often than not, Ebola strikes like the worst and most humiliating flu you could imagine. People get the sweats, along with body aches and pains. They run a fever. Then they start vomiting and having uncontrollable diarrhea.

These symptoms can appear anywhere between two and 21 days after exposure to the virus. Sometimes, people go into shock. Sometimes, they bleed. Again, about half of those infected with the virus die, and this usually happens fairly quickly — within a few days or a couple of weeks of getting sick.

This is how one Ebola victim described what it feels like to get the virus and survive:

"I couldn't move from the bed. I couldn't talk. I couldn't do anything. I lost 25 pounds. I was in the hospital for one month when they discharged me... I was discharged from the hospital after one month. After two months, I started to improve. But I still had problems. I was forgetting a lot. My hair was falling out. The hair from my head was all over. My skin was peeling off. I weighed 25 pounds less. I had heart palpitations. The hair took months to grow back. My memory was bad for one year."

3) How do you get Ebola?

Ebola isn't as contagious as Hollywood depictions, either. It seems to spread through direct contact with the bodily fluids — vomit, semen, sweat, or blood — of someone who is symptomatic and shedding the virus. People who get the virus but don't yet show symptoms aren't contagious. The further along they are in the disease, the more virus is in their bodies, and the more contagious they become. That's why corpses of people who die from Ebola are so dangerous.

To be clear, "direct contact" means these fluids need to get into your broken skin (such as a wound) or on to your mucous membranes (mouth, nose, eyes, vagina).

Ebola can also live on surfaces for a few hours, and in blood outside of the body, for up to a few days. So there is a risk of getting Ebola by touching a contaminated surface. But you'd then need to put your hands in your mouth or eyes. This is believed to be a less common mode of transmission. Again, most people seem to get infected through direct contact with bodily fluids.

4) Can you really get Ebola through sex?

Yes. You can get Ebola through sex with an Ebola-infected person. The virus has been able to live in semen for up to 82 days after a patient became symptomatic, which means sexual transmission — even with someone who has survived the disease for months — is possible. But because Ebola sufferers are so sick, and many of them die, transmission through sexual contact hasn't been much of a worry.

5) Why did this epidemic spiral out of control?

map

When the Ebola outbreak was identified in March, it had already spread to three countries in West Africa: Liberia, Guinea, and Sierra Leone. The disease then appeared in Nigeria, Senegal, the United States and, most recently, Spain.

There is also an unrelated outbreak of Ebola in the Democratic Republic of the Congo involving a different type of the virus right now. So that's eight countries hit with Ebola in one year.

Before this year, Ebola was a disease mostly confined to remote African villages.

Though the outbreaks outside of West Africa so far are contained, this epidemic is big. Before this year, Ebola was a disease that was mostly confined to remote African villages and usually only affected a few people in one or two small communities at a time — unlike the thousands of cases internationally we're seeing now.

From what we know right now, the causes of the biggest Ebola outbreak in history can be boiled down to these four things:

1) The virus turned up in West Africa this year for the first time ever. Not only did this mean officials there weren't on the lookout for it — they had never seen Ebola in these countries before — but it also delayed diagnosis of the problem by about three months, and allowed the virus to circulate widely before public-health measures were introduced to stop it.

2) The three West African countries most-affected are also some of the poorest in the world. They spend less than $100 per year per person on health care. They have few health professionals, and scarce personal protective equipment to protect them. They don't have robust disease surveillance networks in place. They have poor infrastructure to carry the sick around and get samples to labs for testing. They have few labs. The literacy rates are very low, meaning public-health information campaigns have been challenging. In the case of Liberia and Sierra Leone, their economies — and people's psyches — were only just recovering from years of brutal civil war, which left the population traumatized with little public trust in officials.

Vox explains how the Ebola outbreak spiralled out of control.

3) An accident of geography sparked an Ebola outbreak in a porous border region. The outbreak started in Guéckédou, a rainforest region in southeastern Guinea. Guéckédou also happens to share a very porous border with Sierra Leone and Liberia, where people travel in and out every day to go to the market or conduct business. Right now, epidemiologists believe travelers in the area quickly spread Ebola around, so when the situation was diagnosed in March, Ebola had already gone international. Suddenly three countries were battling the virus, and had to coordinate their responses. The usual methods for containing Ebola, like contact tracing, don't work in an epidemic of this size. At this scale, responding to Ebola becomes much more challenging and the disease difficult to stop.

4) The international response was slower than the virus. It took three months for health officials to identify Ebola as the cause of the epidemic, but another five months for the World Health Organization to declare a public health emergency, and two more months to mount a humanitarian response that still isn't fully in place and might not be for a few more weeks. Meanwhile, the caseload continues to grow exponentially. We still don't fully understand why the global response was so slow, but many observers say it was an avoidable tragedy that spiraled because international organizations failed to act.

6) How bad could this epidemic get?

As of October 2014, roughly 8,000 people have been infected and the death toll is nearly 4,000. So how much worse could this get? The World Health Organization projects that 20,000 people will be infected in November. HealthMap put the number at about 14,000 if there's no improvement in the situation.

ebola projections

(Joss Fong/Vox)

But there are fears that the supplies and health-care workers needed to bend the epidemic curve downward and save lives won't reach Africa quickly enough. Doctors need to be trained. Hospitals need to be built. Personal-protective equipment needs to be distributed.

Even more worrying: many suspect that there has been widespread under-reporting of actual Ebola cases, since people have been turned away from overflowing hospitals and others have been hiding in their homes, afraid that coming out with Ebola will mean they never see their families again or that they are ostracized by their neighbors.

Assuming the worst is true, the Centers for Disease Control and Prevention has a much bigger projection for this epidemic: up to 1.4 million people infected by January.

7) If Ebola is not that contagious, why do people wear plastic space suits to care for Ebola patients?

ebolasuit

(Sean Gallup/Getty Images News)

Because the virus is so deadly. Depending on the strain of Ebola, it can kill between 50 and 90 percent of those infected. And there is no known cure. Those suits are thought to be extra protection.

What's more, though all the science we have points to the fact that transmission must happen through contact with bodily fluids, science is never certain. Until this year, Ebola has been a rare disease and the research community is still getting the full picture of its transmission. So the suits cover workers from all potential contact they may have while caring for Ebola patients.

There is some controversy over the limits of these suits, however. Some say they are too cumbersome and, without proper training in how to put them on and take them off, rendered useless.

That may be what happened in Spain, where a nurse contracted the virus after treating an Ebola patient who had been repatriated from Sierra Leone. The nurse believes she might have caught Ebola by touching her face with a gloved hand after treating her patient. Her colleagues also said staff at the hospital did not receive adequate training in how to suit up.

8) How do you stop the spread of Ebola?

Once an outbreak is identified and patients who are sick have been isolated, you'll hear that one of the tried-and-true methods for stopping the disease from spreading further is "contact tracing." This public-health measure works exceptionally well for small-scale outbreaks, like the case in Texas.

According to the Centers for Disease Control and Prevention director Tom Frieden, everyone who came in contact with the deceased Texas patient, Thomas Eric Duncan, while he was infectious has been identified. From there, officials outline and investigate all of the patient's movements before the patient was in isolation and during the period when he could have been contagious.

frieden

CDC director Tom Frieden. (Chip Somodevilla/Getty Images News)

They then build "concentric circles," the closest representing the people who the patient could have exposed, and a second with all the other people those initial contacts may have interacted with.

These contacts are watched for 21 days — the incubation period for the virus — to make sure they don't develop symptoms. Their temperatures are taken twice daily. If they show symptoms, they are placed in isolation and tested for the virus. If they don't, after 21 days, they are declared risk free.

The CDC is also taking other precautionary measures. With the Department of Homeland Security, the agency announced that airport officials would begin screening flight passengers coming in from West Africa for signs of infection.

It's unclear whether airport screening will actually be helpful. Take Thomas Duncan's case. CDC officials said he had no fever on departing Liberia and arriving in the US. He may have lied during questioning about his contact with an Ebola patient — and his potential risk — at the Monrovia airport. So his case demonstrates the difficulty of stopping international spread of this disease through airport screening.

Again, Ebola can incubate in someone before they become symptomatic for 21 days. So like Duncan, people might be harboring the virus when they fly somewhere but no one would be able to detect it. Twenty-one days is more than enough time to hop on a plane and bring the virus to a new country — and into new people — anywhere in the world.

9) Is there a cure for Ebola?

Right now, no. But researchers are busy working on developing both treatments and vaccines. In September 2014, the drug company GlaxoSmithKline announced it took the unprecedented step of starting mass production on an Ebola vaccine that has just begun being tested in humans.

The usual drug approval processes are being condensed or skipped

That news followed a decision by the World Health Organization to allow unproven and experimental treatments on people in this public health emergency — which means the usual drug approvals process will be condensed or phases of clinical testing potentially skipped.

One such drug is ZMapp, an antibody therapy that was used in the two American medical missionaries infected with Ebola in Liberia. It's made up of a cocktail of monoclonal antibodies, which are essentially lab-produced molecules manufactured from tobacco plants that mimic the body's immune response to theoretically help it attack the Ebola virus.

The report that the Americans got the drug — dubbed by CNN as a "secret serum" — led many to wonder why they skipped to the front of the line and who else might be saved with ZMapp. While these patients did improve after receiving the drug, a third patient who got ZMapp died. We won't know whether the drug worked or whether it's harmful on the basis of data from three patients, especially since half of those infected with this strain of the virus live anyway.

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Kent Brantly, one of the American medical missionaries infected with Ebola. (Photo by Jessica McGowan)

Whether this Ebola drug development actually turns out to be the silver lining of the worst epidemic in history remains to be seen. For every 5,000 compounds discovered at this stage, only about five are allowed to be tried in humans. These Ebola therapies are at only the earliest stage of drug testing, and they have a long way to go before proving useful. What's more, an Ebola drug won't fix all the health systems issues that allowed the disease to spread within Africa, and potentially, outward.

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Ebola is a scary and deadly disease. But one of the scarier aspects of the current outbreak is how hospitals outside of Africa have reacted to the Ebola patients who turned up at their facilities. A Dallas hospital initially sent home Thomas Eric Duncan with an antibiotic after diagnosing him with a "low grade, common viral infection." He died at the same hospital Wednesday morning.

Then there is this very scary account from the Daily Beast, flagged by Garance Franke-Ruta, of what happened when a nurse (who has since been diagnosed with Ebola) tried to seek care for the disease in Spain.

ebola spread

(The Daily Beast)

The nurse, Teresa Romero Ramos, had been helping care for an Ebola patient and reportedly told health workers "I think I have Ebola." Yet she received little medical attention until a test came back positive.

We don't know whether the nurse spread Ebola to anyone else as she tried to seek help. Ebola is a difficult disease to spreadIts much less infectious than measles, for example. But we do know that Ebola is only contagious when patients begin to show symptoms, as Romero did. Moving to treat her sooner would have decreased the risk of transmission.

So why didn't the Spanish hospital take a complaint of Ebola more seriously? One possible explanation is that hospitals can be skeptical when a patient presents with possible symptoms because Ebola is such a rare disease that is difficult to transmit. Here in the United States, most of the suspected cases have turned out to be false alarms.

This doesn't justify Ebola patients' symptoms not getting the attention they deserve, but it does help explain how Western hospitals have repeatedly botched their handling of new Ebola cases in ways that could allow the disease to spread further.

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The first patient ever diagnosed with Ebola in the United States died today in an isolation unit in Texas — raising questions about the quality of care he received and the initial missteps leading up to his diagnosis.

The patient, a Liberian named Thomas Eric Duncan, was visiting his girlfriend, their son, and other family in the United States. He left Monrovia on September 19 and arrived in Dallas on September 20. He had no symptoms when he departed Liberia or entered the US.

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Texas Health Presbyterian. (Photo courtesy of Mike Stone/Getty Images News)

Four days later Duncan started to feel ill, and soon after, sought care at Texas Health Presbyterian Hospital. Ebola was not initially suspected. Instead, Duncan was diagnosed with a "low grade, common viral infection" and sent home with an antibiotic.

On this first hospital visit, Duncan's sister said a nurse was informed that Duncan had come from Liberia. This should have raised flags about his disease. But this vital information "was not fully communicated throughout the full team," said Mark C. Lester, executive vice president of the health-care system that includes Texas Health Presbyterian.

In other words, hospital staff missed an opportunity to diagnose Duncan, get him into care, and also stop Duncan from spreading the virus while he was contagious.

By September 28, Duncan — who is 42 and recently quit his job in Monrovia as a driver for a shipping company — had fallen gravely ill. He was sent to Texas Presbyterian in an ambulance. 

This time, hospital staff suspected Ebola. Here's a timetable in calendar form:

ebola

For just over a week, Duncan remained in intensive care and isolation at the hospital, where his condition had worsened from serious to critical. This weekend, he had been "fighting for his life," according to the CDC director Tom Frieden, on dialysis and a respirator. He had also received the experimental antiviral drug brincidofovir, which the Food and Drug Administration approved for emergency use.

On October 8 at 7:51 a.m., more than a week after he was diagnosed, he died.

His girlfriend Louise Troh reacted in a statement: "I trust a thorough examination will take place regarding all aspects of his care. I am now dealing with the sorrow and anger that his son was not able to see him before he died."

Duncan's body will be wrapped in multiple, leak-proof bags, disinfected, and cremated per CDC protocol.

Public health authorities are tracking possible related cases

The misstep in failing to diagnose Duncan at an early stage might have affected his outcome, but it has also affected the lives of everyone with whom he came into contact.

Officials are following up with 38 people who had some kind of exposure to Duncan or his family. They are also tracking ten people who had close contact with Duncan. These include health workers and emergency responders who cared for Duncan, and Duncan's family members. So far no one has fallen ill.

According to The New York Times, Duncan had probably contracted the virus in Liberia from his landlord's daughter who was sick with Ebola — Duncan had helped bring her to the hospital (and she later died). It's not yet clear whether Duncan knew he had been exposed when he boarded the plane in Monrovia, though the CDC confirmed that his temperature had been checked at the time and he was not running a fever.

The CDC still says it can contain any US outbreak

"It is certainly possible that someone who had contact with [Duncan]... could develop Ebola in the coming weeks," said the CDC's Frieden. Still, he added: "I have no doubt we will stop this in its tracks in the US. I also have no doubt as long as this continues in Africa, we need to be on guard."

That said, the failure to screen and diagnose Duncan initially — and recent news of a nurse contracting Ebola in Spain after treating an infected patient there — seems to have raised public concern about Ebola. The CDC reported that they now receive about 800 calls or e-mails about Ebola each day — compared with just 50 prior to Duncan's case.

The CDC also said it has tested about 15 other individuals in the US for Ebola this year and all have tested negative so far, except for Duncan.

As a precautionary measure, the Department of Homeland Security announced that they would begin screening flight passengers coming in from West Africa for signs of infection, starting with five American airports.

There have been other Americans who have come down with Ebola in Africa and returned to the US for treatment. Most recently, Nebraska Medical Center took in Ashoka Mukpo, a freelance NBC cameraman who got Ebola in Liberia. All have survived so far.

Further reading: What we know about Ebola in the US

WATCH: How the 2014 Ebola outbreak spiraled completely out of control

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The Centers for Disease Control and Prevention confirmed the first-ever case of Ebola diagnosed in America on September 30. On the morning of October 8, he died.

The patient, Thomas Eric Duncan, came from Liberia and had remained in isolation at a hospital in Dallas, Texas for over a week. The CDC is currently tracing all of his contacts in an attempt to isolate the disease.

As of October 7, there have been no other cases of Ebola diagnosed in the United States — although there have been about a dozen false alarms. Here's what we know and don't know about Ebola in the US.

What we know

How this Ebola outbreak became the worst we've ever seen

The first person in the US diagnosed with Ebola

— The patient, Thomas Eric Duncan, left Liberia on a commercial flight on September 19. He was screened for a fever on departure, and didn't have one, which means he wasn't infectious. He flew through Belgium and DC, and arrived in Dallas on September 20.

Days before his trip, Duncan probably contracted the virus from his landlord's daughter, when he helped bring the girl to the hospital. She later died from Ebola.

— Duncan came to the United States to visit his girlfriend and family.

— Around September 24,
he started to feel ill, which means he would have been infectious. His girlfriend brought him to Texas Health Presbyterian Hospital to seek care.

Initial missteps by health officials

He was first diagnosed with a "low grade, common viral infection" and sent home with an antibiotic.

The patient's sister said that Duncan told a nurse that he had come from Liberia. This vital information "was not fully communicated throughout the full team," said Mark C. Lester, executive vice president of the health-care system that includes Texas Health Presbyterian. Ebola was not suspected.

By September 28, Duncan had fallen gravely ill. He was sent to Texas Presbyterian in an ambulance. He was running a high fever and vomiting.

— This time, hospital staff suspected Ebola and
the patient was placed in an isolation unit. On September 30, the CDC confirmed that he has Ebola. He remained in intensive care and isolation, where his condition worsened from serious to critical and he had been "fighting for his life," according to the CDC director Tom Frieden.  Duncan had been on dialysis and a respirator.

— The hospital reported that Duncan had used an experimental treatment brincidofovir, made by the biopharmaceutical company Chimerix, approved on an emergency basis by the Food and Drug Administration.

— He died on October 8. His body will be wrapped in multiple, leak-proof bags, disinfected, and cremated per CDC protocol.

How the CDC is trying to prevent Ebola from spreading

— The CDC says it has identified the people who have come into contact with the patient while he could have been infectious. Officials said 38 potential contacts are now being followed daily to see if they develop symptoms, and about ten definite contacts are being followed.

— These people will be tracked for 21 days, their temperatures checked twice each day.

— The high-risk individuals include health professionals who cared for Duncan, and the girlfriend and family Duncan was staying with in Dallas.

— The four people who shared an apartment with Duncan (his girlfriend and three others) have been under a strict quarantine and moved to a home in the Dallas suburbs, after it took officials four days to start cleaning the potentially Ebola-contaminated apartment in which they were initially quarantined.

— So far no one the CDC is tracking has fallen ill.

— America does not intend to close its borders to visitors from Ebola-stricken West African countries, though the Department of Homeland Security announced that they would begin screening flight passengers coming in from West Africa for signs of infection. For more on Ebola and airport screening, see here.

Ebola hasn't spread in the US

— The CDC has tested about 15 other individuals in the US for Ebola this year and all have tested negative so far, except for Duncan. Since the announcement of the Dallas patient, however, fear and awareness are heightened and the CDC reported that, while they received 50 calls or e-mails prior to Duncan's case, that number has risen to 800 calls or e-mails per day.

— There have been other Americans who have come down with Ebola in Africa and returned to the US for treatment. Most recently, Nebraska Medical Center took in Ashoka Mukpo, a freelance NBC cameraman who got Ebola in Liberia. All have survived so far.

Ebola is a bigger problem in Africa than the United States

— This Ebola outbreak is by far the largest on record, killing more people and spreading to more countries than all previous Ebola outbreaks combined. The virus has made it to Guinea, Sierra Leone, Liberia, Nigeria and Senegal (a separate outbreak has also occurred in the Democratic Republic of the Congo).

— Ebola has killed more than 3,400 people this year and there have been more than 7,400 cases.

— Ebola is a difficult virus to transmit and is only transferred through direct contact with bodily fluids, such as vomit, sweat and blood. It cannot go airborne which makes it usually containable by sophisticated health care systems.

— The Ebola outbreaks are concentrated in low-income countries with incredibly weak health care infrastructures. The United States has a health care infrastructure that would likely prevent the large, Ebola epidemic that has ravaged West Africa.

— There is currently no Ebola cure, although doctors have tried different treatments during this outbreak that have varying levels of research behind them.

How to learn more

— This is what Ebola feels like.

— 16 things you need to know about Ebola.

— The man who discovered Ebola explains why this outbreak spiraled out of control.

— Centers for Disease Control and Prevention director Tom Frieden says the outbreak will get worse before it gets better.

— This explains exactly how you can — and can't — get Ebola.

— Most public health experts think it would be very difficult for an Ebola outbreak to happen in the United States because of our strong health infrastructure.

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Gloria Tumwijuke can't forget the patient who gave her Ebola: she was a young mother, five months pregnant with another child. She arrived at the hospital on a blood-drenched mattress, blood rushing out of her eyes, nose, and ears. Gloria, a midwife, didn't suspect Ebola. She tried to save her patient and instead contracted one of the world's deadliest viruses.

Gloria is among a handful of survivors of a 2012 Ebola outbreak in the Kibaale district of western Uganda. The disease struck 11 people; four died. (Read: 17 things you need to know about the Ebola virus.)

From her home in Kibaale, she told me about what Ebola did to her body, how she beat it, and what it was like return to a community where everyone was afraid of her. Here's a transcript of our conversation, edited for clarity.

Julia Belluz: How did you come into contact with the Ebola virus?

Gloria Tumwijuke: I was seeing a mother who had had a pregnancy for five months, and she came into the hospital bleeding. The mother was bleeding in the mouth, nose, and ears. They carried her into the hospital on a mattress, and the mattress was covered with blood. She couldn't talk. I was getting her history and found out her relatives had passed away, her husband died. All of her children died.

I started cleaning her, putting all the fluids in her, giving her antibiotics. After removing the fetus, she kept severely bleeding. The baby was already dead. I cared for her for six hours but eventually she died. She had Ebola. I ended up getting Ebola.

JB: Were you wearing protective gear — gloves, a gown, a mask — when you cared for this patient?

GT: When she came in, I was putting on gloves. I didn't put on boots. I didn't have a gown. I was trying to remove the placenta from her, and blood gushed on me, on my arms and body. I cleaned myself quickly because I was worried. Then I continued to help her.

I realized I didn't protect myself very well. But the mother entered into the hospital very quickly, and I had to rush quickly to help her. She was going to fall off the bed, and I was trying to support her. I didn't have time to put on my gown. This taught me to protect myself before I do any procedure.

156442393 Ugandan health officials prepare an isolation center at Nyimbwa Health Center in Uganda on November 15, 2012. Photo courtesy of AFP/Getty Images.

JB: At that time, did you suspect this woman might have Ebola?

GT: I didn't even know Ebola was in Uganda. At that time, Ebola had not yet been known in my region.

JB: When did you realize you had the virus?

GT: A week after my patient died, I started vomiting. I started having diarrhea and sweating. I started hearing people talk about the virus in the same hospital in which I was working. I read in the newspapers that they were talking about suspecting the virus was here. But after I saw I had all the signs and symptoms of Ebola, I remembered the pregnant lady, and she had all the signs. That's when I suspected I had the virus.

JB: What happened next?

GT: I was taken to the hospital by ambulance. They took a sample of my blood, and told me I had Ebola. They transferred me to an isolation room, and started to care for me. They put fluids in me through an IV, and gave me antibiotics. They were monitoring me frequently. I couldn't move from the bed. I couldn't talk. I couldn't do anything. I lost 25 pounds. I was in the hospital for one month when they discharged me.

JB: What were you thinking when you got the Ebola diagnosis?

GT: In my head I was like, 'I'm going to die.' I just thought I would die. My sister said, "You're not going to die." I couldn't talk. I was worried about the people who touched me before they knew I had the virus. When they told me they were going to keep on treating me, I was worried about my friends dying. I can't believe I am alive.

JB: Did you give anyone the virus?

GT: No, no one I know got the virus. The laborers who were caring for (the pregnant woman), all of them died.

JB: When did your condition start to improve?

GT: I was discharged from the hospital after one month. After two months, I started to improve. But I still had problems. I was forgetting a lot. My hair was falling out. The hair from my head was all over. My skin was peeling off. I weighed 25 pounds less. I had heart palpitations. The hair took months to grow back. My memory was bad for one year.

JB: How did people receive you when you returned to your community?

GT: They ignored me, thinking I still had a sickness because they think Ebola can't (be survived). They hide from me. People would run away from me. They were not willing to be near me. But the hospital discharged me because they were sure I was free from Ebola. I showed people  (my discharge) certificate. They started to believe I was okay. When I showed them the certificate, they started to welcome me.

JB: When your friends were avoiding you, how did you feel?

GT: I didn't feel bad because it is their right: Ebola spreads when you contact other people who have the virus. But I could feel some stigma when they ran away from me.

JB: This virus can kill up to 90 percent of those who get it. Why do you think you survived when so many others die?

GT: I had my sister who is a medical person. She could go and buy all the drugs, fluids, and antibiotics for me. She was by my side. She changed my dirty sheets. She knew how to prevent herself from getting Ebola by using protection. My husband is a nurse. He was also helping my sister to treat me and be careful. He could pray for me. When I survived he was so happy.

JB: Did you ever feel any guilt being one who lived while so many others don't?

GT: When I hear other people die, in my heart I feel like god really loves me. Because many people died and he left me in the hospital. When I'm hearing of other people dying, I feel bad. I feel like maybe I lived because I had a lot of help. I had IV fluids. My heart tells me maybe if those people could have good nurses who can offer their services, maybe those people really can survive.

JB: Have you experienced any long term side-effects from the virus?

GT: Actually I'm good. I don't have any problems. After four months I was back to normal. The thing that persisted for the whole year, it was forgetting. My memory was bad. Also I couldn't resume my period for five months.

JB: In this current outbreak, a lot of health-care workers have died from Ebola, and now there's fear and people are walking off the job. What advice would you give to other health workers in an outbreak?

GT: When you put on protective gear and you're not in direct contact with the person's (bodily fluids) you can treat them and they get better. People need to understand that because, if we didn't have health-care workers who help us, who didn't run away, what would we do?

JB: How are you feeling when you read the news about this outbreak in West Africa?

GT: I'm praying for those people who are very sick. I'm praying for the health workers too.  I am just praying so they can also survive like me. I'm just imagining they should get enough care, which I needed. Enough care, enough treatment so they can also come up and be a survivor like me.

More: Watch this video about what it's like living in Sierra Leone right now and read our full explainer: 17 things you need to know about the Ebola virus.

Ishmeal Alfred Charles, who lives in Freetown, Sierra Leone, explains how the Ebola epidemic has transformed life in his country.

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A Spanish nurse who had been treating an Ebola victim in Madrid has tested positive for the disease, according to the Spanish health minister.

This is the first case of Ebola contagion outside of West Africa during this epidemic, and it raises questions about whether even the most developed health systems can prevent the spread of disease as so many health officials have promised. 

The nurse contracted Ebola while caring for a repatriated priest at the Madrid hospital Carlos III. The priest, Manuel Garcia Viejo, died on September 25, 2014.

The nurse entered Viejo's room only twice, including once after his death, the New York Times reports.

According to the BBC, the nurse was admitted to a hospital outside of Madrid with a high fever and put in isolation on Monday October 6. The other 30 workers who had been caring for the priest are now being checked daily for symptoms.

Other Ebola patients have been flown to their home countries outside of West Africa for treatment, although until now, those cases haven't yet resulted in secondary spread.

Ashoka Mukpo, a
freelance cameraman who was covering the epidemic with NBC in Liberia, just arrived at Nebraska Medical Center to receive care. Three other American missionaries — Kent Brantly, Nancy Writebol, and Richard Sacra — were all treated in the US after getting the disease in Liberia.

Learn about how the Ebola virus spreads, why the situation in West Africa is worse than anyone knows, and  Ebola in the US.

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There are four hospitals in the United States with special isolation wings to treat highly infectious patients. George Risi runs one of them.

Risi is an infectious disease specialist at St. Patrick's Hospital in Missoula, Montana. In 2007, his hospital became the support facility for the nearby Rocky Mountain Laboratories, a federal lab that does work with certain rare and contagious diseases. If anyone got sick at the Rocky Mountain Labs, they could go to St. Patrick's.

So far, the other three hospitals with these isolation wings are the three facilities that have treated Americans who contracted Ebola abroad: Emory, the University of Nebraska, and the National Institutes of Health. Risi's hospital has not had a patient yet, but his hospital could be a natural choice in the future.

I spoke with Risi on Thursday about how his hospital's isolation unit was built, what makes it different from other hospital facilities, and why he thinks any American hospital could handle an Ebola patient.

Sarah Kliff: Tell me a little bit about when your isolation unit was built and what that entailed.

George Risi: Our hospital is the support hospital for the Rocky Mountain Labs, which deals with high hazard, infectious diseases and its part of the National Institute of Allergies and Infectious Diseases campus out here.

When we were asked to be the support facility, we looked at the other models like the stand alone unit at Emory. The problem with that model is that its expensive to maintain a unit that's stand alone unit if it won't be used regularly.

isolation unit

One of Emory University's isolation units (Emory University)

For those kinds of reasons, we went ahead and retrofitted rooms in our intensive care unit to provide that kind of support. That allows us to have full access to the pharmacy and  also see other patients in those rooms. We use these rooms all the time as regular ICU rooms.

SK: What makes these rooms different from typical ICU rooms? What makes them isolation units?

GR: The difference is there is special air handling. Each of those three rooms has negative pressure: the air is drawn in from the hallway and then goes out through a series of high efficiency particulate air [HEPA] filters. The HEPA filters connect to duct work that goes up to the top of the roof of the hospital and is discharged 8 feet above the roof.

Nothing gets through two sets of HEPA filters but, if it did, anything would be dispersed and all of these viruses are killed by ultraviolet light.

We put in anterooms, which are the entrance rooms with two sets of doors. Also all the surfaces are smooth and readily cleanable without a lot of cracks and crevices where blood and bodily fluids could stay. But a lot of this has really become standard. Most hospitals have some rooms with anterooms. The Dallas hospital, I'm sure has something quite similar.

SK: What kind of protective gear do you keep on hand for people who might have to work with a highly contagious disease at some point?

GR: The gear depends on the stage of illness and which disease. For someone with tuberculosis, we would use N95 masks [which filter out air particles]. Those are the ones that are appropriate for isolation of an airborne isolation. We'd also be gowning and gloving depending on the nature of the disease.

SK: I'm curious about the larger suits that we saw Emory doctors wear when they escorted Kent Brantley out of an ambulance. Is that something that your hospital, or others, keep on hand?

GR: We certainly have a supply of them on hand and would probably put in a big order to get more if someone were admitted with a highly contagious disease. Right now, we have enough to manage somebody for several days.

SK: Has your hospital done any work to prepare for the possibility of treating an Ebola patient?

brantley

Dr. Kent Brantley leaves Emory University after being cured of Ebola (Jessica McGowan / Getty News Images)

Ever since the Rocky Mountain Labs has had us as their support hospital, we've had a training program. Every six months or so we have a workshop and also do periodic drilling.

Its true that these are exotic diseases but, in a way, they're not that exotic at all. If you trust your protective gear and if you use it appropriately, the risk of getting infected is minimal and that's no different from other diseases. The key is not to become excited or overwhelmed if you're asked to care for a patient like this.

SK: One challenge some hospitals have talked about is what to do with the waste from Ebola patients and how to dispose of that. Does your hospital have a plan?

GR: We're in the process of re-evaluating that. We have an autoclave on site, which is what you use to sterilize surgical items but from what we've heard from Emory about the volume, we may need to get more. That's something we're working through right now.

SK: Are there are things you've learned from hospitals like Emory that have seen Ebola patients that are helping you prepare right now?

GR: I think we've learned a lot about the importance of keeping moral up and the importance of emphasizing the ways that the disease can and can't be spread. A lot of this is leading from the front, such that the physicians who need to be involved will be willing and able to see an Ebola patient if that happens. That was part of the reason of my going to Sierra Leone with Kate Hurley, who is the head nurse of the isolation unit. We wanted to get over the fear factor.

This is something we've been talking about for years, how you handle this kind of patient, so its not new to us. The possibility is a little more real with the patient now in Dallas.

SK:  What's different about treating Ebola in Sierra Leone, compared to the type of facility you work in in Montana?

GR: It's a very different situation over there in a country that is trying to emerge from decades of civil war, poverty and a stressed health care system.

There are limits in terms of the medical support and the sheer numbers. At our hospital, the average daily census was 90 patients. This is equatorial Africa, so you could spend maybe three and a half hours in one of the protective suits before you had to come out and rehydrate.

We were very limited in what we could do. We didn't have access to blood products, or investigational drugs. It was really just IV hydration, that was kind of all we could provide. Despite that, we did save more people than we lost. Our mortality rate was 40 to 45 percent, which means 55 to 60 percent of our people survived and are immune. Some of them actually helped us manage our patients after they survived and became immune. They were able to help clean up and bring food, things like that.

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Understanding local beliefs and customs is an essential part of any disaster relief effort, and anthropologists have been dispatched to West Africa to study the interplay between the disease and human culture in the Ebola epidemic.

Vox spoke to Almudena Mari Saez, an anthropologist and researcher with Charité-Berlin who has been working in Guinea, following hunters to figure out how the virus works its way into humans from animals. She arrived in Gueckedou — a remote, rain forest region on the border with Sierra Leone and Liberia, where the outbreak started — three weeks after an international epidemic was declared in March.

Here's what she had to say about how Guinean customs and fears perpetuated Ebola and how the social fabric in the country has been torn apart by the virus.

Julia Belluz: In the news here, we've been hearing that eating "bush meat" is very dangerous for people and potentially the cause of this epidemic. Can you tell me what you found?

Almudena Mari Saez: While I was there, I was talking with the hunters and the family of the hunters to know which animals they are killing, who is killing them, how they are killing, then who is involved in the cooking process or in the selling process. To find out, I was interviewing people and following them.

Most of the time, people go hunting once a month or twice a month, depending on the size of the animal. Bush meat can be anything: small rodents, bats, monkeys. They smoke the animals over fire, and then cook them in soup.

So the problem is not eating the bush meat. The virus will die, it can't survive [during cooking]. The problem is handling the animal, because Ebola is transmitted by the bodily fluid of the animal. So the problem is the person who touches the blood, or if the animal is still alive and the animal pees in your hands, and you touch your eyes and touch your mouth. This is the way the virus can come into your body.

JB: One disquieting feature of this epidemic is that so many health workers have been harassed or even killed while caring for the sick or trying to spread public-health messages about Ebola. What's going on?

AMS: People need to empathize with this population. Someone in a village said this to me: "Imagine you are in your house and then 10 foreigners come into your village and then start saying to you, 'There is a new virus, there is a new disease. The disease has these symptoms. To be protected you need to not touch the person who is sick.' What should you do?"

At this moment, people are afraid. There were rumors that Ebola was being spread by westerners. There were moments that were very difficult. You're in the village and one car arrives with a death, and the village starts moving, with all the conspiracy theories and rumors. You are trying to explain something crucial and then there is all this mistrust, and you can do nothing.

JB: As an anthropologist, your work depends on you being able to build trust with people. How did you do that in this environment?

AMS: In these circumstances, you don't have the time. You can't touch anyone. Because you are at risk, because you don't know if they have cases of Ebola in the village. Sometimes the only thing you can use as a tool to make people confident with you is use your eyes, your voice, the way you to talk.

JB: It's very sad that Ebola can rip apart the social fabric of communities, that people can't touch each other or even express their affection for sick and dying family members. What were people saying about that?

AMS: In Guinea people were telling me that when someone dies they want to express the love they had for that person. When someone dies, they will touch the person, cry, hug the dead body to express how much they love this person. Then they clean and dress the body with new clothes. Then they bury the body. And then there are special rituals.

But now burials are one of the principal modes of transmission of Ebola. So the social relationships are broken. You are afraid of everyone because you are not sure who has been infected. There is an atmosphere of mistrust, and you don't know from where this disease is coming. You don't trust the NGOs, the health workers. There is a big mistrust in  human relationships.

This transcript has been edited for length and clarity.

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A freelance cameraman working with NBC in Liberia has tested positive for Ebola, according to the news network. He will be flown back to the US to be treated at Nebraska Medical Center, where American Ebola survivor Rick Sacra got care.

On assignment in Monrovia with NBC News chief medical editor and correspondent Dr. Nancy Snyderman, the 33-year-old — identified as Ashoka Mukpo — had been hired to report on the outbreak on Tuesday. He had been working in Liberia for three years, and had been covering the epidemic for other news agencies.


On Wednesday, Ashoka started to feel sick, checked his temperature, and found he was running a mild fever. He reportedly quarantined himself at that point. The next morning, he went to a Médecins Sans Frontières (MSF) treatment center to be tested for the virus and found out 12 hours later that he had been infected, NBC reported.

"Obviously he is scared and worried," Ashoka's father Dr. Mitchell Levy told told the Today show. His son has been "seeing the death and tragedy and now it's really hit home for him. But his spirits are better today."

The crew who had been working with the patient, including Snyderman, are not showing any symptoms of illness but they will be flown back to the US and have voluntarily placed themselves in quarantine as a precautionary measure. 


He is the first American journalist to be diagnosed with Ebola in this epidemic. The three other Americans — Kent Brantly, Nancy Writebol, and Richard Sacra — who have come down with the illness were missionaries and health professionals working in Liberia. They were all treated in the US and survived. Brantly and Writebol were treated at Emory Hospital. Sacra was also treated in Nebraska. Patrick Sawyer, a Liberian-American who got Ebola in Liberia where he worked at the Ministry of Finance, died in Lagos, Nigeria in July. 

Here's a letter to staff from NBC News President Deborah Turness:

As you know, Dr. Nancy Snyderman and our news team are in Liberia covering the Ebola outbreak. One of the members of their crew is an American freelance cameraman who has worked in Liberia for the past three years and has recently been covering the epidemic for US media outlets. On Tuesday he began working with our team. Today, he tested positive for Ebola.

We are doing everything we can to get him the best care possible. He will be flown back to the United States for treatment at a medical center that is equipped to handle Ebola patients. We are consulting with the CDC, Medicins Sans Frontieres and others. And we are working with Dr. Nancy on the ground in Liberia.

We are also taking all possible measures to protect our employees and the general public. The rest of the crew, including Dr. Nancy, are being closely monitored and show no symptoms or warning signs. However, in an abundance of caution, we will fly them back on a private charter flight and then they will place themselves under quarantine in the United States for 21 days - which is at the most conservative end of the spectrum of medical guidance.

We know you share our concern for our colleagues and we will continue to keep you up to date and informed. Please don't hesitate to reach out to me or David Verdi with any questions.

Deborah

This is the worst Ebola epidemic in history. More than 3,000 people have died and there are more than 7,000 cases of Ebola. The countries most affected by the disease right now include Sierra Leone, Liberia, and Guinea in West Africa.

To learn more about how the Ebola virus spreads, read our story on how you can — and can't — catch the disease.

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Ebola is not currently an airborne disease. You can't catch Ebola by sitting across the room from someone who has it. You can only catch Ebola from coming into direct contact with the bodily fluids of someone who has the disease and is showing symptoms.

(One caveat: If someone with Ebola symptoms sneezes or coughs and the saliva or mucus hits your eyes, nose, or mouth, that can transmit the disease, but this is rare, and it's mainly a concern for health workers. It's also not what people mean by "airborne.")

Back in September, however, an op-ed by Michael Osterholm in The New York Times raised a disturbing possibility — what if the Ebola epidemic in West Africa goes on long enough and the virus keeps mutating? Could Ebola somehow become airborne then? And wouldn't that allow the disease to spread even faster around the world? More recently, Dr. Oz raised the specter of airborne Ebola on The Today Show.

This is a scary scenario. But fortunately for the world, most infectious disease experts remain very skeptical that Ebola will ever become airborne. "This is way down on the list of possible futures for Ebola and in all probability will never happen," explained Ian Jones, a virologist with the University of Reading, back in September.

'We've never seen a human virus change the way it is transmitted'

But why are experts so confident Ebola won't become airborne? It's worth reading this long post by Vincent Racaniello, a virologist at the College of Physicians and Surgeons at Columbia University.

He goes into detail about how viruses mutate, but here's his bottom line: "We have been studying viruses for over 100 years, and we've never seen a human virus change the way it is transmitted":

When it comes to viruses, it is always difficult to predict what they can or cannot do. It is instructive, however, to see what viruses have done in the past, and use that information to guide our thinking. Therefore we can ask: has any human virus ever changed its mode of transmission?

The answer is no. We have been studying viruses for over 100 years, and we've never seen a human virus change the way it is transmitted.

HIV-1 has infected millions of humans since the early 1900s. It is still transmitted among humans by introduction of the virus into the body by sex, contaminated needles, or during childbirth.

Hepatitis C virus has infected millions of humans since its discovery in the 1980s. It is still transmitted among humans by introduction of the virus into the body by contaminated needles, blood, and during birth.

There is no reason to believe that Ebola virus is any different from any of the viruses that infect humans and have not changed the way that they are spread.

I am fully aware that we can never rule out what a virus might or might not do. But the likelihood that Ebola virus will go airborne is so remote that we should not use it to frighten people. We need to focus on stopping the epidemic, which in itself is a huge job.

This jibes with what Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, told the Senate in mid-September: "Very, very rarely does [a virus] completely change the way it's transmitted."

Fauci noted that viruses do mutate a lot, in ways that might make the disease more virulent or a little bit more efficient at spreading. That's why researchers are currently trying to monitor the mutations. But with all the dire things to worry about with Ebola, he said, the prospect of the disease going airborne is not "something I would put at the very top of the radar screen."

Further reading: For more on the science of Ebola transmission, check out this previous post by Susannah Locke. She notes that, yes, some pigs infected with Ebola may be able to transmit the disease by coughing and sneezing large droplets. But there's a huge caveat here: Ebola affects pigs in a completely different manner than it does humans (in pigs, Ebola shows up as an infection of the lungs; in humans, it mainly targets the liver).

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A hospital in Dallas that diagnosed America's first-ever known Ebola case also failed to recognize the patient's Ebola potential when he first sought care, missing an opportunity to isolate him when he was already contagious.

The patient, Thomas Eric Duncan, had been visiting the US from Liberia. He left Monrovia on September 19 and traveled through Brussels and Washington, DC, arriving in Dallas on September 20. He had no symptoms when he was departing Liberia or entering the US, which means he wouldn't have been infectious at the time.

getty

Texas Health Presbyterian. (Photo courtesy of Mike Stone/Getty Images News)

Four days later he started to feel ill, which means he would have been infectious. Two days after that, he sought care at Texas Health Presbyterian Hospital. He was diagnosed with a "low grade, common viral infection" and sent home with an antibiotic.

The patient's sister said that Duncan told a nurse that he had come from Liberia. This vital information
"was not fully communicated throughout the full team," said Mark C. Lester, executive vice president of the health-care system that includes Texas Health Presbyterian. "As a result, the full import of that information wasn't factored into the clinical decision-making." Ebola was not suspected.

ebola

CDC guidance not followed

If this is correct, the hospital did not follow CDC guidance. In advance of Ebola reaching America, the CDC put out guidance for health workers, including this recommendation: "Treat all symptomatic travelers returning from affected West African countries as potential cases and obtain additional history."

A thorough medical history can help health professionals diagnose between 70 and 90 percent of illnesses.

By September 28, Duncan — who is in his mid-40s, according to
the New York Times, and recently quit his job in Monrovia as a driver for a shipping company — had fallen gravely ill. He was sent to Texas Presbyterian in an ambulance. At that point, he was running a high fever and vomiting. This time, hospital staff suspected Ebola and placed Duncan in an isolation unit. On September 30, the CDC confirmed that he has Ebola.

Duncan remains in intensive care and isolation at the hospital, where he is in serious condition.

Public health authorities following potential cases

The misstep in failing to diagnose Duncan at an early stage has affected the lives of everyone with whom he came into close contact. Up to 18 people are reportedly at risk, though NBC reports that a total of 80 people had some kind of exposure to Duncan or his family.

The close at-risk contacts include five school children who attend four schools. The children have been advised to stay home from school.

The three members of the ambulance crew that transported Duncan to the hospital have tested negative for Ebola, Reuters reported, and are being monitored and restricted to their homes. Duncan's family members are being monitored, too, and have been ordered to stay home. So far no one has fallen ill.

The CDC director Tom Frieden said he is not concerned about the people who shared Duncan's flights, United Airlines flight 951 to Washington Dulles and flight 822 to Dallas/Fort Worth, since Duncan was not symptomatic then and shedding the virus. "There is zero risk of transmission on the flight," said Frieden.

According to the New York Times, Duncan probably contracted the virus from his landlord's daughter who was sick with Ebola. On September 15, he helped bring the woman to the hospital. She was turned away, like many Liberians, because of a lack of capacity to care for her. She later died in her home.

We've had hemorrhagic fevers in the US that didn't spread


"It is certainly possible that someone who had contact with [Duncan]... could develop Ebola in the coming weeks," Frieden said. Still, he added: "I have no doubt we will stop this in its tracks in the US. I also have no doubt as long as this continues in Africa, we need to be on guard."

He has reason to be confident. While the Texas patient is the first-ever diagnosed with Ebola in America, several travelers have brought similarly deadly viruses to the US in the past and didn't give them to anyone.

There have been four cases of Lassa hemorrhagic fever, a viral infection common in West Africa, here. This isn't surprising since Lassa infects up to 300,000 people in Africa each year, which makes it a lot more common than Ebola. Like Ebola, Lassa isn't easily spread — only through contact body fluids — so, reassuringly, there were no secondary cases here.

We've also had one case of Marburg, another hemorrhagic fever, imported to the US in a traveler from Uganda. Again, the patient didn't transmit the virus to anyone else.

To learn more about Ebola, read the Vox cardstack. To learn more about how you can — and can't get the virus — see here.

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1. Ebola was first discovered in 1976 in Zaire (now known as the Democratic Republic of Congo).

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An electron micrograph containing the Ebola virus taken in 1976.

2. Between 1976 and 2013, 20 Ebola outbreaks killed a total of 1,548 people.

Previous Ebola outbreak

Previous Ebola Outbreaks by relative size. Joe Posner / Vox.

3. Four strains of Ebola can infect humans. The Zaire strain is the most deadly, and is the disease spreading in this outbreak.

Deadliness of Ebola Strains

The current outbreak is the Zaire ebolavirus. Joss Fong / Vox.

4. Ebola patients have to be kept in isolation wards. One problem is that West Africa lacks enough of them.

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Ibrahim Fambulle, barely able to stand, tries to walk to a different isolation room in an Ebola ward on August 15, 2014 in Monrovia, Liberia. Photo by John Moore/Getty Images.

5. This is the worst Ebola outbreak ever.

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Ebola deaths by outbreak. Joss Fong/Vox.

6. It's spread to seven countries and killed 3,091 people - nearly twice as many as all other outbreaks combined.

Ebola deaths, 2014 outbreak

7. Ebola has killed more than 200 health care workers in Africa.

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A Sierra Leonese burial team carries the coffin of Dr Modupeh Cole, Sierra Leone's second senior physician to die of Ebola. Carl De Souza/AFP/Getty Images.

8. Ebola is also spreading through unsafe burial practices in Africa.

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The Tweh farm cemetery in Liberia, where burials have ben halted, September 30, 2014. Pascal Guyot / Getty Images.

9. The only way to catch Ebola is to have direct contact with the bodily fluids of someone who has Ebola and has begun showing symptoms.

Ebola flowchart

10. Modern public health systems can stop Ebola. West Africa's poverty and underfunded health care system allowed it to spread.

Health workforce

11. The CDC projects as many as 1.4 million people could be infected with Ebola by January if the outbreak isn't stopped.

CDC ebola projection

12. But Nigeria and Senegal stopped their Ebola outbreaks cold.

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Medics carry a Nigerian patient during his transfer to another hospital in Istanbul, Turkey on September 25, 2014. Metin Pala/Anadolu Agency/Getty Images.

13. A Texas hospital diagnosed the first-ever American case of Ebola on September 30.

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14. The United States has a robust health infrastructure that will near-certainly prevent the disease's spread.

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15. There is no cure, treatment or vaccine for Ebola.

Ebola vaccine testing

A possible Ebola vaccine called Chimp Adenovirus type 3 being tested in London. Steve Parsons-WPA Pool/Getty Images.

Calm down. You don't have Ebola.

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On Tuesday, the Centers for Disease Control and Prevention (CDC) announced the first case of Ebola diagnosed in the United States. The patient is currently being isolated in a hospital in Dallas, Texas.

The current Ebola outbreak has already infected thousands of people in West Africa — including several Americans who were diagnosed there and then brought back to the United States for treatment. But this is the first time a person has been diagnosed with the disease inside US borders.

According to the CDC, the patient had recently been in Liberia and flew to the US before he was symptomatic or contagious. He later fell ill, visited a hospital, and was sent home because they did not suspect Ebola. At a later date, the hospital admitted him and placed him in isolation.

It's not surprising that an Ebola case has finally popped up in the United States — especially with air travel as common as it is. But it's also not a disaster. Experts say that public-health officials would likely be able to contain any Ebola outbreak in the United States pretty quickly.

Why is that? One big reason is that Ebola is not especially contagious, as diseases go. You can only get Ebola by coming in direct contact with the bodily fluids of someone who is already showing symptoms. That makes it relatively slow to spread (unlike, say, the measles).

More importantly, the United States has ample health resources and infection-control measures to contain outbreaks. This is in stark contrast to West Africa, where poverty and weak health care systems have allowed Ebola to spread and claim the lives of more than 3,000 people.

"Ebola can be scary. But there's all the difference in the world between the US and parts of Africa where Ebola is spreading," CDC director Tom Frieden said in a statement on Tuesday. "The United States has a strong health care system and public health professionals who will make sure this case does not threaten our communities."

Here's a rundown of how public-health officials would respond to any Ebola outbreak inside the United States:

1) The first 24 hours (ideally): Identify the outbreak

As the Texas case showed, Ebola is most likely to arrive in the United States via an infected person flying from West Africa who doesn't even realize he or she is carrying the disease. Ebola can incubate in a person's body anywhere from two days to three weeks before symptoms emerge. During this time, the patient isn't contagious.

Eventually, the patient will start showing symptoms — which will probably look like the flu or traveler's diarrhea at first. (Some of the more famous symptoms of Ebola, like bleeding from orifices, don't tend to come on until later, and only appear in about half of cases anyway.)

Now, even when the patient does start showing symptoms, the disease is fairly difficult to transmit. Ebola doesn't spread through the air, and it's harder to catch than things like the flu. You can't get it just from being on the same plane or in the same public space. The only way to get Ebola is to touch a patient's bodily fluids, like vomit, diarrhea, sweat, saliva, or blood.

Still, at this point, it's important to identify the disease as Ebola quickly — and public awareness can play a big role here. Any patient traveling from West Africa who develops flulike symptoms is a prime suspect. If health workers realize that this might be Ebola early on, other people should be able to avoid getting infected by keeping away from the patient's bodily fluids.

Unfortunately, in the case of the Texas patient, this didn't work perfectly. He ended up spending four days contagious and possibly putting other people at risk before health care workers suspected that he might have Ebola and placed him in isolation at a hospital.

The patient first started feeling ill on September 24 and went to the hospital two days later. There, the CDC says health care workers didn't ask about his travel history (he'd arrived in the US from Liberia a few days earlier) and therefore didn't suspect that he had Ebola. (Update: The AP reports that the patient's sister disagrees and says that hospital officials knew that he had been in Liberia.) They sent him home, which put other people in the community at risk. It wasn't until September 28 that he was admitted to the hospital when he became even sicker. Then people realized that he might have Ebola and placed him under isolation.

In West Africa, the problem of identifying patients early has been far more widespread. Ebola managed to spread for three months around Guinea, Liberia, and Sierra Leone before officials actually identified it as Ebola — which is partly why the disease was able to affect so many people.

2) The next step: Isolate the patient

In US hospitals, any suspected case of Ebola should be treated as a potential risk until tests come back negative. The CDC has said that the patient in Texas, who has by now tested positive, is in "strict isolation" — which is exactly what needs to happen.

Standard procedures to protect other patients and health-care workers from the patient's bodily fluids will then be put into place. Because Ebola doesn't hang out in the air, hospital workers won't necessarily have to wear respirators or what you might think of as full Outbreak gear. However, they will protect their body and face from any bodily fluids that might splash on them, using things like gowns or full body suits, masks, gloves, and goggles.

Anything that touches the patient will have to be sterilized or disposed of in a safe manner. And if the patient dies, the body will have to be carefully handled so that it doesn't transmit fluids. (The death rate for the current outbreak has been roughly 50 percent, although good health care in the US might be able to boost those odds.)

Unfortunately, West Africa lacks many of these protections — which is one reason why the disease has spread so widely there. Many health-care workers in Guinea, Liberia, and Sierra Leone don't even have the necessary goggles, gowns, and gloves to deal with Ebola patients. What's more, health-care workers are often in short supply in those countries.

A Liberian health worker interviews family members of a woman suspected of dying of the Ebola virus in Monrovia, Liberia. (John Moore/Getty Images)

3) Then, track down other potential patients

Detective work is the next crucial part of controlling a disease like Ebola. Health workers will interview the patient, the patient's relatives, and other potential close contacts to monitor them and make sure that they don't spread the disease to others if they have it. Officials will then suggest various options for these people, depending on the level of risk, including watching and waiting, isolation at home, and testing for infection.

In the United States, that's perfectly doable. The CDC says that everyone who came in contact with the Texas patient while he was infectious has been identified, including family members and "two to three community members." The ambulance workers who brought the patient to the hospital have tested negative for Ebola and will be quarantined and monitored, according to Reuters.

But the situation is wildly different in West Africa, where tracking down contacts has been especially problematic. As an editorial in The Lancet put it, "The geographical spread of cases and movement of people in and between the three countries presents a huge challenge in tracing those who might be infected." And the World Health Organization has said that "low coverage of contact tracing" has been a huge problem in Liberia's attempts to contain Ebola.

4) Keep patients in the hospital until they're no longer a threat

It's important to remember that roughly 50 percent of the patients in the current West Africa Ebola outbreak have survived. There's no specific pill or shot that will make an Ebola infection go away, but doctors can try to make the patient comfortable, give IV fluids, and treat symptoms. (There are also some experimental treatments, but their efficacy is still unknown.)

But even if a patient seems to be healing, health authorities typically won't release him or her from the hospital until it's clear that the person has cleared the virus from the body, has tested negative, and won't be a danger to others. Those precautions are necessary to prevent the disease from spreading.

This might seem intuitive, but it hasn't always happened in West Africa. For example, the BBC has reported that patients sometimes go missing from hospitals in Sierra Leone — a country where many people don't trust that medical care will help them. That increases the odds that the outbreak will spread.

A best-case and worst-case scenario for Ebola in the US

The best-case scenario for the United States is that a patient traveling from West Africa realizes that they might possibly have Ebola as soon as they start feeling sick. Everyone else makes sure not to come in contact with this person's bodily fluids. And the outbreak ends with just one patient.

The worst-case scenario, meanwhile, is that an Ebola patient comes to America, is ill for days, and comes in contact with a lot of people before anyone realizes that something unusual is going on. That could be much worse, although it's not a guarantee that Ebola will get transmitted to other people. Already, the ambulance workers who brought the Texas Ebola patient to the hospital have tested negative for the disease. And family and community members are being monitored.

Even if Ebola spreads from the initial patient to others, it's much less likely here that the virus will get spread farther than one city or town than it is in West Africa. "I don't think we’ll have a serious public health threat in any of the developed countries," Osterholm told me in July. The real problems are for countries like Guinea, Liberia, and Sierra Leone that don't have the resources to contain the outbreak quickly.

For more on the basics of the Ebola outbreak, check out 14 things you need to know about Ebola.

Updated on October 1: Updated in response to new information about the Texas Ebola patient originally being sent home from the hospital because Ebola was not initially suspected. Updated again in the afternoon with news from the AP that the patient's sister says that the hospital did know that the Texas patient had been in Liberia on his first visit.

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Last spring, most people would have guessed that this Ebola outbreak in West Africa would be over by the end of summer. Yet, nine months on, we're in the midst of the deadliest outbreak in history, and one that has defied the odds: it has lasted longer, killed more, and spread further than any previous outbreak. For the first time ever, an Ebola case has been diagnosed outside of Africa in the US. Right now, many are worried about where Ebola will turn up next.

Where the outbreak is occurring now

To understand where Ebola will spread, we need to look at where Ebola is occurring now. In December, the virus is believed to have first showed up in a two-year-old boy in a village in Guéckédou, southeastern Guinea. That geography was unfortunate: Guéckédou happens to share a very porous border with Sierra Leone and Liberia, where people travel in and out every day to go to the market or conduct business.

By the time the Ebola outbreak was identified in March, it had already spread to all three countries along the border.
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And it continues to spread further: In July, a Liberian-American got on a plane bound for Nigeria, bringing the virus with him and spurring 20 cases and eight deaths in Africa's most populous country. Soon, another case turned up in Senegal.

On September 30, the first-ever case was diagnosed in Dallas, Texas. There is also an unrelated outbreak of Ebola in the Democratic Republic of the Congo involving a different type of the virus right now. That's seven countries hit with Ebola in one year.

The situations in Senegal and Nigeria have since stabilized, but the outbreak continues to rage on in West Africa. So the burden of the disease is still in Sierra Leone, Guinea and Liberia right now.

eboladeath
Where Ebola will go next


There have been suspected Ebola cases in Europe and Asia but none were confirmed. The only Ebola-positive patient to show up outside of Africa so far has been the Texas case.

As the death toll continues to rise in Africa, public health officials are increasingly worried about the virus spreading further. But the main concern remains spread within Africa, where outbreaks persist because there's poor sanitation and a shortage of resources to contain them.

"Our first concern is that this is going to go into adjacent areas through people traveling in the region," said Daniel Bausch, associate professor at the Tulane University School of Public Health and Tropical Medicine, who is working with the WHO and MSF on the outbreak. "In the short term, the main vector is the traveler: local people traveling from one village to the next, on more regional scale, plane travelers."

This pie chart shows the final destinations of travelers originating in the three countries currently most affected by Ebola. As you can see, travel from Sierra Leone, Guinea and Liberia within the continent is much more prevalent than travel elsewhere.

Jpg_final_destinations_of_airline_travelers_departing_from_guinea__liberia__and_sierra_leone_by_who_region_during_the_month_of_august_nologo

Chart courtesy of Bio.Diaspora

All countries in West Africa are already on alert. National authorities in Ghana, Nigeria, Togo and the Côte d'Ivoire have been working with the WHO on prevention efforts and monitoring potential cases.

To do this, contact tracing is essential, said Bausch. "With Ebola outbreaks, most of the time there's one or very few introductions of the virus from the wild into humans, and all the transmission after that is human-to-human transmission. So people who are traveling locally as well as on planes and other modes of transport, that's the way this would get around."

These efforts helped Nigeria stop the disease from turning into a full-scale outbreak, and they're being used by the CDC to make sure the Texas case is contained. As the New York Times reports:

After the first patient — a dying Liberian-American — flew into Lagos on July 20, Ebola spread to 20 other people there and in a smaller city, Port Harcourt.

They have all now died or recovered, and the cure rate — 60 percent — was unusually high for an African outbreak.

Meanwhile, local health workers paid 18,500 face-to-face visits to repeatedly take the temperatures of nearly 900 people who had contact with them. The last confirmed case was detected Aug. 31, and virtually all contacts have passed the 21-day incubation period without falling ill.

The worst-case scenario

Even if the outbreak didn't move across any other country border, intensification within the already affected areas is the most immediate health threat.

"The worst-case scenario is that the disease will continue to bubble on, like a persistent bushfire, never quite doused out," said Derek Gatherer, a Lancaster University bioinformatician who has studied the evolution of this Ebola outbreak. "It may start to approach endemic status in some of the worst affected regions. This would have very debilitating effects on the economies of the affected countries and West Africa in general."

There are several predictions for potential cases being floating around. The World Health Organization projects that 20,000 people will be infected in November. HeathMap put the number at about 14,000 if there's no improvement in the situation.

But there are fears that the supplies and health-care workers needed to bend the curve downward and save lives won't reach Africa quickly enough. Doctors need to be trained. Hospitals need to be built. Many suspect that there has been widespread under-reporting of actual Ebola cases, since people have been turned away from overflowing hospitals and others have been hiding in their homes, afraid that coming out with Ebola will mean they never see their families again or that they are ostracized by their neighbors.

Assuming the worst is true, the CDC has a much bigger projection for this epidemic: up to
1.4 million people infected by January.

ebola
This dire situation could come about because of a "persistent failure of current efforts," Gatherer added. "Previous successful eradication of Ebola outbreaks have been via swamping the areas with medical staff and essentially cutting the transmission chains. Doing that here is going to be very difficult and expensive. We have little option other than to pump in resources and engage with the problem using the tried-and-tested strategy — but on a scale previously unused."

Ebola doesn't spread quickly, and it hasn't mutated to become more transmissible over the years. "The good news is that Ebola has a lower reproductive rate than measles in the pre-vaccination days or the Spanish flu," wrote a mathematical epidemiologist who studies Ebola in the Washington Post. He found that each Ebola case produces between 1.3 and 1.8 secondary cases. Compare that with measles, which creates 17 secondary cases. Since about two weeks pass between the first Ebola case and secondary cases, it allows time for people to protect themselves.

But again, in areas where resources are already extremely constrained, it's difficult to mount the measures necessary to stop secondary spread. And that's the case in the countries affected right now. As Dr. Bausch said, "If you're in a hospital in Sierra Leone or Guinea, it might not be unusual to say, 'I need gloves to examine this patient,' and have someone tell you, 'We don't have gloves in the hospital today,' or 'We're out of clean needles,' — all the sorts of things you need to protect against Ebola."

In these situations, local health-care workers — the ones most impacted by the disease — start to get scared and walk off the job. And the situation worsens.

When Bausch was in Sierra Leone this summer, he said all the nurses went on strike in one of the hospitals where he was working. "There were 55 people in the Ebola ward," he said, "and myself and one other doctor."

He'd walk into the hospital in the morning and find patients on the floor in pools of vomit, blood, and stool. They had fallen out of their beds during the night, and they were delirious. "What should happen is that a nursing staff or sanitation officer would come and decontaminate the area," he said. "But when you don't have that support, obviously it gets more dangerous." Without strong local health systems in place, diseases like Ebola spread: mostly within Africa, sadly, and then sometimes further.

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The current Ebola outbreak in West Africa (and the US) is the worst on record, infecting about 6,500 people and killing more than 3,000 as if September 30. The World Health Organization predicts that it will take six to nine months to halt the outbreak for good — and, in the meantime, the number of total infections could reach as high as 20,000.

What's more, the longer the outbreak goes on, the greater the chance of it spreading.

Some readers have been asking what they can do to help. For those interested, the US Agency for International Development has put together a list of 37 non-governmental organizations that are working on the Ebola crisis, with direct links for how to donate to them online (or via snail mail).

The agency is encouraging Americans to donate, according to a recently released statement:

The U.S. Agency for International Development’s Center for International Disaster Information (USAID CIDI) encourages Americans to support relief efforts appropriately and responsibly. Those who wish to help are encouraged to do so by giving monetary donations to trusted and experienced relief organizations, and to refrain from sending material donations such as bottled water, clothing and canned goods, unless they are specifically requested by a responding organization. Monetary donations to relief organizations working directly with disaster-affected people are the most effective way to help.

Some organizations on the list are more obvious players in a health crisis, like Doctors Without Borders and the Red Cross.

What's more, because this crisis is affecting some of the poorest countries on Earth (which have also been recently affected by Ebola-related quarantines and air-flight cancelations), food access is also expected to play a major role. That's why organizations like the World Food Program are on the list, too.

Further reading: This piece by Julia Belluz offers some tips on the best ways to donate money — resources like Charity WatchGiveWell, and Charity Navigator can help assess effectiveness of different non-profits.

Update: Edited the piece to reflect the case revealed in the US on September 30 as well as more recent numbers for total case counts and deaths.

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The United States is the seventh country with a Ebola patient diagnosed this year, and the only country outside of Africa with a confirmed case.

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Ebola has spread quickly since it first turned up in December in rural Guinea. Guinea shares a border with Sierra Leone and Liberia, where the disease next spread. In July, the first case reached Nigeria and, soon after, a the disease was diagnosed in Senegal.

On September 30, the first-ever case was diagnosed in the United States.

There is also an unrelated outbreak of Ebola in the Democratic Republic of the Congo involving a different type of the virus right now.

To learn more, see Vox's 14 facts you should know about the Ebola outbreak.

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The 2014 Ebola outbreak in West Africa has killed more people than sum total of all the previous outbreaks since the virus was first identified in 1976. Today, the first-ever case in the United States was diagnosed. Vox health reporter Julia Belluz explains in two minutes how the outbreak spiraled completely out of control.

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Further reading: See Vox's 14 facts you should know about the Ebola outbreak, and here is list of aid groups working on the Ebola crisis and how to donate.

You can watch the CDC's press conference announcing the first Ebola diagnosis in the United States here. It is scheduled to start at 5:30 p.m.

Related: 14 things you need to know about Ebola.

Before this year, Ebola was a disease relegated to remote villages in Africa. Even public health officials didn't worry about it spreading very far. Until recently, they would probably tell you that the virus typically burned out after ravaging only a handful of people.

But then came 2014.

This year has, in many ways, rewritten the Ebola rulebook. We're in the middle of an unprecedented, nightmarish epidemic that has spread from a rural rainforest region in West Africa to large urban centers. We've seen the first-ever case of Ebola diagnosed in the US. The World Health Organization's director has called this epidemic "the greatest peacetime challenge" the world has ever faced, with the number of cases doubling each week.

Now, health care officials are starting to talk about a worst-case scenario for Ebola.
The World Health Organization projects that 20,000 people will be infected in November. The Centers for Disease Control and Prevention, meanwhile, projects up to 1.4 million people could be infected by January, assuming that Ebola cases continue to increase exponentially (as they have) and are currently underreported.

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(Chart source: HealthMap)

This worst-case scenario could become a reality, experts say, if the situation in West Africa continues to deteriorate. Here are five reasons why:

1) The best methods we have to contain Ebola are failing

Public health officials are terrified that one of the cornerstones of an Ebola response — tracing the contacts of those infected — can't keep pace with the epidemic.

In the past, trusty volunteers and public-health workers would follow all the people who had come into contact with an Ebola patient for 21 days (the virus' incubation period) to make sure that those people didn't develop any of the early flu-like symptoms of the disease. If anyone did, they would be put in quarantine to be monitored further and to ensure they didn't give the virus to anyone else.

This method worked extremely well. It helped to curb every previous known Ebola outbreak in history — and it even seems to have worked in the small outbreaks this year in Senegal and Nigeria, which have just reported zero suspected cases.

But in Liberia, Sierra Leone, and Guinea, which each have thousands of infected people, contact tracing becomes impossible. Consider this: the WHO estimates that every person in this region has at least ten contacts. Liberia already has over 3,000 cases of Ebola. That would be 30,000 potential contacts to follow-up. Imagine, if by the year's end, we see nearly 300,000 cases.

So the best method to curtail this untreatable disease is useless at the scale of the outbreak before us. And this keeps health professionals familiar with the disease up at night.

2) We may not get the health workers we desperately need

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Nurses escort a man infected with the Ebola virus to a hospital in Monrovia. (Photo courtesy of Zoom Dosso/AFP/Getty Images.)

One unique and terrible feature of the epidemic is the fact that doctors, nurses, and hospital staff are getting infected and dying at an unprecedented rate. The WHO has reported, as of September 22, that 384 health-care workers have gotten the virus and 186 have died.

The WHO has said it needs a 20-fold increase in health personnel (20,000 national staff and 1,000 internationals) and President Obama has promised to train 500 health workers per week to work to beat back the epidemic.

But in the current environment, it's difficult to both recruit and retain the exact health-care professionals needed to treat Ebola patients. And officials worry that doctors simply won't show up.

"One of the things that is not always that well understood is just how difficult it is to find the labor to do this work in West Africa, both nationally as well as the expats," said Daniel Bausch, associate professor at the Tulane University School of Public Health and one of the Ebola experts training American staff to go to West Africa. In Liberia, for example, the medical school was closed during its civil war from 1999 to 2003, so the country was not graduating medical doctors, he said.

Much of the challenge has come from keeping local workers on the job. Ebola outbreaks don't typically happen in West Africa, and that meant doctors and nurses weren't prepared for what treatment would entail. Even after they learned about Ebola, they didn't have the resources (gloves, gowns, masks and personnel) to stay safe. Some have walked off the job because the stress and danger of caring for people in a drastically under-resourced setting became overwhelming.

The populations affected also had no experience with this nightmarish disease. Suddenly, they saw health workers coming into their communities — including foreign aid workers — spreading word about an almost unbelievably violent virus and taking their relatives away to containment facilities, sometimes never to be seen again.


This environment bred a disturbing reaction. There is, understandably, fear everywhere. There is denial. But worst of all, there have been reports of sporadic violence: West Africans stoning, beating, and even killing health workers, both national and international, who are simply there to help.

People on the ground aren't optimistic that the needs and promises about health personnel will materialize.

"In the last six months, a fair number of doctors have been infected and killed by the Ebola virus," said Bausch. "Obviously if you're one who hasn't been infected with Ebola, how enthusiastic are you about doing that work if you see colleagues getting sick and dying? So you go to West Africa, and you say, 'Raise your hand if you want to work in an Ebola treatment unit.' You don't see many hands in the air."

That's not to mention the difficulty of identifying and training international workers who are willing to go to West Africa amid the violence and underfunding that some have been met with. So even if more hospital beds and care facilities are erected in the coming months, as President Obama has planned, without the doctors, nurses and cleaners to staff them, they won't be of much help.

3) West Africa's fragile economies are falling apart

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A Liberian health worker interviews family members of a woman suspected of dying of the Ebola virus inside a home in Monrovia, Liberia. (Photo courtesy of John Moore/Getty Images)

Before the Ebola outbreak began, some of the Western Africa nations it hit hardest were seeing promising signs of economic growth. Sierra Leone, for example had the second highest real GDP growth rate. Liberia was 11th in 2013. The US, by comparison, ranked 157.

Now, there's worry that the Ebola outbreak will slam the brakes on that development.

"A prolonged outbreak could undercut the growth that these countries were finally starting to experience, taking away the resources that would be necessary for improving the health and education systems," says Jeremy Youde,  a professor of political science at the University of Minnesota Duluth.

"These countries are generally not starting from a great position as it is, so they don't have much of a cushion to absorb long-term economic losses. If the international economy turns away from West Africa and brands it as diseased, that could be very problematic."

Last week, the World Bank said Ebola may deal a "potentially catastrophic blow" to the West African countries reeling with the virus. Businesses are shutting down, people aren't working, kids aren't going to school.

There's widespread food insecurity. "The fertile fields of Lofa County, once Liberia's breadbasket, are now fallow. In that county alone, nearly 170 farmers and their family members have died from Ebola," the WHO director warned. "In some areas, hunger has become an even greater concern than the virus."

So, as the epidemic continues, these countries become further destabilized and their fragile economies, broken. People die not just of Ebola but of all of its social side-effects.

4) People are dying in record numbers from other diseases

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Ebola cases by country from January to September 2014. (Chart courtesy of the WHO)

Before the Ebola outbreak, the three countries most affected had very weak health systems and little money to spend on health care. Less than $100 is invested per person per year on health in most of West Africa. These countries record some of the worst maternal and child mortality rates on the planet.

Ebola is depleting those already scarce supplies. Hospitals and clinics have shut down since the outbreak, so people don't have access to the usual maternity or malaria care they need. The ones that are still open are reportedly overwhelmed with Ebola patients.

"The whole general health system is collapsing," Jimmy Whitworth, the head of population health at Britain's Wellcome Trust, told the Independent in an interview. If they do still have access to care, he added, "People aren't going to hospitals or clinics because they're frightened, there aren't any medical or nursing staff available."

"West Africa will see much more suffering and many more deaths during childbirth and from malaria, tuberculosis, HIV-AIDS, enteric and respiratory illnesses, diabetes, cancer, cardiovascular disease, and mental health during and after the Ebola epidemic," wrote  disease researchers Jeremy Farrar, of the Wellcome Trust, and Peter Piot, of the London School of Hygiene and Tropical Medicine in a new article in the New England Journal of Medicine.

This outbreak will have lasting effects on health care for West Africa. Dr. Ezie Patrick, based in Nigeria with the World Medical Association, told Vox that the ratio of doctors per population is about 1: 6,000 in some places. "This shows the gross inadequacy of doctors," he said. "Sadly Ebola is claiming the lives of the few doctors who have decided to work in these challenging health systems thereby worsening the dearth and also increasing the brain drain leading to far fewer doctors in the region."

5) Violence and terror escalates, isolating a region

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Liberian security forces enforce a quarantine in Monrovia, Liberia. (Photo courtesy of John Moore/Getty Images)

Until this epidemic is stopped, all countries will need to be on alert for Ebola victims: airport staff outside of West Africa may need to start screening for Ebola, hospitals are already arming themselves with equipment and training their staff to deal with the disease, and people everywhere will learn to fear this deadly virus.

But the impact of a long-running epidemic will be felt the most in West Africa, where there's some debate about whether Ebola could become a permanent fixture.

For now, Bausch and others worry that the denial and fear about Ebola could spread further, ripping apart the social fabric of West Africa and isolating the region from the world. As Piot and Farrer wrote in the New England Journal, it's not the biology or mutations of the disease that are causing the devastation; it's social factors: "... the combination of dysfunctional health systems, international indifference, high population mobility, local customs, densely populated capitals, and lack of trust in authorities after years of armed conflict."

"That these communities that have been resistant (to aid) means they are clearly in denial, violent denial," Bausch observed. "I would fear a much more unhealthy social adaptation: that the violence against the international community would become so ferocious, like with the death of the people in Guinea a few days ago, that none of us (health workers) are understandably going to risk our lives (to work there)."

The side effect of the fear is that not only isolating and ostracizing people with Ebola, but an entire block of countries. "With that horrific social adaptation, in the process you have the society that further breaks down: people not getting treated for malaria, people dying of starvation, all the trade routes (cut off), commercial processes break down. I hope we don't see it. It's the worst-case scenario."

Is there reason for hope?

Right now, there's some reason for hope. Most of the projections about cases escalating to the hundreds of thousands or millions are based on all the interventions we have put in place failing. As the CDC's director Tom Freiden said, this is a "fluid and dynamic situation. What the modelling shows us is even in dire scenarios, if we move fast enough we can turn it around."

Hopefully, the unprecedented response by the global community — the UN resolution, the personnel the US, Cuba, England and other countries are sending over — will get there fast enough to make a difference. As Frieden said, "The surge now can break the back of the epidemic. But delay is extremely costly in terms of lives and effort."

It appears Senegal and Nigeria battled back the virus through contact tracing and isolating cases. Though they only had a few cases and deaths each — tiny outbreaks compared to the scale in the other affected countries — they show that with the world on alert, when the disease turns up elsewhere, health officials can still mount successful responses. The worst-case scenario is, in other words, avoidable.

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Welcome to Burden of Proof, a regular column in which Julia Belluz (a journalist) and Steven Hoffman (an academic) join forces to tackle the most pressing health issues of our time — especially bugs, drugs, and pseudoscience thugs — and uncover the best science behind them. Have suggestions or comments? Email Belluz and Hoffman or Tweet us @juliaoftoronto and @shoffmania. You can see previous columns here.

It's been nearly 40 years since the discovery of Ebola, yet we're dealing with its deadliest outbreak in history and one that is four times larger the first.

Back then, in 1976, the scientific community knew nothing about the hemorrhagic fever. Blood containing the mystery virus was innocently sent in a blue thermos to Belgium, where Flemish scientists figured out they were unwittingly handling a violently lethal pathogen, and named it after a river in what was then Zaire.

Since then, we've learned a lot about Ebola: that it's spread through contact with the bodily fluids of an infected person, that we can stop it by using simple precautionary measures and basic hygiene practices. But every once in a while, these nightmarish outbreaks pop up and capture the international imagination. Worries about global spread are worsened by the fact that Ebola has no vaccine and no cure.

Here's what's surprising and interesting about this state of affairs: it is not caused by a lack of human ingenuity or scientific capacity to come up with Ebola remedies. It's because this is an African disease, and our global innovation system largely ignores the health problems of the poor.

Why Ebola is an African disease

Since the first Ebola outbreak, which killed 280 people in 1976, we discovered that the virus is zoonotic, meaning it's transmitted to humans from an animal reservoir. And those animal reservoirs — believed to be certain species of fruit bats — are endemic in Africa. So that's one reason why all the Ebola outbreaks so far have happened on this one continent.

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The countries where Ebola has popped up also happen to be some of the poorest on the planet, with the least health spending per capita. In some cases, less than $100 US per person is invested each year to care for citizens here.

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Compare that with the US, where more than $8,000 US is spent every year on the health care of each citizen.

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Ebola can have a death rate of up to 90 percent, but we know that isolating sick patients and applying precautionary measures in healthcare settings — wearing gloves, gowns, and masks — will stop the spread of the disease. So can following and testing the contacts of those who fall ill. That's why if the virus ever escaped a containment facility in a country like the US, public-health officials are so confident we could quickly snuff if out it before it ravaged any one, let alone entire communities.

Sadly, the same just isn't true in many parts of Africa. Aid workers on the ground in Guinea, Liberia, and Sierra Leone — where the current outbreak has killed more than 800 people — report that they don't have access to the basics to protect themselves and their patients. Many of their hospitals are dilapidated, there's limited infection control and almost no capacity for contact tracing.

In the current outbreak, more than 60 health workers have already died; all were African nationals, not foreign aid workers. Reports from the ground suggest that the death toll will rise as health professionals are over-taxed, under-resourced, and abandoning hospitals out of fear and overwork.

The reason for Ebola's spread

Ebola will continue to move through Africa — this time, and again in the future — not only because of the viral reservoirs and broken health systems specific to the continent. There are much larger issues at play here. Namely, the global institutions we designed to promote health innovation, trade, and investment perpetuate its spread and prevent its resolution.

This shouldn't be news. Most all of the money for research and development in health comes from the private sector. They naturally have a singular focus — making money — and they do that by selling patent-protected products to many people who can and are willing to pay very high monopoly prices. Not by developing medicines and vaccines for the world's poorest people, like those suffering with Ebola.

Right now, more money goes into fighting baldness and erectile dysfunction than hemorrhagic fevers like dengue or Ebola. In the graph below, you can see global pharmaceutical spending in 2013. Neglected diseases (ie., Ebola) got hardly any of the share of funding. These illnesses primarily grip people in developing countries and rely on investment from the public sector, which funds only a small fraction of total health R&D compared to industry. (In 2009, for example, $240 billion US was invested in health R&D. Of that, $214 billion went to high-income countries, and of that 60 percent came from industry, 30 percent from the public sector, and 10 percent from other sources.)

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When a virus like Ebola does attract money, it's mainly from department of defense and not traditional disease research structures since Ebola is considered a potential bioterrorism weapon.

The result of this architecture of investments is that most health products that hit the market don't focus on sicknesses of the poor. Of the 850 health products approved by regulators between 2000 and 2011, only 37 focused on neglected diseases.

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Source: Doctors without Borders

So we can't be surprised about the current Ebola outbreak. We can't lament the fact that there's no cure or that it's an unstoppable and violent virus when remedies could be expedited; we just don't prioritize them over other, more potentially profitable health problems.

As long as we perpetuate this global system of R&D funding, outbreaks of neglected diseases like Ebola will keep happening. Sadly, it's a cause shared by many more diseases of the poor, some of which affect multiple times more people than the one that's currently making headlines.
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When Dr. Peter Piot was a young scientist, in 1976, he received a shiny, blue thermos in his Antwerp lab. It was filled with the blood of a Belgium nun who worked in the Democratic Republic of the Congo (then Zaire). The woman had fallen ill with a mysterious sickness, and Piot was asked to screen the blood for yellow fever.

"We didn't even imagine the risk we were taking," Piot, now the director of the London School of Hygiene and Tropical Medicine, wrote in his memoir No Time to Lose. The sample tested negative for yellow fever and a range of other pathogens. But Piot would later discover that — in that "soup of half-melted ice" and cracked vials — lurked a deadly virus he named Ebola.

Just before his discovery, Piot's professors told him that he had no future in infectious diseases. Back then, many people believed that science had solved the problems viruses created in humans with new vaccines and antivirals. Then came Ebola — a disease for which we still have no cure — and later HIV/AIDS in the 1980s.

Piot is now one of the world's foremost infectious diseases experts, and a former under-secretary general of the United Nations. He's been watching the world's largest-ever Ebola epidemic unfold from his post in London, and we spoke with him about his thoughts on the outbreak and how the global community can prevent future tragedies of this scale. This transcript has been edited for length and clarity.

Julia Belluz: You've been working on Ebola since you co-discovered the virus in 1976. For nearly 40 years, this disease has largely been ignored by the international community except for brief flashes of interest, mostly spurred by Hollywood. Now we are seeing unprecedented attention and political galvanization around Ebola. What changed?

Peter Piot: In the 38 years since 1976 until this current outbreak, there have been something like 1,500 people who died in total. So that's less than 50 deaths per year. Up to now, it was not a real public health problem. This year, nearly 3,000 have died. All 24 previous outbreaks were both time and place limited to very confined communities. Even in the worst case, Ebola would kill 300 people. Here it has involved entire countries, and it has been going on for over nine months now.

JB: But the death toll was rising rapidly for months before the international community responded. What do you think finally sparked collective action?

PP: It was the Americans getting Ebola, I'm afraid. Beyond that, I don't know what changed it, really. Early in the second or third week of July, I gave an interview with CNN and I said this crisis requires a state of emergency and a quasi-military operation. After the interview, I thought maybe I exaggerated. But I felt that it was really getting out of hand and it looked like a completely different type of Ebola outbreak than we'd seen before. Then it took another month, so I really don't know.

JB: Before this year, could you have imagined an Ebola outbreak of this size?

PP: I never thought it would get this big. I always thought it was an accident of history where someone becomes infected — from a bat probably — and then an outbreak is contained. Ebola came and went. I really never thought this could happen. But it shows again: when the right, or bad conditions are all combined with each other, then these things will happen again.

JB: We've seen a surge in the number of deaths now for weeks with no sign that the virus is slowing down. Why do you think this outbreak spun so far out of control?

PP: I think this is a result of a perfect storm of a lack of trust in authorities, in western medicine, dysfunctional health services, a belief in witchcraft as cause of disease and not viruses, traditional funeral rites, and a very slow response both nationally and internationally. The longer we wait, the longer there is an insufficient response, the worse it will get, the more difficult it will be to control this epidemic through quarantine and isolation and all the methods that worked in the past.

JB: Most of what you point out here has to do with things that we had no control over — an accident of geography, local beliefs. Can you point to a place where the ball was dropped in this Ebola response, something that should have been done to minimize the suffering in West Africa?

PP: It took more than three months to diagnosis the epidemic. The first case was in December and then they only diagnosed that it was Ebola in March. But then it took far too long before the international community did anything. That goes from the WHO, to the US, and UK governments. It took 1,000 deaths before a public health emergency was declared by the WHO, and cynically it took two American doctors to become infected. I think that's where particularly the local office of the WHO was inadequate, that's for sure. But it's not just WHO. It's the member states of the WHO, the ones who decide about the budget at the WHO.

JB: What do you think will be the lessons learned from this epidemic?


PP: This outbreak has highlighted the fact that we need to make sure we are far better equipped for epidemics in general. There will be others. But the good news is also that experimental therapies and vaccines for Ebola are now being tested for their efficacy so I think that's positive. For the next outbreak, we should have stockpiles of vaccines and therapies.

I also think this outbreak is changing the paradigm that there will be more investment, and accelerated development of drugs for rare diseases. Another impact is that there will be a financially protected team that can deal with outbreaks at the WHO and that there will be massive support to strengthen the health systems and services in these countries.

eola A Liberian health worker interviews family members of a woman suspected of dying of the Ebola virus  in Monrovia, Liberia. (John Moore/Getty Images)

JB: Strengthening health systems seems to be the thing we need most to make sure all nations can identify and respond to outbreaks like this, but that's also the hardest thing to fix.

PP: I don't think you can fix it. Each country is different. There is an illusion that there is one fix for the three neighboring countries [battling Ebola — e.g. Liberia, Sierra Leone and Guinea]. But they all have different problems. It's important to have a commitment to the long-term view — so when we're talking about global health programs and international development, that there is the long-term view that includes building health systems. That's not a matter of two or five years, that's ten years you need as a horizon.

JB: Those long-term timelines don't exactly square with political agendas, which are  short term. What happens when the political will and interest falls away?

PP: We've been there before. After war, we say 'never again.' After Katrina, we say 'we'll do this and that,' and then it gets out of the public eye. I don't know how to do it. I hope that the Ebola epidemic is a wake up call for that if we don't invest more in these health systems, that we are at risk for a repetition of the current Ebola crisis.

JB: What is the biggest public-health threat on the horizon?

PP: The biggest threat remains a flu pandemic. There I think we're better prepared with early alerts and the good news is that China is quite open now. The first cases of flu often come from China. In more recent years — still fortunately small outbreaks — there was open and prompt reporting [to the international community about flu cases]. I think there we have made real progress. But I think it'll come back to the fact that there has to be some central leadership.

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In a new Vox video (above) aid worker Ishmeal Alfred Charles describes the realities of life in Freetown, Sierra Leone, a city currently losing its battle against Ebola.

During Sierra Leone's bloody 11-year civil war in the 1990s, there were no government-imposed lockdowns, even though people would often hide in their homes out of fear of reprisal from rebel fighters.

But now, because of the ongoing Ebola epidemic, the government is effectively grinding the country to a halt by imposing mandatory lockdowns on its citizens. The first ran from September 19 to 21, when Sierra Leoneans were not be allowed to leave their homes in an attempt to stop the spread of the virus and isolate new cases. Some 350 people with Ebola were identified.

As the death toll in the country rises exponentially, Sierra Leone's President Ernest Bai Koroma announced this week that he would extend the quarantine to include another one million people in three districts and 12 tribal chiefdoms in the country. This is an unprecedented move in a country desperate to contain the outbreak.

To get a sense of just how dire the situation is, read parts of the president's recent address to the nation:

The isolation of districts and chiefdoms will definitely pose great difficulties for our people in those districts. But the life of everyone and the survival of our country take precedence over these difficulties...

These are trying moments for everyone in the country, but we are a resilient people, a people that have shown their ability to unite and stand up as one to overcome difficulties...

We will use these strengths to confront those tendencies that undermine the fight against the disease, we will utilize our better calling to end this outbreak, and by the grace of God Almighty, we shall overcome and free our land from this evil virus.

The districts where Ebola is believed to be moving fast — Port Loko, Bombali, Moyamba — are now under isolation. People can't leave their homes or go to school or work. During this period, government and public-health officials are going door to door, educating people about Ebola and trying to identify patients who should be brought to containment facilities.

Officials in Sierra Leone are worried that many Ebola victims are either going underground or simply unable to access care.

The New York Times recently reported that the government of Sierra Leone has acknowledged the death toll is "worse than what was being reflected in reports."

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Under-reporting is a concern in all countries most affected by Ebola right now — Sierra Leone, Liberia and Guinea. They are reportedly dealing with 6,000 cases and 2,900 deaths at the moment but the WHO said these figures  "vastly underestimate the true scale of the epidemic."

In its latest update on Ebola, the agency said that this epidemic amounts to "the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long."

Not everyone's convinced the quarantine is a good idea

Still, not every agrees forceful measures like the quarantine in Sierra Leone are a good idea. Médecins sans Frontières has expressed the worry that mandatory isolation will "end up driving people underground and jeopardizing the trust between people and health providers."

Some were also concerned that, because the latest lockdown came without a warning, people were unprepared and could go hungry. There's also the very real possibility that quarantines will deal a tragic blow to Sierra Leone's already fragile economy.

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Speaking at a United Nations special meeting of world leaders on the Ebola crisis, President Barack Obama said the world needed to wake up to the deadly threat.

"If this epidemic is not stopped, this disease could cause a humanitarian catastrophe across the region," Obama said, adding: "We are not moving fast enough. We are not doing enough. There is still a significant gap between where we are and where we need to be."

Dr. Joanne Liu, international president of Médecins Sans Frontières, said Ebola is killing more than just those infected by the virus. "Mounting numbers are dying of other diseases, like malaria, because health systems have collapsed," she said.

"The sick continue to be turned away, only to return home and spread the virus among loved ones and neighbors."

This is the worst Ebola epidemic in history. To learn more about why, read our Vox cardstack.

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Any big gathering involving thousands of people from around the world — potentially swapping deadly microbes — always raises alarm bells for public health folks. And there is perhaps no larger gathering than the Hajj, the annual pilgrimage of roughly three million Muslims from all over the world to Mecca, Saudi Arabia.

In the past Hajj pilgrims have spread meningitis, tuberculosis, and polio — but six months into the world's biggest Ebola epidemic, governments are trying to keep them from getting the incurable virus.

The Saudi Ministry of Health last month banned Hajj visas for Sierra Leone, Guinea, and Liberia — the three nations most affected by Ebola this year with at least 5,800 cases.

Nigeria, which has been battling Ebola, was left out of that ban. It also happens to be one of the countries in the world with the highest concentration of Hajj pilgrims, according to data from the infectious-disease tracking website HealthMap.

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There were only 20 Ebola cases in Nigeria (relatively few compared to the West African nations that are currently managing thousands), and the country reported last week that they have no suspected cases at the moment.

Several people were still under surveillance in Lagos and the southern oil city of Port Harcourt. If any of those people test positive, there's a slight chance they may have already infected others. However, the risk of bringing the disease to Mecca seems to be fairly remote. The southern part of Nigeria, where Lagos and Port Harcourt are located, is mostly Christian while the northern part of the country, which has not had any reported Ebola cases, is Muslim.

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A WHO staff member briefs a Hajj pilgrim with information on Ebola prevention before his departure at Lagos airport, Nigeria. (Photo courtesy of the WHO.)

Still, Nigeria's proximity to a potential health disaster has the World Health Organization on alert.

Since September, the WHO has been briefing Hajj pilgrims on how to protect themselves from Ebola and putting them through health screening at the Lagos airport. Health officials have been taking the body temperature of pilgrims, as well getting their travel history and contact details.

In Saudi Arabia, pilgrims arriving at the King Abdulaziz International Airport airport near Mecca are also being screened for Ebola.

A Lagos State health official told South Africa's News24, "The idea behind the screening all passengers in and out of Nigeria is basically to make sure that Nigeria doesn't export any case to any country and at the same time we don't import any case."

The WHO is not recommending travel restrictions from Ebola-affected countries, but public health agencies like the Centers for Disease Control and Prevention suggest people from high-risk countries postpone Hajj travel.

Besides Ebola, health officials are also on alert for another deadly pathogen: Middle East respiratory syndrome coronavirus (MERS).

Cases in the Arabian Peninsula have increased rapidly in the past few months. The WHO and CDC suggest that, while the risk to Hajj pilgrims appears to be low, people with weakened immune systems or existing respiratory problems reconsider travel plans. They also suggest all travelers avoid contact with camels, believed to be the animal reservoir of the virus.

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Before this year, ebola epidemics have never made significant enough impacts to generate a global humanitarian response. But 2014 has been different.

Although there are fewer people affected by ebola than other global crises, the Centers for Disease Control and Prevention reported that 1.4 million people could be infected with the virus by mid-January.

In order to stop the outbreak, West African countries and various organizations need vast sums of money. However, according to the Financial Tracking Service — an organization which tracks real time humanitarian aid across the world — Ebola is low on the pecking order. The infographic below explains which crises have received more financial relief from countries and NGOs this year.

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Who is funding the response against the Ebola epidemic?

Although West Africa has been receiving a considerable amount of money to fight the disease, it has primarily been funded by the World Bank and the US, which account for 51 percent of the aid.

The United States is involved through the US Agency for International Development, USAID, which funnels the funding into agencies on the ground in addition to deploying its own personnel to help with disaster relief.

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Where is the money spent?

The majority of the money flowing into Ebola affected countries is used by the World Health Organization, the International Red Cross, local government agencies and various United Nations organizations on protection kits and other medical supplies.

However there isn't an efficient system that accounts for all the money, which can lead to gross overspending and misuse in some areas. Congressional report on humanitarian assistance said that financial provisions for disaster management could have unexpected consequences. It notes that tracking supplies would not be possible. It also mentions that NGOs who are generally intermediaries have a higher potential to mismanage funding.

The response so far has been unprecedented. Last week, the UN called for an increase in spending to combat Ebola and with the escalation of infections, most countries are on high alert and are aggressively investing in countering the disease.

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A Red Cross team was attacked in Guinea yesterday while collecting dead bodies believed to be infected with Ebola.

This is the latest in a series of attacks on Ebola aid workers, the most disturbing being the recent stoning and killing of a team of eight journalists and health professionals who had been spreading public-health messages about Ebola in Guinea.

In the most recent attack in Guinea, the Associated Press reported, one aid worker was recovering from a wound in the neck after a crowd grew hostile to a Red Cross team's efforts to encourage safe burial practices — one of the main reasons for Ebola spread in the region.

"Family members of the dead initially set upon the six volunteers and vandalized their cars, said Mariam Barry, a resident," the AP reported. "Eventually a crowd gathered and headed to the regional health office, where they threw rocks at the building."

Other aid workers, including members of Doctors without Borders, have reported that fear of the virus or the belief foreigners are giving people the illness have spurred locals to attack health teams or run away at their sight.

Spreading public health messages has been extremely challenging in an environment with low health literacy and public trust in officials. Since this is the first time Ebola has ever appeared in West Africa, there was little understanding about the virus and public health officials have had a difficult time getting their messages across.

In Liberia, distrust in the government led some people to think Ebola is a government scam to attract international aid.

This year, Ebola has killed more people than sum total of all the previous outbreaks since the virus was first identified in 1976. So far, there have been more than 5,800 cases in Guinea, Sierra Leone, Liberia, Nigeria, and Senegal.

Yesterday, the CDC projected the case load could reach beyond a million by the new year in a worst-case scenario.

Further reading: Why public health officials around the world are now panicked about Ebola, seven reasons why this outbreak got so bad, and a list of aid groups working on the Ebola crisis and how to donate.

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Since 1976, Ebola has plagued Central and (most recently) Western Africa. The scale of the current outbreak is unprecedented, and shows no signs of slowing down. The infographic below illustrates how many people have been affected by the deadly disease since it was first discovered.

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The current epidemic has affected Sierra Leone, Liberia, Guinea, Senegal and Nigeria. Although parts of the Democratic Republic of Congo have reported cases,  they have been declared unrelated to the outbreak in West Africa.

This interactive map from the Huffington Post on September 16, 2014 details the number of reported deaths caused by Ebola. Hover over each district to see a precise figure within West Africa.

Further reading: For more on how Ebola outbreaks happen, check out this previous post by Susannah Locke. She notes that outbreaks can last a couple of months and then temporarily disappear for a few years.

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Eight people, including health workers and three journalists, have been found dead in Guinea, where they were distributing health information about Ebola.

"The eight bodies were found in the village latrine. Three of them had their throats slit," a Guinean government spokesperson told Reuters.

The team was allegedly attacked while working near the city of Nzérékoré. The group had been stoned on Tuesday and then went missing, according to the Guardian. They were believed to be held captive.

The Guardian reported that their messages about Ebola had been met by hostile residents:

"The meeting started off well; the traditional chiefs welcomed the delegation with 10 kola nuts as a traditional greeting," said a local resident who was present at the meeting earlier this week and gave only his first name, Yves. "It was afterwards that some youths came out and started stoning them. They dragged some of them away, and damaged their vehicles."

Some believed they were actually in Guinea to spread the disease.

This isn't the first time public health workers have been attacked during the epidemic. Aid workers, including members of Doctors without Borders and the Red Cross, have reported that fear of the virus or the belief foreigners are giving people the illness have spurred locals to attack health teams or run away at their sight.

Part of this reaction is the result of the fact that this is the first time the virus has surfaced in West Africa, where many people had no idea about Ebola before this year. Spreading public health messages has been extremely challenging in an environment with low health literacy and public trust in officials.

In Liberia, distrust in the government led some people to think Ebola is a government scam to attract international aid.

But the killing of Ebola workers in Guinea takes this hostility to a new and disturbing level.

This year, Ebola has killed more people than sum total of all the previous outbreaks since the virus was first identified in 1976.

Further reading: Here are the seven reasons why this outbreak got so bad and a list of aid groups working on the Ebola crisis and how to donate.

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Calling for a twenty-fold increase in resources for Ebola and the establishment of a UN Emergency Health mission, UN Secretary-General Ban Ki-moon sounded the loudest possible alarm over the epidemic today.

The UN Security Council held an emergency meeting to discuss Ebola, only the second disease that has warranted a gathering by the council after HIV/AIDS.

The group unanimously passed a resolution asking countries around the world to urgently send medical workers and supplies to stop the epidemic.

"It's a call to action not just from the Security Council but from the whole United Nations family," said Ambassador Samantha Power of the United States. The resolution was drafted by the US and was co-sponsored by 131 countries — the most of any council resolution ever.

In his remarks at the session, the secretary general noted that the number of Ebola cases is doubling every three weeks and that the virus is a threat to international peace and security. "There will soon be more cases in Liberia alone than in the four-decade history of the disease."

He spoke about how the disease is "destroying health systems" and making it impossible for health-care workers to address other more common ailments that affect people.

"The virus is also taking an economic toll. Inflation and food prices are rising. Transport and social services are being disrupted. The situation is especially tragic given the remarkable strides that Liberia and Sierra Leone have made in putting conflict behind them," he said.

So what can the resolution do?


"Much of the resolution is a generalized call for greater international solidarity and international contributions to the fight against Ebola," a UN news service reported.

"But it also contains some specific provisions that could accelerate the international community's response to the crisis." For example, the resolution asks countries to lift travel restrictions that have been put in place in the countries most affected by the virus. These have made getting aid workers and supplies into the region a challenge. Since the resolution was supported by countries that have put those restrictions in place, that suggests they'll resume flights following the meeting.

The UN also announced that it will launch a mission specifically focused on Ebola. "This unprecedented situation requires unprecedented steps to save lives and safeguard peace security," Ki-moon said. "Therefore, I have decided to establish a UN emergency health mission, combining the World Health Organization's strategic perspective with a very strong logistics and operational capability."

What can the resolution do? Much of the resolution is a generalized call for greater international solidarity and international contributions to the fight against ebola. But it also contains some specific provisions that could accelerate the international community’s response to the crisis. In particular, the resolution calls on countries to lift travel restrictions to and from affected countries. This has been an ongoing problem for the United Nations and NGOs.  Airlines have cancelled flights, and countries in the region have prevented the use of their airports to deliver personnel and assistance to affected countries.

These restrictions have significantly hindered the ability of international health workers, NGOs and the UN to do its job–and also made the delivery of supplies and personnel more expensive. Key countries in the region, including important travel hubs like Senegal, Cameroon, South Africa and Kenya, have banned travel to and from Liberia, Guinea, and Sierra Leone.  In some cases, countries won’t even let UN planes land to refuel.

- See more at: http://www.undispatch.com/ebola-turning-point/#sthash.ijjrf1oL.dpuf

What can the resolution do? Much of the resolution is a generalized call for greater international solidarity and international contributions to the fight against ebola. But it also contains some specific provisions that could accelerate the international community’s response to the crisis. In particular, the resolution calls on countries to lift travel restrictions to and from affected countries. This has been an ongoing problem for the United Nations and NGOs.  Airlines have cancelled flights, and countries in the region have prevented the use of their airports to deliver personnel and assistance to affected countries.

These restrictions have significantly hindered the ability of international health workers, NGOs and the UN to do its job–and also made the delivery of supplies and personnel more expensive. Key countries in the region, including important travel hubs like Senegal, Cameroon, South Africa and Kenya, have banned travel to and from Liberia, Guinea, and Sierra Leone.  In some cases, countries won’t even let UN planes land to refuel.

- See more at: http://www.undispatch.com/ebola-turning-point/#sthash.ijjrf1oL.dpuf

Earlier this week, the UN asked for almost $1 billion over the next six months to address the Ebola epidemic.

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Tuesday's announcement by President Barack Obama — that the US would be sending in an army of 3,000 to fight Ebola — came as a relief to the many wondering when the international community would wake up to the daily horror show playing out in West Africa.But the tactics also raised some questions: why was Obama sending soldiers to fight off a virus? And why has he been characterizing this disease spread as a "security threat" and "security priority"?

Why Obama is describing Ebola as a "security threat"


Obama has repeatedly referred to the threat of Ebola in security terms, arguing the virus could cripple the already fragile economies in the African region. He's made the case that this will have consequences for not only the security of countries there, but also for nations around the world — even if the virus doesn't spread beyond Africa.

For examples of this war-like mentality, look no further than the president's address, delivered Tuesday from the Centers for Disease Control headquarters in Atlanta:

"If the outbreak is not stopped now, we could be looking at hundreds of thousands of people infected, with profound political and economic and security implications for all of us. So this is an epidemic that is not just a threat to regional security — it's a potential threat to global security if these countries break down, if their economies break down, if people panic. That has profound effects on all of us, even if we are not directly contracting the disease."

Obama could have called Ebola a "public health threat" or "global health threat." But with this bold declaration that the virus is a "security threat", he is doing two things. First, he's trying to convey that the outbreak in West Africa — even though it's on a distant continent — presents an existential threat to America. This language shifts the focus from "them" to "us." Second, he's signaling that the risk is immediate enough to justify the galvanization of American resources.


Watch the Vox.com 2-minute explainer video about how this outbreak spun out of control

This has become an increasingly common way to talk about disease

The World Health Organizations constitution, penned in 1946, says that "health of all peoples is fundamental to the attainment of peace and security." But only in the last 15 years have diseases increasingly been treated as security issues.

Writing in the medical journal the Lancet, international relations specialist Stefan Elbe points out that 2000 marked a fundamental shift toward the "securitization of disease." That January, the UN Security Council made the unprecedented move of convening a meeting to address the out-of-control HIV/AIDS pandemic. This resulted in a massive concentration of resources into HIV/AIDS research, and made the conversation about addressing the disease an international one requiring a global and coordinated effort.

Since then, the Lancet article continues, "The rise of the new health security paradigm has even seen some health issues becoming formally incorporated into national security strategies."

In 2005,  President George W. Bush became concerned about mutations of the H5N1 bird flu, and declared the flu strain a security threat. Bush's declaration resulted in the establishment of America's first pandemic preparedness plan, says Laurie Garrett, a Council on Foreign Relations senior fellow for global health. And other nations adopted similar strategies.

Over the years, with globalization and the speed at which infectious diseases spread, health threats are seen as something different. "Everybody has come to agree that the economic impact of a serious virulent pandemic is so severe that it can undermine trade and prosperity in any affected country," Garrett says. And this has changed how countries respond to even the most distant threats.

Is security framing the right approach to Ebola?

On Thursday, the UN Security Council held an emergency meeting on the Ebola epidemic. This is the second disease to warrant such a gathering since HIV/AIDS. The reason Ebola is referred to in security terms is simple, Garrett says: "This epidemic is so dire and our toolkit is so limited."

There are no drugs or vaccines yet on the market for the disease, and the Ebola body count is rising fast. Half of the deaths so far have happened in the past month, meaning the rate of infection is exponentially increasing. Already, the virus has spread beyond the three West African nations most afflicted (Guinea, Liberia, and Sierra Leone) into Senegal and Nigeria. At this rate, it's a numbers game: with more and more infections, it's only a matter of time before another sick person gets on a plane and brings the virus across another border. Then another. And another.

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(Ebola cases by country from January to September 2014. Chart courtesy of the WHO)


"In the end, we'll either stop this or see it go from epidemic to endemic based on the same toolkit that was used for the first Ebola outbreak in 1976," Garrett says. That's a sorry state of affairs.

For these reasons, Garrett believes calling Ebola a threat to national and global security is the right thing to do and will help muster resources to address a rapidly deteriorating situation. As Garrett points out in Foreign Policy, since Ebola has escaped its usual environs — the bushes and rural communities of Africa — and made its debut in dense, urban centers this year, it has become a potential existential threat in major cities in Africa and beyond in a way no one could have foreseen.

Drawing on the vast resources of the US military to focus on logistics, capacity building, and coordinating supplies makes sense, she added, noting that it was the US forces who turned the post-Katrina disaster in New Orleans around. "It is at least  possible that the US military, bringing in medical supplies and marshaling forces in an appropriate and organized manner (in West Africa), that they will be viewed as heroes."

ebola A Liberian health worker interviews family members of a woman suspected of dying of the Ebola virus inside a home in an impoverished neighborhood in Monrovia, Liberia. (John Moore/Getty Images News.)

But others don't see it that way. Simon Rushton, who researches the global politics of health at the University of Sheffield, says, "One of the big problems with the Ebola outbreak has been a lack of public trust in not only West Africa's own governments but in the west. Sending a load of US troops is unlikely to build trust, and might have the opposite effect."

We already know that people with the disease have been hiding from public view, afraid of being kept in quarantine, and wary of health workers, Rushton says. "Using military can lead to politics of fear."

A surge response doesn't address the root causes of the epidemic: broken and under-funded health infrastructure, poverty, and misaligned incentive systems for the development of treatments to address diseases of the poor, like Ebola.

"What we're reaping here with Ebola is the consequence of a long-term failure to help countries develop their own health systems," says Rushton. "If stable health systems were in place and functioning properly, Ebola would have been contained."

Military action might be partially effective, it might bring this outbreak to a close. But it might also heighten distrust in the authorities and the international community.

The other danger is that the health resources sent to Africa become disproportionately focused on the Ebola threat. "This surge mentality gives you single-minded focus on one particular disease" at a time when many others are ravaging Africa in numbers far greater than Ebola, Rushton added. But scourges like malaria and diarrhea are not ripe for the imagery and action that "security threats" conjure.

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As the worst-ever Ebola epidemic rages on in Africa, President Barack Obama announced Tuesday that the US will ramp up efforts to combat the the virus as part of "the largest international response in the history of the CDC."

In an address from the Centers for Disease Control and Prevention headquarters in Atlanta, Obama said that the US is willing to take the lead on international efforts to combat the virus. Ebola "is a global threat, and it demands a truly global response," Obama said.

"This is an epidemic that is not just a threat to regional security. It's a potential threat to global security, if these countries break down, if their economies break down, if people panic," he said. "That has profound effects on all of us, even if we are not directly contracting the disease." This outbreak is already "spiraling out of control," he added.

The speech came amid increasing criticism that the international community has not responded quickly and boldly enough to what has become the worst Ebola outbreak in history. And Obama's words at the CDC were more alarming and urgent than his previous comment on Ebola in August, when he emphasized that the disease is one that strikes under-funded health systems.

So far, more than 2,400 people have died this year from Ebola — more than the combined total of all previous outbreaks since the first recorded in 1976 — and the epidemic has spread to five African nations, including Guinea, Sierra Leone, Liberia, Nigeria, and Senegal.

Experts at a senate hearing on Tuesday said that the actual death toll is much higher, and that without effective actions to stop it, the case load will grow into the hundreds of thousands. More cases, they cautioned, will mean more potential for Ebola spread  beyond Africa.

"The reality is this epidemic is going to get worse before it gets better, but right now," Obama said, "the world still has an opportunity to save countless lives. Right now the world has a responsibility to act, to step up, to do more."

3,000 troops dedicated to fighting Ebola

To turn the outbreak around, the White House has committed more than $175 million to what it's calling a "top national security priority."

The focus of the funds is stopping spread in West Africa. The US will send more than 3,000 troops to the most affected areas, and set up a joint operation in Monrovia, Liberia — the hardest hit of the five regions  — to coordinate relief efforts.

In addition, the plan will boost the number of health workers and health-care centers in the region. The US pledged to build as many as 17 additional Ebola treatment units — with a total of about 1,700 beds — and to help recruit medical personnel to staff them. (Right now, people in Liberia are being turned away from treatment facilities because there is no capacity to care for them.) The Department of Defense also plans to establish a site where up to 500 health care providers can be trained each week.

USAID will also support a program of distributing kits with sanitizers and medical supplies to some 400,000 of the most vulnerable households in Liberia.

The Obama administration has asked Congress for an additional $88 million to combat Ebola, including $30 million to send more relief workers and lab supplies from the CDC and $58 million to invest in the development of the experimental Ebola drug ZMapp and two vaccine candidates.

Chances of Ebola spread in the US "extremely low"

Despite the alarm about the situation in Africa, the White House continues to quell worries about Ebola in America. President Obama said the chances of Ebola spreading in the US are "extremely low."

"US health professionals agree it is highly unlikely that we would experience an Ebola outbreak here in the United States, given our robust health care infrastructure and rapid response capabilities," reads a fact sheet from the administration.

"Nevertheless, we have taken extra measures to prevent the unintentional importation of cases into the United States, and if a patient does make it here, our national health system has the capacity and expertise to quickly detect and contain this disease."

Ebola toll could rise to "hundreds of thousands of cases"

At a Tuesday Senate hearing on Ebola in West Africa, health officials who have been working on the front line of this epidemic said that if the world doesn't act now, it's only a matter of time before cases start turning up on shores outside of Africa.

Beth Bell, director of the National Center for Emerging and Zoonotic Infectious Diseases at the CDC, said that the number of Ebola cases could balloon into the "hundreds of thousands" without effective interventions.

Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, said  budget cuts at his agency can be partly to blame for the slow response to the outbreak. The lack of funding "eroded, in insidious ways, our ability to respond in the way I and my colleagues would like to respond to these threats." He also said it's very unlikely that the virus will mutate to become airborne, though he couldn't rule it out given biology's unpredictability.

Too little, too late?

The American Ebola survivor Kent Brantly, who contracted the virus while working as a medical missionary in Liberia, criticized the "painfully slow and ineffective" response to the outbreak, and noted that the international community only seemed to wake up to Ebola in July, after he and his colleague Nancy Writebol got infected.

"Many have used the analogy of a fire burning out of control to describe this unprecedented Ebola outbreak. Indeed it is a fire-a fire straight from the pit of hell," he said, with his wife seated next to him.

"We cannot fool ourselves into thinking that the vast moat of the Atlantic Ocean will keep the flames away from our shores." He called on more investment in Ebola "to keep entire nations from being reduced to ashes."

A worst-case scenario

Dr. Bell painted a picture of a best and worst case scenario for this outbreak. "The best case scenario is that over the coming months we're able to effectively isolate and treat Ebola patients, we're able to effectively trace all their contacts to make sure they're all followed for 21 days, we're able to do something about safe burial practices so we don't have bodies in the streets." Eventually, she said, we'll see the caseload decrease.

"In the worst case scenario, we continue to see an exponential rise in cases that we're currently seeing. And an important corollary to that is exportation to other countries." She noted that the outbreak that originated in Guinea in December has already spread to Liberia, Sierra Leone, Nigeria and Senegal. "You can imagine the outbreak spreading outside the borders as part of a worst-case scenario."

Learn more about why this Ebola outbreak became the worst we've ever seen in our 2-minute Vox explainer

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Kent Brantly has a unique perspective on the Ebola epidemic: he has both worked as a doctor to treat the virus in patients and he is a victim of the disease, having contracted Ebola in July while working as a medical missionary in Liberia.

Today, he testified in DC before a senate senate committee on the West African outbreak. Here are highlights from his speech:

On the horror of having Ebola

On July 23, I started to feel ill. Three days later, I learned that I had tested positive for Ebola Virus Disease. I became a patient, and I came to understand firsthand what my own patients had suffered. I was isolated from my family, and I was unsure if I would ever see them again. Even though I knew most of my caretakers, I could see nothing but their eyes through their protective goggles when they came to treat me. I experienced the humiliation of losing control of my bodily functions and faced the horror of vomiting blood-a sign of the internal bleeding that could have eventually led to my death.

How the world woke up to Ebola after he was infected

This unprecedented outbreak began nine months ago but received very little attention from the international community until the events of mid-July when my friend and colleague, Nancy Writebol, and I became infected. Since that time, there has been intense media attention and therefore increased awareness of the situation on the ground in Liberia, Guinea, Sierra Leone and neighboring countries.

The response, however, is still unacceptably out-of-step with the size and scope of the problem now before us.

What it's like to treat Ebola patients

Treating Ebola patients is not like caring for other patients. It is grueling work. The personal protective equipment (PPE) we wore in the Ebola Treatment Unit becomes excruciatingly hot, with temperatures inside the suit reaching up to 115 degrees. It cannot be worn for more than an hour and a half. Because of the elaborate safety protocols involved in treating an Ebola patient, each one takes an average of 30 minutes of time from a team of three to five people. It is easy to see that a significant influx of medical personnel will be needed to adequately care for the thousands of people that epidemiologists now are predicting will fall victim to the disease in the coming weeks.

On using military to respond to the Ebola virus

The use of our military is a legitimate and defensible request because if we do not do something to stop this outbreak now, it quickly could become a matter of U.S. national security-whether that means a regional war that gives terrorist groups like Boko Haram a foothold in West Africa or the spread of the disease into America. Fighting those kinds of threats would require more from the Department of Defense than what I am asking for today.

Why the outbreak got out of control in Liberia

The laboratory we used to confirm Ebola Virus Disease in patients was 45 minutes away and inadequately staffed. A patient would arrive at our center in the afternoon, and their blood specimen would not be collected until the following morning. We would receive results later that night at the earliest. This means that the turn-around time to positively identify Ebola cases was anywhere from 12 to 36 hours after the blood was drawn. If a patient is not infected with the virus, that can be a life-threatening delay...

These laboratory delays can have an even greater-and deadlier- consequence. The longer it takes to confirm a positive result, the longer an Ebola- infected patient is left in the "suspected" side of the isolation unit. Every precaution is taken to protect people in that part of the facility from cross-contamination, but there is always the potential that those without the disease can become infected if they are in close proximity to an Ebola-positive person.

On receiving the experimental treatment ZMapp

I am deeply grateful to the personnel at Mapp Biopharmaceuticals who even before this outbreak had devoted their lives to combatting Ebola.

I hope that the devastating impact of the current epidemic will result in new discoveries for treatments and vaccines in the future, but we cannot wait for a magic bullet to halt the spread of Ebola in West Africa. The current epidemic is beyond anything we have ever seen, and it is time to think outside of the box.

The challenges ahead

Historically, Ebola outbreaks have been contained through the identification and isolation of suspected cases, and this has worked extremely well to stop the disease. Today, however, the number of cases and rate of transmission are surpassing the ability of these traditional interventions to bring the situation under control. Intensive medical care is important, but it is given only to patients in isolation units. We know that the virus is being spread primarily by those who are unwilling or unable to go to an Ebola Treatment Unit...


The World Health Organization has laid out a roadmap similar to what I have just described, but they are so bound up by bureaucracy that they have been painfully slow and ineffective in this response. Their recommendations for home care were made August 28, and I am not aware of any significant progress in the implementation of their plan to date. It is imperative that the U.S. take the lead instead of relying on other agencies...

Many have used the analogy of a fire burning out of control to describe this unprecedented Ebola outbreak. Indeed it is a fire-a fire straight from the pit of hell. We cannot fool ourselves into thinking that the vast moat of the Atlantic Ocean will keep the flames away from our shores. Instead, we must mobilize the resources needed to keep entire nations from being reduced to ashes.

Learn more about why this Ebola outbreak became the worst we've ever seen in our 2-minute Vox explainer

read more

During Sierra Leone's bloody 11-year civil war from 1991 to 2002 there were no government-imposed lockdowns, even though people would often hide in their homes out of fear of reprisal from the rebels.

But now, thanks to the Ebola outbreak, the government has announced a three-day mandatory lockdown. From September 19 to 21, citizens of the country will not be allowed to leave their homes in an attempt to stop the spread of Ebola and isolate new cases.

Ishmeal Alfred Charles, who has been working on the Ebola front-line in Freetown, Sierra Leone, says people are devastated about the drastic move. This is what he told Vox:

"This is the first time a lockdown is happening under normal circumstances. During the rebel wars, people did it on their own, for their own safety.

It is only under Ebola we have been faced with such an unfortunate situation.

I feel so terrible about the lockdown. It will multiply the psychosocial impact.

No schooling, no business, nothing is happening. Poverty is on the increase. People are suffering and dying not only from Ebola but from its effects.

This is a sad times for us."

According to the Guardian, Médecins sans Frontières (MSF) has raised concern about the measure.

An MSF spokeswoman said, "It has been our experience that lockdowns and quarantines do not help control Ebola as they end up driving people underground and jeopardizing the trust between people and health providers. This leads to the concealment of potential cases and ends up seading the disease further."

This has been the largest Ebola outbreak in history, with a death toll that has now surpassed 2,000. Sierra Leone has registered 491 deaths as a result of the virus.

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There's a new study about Ebola spreading beyond West Africa, and it seems alarming.

But before you read ahead, please keep this perspective: although Ebola is a brutal nightmare of a disease, and the media have rightly been paying a lot of attention to this epidemic (the worst in history), it's extremely rare, even among causes of death in Africa where Ebola usually strikes. HIV/AIDS, malaria, and diarrhea kill millions of people in Africa every year; Ebola has killed a couple thousand since 1976, when it was discovered.

The chances of a case in the developing world turning into an outbreak are also remote. That's because we know how to stop Ebola and have the tools necessary to do so. Many of these tools are sadly missing in African's under-funded health systems and have therefore created an environment in which the epidemic has spun out of control.

With those caveats in mind, let's look at the new data.

Where will Ebola fly to?

In epidemic or pandemic situations, travelers are the most likely method of transport for a disease. So infectious diseases researchers looked at flight patterns out of West Africa and local transmission dynamics to figure out how likely it would be that an Ebola-positive person gets on a plane with the virus and brings it to a new setting.

aifraff

(Graphic courtesy of PLoS Currents: Outbreaks.)

In a Sept. 2 article in the journal PLoS Currents: Oubtreaks, they published their findings. "Results indicate that the short-term (3 and 6 weeks) probability of international spread outside the African region is small, but not negligible," they wrote.

Ghana, the United Kingdom, Gambia, the Ivory Coast, and Belgium were the countries most at-risk of importing at least one case by Sept. 22, the date they chose as the projected cut-off for their model.

Out of the 16 countries analyzed, the US ranked 13th (toward the last) for risk of importing Ebola by that time. The risk for the US was as high as 18 percent and as low as one percent.

Still, they wrote, "The extension of the outbreak is more likely occurring in African countries, increasing the risk of international dissemination on a longer time scale." In other words, again, it's still Africa most at immediate risk for bearing the burden of this terrible disease. But if the epidemic continues to grow in Africa over the coming the months, that risk of Ebola mutating and going global could grow, too.

Obama calls Ebola "national security priority"

For these reasons, President Barack Obama has called Ebola a "national security priority," according to Time magazine. On NBC's Meet the Press this Sunday, he said, "Americans shouldn't be concerned about the prospects of contagion here in the United States short term, because it's not an airborne disease."

But, he added: "If we don't make that effort now, and this spreads not just through Africa but other parts of the world, there's the prospect then that the virus mutates." At that point, "it could be a serious danger to the United States."

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The third American infected with Ebola will returning to the US for treatment at the Nebraska Medical Center in Omaha, Neb. and is expected to arrive Friday.

The physician, 51-year-old Rick Sacra, was working with the Christian missionary  organization SIM USA in Liberia when he tested positive for Ebola. He wasn't treating Ebola patients, however, but instead working in obstetrics at a hospital in Monrovia, Liberia.

According to the Boston Globe, the Massachusetts native spent most of his career working as a medical missionary in Liberia.

"Rick was receiving excellent care from our SIM/ELWA staff in Liberia at our Ebola 2 Care Center," said Bruce Johnson, president SIM USA in a statement. "They all love and admire him deeply. However, The Nebraska Medical Center provides advanced monitoring equipment and wider availability of treatment options."

He added: "SIM's global family from over 50 countries is extremely grateful for the generous cooperation of many agencies and organizations in the U.S. and in Liberia which made it possible for Rick to be brought to Omaha."

Sacra is technically the fourth American to test positive for Ebola in the current outbreak, which has killed more than 1,500 people (nearly all Africans) to date. That's more than the total number of people killed by all other Ebola outbreaks combined since the first in 1976.

Two other American medical missionary volunteers, Kent Brantly and Nancy Writebol, were recently released from Emory University Hospital after being treated for the Ebola virus, which they had contracted in Liberia.

Patrick Sawyer, an American-Liberian, died from Ebola in July after contracting the disease in Liberia.

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If you'd asked public-health experts a year ago whether an Ebola outbreak could turn into an epidemic spread across borders, they probably would have confidently told you that there was no way: the virus isn't transmitted very easily, and people usually get so sick and die so quickly, it has little opportunity to infect a new host.

Then came 2014, the year that is rewriting  the Ebola rulebook. More people have died from the virus in the last nine months than the total number of deaths since the first recorded outbreak in 1976. The virus has also popped up in enough countries — first Guinea, then Liberia, Sierra Leone, Nigeria, and now Senegal — that the cases add up to the world's first Ebola epidemic.

eboal chart

How did Ebola spiral so badly out of control?

There are a few obvious features that have made this outbreak different and more violent: the virus hit unprepared countries in West Africa that had no previous experience with Ebola, and it quickly moved to densely populated urban hot spots (as opposed to isolated, rural areas where the virus typically popped up in Central and East Africa).

But there are other more subtle factors that are helping Ebola survive today for the first ever Ebola epidemic. They hold lessons for public health responses of the future on how to better contain such a deadly disease.

1) Public-health campaigns started too late and didn't reach enough people

In Uganda, as soon as an Ebola case is identified, public health officials overwhelm all streams of media with messages about how to stay safe. People won't leave their houses out of fear of infection, and they immediately report suspected cases to surveillance officials. It's one of the reasons Uganda has successfully stamped out four Ebola outbreaks, even ones that have turned up in urban areas.

Dr. Anthony Mbonye, Uganda's director of health services, said this aggressive public-health awareness campaigning didn't start soon enough in the current West African outbreak. "They responded too slowly to make the community aware of the disease," he told Vox.

Ishmeal Alfred Charles, who has been working on the Ebola front-line in Freetown, Sierra Leone, said there was little awareness about Ebola until late July, about four months after the first suspected cases emerged in the country.

charles

Ishmeal Alfred Charles washing his hands in Freetown, Sierra Leone. (Photo courtesy of Charles.)

"It only got serious when we lost Dr. Sheik Umar Khan," he said of the prominent local Ebola physician whose July 29 death made international headlines. "That's when the political wheels (started turning) and the government started putting resources together to help."

Charles also noticed that, in the initial periods of the outbreak, most of the public-health messaging about Ebola was concentrated on mainstream media, including TV and radio, so it was mainly reaching the middle- and upper-classes of the country.

"Not a lot of people have access. We're talking about people who are living in very poor communities so they basically have little or no Internet or TV or to radio."

For this reason, by the summer, Charles — who works as a program manager with the Catholic aid agency Caritas — took to the streets to spread the word. "We get people out into small communities to talk to people (about Ebola)," he said. "We gave megaphones to our community volunteers and told them to go public places, to markets, to houses." Of course, the message came too late and Ebola has now reached almost every district in Sierra Leone.

2) The countries affected by Ebola have some of the world's lowest literacy rates

Health campaigning and raising health literacy is not easy in places where people can't read. As you can see in the map below, the countries that are now most affected by Ebola  — Guinea, Liberia, and Sierra Leone, circled in green — are also the ones with the lowest literacy rates in the world.

literarcy

Adult literacy by country. (Map courtesy of Uncesco.)

3) There's a strong Ebola rumor mill

The low levels of literacy, poor access to health information, and delayed public-health campaigning only fueled the Ebola rumor mill. There's no proven treatment for Ebola but lies about supposed cures have spread fast. One persistent myth has been that hot water and salt can stop Ebola. Others suggest faith healing or hot chocolate, coffee and raw onions will stamp out the virus. Homeopathy has also emerged as a supposed Ebola crusher.

In the US, the the FDA has warned consumers to watch out for Ebola quackery, while African public health officials are getting creative to debunk the lies. The electro-beat song 'Ebola in Town' was created to set the record straight about how to avoid the illness. "Ebola, Ebola in town. Don't touch your friend! No kissing, no eating something. It's dangerous!"

In Lagos, Nigeria, the local government resorted to hiring a "rumor manager" to help wage a war on the misinformation that is swirling about. "The rumors themselves can actually cause a lot of damage," Lagos state Commissioner for Health Jide Idris told reporters. And he has reason to be worried. If this disease starts to take off in Lagos - Africa's largest city, population 22 million - some say this could "instantly transform this situation into a worldwide crisis."

4) Sierra Leone, Liberia, and Guinea are some of the poorest countries in Africa with fragile health systems

Before the Ebola outbreak, the three countries hardest hit this year had very weak health systems and little money to spend on health care. Less than $100 is invested per person per year on health in most of West Africa and these countries record some of the worst maternal and child mortality rates on the planet.

ebola

So resources were already extremely constrained when Ebola hit.

Daniel Bausch, associate professor at the Tulane University School of Public Health and Tropical Medicine, who is working with the WHO and MSF on the outbreak put it this way: "If you're in a hospital in Sierra Leone or Guinea, it might not be unusual to say, 'I need gloves to examine this patient,' and have someone tell you, 'We don't have gloves in the hospital today,' or 'We're out of clean needles,' - all the sorts of things you need to protect against Ebola."

In these situations, local health-care workers — the ones most impacted by the disease — start to get scared and walk off the job. And the situation worsens. In Liberia, nurses have gone on strike because of Ebola. When Bausch was in Sierra Leone in July, he and other doctors were left scrambling during a nurse strike, too. "There were 55 people in the Ebola ward," he said, "and myself and one other doctor."

He'd walk into the hospital in the morning and find patients on the floor in pools of vomit, blood, and stool. They had fallen out of their beds during the night, and they were delirious. "What should happen is that a nursing staff or sanitation officer would come and decontaminate the area," he said. "But when you don't have that support, obviously it gets more dangerous." So the disease spread.

5) These countries have spotty disease surveillance networks

These countries also had spotty disease surveillance networks. "We're dealing with countries with very poor health systems to start with," said Estrella Lasry, the tropical medicines adviser for MSF. "That goes from setting up surveillance systems through setting up networks of community health workers."

ebola

An MSF medical worker feeds an Ebola child victim at an MSF facility in Kailahun, Sierra Leone. (Photo by Carl de Souza/AFP.)

By contrast, places that have been able to fight off the virus in the past — like Uganda — have robust disease surveillance systems, said Lasry. That means that suspect cases can be tested and reported on quickly, and that information can spread through the surveillance network in the country as fast as possible so that prevention measures and public-health campaigns are implemented right away.

While there's no way to completely prevent another outbreak from happening, she said, "We can prevent spread by putting the appropriate measures in place so we can identify Ebola and stopping transmission as quickly as possible."

6) The international community responded painfully slowly

"Ebola is a very preventable disease," said Lawrence Gostin, a health law professor at Georgetown University. "We've had over 20 previous outbreaks and we managed to contain all of them."

But this time, the international response just wasn't there. "There was no mobilization," Gostin said. "The World Health Organization didn't call a public health emergency until August — five months after the first international spread."

Part of the reason for the slow response can be attributed to cuts at the WHO that have left the agency understaffed and under-resourced.

But Gostin said this epidemic has also revealed how poorly designed and unready our global systems seem to be for epidemics. In an article published today in the Lancet, he offered this wake-up call for future outbreaks:

"How could this Ebola outbreak have been averted and what could states and the international community do to prevent the next epidemic? The answer is not untested drugs, mass quarantines, or even humanitarian relief. If the real reasons the outbreak turned into a tragedy of these proportions are human resource shortages and fragile health systems, the solution is to fix these inherent structural deficiencies."

7) The countries most affected — and our world — is increasingly interconnected.

The most worrying vector of spread in any epidemic or pandemic is the traveler. And in this outbreak, the three worst-hit countries shared very porous borders, where the disease could easily hop across in people moving around for work or to go to the market.

But Dr. Bausch said this West African outbreak should also serve as a reminder that we live in an increasingly interconnected planet.

"Even from the most remote areas of our world, people are getting more and more connected," he said, "sometimes nationally, sometimes internationally."

This is the new normal, he said, and it should rewrite how public health officials think about Ebola going forward.

"The various different features of this outbreak —where we have an outbreak cutting across international boundaries, involving urban areas — we can think of this as the new norm and we have to be concerned this can happen every time because of the connectivity of places."

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An American physician working with the missionary organization SIM USA in Liberia has tested positive for Ebola, according to the Washington Post.

The unnamed missionary doctor was treating obstetrics patients at the organization's ELWA hospital in Monrovia, Liberia, and was not working with Ebola patients in the facility's isolation unit, which is separate from the main hospital, according to a news release from the organization. He isolated himself immediately upon developing symptoms and has been transferred to the Ebola isolation unit.

This doctor is now  the fourth American to test positive for Ebola in the current outbreak, which has killed more than 1,500 people (nearly all Africans) to date. That's more than the total number of people killed by all other Ebola outbreaks combined since the first in 1976.

Two other American medical missionary volunteers, Kent Brantly and Nancy Writebol, were recently released from Emory University Hospital after being treated for the Ebola virus, which they had contracted in Liberia.

Patrick Sawyer, an American-Liberian, died from Ebola in July after contracting the disease in Liberia.

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The World Health Organization just confirmed that the Ebola outbreak in the Democratic Republic of the Congo is separate from the one occurring in West Africa.

"These findings are reassuring, as they exclude the possibility that the virus has spread from West to Central Africa," the WHO statement read.

The outbreak in the DRC is located in the remote Boende district, in the north-western part of the country. According to the release from the agency, a laboratory report stated, "the virus in the Boende district is definitely not derived from the virus strain currently circulating in west Africa."

Until this year, all previous Ebola outbreaks have occurred in Central Africa. The DRC has had seven outbreaks since 1976, when the first known Ebola outbreak occurred there (then Zaire).

The virus circulating now in the DRC is known as the Zaire strain, which is indigenous to the country. An epidemiological investigation showed that this outbreak started with the preparation of bushmeat —usually fruit bats or monkeys — for consumption on Aug. 11. So far, the WHO has identified 53 cases in the DRC, including 31 deaths.

Where will the Ebola outbreak move next?

healthmpa

(The Ebola outbreak 2014, courtesy of Health Map.)

To date, there have been suspected Ebola cases in Europe, Asia, and North America but none have tested positive. Public health officials are relatively unconcerned about Ebola becoming a big problem in the developed world. That's because outbreaks persist in countries with poor sanitation and a shortage of resources to contain them, not in resource-rich places like the US.

For this reason, continued spread in Africa is really what public health officials are worried about. "Our first concern is that this is going to go into adjacent areas through people traveling in the region," said Daniel Bausch, associate professor at the Tulane University School of Public Health and Tropical Medicine, who is working with the WHO and Médecins Sans Frontières on the outbreak. "In the short term, the main vector is the traveler: local people traveling from one village to the next. On a more regional scale, plane travelers." Travel from Sierra Leone, Guinea, and Liberia — the hardest hit countries — within the African continent is much more prevalent than travel elsewhere.

All countries in West Africa are already on alert. National authorities in Ghana, Nigeria, Togo, and Côte d'Ivoire are working with the WHO on prevention efforts and monitoring potential cases.

To do this, contact tracing is essential, said Bausch. "With Ebola outbreaks, most of the time there's one or very few introductions of the virus from the wild into humans, and all the transmission after that is human-to-human transmission. So people who are traveling locally as well as on planes and other modes of transport, that's the way this would get around."

The worst-case scenario

Even if the outbreak didn't move across any other country border, intensification within the already affected areas is the most immediate health threat. As of Aug. 29, there had been 3,069 probable and confirmed cases and 1,552 deaths. The number of cases continues to accelerate, with 40 percent of the total cases occurring in the last 21 days.

"The worst-case scenario is that the disease will continue to bubble on, like a persistent bushfire, never quite doused out," said Derek Gatherer, a Lancaster University bioinformatician who has studied the evolution of this Ebola outbreak. "It may start to approach endemic status in some of the worst affected regions. This would have very debilitating effects on the economies of the affected countries and West Africa in general."

"Ebola may start to approach endemic status in some of the worst affected regions."

This dire situation could come about because of a "persistent failure of current efforts," he added. "Previous successful eradications of Ebola outbreaks have been via swamping the areas with medical staff and essentially cutting the transmission chains. Doing that here is going to be very difficult and expensive. We have little option other than to pump in resources and engage with the problem using the tried-and-tested strategy—but on a scale previously unused."

Resources are already extremely constrained in most of the countries affected right now. As Dr. Bausch said, "If you're in a hospital in Sierra Leone or Guinea, it might not be unusual to say, 'I need gloves to examine this patient,' and have someone tell you, 'We don't have gloves in the hospital today,' or 'We're out of clean needles,' — all the sorts of things you need to protect against Ebola."

In these situations, local health-care workers — the ones most impacted by the disease — start to get scared and walk off the job. And the situation worsens.

When Bausch was in Sierra Leone in July, he said all the nurses went on strike in one of the hospitals where he was working. "There were 55 people in the Ebola ward," he said, "and myself and one other doctor."

He'd walk into the hospital in the morning and find patients on the floor in pools of vomit, blood, and stool. They had fallen out of their beds during the night, and they were delirious. "What should happen is that a nursing staff or sanitation officer would come and decontaminate the area," he said. "But when you don't have that support, obviously it gets more dangerous." So the disease spreads.

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ebola chart redo use

The current Ebola outbreak in West Africa has now killed more people than all previous Ebola outbreaks combined.

The latest World Health Organization data on this year's Ebola outbreak in West Africa shows 3,069 probable and confirmed cases and 1,552 deaths. The number of cases continues to accelerate, with 40 percent of the total cases occurring in the last 21 days.

The total impact of previous recorded outbreaks — from 1976 to 2013 — included 2,357 cases and 1,548 deaths, according to the Centers for Disease Control and Prevention.

The WHO predicts the disease is going to continue to rip through Africa for another six to nine months, though the organization has vowed to stop the outbreak within that time.

There is also a separate Ebola outbreak occurring in the Democratic Republic of Congo, which the WHO says is unrelated to the West African outbreak.

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One of the big mysteries in the Ebola outbreak in West Africa is where the virus came from in the first place — and whether it's changed in any significant ways. These unanswered questions could be making it more difficult to diagnose the disease and find treatments.

Now scientists are starting to get some answers. In a new paper in Science, researchers reveal that they have sequenced the genomes of Ebola from 78 patients in Sierra Leone who contracted the disease in May and June. Those sequences revealed some 300 mutations specific to this outbreak.

The new analysis could help determine if the virus' behavior has changed — and provide information for future diagnostic tests and treatments.

Among their findings, the researchers discovered that the current viral strains come from a related strain that left Central Africa within the past ten years. And the research confirms that the virus likely spread into Sierra Leone when women became infected after attending the funeral of a traditional healer who had been treating Guinean Ebola patients.

The current Ebola outbreak in West Africa is the worst on record. It has hit four countries, including Sierra Leone, infected approximately 3,000, and killed about 1,500 people. And so far, there is no sign of it slowing down.

The fact that the researchers published the sequence of the Ebola genomes in mere months contrasts with the typically slow pace of scientific research. "We’re trying to do this as fast as possible," says co-senior author Pardis Sabeti, a biologist at MIT and Harvard. This new data increases the number of public Ebola virus sequences fourfold.

The main impact of the paper will be as the foundation of research for years to come as other projects try to sort out what all of these genetic sequences — and their hundreds of mutations — really mean.

The paper is also a sad reminder of the toll that the virus has taken on those working on the front lines. Five of the authors died of Ebola before it was published. All were affiliated with Kenema Government Hospital in Sierra Leone.

What genetic sequences can tell us about Ebola

Ebola tree lineage

(Gire, SK, et al. Science, August 28, 2014.)

Viruses randomly mutate over time. This is completely normal for viruses, and there's no reason to think that Ebola's mutation rate is anything weird or unusual.

Scientists can use these mutations as markers to piece together how the Ebola virus has traveled from person to person. Because they know the general mutation rate of the virus, they can also pin down the dates of when the disease spread.

So what has this analysis revealed? Using genetic sequences from current and previous outbreaks, the researchers mapped out a family tree that puts a common ancestor of the recent West African outbreak some place in Central Africa roughly around 2004. This contradicts an earlier hypothesis that the virus had been hanging around West Africa for much longer than that.

The data, on the whole, supports what epidemiologists have already deduced about how the virus spread into Sierra Leone. More than a dozen women became infected after attending the funeral of a traditional healer who had been treating Guinean Ebola patients and contracted the disease.

One surprise from the paper is that two different strains of Ebola came out of that funeral. This suggests that either the healer was infected with two different strains or that another person at the funeral was already infected.

As Ebola then traveled across Sierra Leone, a third strain of the virus appeared.

Why having Ebola gene sequences is helpful

Some Ebola diagnostic tests have been designed to detect areas that have mutated in the Ebola virus samples from this outbreak, raising the possibility these tests might be losing accuracy. One of the things Sabeti plans to do next is test whether that's actually the case.

Diagnosing Ebola can actually be more difficult than it might sound. The disease often looks like a lot of other feverish illnesses that can be common. And at a later stage, only some patients end up bleeding.

However, it's essential to know who has it as soon as possible, especially so that health-care workers can use appropriate procedures to prevent transmission to themselves and others. So accurate diagnostic tests are absolutely needed.

Researchers are also planning to study the mutations to see if any of them are affecting Ebola's recent behavior. The number of mutations found is completely normal, and it isn't necessarily the case that they'll have a big effect. But it's possible that something intriguing could turn up.

For example, this outbreak has had a higher transmission rate and lower death rate than others, and researchers are curious if any of these mutations are related to that. (Right now, social factors are thought to be the main causes of these two changes.)

"It sets the stage for the next few years of research that will reveal the differences between this virus and previous versions of Ebola virus," says Erica Ollmann Saphire, who researches Ebola and similar viruses at The Scripps Research Institute in La Jolla, California.

"My laboratory will be using this sequence information to understand the molecular effects of these mutations," she says. "We will also be looking at our pool of antibody therapeutics beyond ZMapp to ensure that candidate cocktails are optimally effective against these circulating strains."

Those working on other long-term projects involving vaccines should also find this information helpful.

The longer Ebola circulates, the more opportunities it has to change — possibly for the worse

Although Ebola's mutation rate itself isn't anything unusual, the longer it's circulating in people, the more chances it will have to randomly come up with a mutation that it will find beneficial — possibly to the detriment of human health.

"You never want to give a virus that kind of opportunity," Sabeti says. "We hope that this work opens up new doors for more people to work together to stop this virus now."

Update: Clarified that the speed of publication, not necessarily the speed of sequencing, is remarkable.

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The United States will begin the first-ever human trials of an Ebola vaccine, the National Institute for Health announced Tuesday.

The NIH will start a Phase I trial in September with three volunteers who have already enrolled in the experiment. The NIH hopes to expand the trial group to 20 people, and report initial results about the vaccine's efficacy by the end of the year.

The new vaccine was developed in partnership between the federal government and GlaxoSmithKline, one of the world's largest pharmaceutical companies. It comes as the Ebola outbreak shows no sign of abating, with the World Health Organization projecting Thursday morning the virus could infect as many as 20,000 people.

"This public health emergency demands an all-hands-on-deck response," said Anthony Fauci, director of the National Institute of Allergy and Infectious Disease. "We have accelerated the timeline for testing vaccines we have been working on for many years."

No current vaccine or treatment for Ebola currently exists and finding investment to fight the disease — which tends to afflict some of the poorest populations in the world — has been a constant challenge.

"These outbreaks affect the poorest communities on the planet," says Daniel Bausch, an associate professor at Tulane University who has worked on disease outbreaks.  "Although they do create incredible upheaval, they are relatively rare events. So if you look at the interest of pharmaceutical companies, there is not huge enthusiasm to take an Ebola drug through phase one, two, and three of a trial and make an Ebola vaccine that maybe a few tens of thousands or hundreds of thousands of people will use."

The goal of the Ebola vaccine, Faluci said, was to develop a vaccine that could be used to immunize those who are at high risk of catching the disease, like health care workers,  and also communities that are facing an outbreak situation.

The NIH did not provide any estimate of when the the testing would be completed or when the vaccine could be available for more widespread use. Phase I is only the first step in the drug-approval process. It's the phase where drug companies test whether a drug is safe — that it doesn't create dangerous complications or side effects — before larger studies look at whether the drug actually works.

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On Sunday, August 24, the Democratic Republic of the Congo reported two cases of Ebola. Today, the World Health Organization released a statement saying that it believes this newest outbreak is unrelated to the ongoing outbreak in West Africa.

According to the WHO, the Democratic Republic of the Congo outbreak likely started when a woman ate meat from a wild animal that her husband had recently hunted. She developed Ebola-like symptoms and then died on August 11.

Doctors were initially unaware that she had Ebola, which helped the illness spread to a suspected 23 additional people, including health-care workers and relatives. Already, 13 have died.

The WHO reports that these people hadn't traveled to West Africa recently or had contact with anyone who had.

The Democratic Republic of the Congo (formerly Zaire) knows Ebola well, so it's unlikely that these cases will spiral out of control like they have in West Africa. The nation has had — and controlled — six previous Ebola outbreaks, most recently in 2012. So far, there's nothing unusual going on in the Democratic Republic of the Congo.

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There's an outbreak of Ebola fear and misperception in the US, according to a new poll from the Harvard School of Public Health, via Mother Jones.

The nationally representative Harvard School of Public Health poll found that four in ten adults are worried about a large outbreak in the US, 26 percent are concerned that someone in their immediate family may get contract Ebola over the next year, and 68 percent of respondents said they believe Ebola can spread easily.

The poll also found that there was a link between education and fear, with less educated people reporting more fear about the deadly virus.

The World Health Organization and US Centers for Disease Control all point out that the chance of Ebola spreading through America or any other developed country is very slim, since Ebola outbreaks occur in places with a poor health infrastructure and limited resources to stop the spread.

Unlike air-borne illnesses, Ebola is also difficult to contract. The virus spreads through direct contact with the bodily fluids of a symptomatic person.

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One of the major steps of controlling an epidemic such as Ebola is to track down the chain of human transmission — and perhaps in doing so, find lessons to better protect people now and in the future.

AFP reports that a health official identified a key link in the spread of Ebola from Guinea to Sierra Leone: just one woman.

She was an herbalist in Sierra Leone who claimed that she could heal the disease, according to AFP. The story seems to suggest that if not for this one link, the disease may not have entered Sierra Leone, where it has now killed approximately 370 people.

People with Ebola came from Guinea to seek healing. The healer caught the disease, and died.

Then, people came from surrounding towns for her funeral and caught Ebola from her body or contaminated objects. (Traditional funeral practices involve directly touching the body, which can transmit the disease.) When the mourners returned home to a wider area, they took the disease with them.

People are still working to track the Ebola outbreak down to its initial source — when the virus jumped from an animal to a person in Guinea. According to the New York Times, researchers suspect that this person, often called Patient Zero, may have been a two-year-old boy.

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Kent Brantly and Nancy Writebol left Atlanta's Emory University Hospital on Thursday, after receiving treatment there for Ebola contracted while working as missionaries.

The two, who worked with the Christian organization Samaritan's Purse in Liberia, were released from hospital after "a rigorous course of treatment and thorough testing," Emory's Dr. Bruce Ribner said. He added that they pose "no public health threat."

Here is Brantly's full statement:

"Today is a miraculous day. I am thrilled to be alive, to be well and to be reunited with my family. As a medical missionary, I never imagined myself in this position. When my family and I moved to Liberia last October to begin a two-year term working with Samaritan's Purse, Ebola was not on the radar. We moved to Liberia because God called us to serve the people of Liberia.

"In March, when we got word that Ebola was in Guinea and had spread to Liberia, we began preparing for the worst. We didn't receive our first Ebola patient until June, but when she arrived, we were ready. During the course of June and July, the number of Ebola patients increased steadily, and our amazing crew at ELWA Hospital took care of each patient with great care and compassion. We also took every precaution to protect ourselves from this dreaded disease by following MSF and WHO guidelines for safety.

"After taking Amber and our children to the airport to return to the States on Sunday morning, July 20, I poured myself into my work even more than before - transferring patients to our new, bigger isolation unit; training and orienting new staff; and working with our Human Resources officer to fill our staffing needs. Three days later, on Wednesday, July 23, I woke up feeling under the weather, and then my life took an unexpected turn as I was diagnosed with Ebola Virus Disease. As I lay in my bed in Liberia for the following nine days, getting sicker and weaker each day, I prayed that God would help me to be faithful even in my illness, and I prayed that in my life or in my death, He would be glorified.

"I did not know then, but I have learned since, that there were thousands, maybe even millions of people around the world praying for me throughout that week, and even still today. And I have heard story after story of how this situation has impacted the lives of individuals around the globe - both among my friends and family, and also among complete strangers. I cannot thank you enough for your prayers and your support. But what I can tell you is that I serve a faithful God who answers prayers.

"Through the care of the Samaritan's Purse and SIM missionary team in Liberia, the use of an experimental drug, and the expertise and resources of the health care team at Emory University Hospital, God saved my life - a direct answer to thousands and thousands of prayers.

"I am incredibly thankful to all of those who were involved in my care, from the first day of my illness all the way up to today - the day of my release from Emory. If I tried to thank everyone, I would undoubtedly forget many. But I would be remiss if I did not say thank you to a few. I want to thank Samaritan's Purse, who has taken care of me and my family as though we were their own family. Thank you to the Samaritan's Purse and SIM Liberia community. You cared for me and ministered to me during the most difficult experience of my life, and you did so with the love and mercy of Jesus Christ.

"Thank you to Emory University Hospital and especially to the medical staff in the isolation unit. You treated me with such expertise, yet with such tenderness and compassion. For the last three weeks you have been my friends and my family. And so many of you ministered to me not only physically, but also spiritually, which has been an important part of my recovery. I will never forget you and all that you have done for me.

"And thank you to my family, my friends, my church family and to all who lifted me up in prayer, asking for my healing and recovery. Please do not stop praying for the people of Liberia and West Africa, and for a quick end to this Ebola epidemic.

"My dear friend, Nancy Writebol, upon her release from the hospital, wanted me to share her gratitude for all the prayers on her behalf. As she walked out of her isolation room, all she could say was, 'To God be the glory.' Nancy and David are now spending some much needed time together.

"Thank you for your support through this whole ordeal. My family and I will now be going away for a period of time to reconnect, decompress and continue to recover physically and emotionally. After I have recovered a little more and regained some of my strength, we will look forward to sharing more of our story; but for now, we need some time together after more than a month apart. We appreciate having the opportunity to spend some time in private before talking to some of you who have expressed an interest in hearing more of our journey. Thank you for granting us that.

"Again, before we slip out, I want to express my deep and sincere gratitude to Samaritan's Purse, SIM, Emory and all of the people involved in my treatment and care. Above all, I am forever thankful to God for sparing my life and am glad for any attention my sickness has attracted to the plight of West Africa in the midst of this epidemic. Please continue to pray for Liberia and the people of West Africa, and encourage those in positions of leadership and influence to do everything possible to bring this Ebola outbreak to an end. Thank you."

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Since the first known Ebola outbreak in 1976, the virus' attack on West Africa this year has been the worst ever.

But what does that actually look like? The current issue of the New England Journal of Medicine has several pieces dedicated to Ebola, including this one in which the authors chart the outbreak's exponential growth:

ebola

(New England Journal of Medicine)

In the issue, the head of the Centers for Disease Control Tom Frieden also leads an article on what it will take to prevent future Ebola outbreaks, and isolates these three measures:

The first is meticulous infection control in health care settings. The greatest risk of transmission is not from patients with diagnosed infection but from delayed detection and isolation. Since the early symptoms of Ebola virus disease (EVD) - fever, nausea, vomiting, diarrhea, and weakness - are nonspecific and common, patients may expose family caregivers, health care workers, and other patients before the infection is diagnosed.

Second, educating and supporting the community to modify long-standing local funeral practices to prevent contact with body fluids of people who have died from EVD, at least temporarily until the outbreak is controlled, will close the second major route of propagation of the virus. This is a culturally sensitive issue that requires culturally appropriate outreach and education.

And third, avoiding handling of bush meat (wild animals hunted for sustenance) and contact with bats (which may be the primary reservoir of Ebola virus) can reduce the risk of initial introduction of Ebola virus into humans. Bush meat consumption could be reduced through socioeconomic development that increases access to affordable protein sources. Where bush meat consumption continues, safer slaughter and handling can be encouraged. The potential effect of deforestation and other environmental changes on increasing human-bat contacts needs to be further studied and addressed.

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This week, the World Health Organization announced that it is ethical to give untested drugs to Ebola sufferers in what is the worst-ever outbreak. The announcement came after uneasy questions about Ebola medicine emerged following the treatment of two Americans with the experimental drug ZMapp. Some critics asked why Africans didn't have the same access.

Wider use of experimental medications, the WHO said, could be helpful at a time when there are no approved treatments or cures for Ebola. But not everyone agrees. Dr. Philip Rosoff, who specializes in clinical ethics at Duke University, says he's concerned that the decision to test experimental drugs during this outbreak may hurt more people than it helps. Here's a transcript of our conversation.

Julia Belluz: The WHO endorsed the use of experimental treatment in this outbreak, but you disagree with that decision. Why?

Philip Rosoff: If you read the WHO release on the ethics of using these drugs, they emphasize a couple of points: it should be okay to use them, but informed consent should be gotten. That seems to be self-evident but I'm not sure what informed consent means under situations of such desperation when a drug that's never been used in people is held out as a life saver.

JB: Some might say that's a necessary evil: One of the main reasons for approving the use of these medicines was that, with proper data collection after they're given out, we may be able learn about whether they work and we'll potentially have more tools to help people in future outbreaks.

PR: That's the second problem: the WHO talks about collecting data but that's going to be almost impossible to do. It'll be impossible to decide whether it's effective or not because it's not going to be used under controlled circumstances. When people get better, we'll have no idea whether it was because people are using the drug, or if somebody dies after getting the drug you don't know whether it's the disease or the drug. Because these patients are so sick, it may not be possible to detect side effects that you could under more controlled circumstances.

All of these drugs have never been tested in humans. Animal experiments are good and important to do prior to testing in humans. But they're only of limited value. Only a small percentage of drugs that start being tested in labs as potentially interesting finally make it to being approved as safe and effective by the Food and Drug Administration.

"Desperation doesn't necessarily breed good science or good medicine."

JB: Are you concerned about precedent — that we could be rushing to this decision, and if all doesn't go well, it may set a low bar for how we handle future outbreaks?

PR: I think people have been rushing a little too quickly and not thinking about some of the more complex and intricate issues that are raised by this situation. I think that if this goes forward, and people start using this drug and we make a precedent that we're going to use highly experimental, never-before-tried drugs in desperate situations, then we might make more mistakes than see benefits.

Desperation doesn't necessarily breed good science or good medicine. I think desperation breeds desperate measures that aren't the best measures.

JB: You've also mentioned a concern that there may be challenges with deciding who gets treatment. Can you explain that?

PR: Because the outbreak is mostly occurring in Africa, there's a rationing problem. If you are going to use this drug, who should get it? There's quite a bit of controversy about the fact that three people who have gotten [ZMapp] are all Caucasian, all from western countries. None of the people most affected by the outbreak have received this drug. So are all these people equally deserving of this particular drug since we don't know anything about who it might work better with?

There is a long and sordid history of western pharmaceutical companies doing clinical trials in Africa and subjecting Africans who are poor or under-educated to experimental drugs that would never be used there be used on  westerners. Luckily there are conventions that have eliminated that activity. On the other hand, people are concerned that the three people treated so far are from wealthy western countries and not those that are most affected. Either way, this brings up memories about the bad old days.

JB: Another justification for sanctioning the use of unproven drugs is that they're better than the alternative — near certain death from Ebola. Supporters of the use of experimental treatments say that doing something is better than nothing.

PR: I say the question is whether we're actually going to be able to learn anything using this drug in such a spotty way without any kind of control groups. I suppose you could say that you have historical control groups: you know a certain percentage of people who contract Ebola die. If you use this drug in a large enough group of people, you could compare that with a historical control.

But there's any number of problems with that. If this were a uniformly fatal disease where virtually everyone who got it died, you could make a case that you should be able to learn something. But with good, supportive care a reasonable percentage of people with Ebola do live through this.

There's going to be bias in terms of who you decide to put on the drug. For instance, one of the nice things about a randomized trial is that the people who decide who goes on the drug don't have any power over who gets placebo and who gets the drug. If you decide to leave it up to treating physicians, there may be a hidden bias that they should only give it to people who are getting better anyway. And then you may mistakenly assume that the drug is efficacious, but it is not.

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Like an unstoppable forest fire, this Ebola outbreak has been burning through West Africa for weeks. So far, nearly 2,000 cases have been recorded, and the death toll has surpassed 1,000. In total, that's about three times the people affected by the sum of every other Ebola outbreak in history.

But beyond the spread of the deadly virus, other factors are making this outbreak much worse than anyone could have imagined. Here are five reasons why:

1) Other diseases are on the rise

Before the Ebola outbreak, the three countries most affected had very weak health systems and little money to spend on health care. As Vox reported, less than $100 is invested per person per year on health in most of West Africa and these countries record some of the worst maternal and child mortality rates on the planet.

Ebola is depleting those already scarce supplies. Hospitals and clinics have been shut down since the outbreak, so people don't have access to the usual maternity or malaria care they need. The effect of Ebola on health will spread much further than the virus itself. In an interview with the Independent, Dr. Jimmy Whitworth — the head of population health at the UK health foundation Wellcome Trust — said:

"With Ebola, the whole general health system is collapsing. People aren't going to hospitals or clinics because they're frightened, there aren't any medical staff or nursing staff available. Some hospitals have been entirely taken over by Ebola patients, which means other people not getting a look-in."

He and others have projected that, at the very least, more people will die from malaria this year as a result.

2) People are going hungry

The United Nation's World Food Programme declared Guinea, Liberia and Sierra Leone a level three food emergency — its most urgent warning. They and other aid agencies are trying to get food staples into quarantined areas that have been shut down to stop the spread of Ebola.

According to this Reuters report, doing so has been difficult and the result is food shortages and price inflation: "Hunger is spreading fast as farmers die leaving crops rotting in fields. Truckers scared of the highly infectious disease halt deliveries. Shops close and major airlines have shut down routes, isolating large swathes of the countries."

liberia ebola

A Liberian health worker interviews family members of a woman suspected of dying of the Ebola virus in Monrovia, Liberia. (John Moore/Getty Images)

3) Fear is crippling already fragile economies

People fear doctors and nurses will give them the virus. Doctors and nurses fear that they will get sick and have walked off the job. The outbreak worsens, and that fear has scaled up to the nation level. Countries, including the US, are telling their foreign workers to leave West Africa. Despite the fact that the World Health Organization has advised against doing so, many airlines have halted flights in the region.

As a result, the tourism industry in these places is taking a blow and goods can't flow freely. Besides flight bans, quarantine zones and closures at the borders of Guinea, Liberia, and Sierra Leone are crippling local businesses. According to the Economist, the World Bank has already cut its economic-growth estimate for Guinea by one percentage point, and the Liberian finance minister said the IMF's estimated 5.9 percent growth in his country is not going to become a reality this year. So even bigger than the already outsized death toll might be an economic one.

4) The outbreak is a lot bigger than current estimates suggest

On August 13, the United Nations secretary-general Ban Ki-moon said the outbreak in West Africa is now touching the lives of more than 1 million people in and around the borders of the three countries most impacted by the disease.

In an announcement the next day, the WHO said in a statement, "Staff at the outbreak sites see evidence that the numbers of reported cases and deaths vastly underestimate the magnitude of the outbreak." This means the world's worst Ebola outbreak in history is even more deadly than we thought.

5) Misinformation is spreading faster than the disease

There's no proven treatment for Ebola but rumors about supposed cures are spreading fast. One persistent myth is that hot water and salt can stop Ebola. Others suggest faith healing or hot chocolate, coffee and raw onions will stamp out the virus. Homeopathy has also emerged as a supposed Ebola crusher.

In the US, the the FDA has warned consumers to watch out for Ebola quackery. Other public health officials are getting creative to debunk the lies. In Africa, the electro-beat song 'Ebola in Town' was created to set the record straight about how to avoid the illness. "Ebola, Ebola in town. Don't touch your friend! No kissing, no eating something. It's dangerous!"

In Lagos, Nigeria, the local government hired a "rumor manager" to help wage a war on the misinformation that is swirling about. "The rumors themselves can actually cause a lot of damage," Lagos state Commissioner for Health Jide Idris recently told reporters. And he has reason to be worried. If this disease starts to take off in Lagos — Africa's largest city, population 22 million — some say this could "instantly transform this situation into a worldwide crisis."

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As my colleague Julia Belluz pointed out, the recent Ebola outbreak in Africa has forced the global medical community to face thorny ethical questions. Doctors have had to grapple with what it means to give patients experimental treatments, and who should get priority.

But there's a separate ethical conundrum facing religious scholars: what does it mean for two Christian missionaries to receive treatment that the people they traveled to Africa to serve couldn't access?

The Americans who received treatment were not tourists on vacation; they were Christian mission workers charged with the responsibility of carrying out the Christian mandate to serve the unserved, the have-nots, and the physically ill. They were missionaries with the Christian organization SIM USA. Though not affiliated with one particular branch of Christianity, SIM affirms that each of its missionaries is "committed to the essential truths of biblical Christianity." (Here is a link from their website where they explain what they mean by that.) SIM also affirms its first commitment to "Respond to Need" of all kinds, wherever they find it:

Our goal is to meet people's physical needs as we also share how Jesus can meet their spiritual needs. Help and relief come in many forms. Whatever the need, we are compelled to respond with the love of Jesus.

When seen in this light, then, the ethical conundrum raised by the Ebola outbreak is this: Does receiving treatment that could potentially be used for another Ebola patient somehow come into conflict with the missionaries' religious commitment to serving those patients? If Jesus commanded his followers to put the needs of others before their own — "whoever would be great among you must be your servant" — then should the missionaries have turned down the treatment?

Of course, the problem with framing the question this way is that it presumes that the Americans were the ones deciding who the drugs would go to. They weren't. The FDA made that decision — the Americans only agreed to it. But what if the Americans had turned down the treatment?

"It isn't clear to me that if the Americans refused the drugs that they would then go instead to the people who they were serving," says Charles C. Camosy, associate professor of christian ethics at Fordham University. In other words, he said in an email, at the time the missionaries agreed to treatment, the choice seemed to be either (1) the missionaries get the drug, or (2) no one does. "I can understand why someone would be hesitant, but my instinct would be to say that it is not wrong for [the missionaries] to choose (1) over (2)."

According to Celia B. Fisher, another bioethicist at Fordham, the fact that the Ebola epidemic is affecting many people changes the moral question significantly. The question, then, isn't "whether or not a missionary has a moral obligation to prioritize one other person's health over his own," but rather "which choice has the greater possibility of preventing the spread of disease across many people."

If a missionary's goal is curing Ebola in every infected patient, then yes, taking one of the available treatments might be at odds with that goal. But if, however, she is concerned with decreasing the overall length or force of the epidemic, then agreeing to a trial of an experimental drug might be more in line with her goal as a missionary.

"Another issue unique to the current Ebola crisis," noted Fisher, "is that the effectiveness and side effects of the medication are unknown." When the missionaries agreed to take the medication, they, along with the health professionals who administered it to them, were unsure of whether the treatment would work or not. Until it is approved, ZMapp provides "no guarantees and some risks" to those who agree to its use in treatment, said Fisher. In fact, Miguel Pajares, the Spanish missionary who was given the drug, ended up dying. Instead of asking if it's ethical to give limited medications to Americans before Liberians, ethicists need to ask if it's ethical to give potentially harmful medications to Liberians before Americans.

As Fisher notes, previous clinical trials that administered experimental drugs to individuals living in low-resource countries were criticized for treating those individuals like "guinea pigs." There might be a case to be made, then, that agreeing to the unapproved drugs was the altruistic choice for the Americans to make since it may end up providing valuable information to Western doctors as they continue to search for a cure.

Once the missionaries have recovered, Fisher said, they might be able "to motivate the [infected] community to adopt health measures that will stem the disease — a skill the other Ebola patients may not possess." She added: "the most life-saving steps are those that guide the community in public health safety procedures."

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Is it possible that most of the people killed by the Ebola outbreak in West Africa will never actually contract the disease?

New, worrying information from Sierra Leone suggests that damage from the disease may go far beyond deaths from the Ebola virus itself. Rather, Ebola is claiming more victims by damaging already-weak local health systems and their ability to respond to other medical problems, from malaria to emergency c-sections. The Ebola-driven rise in deaths from those other maladies may outpace the deaths from Ebola itself.

The effect of the loss of services may be severe. Even before the Ebola outbreak, Sierra Leone was ranked the seventh-worst country in the world for maternal and child mortality. In 2012, the aid group Save the Children reported that 18 percent of children in Sierra Leone did not survive to age 5, and one in 25 women died of childbirth or pregnancy-related causes. If these fears prove correct, those numbers may be about to get much worse.

Ebola is decimating local health workers

Bichat_hospital_ebola_room

A picture taken on August 6, 2014 at the Bichat Hospital in Paris shows one of the rooms especially prepared for potential patients infected by the Ebola virus. (Fred Dufour/AFP/Getty Images)

The International Rescue Committee's health coordinator in Sierra Leone, Laura Miller, said that damage to the health care system is the "biggest threat" that the Ebola outbreak poses to the country.

Miller estimated that the virus has already killed 10 percent of the medical staff in Kenema district hospital, which is located in one of the most-affected regions of Sierra Leone. She said 40 health care workers from a single government hospital there have died. Although the IRC has not yet lost any of its staff members to infection, Miller noted that many of the local staffers have suffered terrible losses in their own families.

"The people who are on the ground here, who are Sierra Leonean and whose families have been affected, but who are still working every day to combat this outbreak, are the real heroes here," she said.

Losing so many health workers would be a tragedy anywhere, but it is particularly devastating in Sierra Leone, which has been struggling to rebuild its health-care system since the civil war ended 12 years ago. Much of that progress has already been destroyed, and there is no telling how many more workers may die before the infection is brought under control.

Ebola is depleting blood banks and essential supplies

Ebola_aid_supplies_plane

Workers unload medical supplies from a plane on August 11, 2014 at the Robertsfield international airport, near Monrovia. The supplies, coming from China and worth 4.9 million USD (around 3.7 million euro), are destined for countries hit by the Ebola outbreak. (Zoom Dosso/AFP/Getty Images)

Currently, most of the international aid response to the outbreak in Sierra Leone has been focused on building up the Ebola isolation units themselves — the specialized hospital facilities where infected patients are treated. However, Miller worried that this strategy overlooks growing shortages of other vital health resources.

Sierra Leone is currently suffering shortages of everything from latex gloves to the reagents needed for laboratory tests. As those resources are directed towards the desperate struggle to control the Ebola outbreak, they are unavailable for other types of care. The country is also suffering an acute shortage of blood — both because blood donations cannot be collected safely during the Ebola outbreak, and because available stocks have been used up.

All of that means there are fewer supplies available for non-Ebola medical needs.

Ebola is destroying trust in the health-care system

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A picture taken on June 28, 2014 shows members of Doctors Without Borders (MSF) putting on protective gear at the isolation ward of the Donka Hospital in Conakry, where people infected with the Ebola virus are being treated. (Cellou Binani/AFP/Getty Images)

Perhaps worst of all, however, is the damage the disease has done to local communities' trust in the health-care system, which may have harmful ramifications for years to come.

"In the end," said Miller, "the largest number of fatalities in this outbreak are going to be women and children. And it will be because they didn't go to the health facility."

Some of that loss of trust is entirely reasonable: hospitals in affected regions of Sierra Leone are very dangerous places right now. Medical facilities have struggled to implement effective infection control measures, which has left health workers and uninfected patients at risk of contracting Ebola.

But, Miller said, wild rumors are also circulating, accusing health care workers of injecting people with Ebola, and other false claims. This has raised suspicions of all medical care, but particularly injections. That fear has made families reluctant to vaccinate their children and women reluctant to accept Depo-Provera contraceptive shots. If this problem persists, it will also make replenishing depleted blood supplies a major challenge, even after the outbreak is controlled enough for blood donation to resume. That trust will have to be earned back over time, and it will likely take a lot of work to regain what has been lost.

All of this means dangerously reduced health-care services

Conakry_health_workers

Medical staff attending a meeting as they prepare for an intervention at the isolation ward of the Donka Hospital in Conakry, where people infected with the Ebola virus are being treated. (Cellou Binani/AFP/Getty Images)

In the meantime, people are left without the care that they need. "There's going to be a major decline in the number of women who decide to deliver at the health facility, the number of new acceptors of family planning, the number of women who attended four antenatal care visits, the number of children who went to get malaria treatment," Miller said.

The IRC has seen "significant, dramatic declines in service delivery at the health facilities" in the past month, "because people are rightfully scared to go to the health facility right now."

Correction: This article originally said that Laura Miller is the IRC's medical country director, but she is actually its health coordinator. It also said that blood bank resources had been used in Ebola treatment, but the IRC has clarified that transfusions are not typically part of treatment for the disease, so the reference to blood being used for Ebola treatment has been removed.  The article has also been updated to reflect that the estimated 10% of health workers were lost in a single hospital, not the entire Kenema district.

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As the death toll from the current Ebola outbreak in West Africa surpassed 1,000, an expert panel met in Geneva to weigh the ethics of giving sufferers not-yet-approved Ebola treatments.

Their conclusion? This outbreak is so bad, it calls for exceptional measures, and so it's ethical to try drugs — even untested, experimental ones — in humans.

In the particular circumstances of this outbreak, and provided certain conditions are met, the panel reached consensus that it is ethical to offer unproven interventions with as yet unknown efficacy and adverse effects, as potential treatment or prevention.

This uneasy conversation was brought to the fore after two Americans received an experimental drug called ZMapp, and critics raised questions about why Africans didn't have the same right.

Though some have pointed out that people probably would have criticized the WHO for testing treatments in Africans, others have said that — because this disease is so deadly and sufferers are left with few alternatives — the potential benefits of using unapproved therapies probably outweigh the harms.

Still, the WHO had some cautions:

Ethical criteria must guide the provision of such interventions. These include transparency about all aspects of care, informed consent, freedom of choice, confidentiality, respect for the person, preservation of dignity and involvement of the community.

As well, they said data must be collected in order to guide future use and fully understand the safety and effectiveness of these drugs.

You can read the full announcement here.

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The deadliest Ebola outbreak in history is going on right now, and the efforts to contain it will be underway for quite some time. If you want to stay up-to-date, this Twitter list is a great place to start for English-language news, analysis, and first-person reports.

Check it out below. Or click here to subscribe to the list on Twitter.

(We may continue to add names to the actual Twitter list without adding them below. So please subscribe to the list for updates.)


Reports from West Africa

1) Umaru Fofana

Sierra Leonean journalist, writing for BBC & Reuters


2) Bate Felix Tabi Tabe

Correspondent for Reuters


3) Abdul Tejan-Cole

Ex ACC Commissioner Sierra Leone, in Senegal


4) David McKenzie

CNN reporter, in West Africa

5) Clair MacDougall

Reporting from Liberia for various news outlets

6) Ben Solomon

Video Journalist for The New York Times, reporting from Sierra Leone

7) Tommy Trenchard

Journalist and photographer, reporting from Sierra Leone

8) Jason Beaubien

NPR reporter, in Sierra Leone

News and analysis

9) Crawford Kilian

Retiree meticulously tracking infectious disease news



10) Helen Branswell

Medical reporter for The Canadian Press.

11) Abena Dove Osseo-Asare

Historian of medicine

12) Sanjay Gupta

CNN chief medical correspondent and a staff neurosurgeon at Emory University in Atlanta, where two Americans with Ebola are being treated


13) Laurie Garrett

Senior fellow at Council on Foreign Relations, former journalist


14) Susan Shepler

Professor at American University, focusing on youth and conflict in West Africa


15) Maryn McKenna

Journalist, Atlanta resident

16) Tara Smith

Infectious disease epidemiologist

17) Kim Yi Dionne

Professor of government at Smith College

18) Ian Mackay

Virologist

19) Kerry Sheridan

AFP reporter

20) BBC Africa

African news from the BBC


Organizations fighting Ebola

21) Doctors Without Borders (MSF) UK press team

MSF is one of the only organizations directly treating Ebola patients. This is their UK feed.


22) MSF Picture Desk

Photos from the field, from Doctors Without Borders (MSF)

23) IFRC

International Federation of Red Cross and Red Crescent Societies


24) WHO

The UN's World Health Organization

25) UNICEF Liberia

Liberian outpost of the children's welfare organization


The American Angle

26) CDC

Centers for Disease Control and Prevention

27) Emory Healthcare

Its hospital is treating two Americans with Ebola

28) Samaritan's Purse

Christian aid organization affiliated with the two Americans with Ebola

29) Cameron McWhirter

Wall Street Journal reporter, in Atlanta


Want even more? Kristen Hare, from Poynter.org, has an ever-growing Twitter list of Ebola outbreak reporters. And also h/t to Kim Yi Dionne, who has a great list of Twitter and Facebook accounts.

Update: Add more Twitter accounts on August 11.

Correction: The piece originally misidentified David McKenzie's news outlet. He's at CNN, not the BBC.

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Ebola is not like the flu. You're not going to catch the disease from simply being across the room from someone who has it.

Basically every health agency in the world agrees on this point. In order to catch Ebola, you have to come in contact with bodily fluids — such as sweat, saliva, vomit, or diarrhea — of someone who already has Ebola and is exhibiting symptoms. (A person who is infected but not yet showing symptoms generally isn't infectious.)

And yet, remarkably, many readers have been unconvinced by this point. They keep e-mailing and pointing to a 2012 paper finding that, in a single laboratory study, Ebola spread from pigs to monkeys that hadn't directly touched each other. Some readers claim this paper is proof that Ebola can travel miles through the air to kill people.

Those claims are wrong — but what does the study really say? To find out, I called up the first author of that study, Hana Weingartl, a scientist at the Canadian Food Inspection Agency.

Why pigs are different from people

Here's what actually happened in the 2012 experiment. Six piglets with Ebola were housed next to four monkeys separated in cages.  A buffer zone of roughly 8 inches separated the pigs from the monkeys so that they couldn't touch each other directly. Then, two of the monkeys got Ebola fast enough that it was clear that they caught it from the pigs.

But just because this happened between pigs and monkeys doesn't mean it's likely to happen between people. The big difference is that pigs cough and sneeze a lot when they're sick with Ebola — way more than people do.

"You cannot take the pigs and think that it will go the same way in humans," Weingartl said. "One has to consider the species. For pigs, the [Ebola] infection ends up as an infection of the lungs — they have high amounts of the virus in the respiratory tract and so they cough it out. Or when they sneeze or squeal, it just gets out of the lungs. So the virus is in the air directly."

But Ebola affects primates in a different way, Weingartl says. For them, "the main target organ is the liver, so they have high amounts of the virus in the blood and in the feces. They will not be coughing out the virus. And that’s why indirect transmission without contact is probably not happening [among primates and humans]."

Several papers have addressed possible transmission between primates in laboratory settings, including one published on July 25. That one showed no airborne transmission. Another from back in 1995 described transmission without direct contact, but couldn't determine if this was from big droplets, tiny aerosol droplets, or something else.

Of course, it's entirely possible that a big spit droplet from a human Ebola patient could fly a few feet through the air and land on someone else. But current Ebola protection measures seem to guard against this. Health-care workers are told to cover their faces and bodies with protective gear, for example, and patients are generally separated from the general population by a buffer zone of plastic fencing.

It's highly unlikely that Ebola can travel long distances through the air

What some readers seem to be worried about, though, is not a big cough droplet that travels a few feet, but whether Ebola could travel longer distances in tiny, tiny droplets. This is called "aerosol transmission," and it's something that the measles and some kinds of influenza can do.

Experts say that this is highly unlikely. And this 2012 study of pigs and monkeys doesn't contradict that — indeed, it didn't really address the question of aerosol transmission. It couldn't distinguish between big droplets and little aerosol droplets because the pigs were simply too close to the monkeys.

What the study was designed to do is figure out if Ebola could go from a pig to a primate without them directly touching. Researchers were curious about this because there was evidence that a different, nonlethal-to-humans species of Ebola had done so in the Philippines.

So yes, two monkeys got Ebola from pigs in a laboratory. But that doesn't mean that they would have gotten it if they'd been 10 feet away from each other. And it doesn't mean that any of this would necessarily happen in people.

Further reading: Epidemiologist Tara Smith has several interesting posts on this topic (pig-to-monkey Ebolaare we sure Ebola isn't airborneprimate-to-primate study).

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The Ebola outbreak in Africa has confronted ethicists and health officials with a terrible dilemma: when a limited amount of an experimental treatment exists, who should get access first?

There are currently no Ebola treatments on the market. But in this deadliest Ebola outbreak in history, two Americans missionaries received an experimental Ebola drug called ZMapp after getting the disease in Liberia.

Now, infectious disease experts around the world are proclaiming that African Ebola victims should have the same right. In response, both the Obama administration and the World Health Organization set-up expert groups to weigh the moral debates around the more widespread use of untested drugs in what has now been deemed an international health crisis.

To make sense of the thorny problems at the heart of this outbreak's morality crisis, we called medical ethicists and doctors. Here are the four questions they say they are grappling with.

1) Is it okay to skip the drug testing pathway in a crisis?

In order to get a drug on the market, a rigorous (though admittedly flawed) process has been established. Generally it works like this: first drugs are tested in animals, then in a small group of humans for safety, and if all goes well, testing moves to a larger group of people for efficacy.

"That's the path ZMapp drug was on," said Dr. Ezekiel Emanuel, chair of the department of medical ethics and health policy at University of Pennsylvania's medical school. "Now because we have a crisis, we have short-circuited that path on the grounds of compassionate use."

    Clinical Trials Phases from ClinicalTrials.Gov

  • Phase I: Researchers test a new drug or treatment in a small group of people for the first time to evaluate its safety, determine a safe dosage range, and identify side effects.
  • Phase II: The drug or treatment is given to a larger group of people to see if it is effective and to further evaluate its safety.
  • Phase III: The drug or treatment is given to large groups of people to confirm its effectiveness, monitor side effects, compare it to commonly used treatments, and collect information that will allow the drug or treatment to be used safely.
  • Phase IV: Studies are done after the drug or treatment has been marketed to gather information on the drug's effect in various populations and any side effects associated with long-term use.

There's an open debate about whether this is appropriate: While experimental treatments may offer potential help, they can also be risky because of the lack of testing.

The ethical argument for skipping the clinical trials process is that patients with a high chance of dying have few alternatives. So sometimes regulators grant them access to treatments outside of the well-worn clinical trials, before they are approved, because their only other alternative is probably death.

This is reportedly how Dr. Kent Brantly and Nancy Writebol, the American missionaries working in West Africa, got access to this very early-stage drug.

But there is another ethical justification for potentially doing harm to a patient in a moment of crisis, said Jonathan Moreno, a professor of medical ethics at the University of Pennsylvania. In addition to the "do no harm" adage, in emergencies, the physician and philosopher Hippocrates advised that medics should "be bold." So, he added: "There's huge lethality and we don't have much in the way of alternatives, so Hippocrates would have said, 'Let's get in there' (with experimental drugs)."

2) Why did Americans get an experimental drug while hundreds of Africans die of Ebola?

But it's not that easy. Giving the drug to the missionaries raised another ethical dilemma: Why did the Americans get to try ZMapp, while Africans did not?

Emanuel said this is a common problem that comes up when you skip the clinical trials and drug approvals processes. "Once you do compassionate use, you invariably create inequalities," he explained. "Some people get it, and other people don't get it, and largely though not exclusively the people who end up getting it are well connected and somehow much better off."

That was the case here: ZMapp is in limited supply in America, created using mostly Department of Defense funding, so Emanuel said he was not surprised that Americans with connections to government were granted access.

3) What if the Ebola drug doesn't work?

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Ebola news in Abuja, Nigeria. By Getty Images.

Some have seized on the moment to argue that more experimental Ebola drugs should be rolled out in Africa, which raises another ethical issue: On a societal level, the benefits of rushing ZMapp to patients may not outweigh the harms.

Right now, all the data we have related to ZMapp are promising monkey studies involving similar drugs (other "monoclonal antibodies") but the actual ZMapp experiments in non-human primates has never been published. What's more, no Ebola-fighting monoclonal antibody has ever been tested in humans. So we don't yet know that the drug works. If the Americans live, that may be no indication of ZMapp's efficacy. This strain of Ebola kills around 70 to 80 percent of those who get it, so survival may not necessarily be attributable to any medication.

We'll need more robust data than a single experiment involving two people to know whether ZMapp is safe and effective. More often than not, promising animal studies lead nowhere, Emanuel cautioned: In cancer therapeutics, for example, for every hundred drugs that work, only three to five end up being useful in humans.

"First, we need to know whether the drug works, and second what are its side effects," said Emanuel. "Is it an unalloyed good or are there serious side effects to consider?" With ZMapp, we just don't know.

4) Who should fund access to Ebola medicines?

If an organization like the WHO decided we should give Ebola-endemic areas access to the early-stage therapies that are out there, who will pay to do that?

Most of the money for Ebola drug development comes from the US government since the private sector does not generally invest in rare diseases that affect the poor. Calls to speed up the development and scaling of experimental therapies will require the private sector to change its ways and put more money into largely unprofitable business propositions. Or it'll require governments to step up their funding.

If governments or industry decide to increase funding to rush Ebola drugs to patients, it'll then come down to how much uncertainty regulators are able to take on. When regulators allowed unapproved drugs on to the market in previous health emergencies (such as the 2009 H1N1 epidemic) they had already been tested in people or they were given out on compassionate use grounds for individual patients.

"That's different than saying we're going to make the routine therapy for a disease like Ebola an unapproved drug," explained Dr. Dan Bausch, associate professor of tropical medicine at Tulane University. "There's no precedent for that."

With Ebola, African subjects would need to be enrolled in a natural experiment, he explained, since they're the ones who would be infected with Ebola. (You wouldn't design a trial that gives people a deadly disease for the sake of science.) Or regulators would need to agree on a protocol and eligibility criteria for offering the unproven Ebola drugs to certain infected patients, and then monitor their recovery.

This change would not happen overnight. "You'd have to engage local people in the process, get informed consent in their language and in their terms," said Moreno. "Once you've done that, this could take years. If you're a drug company or a government group, what's the commitment to that region or country? You can't just fly in and out."

Regulators will weigh these risks and benefits on a case-by-case basis for each of the Ebola drugs in the pipeline. In the background, they'll need to consider the fact that something could go wrong in giving untested drugs to patients. "There could be legal and political problems. You could be accused of testing and taking advantage of poor people."

But whoever invests in Ebola will have ethical reasons for doing so. "In the 21st century globalization," said Moreno, "there's good reason for us to be worried about an epidemic disease. There's a humanitarian as well as prudential reason for governments to get involved."

Dr. Bausch put it more simply: "If I had Ebola, and I was asked, 'Do you want to take this drug?' I would. So I think we need to explore the best way to improve therapy for people in West Africa and not be hypocritical."

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The UN's World Health Organization declared the Ebola outbreak in West Africa a Public Health Emergency of International Concern (PHEIC) in the early morning of August 8.

So what does that actually mean?

Technically, it means that the WHO committee thinks the outbreak is a public health risk to other nations and that the outbreak might be in need of an international response. Those are the general criteria for the PHEIC category.

This does not, however, mean WHO will go in and fix everything in the Ebola fight. The declaration itself comes with recommended things that various nations should do, but it doesn't automatically come with funding, gloves, aid workers, or any of the other resources that the exceptionally poor nations with Ebola need to actually do those things.

Doctors Without Borders director of operations Bart Janssens summed it up well in statement: "Declaring Ebola an international public health emergency shows how seriously WHO is taking the current outbreak but statements won’t save lives. . . .  Countries possessing necessary capacities must immediately dispatch available infectious disease experts and disaster relief assets to the region." Doctors Without Borders has been one of the major organizations directly treating Ebola patients.

Since WHO started using the PHEIC category in 2007, the organization has only declared it two other times: for the 2009 swine flu pandemic and for polio in May of 2014. Polio doesn't seem to have improved since that statement, according to the AP.

In the WHO's declaration about Ebola, its recommendations include that Guinea, Liberia, Nigeria, and Sierra Leone should screen for Ebola at major exit points from their countries, including airports. The WHO also says that Ebola patients shouldn't cross borders, unless for medical care, and that people who have had contact with an Ebola patient shouldn't either, until it's clear that they haven't caught the disease. That means a waiting period of 21 days, which is how long Ebola can hide in the body before it causes symptoms.

The WHO says that unaffected states don't need to institute any travel bans.

You can read the statement yourself here and listen to the related press conference here:

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The CDC sent out a bulletin about its interim guidelines on how to safely deal with specimens from people who might have Ebola. The website includes this diagram of how to properly package and ship, say, a vial of blood to a laboratory capable of testing for Ebola:

Packaging-diagram-1200

Specimens for shipment should be packaged following the basic triple packaging system which consists of a primary receptacle (a sealable specimen bag) wrapped with absorbent material, secondary receptacle (watertight, leak-proof), and an outer shipping package. . . . NO specimens will be accepted without prior consultation. . . . Do not ship for weekend delivery unless instructed by CDC.

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1) This is the deadliest Ebola outbreak ever: the disease has crossed more borders (there are now confirmed cases in Guinea, Liberia, Nigeria, and Sierra Leone) and has killed more people (nearly 1,000) than any other outbreak in history.

Ebolav3

2) Ebola is terrifyingly lethal, killing up to 90 percent of those infected; there are no effective treatments or cures on the market.

3) But Ebola is not actually that contagious: since transmission only happens through direct contact with the body fluids of an infected person, it can be contained with simple precautionary measures and good sanitation.

4) Ebola is really a problem of broken and underfunded health systems that can't put those basic public-health measures into place.


Health_spending_per_capita_jpg
5) This is a problem shared by other diseases in Africa, which sadly kill many more people than Ebola — and rarely capture the attention of a global R&D system designed to ignore unprofitable health issues facing the poor.

Leading_cods_jpg

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CNN reporter David McKenzie reports from an Ebola hospital in Sierra Leone.

Thanks, CNN, for letting us post this video. (CNN)

There has been a flood of interest about the experimental serum used to treat the American Ebola patients, so the Centers for Disease Control and Prevention just released their answers to common questions that have been popping up. For example:

Patients

They basically outline that this treatment is still very much at the pre-human phase of clinical trial development, and so it's a long way off from reaching patients. You can read more here.

This effort is part of CDC's response to public interest and anxiety over Ebola. Time magazine reported that there has been a flurry of worried callers to the agency over Ebola in recent weeks. "We've triaged those calls and about half-dozen or so resulted in specimen coming to CDC for testing and all have been negative for Ebola," CDC spokesman Tom Skinner told Time.

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In the absence of official confirmation about how the two American patients with Ebola are being treated, rumor and speculation filled the void.

First were the reports that the blood serum of a teenage Ebola survivor may have saved Dr. Kent Brantly and Nancy Writebol, who contacted the deadly disease in Liberia while working with the Christian aid organization Samaritan's Purse. The latest  news centers around an experimental "secret serum" called ZMapp. Already, CNN's Dr. Sanjay Gupta has proclaimed that the medicine "appears to have worked."

Sadly, Dr. Gupta seems to be over-promising. Here's why.

Treating Ebola with the blood of a survivor

The science behind the first alleged treatment — using the blood serum of a survivor to cure those who are suffering — is the subject of controversy in the Ebola research community, said Dr. Thomas Geisbert, a professor or microbiology and immunology at the University of Texas Medical Branch.

"Back in 1995 during the large outbreak of Ebola Zaire virus in the Democratic Republic of the Congo, there were reports that convalescent serum was used from people who survived Ebola to treat people who were infected," he said.

A small case series report about the treatment involving eight patients was published in the Journal of Infectious Diseases. Only one of the eight people died, a fatality rate much lower than the then-outbreak, which killed some 80 percent of those infected.

Unfortunately, however, the serum theory was not confirmed by later studies. "When we tested that hypothesis in a lab, and took convalescent blood from animals who survived and gave it to Ebola-infected animals, they all died," said Dr. Geisbert. "There was the belief that most of those patients treated were in the process of recovering anyway."

The "secret serum"

Yesterday, the "secret serum" called ZMapp emerged as the primary treatment of the Americans. This is an antibody therapy developed by several stakeholders — Mapp Biopharmaceutical, Inc. and LeafBio in San Diego, Defyrus Inc. from Toronto, the U.S. government and the Public Health Agency of Canada — to treat Ebola. It's made up of a cocktail of monoclonal antibodies, which are just lab-produced molecules that mimic the body's immune response.

To create these molecules, scientists gave mice Ebola proteins and watched the animals' immune systems respond. After identifying the antibodies that fought off the disease in mice, they created almost identical antibodies from plants for use in humans. The idea is that, when given to Ebola-infected people, the drug will boost their immune system so that they too can eliminate the virus.

But this drug has never undergone testing in people, only monkeys. The data on the efficacy of ZMapp in monkeys has never even been published.

Studies on similar drugs are not entirely confidence inducing, either. In this study, two of the four monkeys given monoclonal antibodies 48 hours after exposure to Ebola survived. In this second study, the animals had a 43 percent survival rate when given the drug cocktail after the onset of symptoms. So even though the treatment of monoclonal antibodies decreased the mortality rate — if given close to exposure of the illness —  scientists haven't moved past these tiny animal studies to testing in actual people.

Mapp Biopharmaceuticals is also just one of some 25 labs in seven countries working on these antibody cocktails for Ebola, and none of them have entered a phase one trial in humans, according to the journal Science. For this reason Dr. Martin Hirsch, a Harvard virologist, told Vox, "It’s too premature to say that the patients being treated miraculously improved."

That doesn't mean ZMapp isn't a promising therapy, however. It just means the American Ebola victims are effectively undergoing a science experiment. Even if they survive, it wasn't necessarily the drug that saved their lives. Over 20 percent of people who get this type of Ebola survive. To know whether the drug truly works, it needs to be properly tested in clinical trials. And doing that will require funding drug companies and governments may not want to invest.

Why ZMapp?


According to the US National Institute of Allergy and Infectious Diseases, Samaritan's Purse contacted CDC officials working in Liberia. They asked about the status of several experimental Ebola treatments that they had identified for possible use in the infected American missionaries.

"CDC officials referred them to an NIH scientist who was on the ground in West Africa assisting with outbreak response efforts and broadly familiar with the various experimental treatment candidates," said an NIH spokesperson. "The scientist was able to informally answer some questions and referred them to appropriate company contacts to pursue their interest in obtaining experimental product."

Right now, Samaritan's Purse will not confirm why ZMapp ended up being the chosen treatment.

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The plane carrying the second American Ebola patient landed in Bangor, Maine en route to Atlanta, according to the Associated Press.

Nancy Writebol, who got infected with Ebola while working as a missionary in Liberia with the Christian aid organization Samaritan's Purse, will be treated in an isolation unit at Emory University Hospital in Atlanta.

The plane is expected to arrive in Atlanta around 11 a.m. after refueling in Bangor. Writebol a Charlotte native, is in serious condition, according to Samaritan's Purse.

Want to learn more? Read here about why an Ebola outbreak in the US is unlikely and here about what a worst-case scenario would look like.

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We know that Ebola outbreaks can be stopped — public-health officials have stopped them in the past. So how can they stem the current disaster unfolding in West Africa?

By and large, experts understand what broad steps they need to take to contain the disease. The biggest problem to date is that, in West Africa, authorities lack the financial resources and human power to mount an effective response. On top of that, cultural factors have complicated the situation and led to mistrust of health-care workers.

So far, the World Health Organization (WHO) has estimated more than 1,600 cases of Ebola and 800 deaths, centered in Guinea, Liberia, and Sierra Leone. These countries are some of the poorest on Earth and cannot control the outbreak by themselves.

Outside organizations, such as Doctors Without Borders and the International Federation of Red Cross and Red Crescent Societies have been doing the best that they can. And on July 31, the WHO announced a $100 million push to get hundreds more people on the ground in these countries.

But even that might not be enough, argued Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. In a recent piece for the Washington Post, he suggested that countries like the United States, France, and Canada need to start sending many more people:

The G-7 nations — the United States, Canada, Germany, Britain, France, Italy and Japan — must immediately mobilize and deploy hundreds of infectious-disease experts, along with medical and technical assets to map the epidemic. Hundreds more personnel will be needed to establish treatment centers and to work with local leaders and educators to help people learn how to stop virus transmission.

No matter where help comes from or how fast it arrives, the road ahead will be challenging. "It's not going to be quick or easy.  Even in a best case scenario, it could take three to six months or more," said Centers for Disease Control and Prevention director Tom Frieden in a press conference.

Still, it is possible to stop the outbreak. Here's the general outline of what would need to be done:

1) First, find all the Ebola patients

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A member of the Guinean Red Cross uses a megaphone to give information concerning the Ebola virus during an awareness campaign in Guinea. (Cellou Binani/AFP via Getty Images)

The crucial first step is to identify everyone who's actually been infected with Ebola so that they can be isolated and get medical treatment.

That's easier said than done, though. For starters, the broader public needs to be educated enough about the disease to recognize it. That means knowing that if a friend or family member has symptoms that look similar to malaria or a diarrheal disease, it might actually be Ebola.

And, in West Africa, there's still not enough widespread knowledge about Ebola — in part because this is the first time that the disease has occurred in this region. "The biggest risk is the lack of awareness," a spokesperson for the International Federation of Red Cross and Red Crescent Societies told me.

It won't be easy to change that. Ebola is spreading in both cities and rural villages in these three countries, and about half of adults are illiterate. That means just fliers or emails aren't going to cut it. Educating everyone about Ebola will require human messengers to go into individual communities, including some in very remote areas.

2) Next, find everyone that patients have been in contact with

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A social network. (brewbooks/Flickr)

People must find everyone who the Ebola patients have been in close contact with and monitor them for signs of infection. This is critical to containing the outbreak — letting just one unidentified patient slip free can start a new flare-up of cases.

But tracking all of these people in West Africa has been difficult given Ebola's wide geographic spread. What's more, this kind of detective work takes a lot of human power, and there simply haven't been enough boots on the ground so far.

That means this is another area in which the biggest need is simply to deploy more people — more workers specifically trained to investigate these networks of contacts and monitor everyone for fevers. (The contacts need to be monitored for 21 days — since that's how long Ebola can incubate in someone before symptoms show up.)

3) Let health-care workers do their jobs

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(European Commission DG ECHO)

About 40 percent of people who contract Ebola have survived during the current outbreak. And it's likely that even more would survive if they had better access to health care.

In West Africa, however, there still aren't enough health care workers to go around. "It is believed that people are still dying in their villages without access to medical care," says a Doctors Without Borders statement released on August 1. More health-care workers are needed on the front lines. That will take extra resources and money.

But there's another complicating factor at work here: Even when health-care workers are present, some are facing sharp resistance. This particular region of West Africa has a history of civil wars and poor governance — all of which have helped foster mistrust between communities and health-care workers. Health workers have been threatened with violence in some areas and have had to pull out of some communities.

Fixing this problem is considerably difficult. Sierra Leone's government has declared a public emergency and has said that it will use military and police to enforce quarantines and accompany health workers, if necessary. Liberia has also said that it would use security forces to help implement its plans. These measures might aid health care workers in some places. But unless they're accompanied by large-scale public-education campaigns, they won't necessarily improve public attitudes about health care.

4) Isolate patients until they're not infectious

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A mobile laboratory that aids diagnoses. (European Commission DG ECHO)

Patients with Ebola become infectious once they show symptoms — and at that point they need to be isolated so they won't spread the virus to other people.

In West Africa, however, various cultural factors have made this step more difficult, hampering efforts to stop the outbreak. There have been many news reports of families hiding sick relatives from authorities and dozens of missing patients in Sierra Leone.

This is a question both of education and of access to Ebola lab tests. The US Centers for Disease Control and Prevention is one of several groups sending health communication experts into West African communities to try to address these kinds of problems. And health-care clinics need access to laboratory facilities to test if a patient has Ebola in the first place and later figure out when the patient is free from the disease and ok to go home.

5) Prevent disease transmission in health-care settings
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(European Commission DG ECHO)

The methods to stop the transmission of Ebola are well known — health-care workers need to protect themselves from bodily fluids such as sweat, vomit, and diarrhea by using personal protective gear like gloves, gowns, goggles, and masks.

But at least 60 health-care workers have died from Ebola in this outbreak, according to the WHO. Some of those workers may have not even known that they were treating Ebola, or didn't have access to proper equipment, or didn't know how to protect themselves. (For more on this topic, read Julia Belluz's story on why so many health-care workers are dying.)

To fix this, more medical experts specifically trained in Ebola infection control need to be working in the region. And those experts, in turn, can train other health-care workers. What's more, health facilities need enough funding to provide personal safety gear. (Some gear, like protective suits, gets burned at the end of the day — so the longer the outbreak lasts, the more suits are needed.)

6) Stop the transmission of disease from dead bodies

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(European Commission DG ECHO)

The corpses of Ebola patients can still transmit the virus through bodily fluids like sweat. This means that anyone touching a dead body should be using safety precautions such as gloves.

But in many parts of West Africa, this isn't being done. In some traditional burial practices, family members wash dead bodies by hand. That can help spread the disease.

This is an area in which education and culturally sensitive communication will be key. It's easy to imagine how banning certain traditional burial rites could actually worsen relations between public-health officials and communities. For example, in previous outbreaks in Uganda, health-care experts worked with families in a respectful way to modify burials and make them safe. (Liberia seems to be taking a different route and declared that all bodies of Ebola victims would be cremated.)

7) Educate people in nearby areas that don't yet have Ebola

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UNICEF and partners doing an education session in a school in Guinea. (UNICEF Guinea)

This is part of the plan for both the WHO and other organizations. For example, in addition to its work in Liberia, Guinea, and Sierra Leone, the International Federation of Red Cross and Red Crescent Societies has educational campaigns in Cote d’Ivoire, Mali, and Senegal — countries that have yet to have a single case of the disease. The idea here is to prepare those countries before the outbreak spreads there.

But the Red Cross is struggling with this task. "We need financial support and more additional human resources to fight the Ebola virus," a spokesperson wrote to me in an email on August 1. The organization said it was currently seeking $7.7 million for its various Ebola-related activities.

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Finding money to back an investment in Ebola treatments has been difficult — but not impossible.

A Canadian pharmaceutical company called Tekmira has been at work for the past few years on an Ebola treatment called TKM-Ebola. It has been among the most advanced attempts at a drug that could protect against, and treat, the disease — but was also recently dealt a setback by the Food and Drug Administration.

Diseases like Ebola often have difficulty attracting investment, as pharmaceutical companies rarely see a large payday in tackling a disease that has rare outbreaks and affects a low-income area of the world.

But TKM-Ebola has attracted the interest of the government. The Defense Department awarded it a contract for $140 million in 2010, after the vaccine proved completely effective in treating non-human primates in chimps. The government's interest in vaccinating against Ebola is largely rooted in preventing bioterrorism attacks, where the disease could be used a weapon.

In January, TKM-Ebola began Phase One trials with the Food and Drug Administration, injecting its first patient with the drug on January 14. This is the phase where drug companies test whether a drug is safe — that it doesn't create dangerous complications or side effects — before bigger studies look at whether the drug actually works.

The drug got added to the FDA's "fast track" schedule two months later, in March. That's a designation given to drugs that can help treat conditions without any current therapies. Once a drug receives that designation, its creators are eligible for more frequent meetings with FDA regulators, aimed at speeding up the drug's development.

But more recently the federal government has dealt TKM-Ebola a setback: the FDA halted the treatment's phase one trials at the start of July, requesting that Tekmira provide additional information about how the drug actually works, before the company begins giving trial subjects even larger dosages. That happens in Phase One trials to test how much the human body can handle.

So for the past month now, the TKM-Ebola trial has been on hold as Tekmira pulls together this information. "Our team is working expediently to respond to the FDA," Tekmira chief executive Mark Murray said in a recent statement. "We are mindful of the need for this important therapeutic in situations such as the ongoing Ebola outbreak in West Africa."

TKM-Ebola may not be the only hope: the New York Times reported Sunday that unnamed Ebola vaccine has been added to the FDA's Fast Track, and will be injected into human subjects beginning in September.

Still, both of these treatments are early in the research and development project. After Phase One testing comes Phases Two and Three, which typically involve running trials on hundreds and then thousands of subjects, respectively.

The halting of the Phase One research, Jonathan Gardner at EPVantage writes, not only "represent a setback for research into treating the deadly virus, it also serves to demonstrate how far the sector is from discovering a cure or vaccine."

Correction: An earlier version of this article mistakenly identified TKM-Ebola as a vaccine. While it has been tested as an Ebola treatment, it is not a vaccine.

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The State Department has brought one of two US citizens infected with Ebola in West Africa back for treatment. The patient, Dr. Kent Brantly, is now being treated in a special isolation unit at Emory University Hospital in Atlanta, according to Reuters.

Emory University confirmed that they're treating the patient in a statement:

This special isolation unit was previously developed to treat patients who are exposed to certain serious infectious diseases. It is physically separate from other patient areas and has unique equipment and infrastructure that provide an extraordinarily high level of clinical isolation.

Emory University Hospital physicians, nurses and staff are highly trained in the specific and unique protocols and procedures necessary to treat and care for this type of patient. The standard, rigorous infection control procedures used at Emory protect the patient, Emory health care workers, and the general public. As the CDC says, Ebola does not pose a significant risk to the U.S. public.

The statement also said that a second patient should arrive sometime the week of August 3. It's most likely that this patient is missionary Nancy Writebol, the other infected American.

Transmission of Ebola will be prevented using standard protocols, and health officials say that the two pose very little risk to the general public.

Even if there were some terrible, unforeseen accident with one of these patients, Ebola wouldn't be likely to spread very far. First, Ebola doesn't jump from person to person through the air, but through close contact by touching bodily fluids such as sweat, vomit, or blood. The outbreak in West Africa is so severe for a number of key reasons, including a lack of resources, inadequate infection-control measures, and mistrust of health workers. The United States, by contrast, has far better public-health infrastructure. And that makes all the difference.

For a step-by-step walkthrough of the "Ebola loose in America" scenario, read "What would happen if Ebola came to the United States?"

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The disturbing feature of the current Ebola outbreak in West Africa isn't just that it's the largest and deadliest: it's also that so many health workers have lost their lives while caring for the sick.

The death toll right now is at least 60, according to the World Health Organization. To put that into context, in the second biggest outbreak in history—which took place in 1976 in Zaire—only 11 medical personnel died. And that was the first recorded outbreak in history, when measures to prevent transmission of the virus weren't well established.

Why are so many medical staff getting sick now?

First, we need to look at the total numbers affected. In 1976, the death toll was 280 and there were 318 reported cases. In this 2014 outbreak, there have already been 729 deaths and the number of reported cases has reached 1,323. As a point of comparison, that means this outbreak is four times larger than the 1976 flair up.

It's also more geographically dispersed. Previous outbreaks typically occurred in one remote area. Today, Ebola has reached rural and urban areas in Guinea, Liberia, Sierra Leone, and Nigeria. So the numbers of people affected are unprecedented, and therefore the proportion of health-care workers impacted is sadly going to be larger.

But don't we know how to protect health workers?

We do. Since the disease is transmitted through direct exposure to bodily fluids—from vomit to blood and sweat—health-care workers are advised to wear face masks, goggles, gowns and gloves while caring for patients.

The trouble is, health workers in the developing-country context—especially those working in some of the poorest countries on earth, where the disease emerged this time—don't always have access to this protective gear.

It's important to note that they are also the ones who have died in this outbreak. Of the 60 deaths so far, none involved foreign workers (though two Americans are currently battling the virus, and one is a doctor). Foreign aid agencies such as Doctors Without Borders—which apply stringent precautions for all their health personnel—have never lost members of their teams to Ebola. So the problem this time is as much about size of the outbreak as it is about resources.

"What happens in places that have less infrastructure, less developed hospital infection control is—unless you're very fastidious—you're at risk of transmitting the disease," said Dr. Scott Lillibridge, an infectious disease expert and assistant dean at the Texas A&M School of Public Health.

Still, even if health workers in these countries took full precautions and had access to every resource, at the beginning of an outbreak, medical personnel will inevitably get sick: at that point, doctors and nurses don't know what deadly bug lurks within their patients, particularly ones who present with a disease that sometimes masquerades as a common flu.

Exactly how are health professionals getting infected?

No one knows at this point. There was some speculation on the exact method of transmission at the CDC. But a WHO spokesperson told Vox "it's a bit of a mystery" right now. "There have obviously been lapses somewhere in how the doctors and nurses have protected themselves and we don't know if it's clinics that they're working in or elsewhere."

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The US State Department just confirmed that it, along with the Centers for Disease Control and Prevention, will be evacuating two US citizens who have been infected by Ebola in West Africa:

The safety and security of U.S. citizens is our paramount concern. Every precaution is being taken to move the patients safely and securely, to provide critical care en route on a non-commercial aircraft, and to maintain strict isolation upon arrival in the United States.

These evacuations will take place over the coming days. CDC protocols and equipment are used for these kinds of medical evacuations so that they are carried out safely, thereby protecting the patient and the American public, as has been done with similar medical evacuations in the past.

Upon arriving in the United States, the patients will be taken to medical facilities with appropriate isolation and treatment capabilities.

Because of privacy considerations, the names of the patients will not be released. We do know, however, that at least one evacuated patient will be treated in an isolation ward at Emory University Hospital in Atlanta.

We also know that at least two American volunteers—Dr. Kent Brantly and Nancy Writebol— were infected with the virus while working with the Christian aid organization Samaritan's Purse. They were in "serious condition" in Liberia as recently as Friday, and the latest news release from the organization stated, "Medical evacuation efforts are underway and should be completed by early next week."

This will be the first time a patient with Ebola is going to be treated in the US, according to the CDC.

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It's important to remember that not everyone who catches Ebola is doomed. Currently, the outbreak has a survival rate of about 40 percent. And good health care and early detection seems to be able to improve people's outcomes.

Humanitarian organization Doctors Without Borders posted a video interview with this patient — Sasobas Temé Sadnou — who survived. Take a look:

The Ebola outbreak is spreading through West Africa faster than the World Health Organization's efforts to contain the virus, the international group announced Friday morning.

"This is an unprecedented outbreak accompanied by unprecedented challenges. And these challenges are extraordinary," said Dr. Margaret Chan, Director-General of the World Health Organization, in a statement.

To date, there are 1,323 suspected and confirmed cases and 729 deaths in Guinea, Liberia, Sierra Leone, and Nigeria. The large dispersal of the virus is making coordinating responses particularly challenging, said Dr. Chen. So is the number of health workers that have been infected: more than 60 doctors and nurses have died on the Ebola front line.


"It is the largest in terms of geographical areas already affected and others at immediate risk of further spread," said Dr. Chen. "It is taking place in areas with fluid population movements over porous borders, and it has demonstrated its ability to spread via air travel, contrary to what has been seen in past outbreaks."

In the past, Ebola outbreaks typically occurred in rural areas in East Africa. This time, they're also happening in densely populated city centers mainly in Sierra Leone, Guinea, and Liberia on the western side of the continent. "Affected countries have made extraordinary efforts and introduced extraordinary measures. But the demands created by Ebola in West Africa outstrip your capacities to respond."

As a result, the WHO is convening an emergency committee meeting on August 6 to figure out what to do next and whether this outbreak is a "public health emergency of international concern."

"This meeting must mark a turning point in the outbreak response," said Dr. Chen.

"Experiences in Africa over nearly four decades tell us clearly that, when well managed, an Ebola outbreak can be stopped."

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Aid worker Ishmeal Alfred Charles says getting abducted as a child soldier during Sierra Leone's bloody civil war when he was 15-years-old was less scary than living there now under the Ebola threat.

"You knew the rebels were coming," said the Freetown native in a recent interview from Sierra Leone, where he is among hundreds of aid workers trying to beat back the deadly virus in what is now the biggest-ever outbreak and the first to hit West Africa. "They'd attack a town, and so you made a move. You knew to hide."

Now, he can't flee. It's too expensive to fly elsewhere. And he can't hide from an enemy that could be lurking anywhere. Instead, he has stopped shaking people's hands and he installed a hand-washing station—a bucket filled with chlorinated water—outside his house.

20140801_090718 Ishmeal Alfred Charles washing his hands in Freetown, Sierra Leone.

"You don't know if the person you're sitting next to is infected with Ebola, so all you're trying to do is be as conscious as you can. Because we have heard of situations where whole families get infected... and you lose everyone in the family."

For most people, Ebola is a distant threat, a nightmarish word that conjures up images of sudden and violent hemorrhaging. But for West Africans like Charles, it's now an everyday possibility. "Wherever you go—on Facebook, in the community, on the phone, in Whatsapp messages—people are talking about Ebola."

As a program manager with the Catholic aid agency Caritas, Charles now works to educate people about a virus that only recently emerged in Sierra Leone. He goes door to door, school to school, church to church; he talks to everyone he can reach about the disease; and he hands out hand sanitizer and chlorine. Sometimes, he uses megaphones in town squares, relaying public-health messages about sanitation and prevention. It's a tedious process, he says, but it's necessary.

"A lot of people still have denial about Ebola," Charles says. "That's one of the biggest challenges."

Stories about medical personnel and the government trying to kill or capture Africans circulate, and it doesn't help that when patients are taken into quarantine, they most often never return.

Dispelling these myths isn't easy. "We show them films, photos of Ebola," says Charles. "We try to make sure they understand, first and foremost, there's a virus called Ebola and it's real."

So far in the current outbreak, there have been 1,323 confirmed and suspected cases of Ebola, and 729 deaths. No one knows why the virus sometimes jumps from the fruit bat—which most scientists believe is its animal host—into the human population. But bad infrastructure and the lack of sanitation practices in what are some of the poorest countries on earth don't help with its containment.

"It's a violent virus. You never know what's going to happen."

The shortage of resources has made the work very difficult, says Monia Sayah, a nurse with Doctors Without Borders.

Sayah, who normally resides in Brooklyn, New York, has just finished two stints on the front line in Guinea, the West African nation where the disease first reemerged in March.

When she arrived, she said her biggest challenge was not trying to get people to believe the disease is real: it was figuring out how to care for the reality of so many sick patients.

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Staff at Doctors Without Borders carry the body of an Ebola victim. Staff/Getty Images

"The workload was very high," she says of dealing with up to a dozen Ebola patients in quarantine. So was the mortality rate: at the beginning, about eight in ten patients were dying, close to the numbers in previous outbreaks of the Zaire Ebola virus, which killed 79 percent of those infected. (The death rate in the current outbreak has dropped to around 60 percent.)

"It's very stressful because you're constantly on alert: a patient here, a patient there. The physical stress of working is very hard because you lose a lot of fluid (wearing protective clothing), and get very tired in the heat as well." All the while, trying to make sure she didn't expose herself to the virus or accidentally cross-contaminate any person or thing.

When she'd arrive at the treatment facility in the morning, she'd put on a gown and then a waterproof and airtight suit, headgear, goggles, two pairs of gloves, and rubber boots. "Every inch of the body is covered," she says. When she left 12 hours later, everything except for her rubber boots—which get decontaminated with choline solution—was burned.

Since there is no treatment or cure for Ebola, caring for patients meant hydrating them, feeding and washing them, helping them walk, and giving them antibiotics to ward off any bacterial infection so that their immune systems can fight the virus.

It also meant touching and comforting them. "They're alone. They are isolated. Normally in this part of Africa people are never alone when they're sick." Most commonly, family members care for their loved ones at home—not strangers in a containment facility.

"We take them away from their families," says Sayah. "We know we're bringing them to a treatment facility, the place they should be to receive the best care, to isolate the virus. But the virus is inside a person."

The other tricky thing about Ebola is how quickly it can overtake its host. "We have patients asking for lunch, and we would go to see them a few hours later, and suddenly they would just die. It's a violent virus. You never know what's going to happen."

Since working in the field, she has seen people lose their entire families. She has watched teenagers perish before her eyes. In another case, she says, "I went to see a woman in the community, and she was lying in a pool of blood. I thought she had a miscarriage there was so much blood." The medical team was able to get her to a treatment facility, and stop the bleeding, but she was already very weak and died shortly thereafter.

What's so critical about Ebola, too, is making a differential diagnosis between what might be the lethal virus and any other number of diseases that have a similar profile at first.

"Trying to make a differential diagnosis is difficult because you're in a village," Sayah explained, "you have nothing with you. All you have is a thermometer."  If you misdiagnose a negative patient, that can mean unnecessary isolation and trauma. If a positive patient is passed, that's another potential site of infection—and more spread.

"You just don't know who may be in contact with the virus"

Ebola specialists believe one of the key reasons this outbreak has spread so far is because of the shortage of health-care personnel to deal with it: if you don't have enough people on the ground doing the labor-intensive job of tracing the contacts of positive patients and ensuring they are identified before becoming ill too, each missed case is the new beginning of more human-to-human spread.

Those missed cases are what worries Tarik Jasarevic, a World Health Organization worker on the ground in Guinea. He says that because of the geographic dispersal of the current outbreak—the demand for so many specialists in a relatively rare disease over several countries—mobilizing people and getting systems in place to care for everyone is problematic.

According to Jasarevic, you need these basic resources to contain an Ebola outbreak: "You need to have enough treatment centers so infected persons can be treated in adequate conditions. You need to have surveillance systems. You need to have a system where suspect cases and deaths are being reported so we can go in very safely and check on suspect sick people. We need to have lab capacity to make sure the people infected are identified."

The WHO and other aid organizations have been short on many of these fronts right now, and the UN just pledged $100-million to help quell the current outbreak.

For now, Jasarevic says he's doing what he can in a very uncertain environment. "You try to wash your hands as much as you can. You try to make sure you don't touch people who are sick. But you just don't know who may be in contact with the virus."

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One of the big questions surrounding the current deadly Ebola outbreak in Guinea, Liberia, and Sierra Leone is how the disease spread to humans in the first place.

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This map is up to date as of June 20, 2014. CDC/VSPB

In all likelihood, the virus was originally circulating among bats or possibly gorillas in the forests of western Africa. Some experts believe that the disease may have spread to humans via "bushmeat" — someone butchering an infected bat for food, say, and coming in contact with its blood.

The disease then traveled from humans to humans. One possible conduit is through certain funeral rites in which dead bodies are washed by hand, notes John Snow, an epidemiologist at Columbia University. (The first recorded case in the current outbreak was a doctor in the rural town of Gueckedou in Guinea — the virus then spread to those at his funeral.)

That's one plausible scenario, at least. But it's worth noting that there are all sorts of other complex factors at play here that make these scenarios even more likely to occur in the first place. In western Africa, for instance, deforestation is putting humans in closer contact with bats, who may be carrying the disease. So has conflict in Sierra Leone.

Over at Mother Jones, James West and Tim McDonnell have an excellent story on all the human activities that are making Ebola outbreaks more likely. Here's the section on deforestation:

Melissa Leach, the director of the University of Sussex's Institute of Development Studies, lived for several years in the border forests of Guinea where this latest outbreak first began. She says the forest landscape there is complex and ever-changing — a "mosaic." Villages here are surrounded by forest and agriculture, and that means bats — thought to carry Ebola — are everywhere. "I lived in a house in a village in Kissidougou district for two years which was full of bats in its roof," she says.

Human activity is driving bats to find new habitats amongst human populations. More than half of Liberia's forests — home to 40 endangered species, including the western chimpanzee — have been sold off to industrial loggers during President Ellen Johnson Sirleaf's post-war government, according to figures released by Global Witness.

Logging, slash-and-burn agriculture, and chopping down trees for an increased demand for fire wood are all driving deforestation in Sierra Leone, where total forest cover has now dropped to just 4 percent, according to the United Nations Environment Programme (UNEP) which says if deforestation continues at current levels, Sierra Leone's forests could disappear altogether by 2018.

"We see deforestation or incursion into forests, whether it's through hunting or just alteration of landscape, causing people and wildlife to have more contact," says Epstein.

There seems to be a broader pattern here. Other researchers have argued that the overall increase in Ebola outbreaks in Africa since 1994 is at least partly a consequence of deforestation throughout the tropics.

"Extensive deforestation and human activities in the depth of the forests may have promoted direct or indirect contact between humans and a natural reservoir of the virus," wrote researchers in one 2012 study.

If there really is a link, that's bad news. The tropical forest region of western Africa now has one of the highest rates of deforestation in the world. Guinea, Liberia, and Sierra Leone are all watching their rain forests get chopped down at a furious pace. And that raises the possibility that the current Ebola outbreak, which has now claimed more than 500 lives, won't be the last.

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The Centers for Disease Control and Prevention issued its highest level of travel notice today, urging people to avoid travel to Guinea, Liberia, and Sierra Leone. The three countries are currently experiencing the worst Ebola outbreak on record.

To give you an idea of how dire this is, on July 31 these are the only three places on Earth with a CDC Level 3 travel warning.

The CDC's statement "urged" all residents to avoid "nonessential" travel to the area. That pretty much means stay out unless you're an aid worker.

Here's a section of the notice about Liberia:

This recommendation to avoid nonessential travel is intended to facilitate control of the outbreak and prevent continued spread in two ways: to protect US residents who may be planning travel to the affected areas and to enable the Liberian government to respond most effectively to contain this outbreak. CDC remains committed to the multinational effort to assist Liberia in controlling the outbreak and is scaling up its response activities by, among other things, deploying additional staff to the affected countries. International humanitarian assistance must continue, and CDC encourages airlines to continue flights to and from the region to facilitate transport of teams and supplies essential to control the outbreak.

The statements about Guinea and Sierra Leone used similar language.

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The worst Ebola outbreak on record is currently unfolding in West Africa, and it's been a long affair that has infected more than 1,000, killed more than 600 people, and has yet to show any signs of slowing down.

The outbreak has gotten so bad that countries like Sierra Leone are now quarantining affected communities and have said that they'll send in the police or military to enforce them if necessary.

Here's the most basic facts you should know about Ebola:

1) Ebola doesn't change as fast as some other viruses
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A microscope image of Ebola virus, magnified 100,000 times. (BSIP/UIG via Getty Images)

The Ebola virus that's causing the current outbreak is a known quantity. And there's no expectation that it will change significantly. Ebola was first discovered in 1976 and has stayed pretty much the same ever since.

Some other kinds of microbes can change drastically from year to year, including certain flu viruses and SARS-related viruses. In these cases, public health experts are always watching to see what new strain has popped up that could have new tricks. This isn't really the case with Ebola.

"The Ebola virus today is acting the same way Ebola viruses have always acted," Michael Osterholm told me. He's a biosecurity expert and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. This means that the severity of the current Ebola outbreak is not because the virus itself has gotten any worse, but because the situation that the virus is in is so bad.

2) Ebola spreads through close contact
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A member of Doctors Without Borders in Conakry, Guinea. (Cellou Binani/AFP via Getty Images)

It's extremely unlikely that someone would catch Ebola from simply being on the same plane or in the same public space with someone who was affected. That's because Ebola doesn't tend to travel through the air like the flu and other respiratory illnesses.

In order to catch Ebola, you have to touch the bodily fluids (such as sweat, vomit, diarrhea, blood, urine, or semen) of an Ebola patient — dead or alive. Because Ebola can stay alive on a surface for at least several days, you could also get it from touching bedding or other inanimate objects contaminated with those bodily fluids. After that, you would have to get the virus into your body by, for example, touching food and eating it.

3) People with Ebola generally aren't infectious until they're sick
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World Health Organization officials prepare to enter a hospital during a 2012 Ebola outbreak in Uganda. (Isaac Kasamani/AFP via Getty Images)

This means there's usually a clue that someone might be contagious — such as fever, aches, or diarrhea. These early clues can be confusing, however, because they often look like other things: namely the flu and other diarrhea illnesses. (Some of the more famous symptoms of Ebola, like bleeding from orifices, don't tend to come on until later and sometimes don't happen at all.)

4) People can survive Ebola
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A nurse examines a possible Ebola patient in Guinea.  (Seyllou/AFP via Getty Images)

The current Ebola outbreak has had a survival rate of about 40 percent, per the latest numbers from the World Health Organization. And good medical care can help people survive.

There are five types of Ebola viruses. The one that's causing the current outbreak (Zaire ebolavirus) has had an overall survival rate of roughly 30 percent since it was first discovered in 1976.

5) The current outbreak is so bad because it's happening in places with poor health infrastructure

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Gloves and boots used by medical staff, drying in the sun, at a center for victims of the Ebola virus in Guinea. (Seyllou/AFP via Getty Images)

The countries at the center of the outbreak — Guinea, Liberia, and Sierra Leone — are among the poorest in the world. All three have GDPs per capita that are less than Haiti's. Heath care spending is also dismally low: between $40 and $100 per person per year. With health infrastructure that weak, it's not so surprising that there have been reports of mistrust and fear of medical workers during the outbreak.

As such, a lot of the job of fighting Ebola in western Africa has fallen to non-governmental organizations such as Doctors Without Borders. That group
has been warning for some time that it doesn't have enough support: "With resources already stretched, health authorities and international organizations are struggling to bring the outbreak under control."

Another factor making the current outbreak so deadly: This is the first Ebola outbreak in the region, which has made awareness and education especially difficult.

6) Ebola could pop up in random countries, but that doesn't necessarily mean disaster
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(Bruce Bennett via Getty Images)

The high rate of international travel these days means that it's possible for a single case of an infectious disease to pop up somewhere far-flung. But that doesn't necessarily mean that there will be a giant outbreak in that new location. A lot depends on how quickly the virus is noticed and how prepared the public health system is to deal with it.

For example, while the Middle East was battling hundreds of cases of the deadly MERS virus, two people brought it into the United States in May. But they didn't spread it to anyone else — and the outbreak never spread.

7) If Ebola came to the US, it probably wouldn't get very far

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(Universal Images Group via Getty Images)

The US has a strong health-care infrastructure, and experts say that means that Ebola here would never look like Ebola in West Africa.

The worst-case scenario is that the first person to bring Ebola over to America would be sick and contact with lots of people before anyone realizes that it might be Ebola and brings her to a hospital. But here, modern hospitals would likely use proper procedures to prevent transmission, and epidemiologists would track down people who are at risk of infection and make sure they don't spread it to others.

Overall, it's unlikely that Ebola would get any farther than a localized problem in one area. Even in the worst-case scenario, Osterholm says, "I don't think we’ll have a serious public health threat in any of the developed countries."

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The ongoing Ebola outbreak in West Africa is the deadliest in history, with more than 500 dead and hundreds more infected. The particular virus in this outbreak, known as the Zaire ebolavirus, is the deadliest type of the disease; it has killed 79 percent of those infected in previous outbreaks.

This isn't how an Ebola outbreak has to work. Researchers have devoted lots of time to building a vaccine that could stop the disease altogether — and according to Daniel Bausch, a Tulane professor who researches Ebola and other infectious diseases, they're making really significant progress.

Bausch says that the obstacle to developing an Ebola vaccine isn't the science; researchers have actually made really great strides in figuring out how to fight back against Ebola and the Marburg virus, a similar disease.

"We now have a couple of different vaccine platforms that have shown to be protective with non-human primates," says Bausch, who has received awards for his work containing disease outbreaks in Uganda. He is currently stationed in Lima, Peru, as the director of the emerging infections department of Naval Medical Research Unit 6.

The problem, instead, is the economics of drug development. Pharmaceutical companies have little incentive to pour research and development dollars into curing a disease that surfaces sporadically in low-income, African countries. They aren't likely to see a large pay-off at the end — and could stand to lose money.

Bausch and I spoke Wednesday afternoon about where things stand with developing an Ebola vaccine, what hurdles remain, and how you test a drug that only shows up in infrequent outbreaks. What follows is a transcript of our conversation, lightly edited for clarity and length.

Sarah Kliff: Can we start with where things are on the science of Ebola vaccines, and how much we know about the best way to prevent the disease?

Daniel Bausch: There have been some significant developments for both vaccines and treatments for Ebola and its sister virus, Marburg virus. We now have a couple of different vaccine platforms that have shown to be protective with non-human primates. The most notable development are monoclonal antibodies that are engineered to bind with the ebola virus. There have been breakthroughs in the past few years and, not only are they protective when given right after exposure, but they also work a few days after the illness starts.

That's the good news, but we've had a real break in trying to move forward to get these into human trials and get them out there as a real tool we can use for people infected with these viruses.

SK: So what stands between that science and getting these drugs to Ebola patients?

DB: Part of that is economics. These outbreaks affect the poorest communities on the planet. Although they do create incredible upheaval, they are relatively rare events. So if you look at the interest of pharmaceutical companies, there is not huge enthusiasm to take an Ebola drug through phase one, two, and three of a trial and make an Ebola vaccine that maybe a few tens of thousands or hundreds of thousands of people will use.

There's not a huge demand for this, but there could be other ways to move forward. There are concerns, for example, about Ebola being used as bioterrorism, and that drives a lot of the funding for this. The Department of Defense might be interested in a vaccine if they thought the disease could be used as a weapon.

We need to find the mechanism to get to the next step, and get them out there for actual use.

SK: As you mention there are multiple phases of drug testing, starting with phase one tests for safety and then moving into later phases to test if the drug actually works. How far have the Ebola vaccine candidates you mention made it in that process?

DB: There is one vaccine that has gone through phase one testing [where the drug is tested on a small number of humans for safety]. Now the challenge is how do we get into phase two trials, which test efficacy. How do you plan a prospective trial of something that we don't know where it will be seen next, in outbreak form?

The drugs are out there. It's much more of a situation with economic and logistical challenges.

SK: Where does most the funding for research on the Ebola vaccine come from now?

DB: The research has been almost exclusively through the National Institutes of Health. I think a lot of that has been driven by our country's concern over bioterrorism, and the use of some viruses as weapons. I'm not saying that's not one legitimate reason to do research, but just that its a different driving force.

The way our whole medical-industrial research system works, and this is not unique to Ebola, is the basic research gets done with NIH funding and, after that, research and development happens through private investment. For many different diseases, they get stalled and prevented from going beyond the basic research side, before they can be a real world treatment.

SK: How would you envision an Ebola vaccine working in practice? Is this something you would give to everybody, or try and provide to people at high risk?

DB: There could be a case for limited widespread use, if that doesn't sound too contradictory. I wouldn't anticipate it would be cost-effective or really practical to take the approach of widespread vaccination. It would work more like how we currently handle Yellow Fever: when you have an outbreak, you go in and really rapidly vaccinate the 100,000 or so people who are in the area that is at risk. I would see it more like that, but with an Ebola vaccine. We would go in right away and say, the next day, we have 100,000 doses with our teams and start protecting people.

SK: Have any humans ever used any of the Ebola vaccines that aren't yet approved for market? I've seen a bit of chatter about the idea of giving patients experimental treatments, which might be better than nothing.

DB: So far its been more tossed around but not really acted on yet. There is one exception, but it wasn't an outbreak. There was a needle-stick injury in a lab, and that person was able to get a post-exposure Ebola vaccine. The person didn't get sick, but we don't know if the vaccine was what protected him. We can't even be sure the accident infected him. The only conclusion we can make is that, with this sample size of one, is that person did not have severe side effects from taking it.

Some concern, about using these non-approved drugs, is that we would be giving the impression of experimenting on people. That creates a lot of reticence — if someone is treated and dies — that you could have causality attributed.

That being said, they do seem to be safe in non-human primates and we don't see adverse effects in the ones that have gone through limited phase-one trials. Most of us in the field, if we were laying in bed with Ebola and asked whether to take it, I think all of us would say, "Bring it on." Safety trials be damned; I would want to give it a shot.

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The New York Times reports on President of Sierra Leone's address, which described new measures to stop the biggest Ebola outbreak on record:

In the address, Mr. Koroma said security forces would be deployed to support health professionals and that "all epicenters of the disease will be quarantined" along with "localities and homes where the disease is identified."

Public meetings will be restricted, houses will be searched for infected people, Parliament will be recalled and top officials will be obliged to cancel all but essential overseas travel.

Sierra Leone has recorded more than 200 deaths in an outbreak that has killed more than 600, according to the latest numbers from the World Health Organization. It's the biggest Ebola outbreak on record.

Guinea and Liberia are the other countries at the center of this outbreak. On July 30, Liberia said it would close schools and consider quarantines and would use security forces to enforce its plans.

Quarantines should theoretically make it easier to find, treat, and isolate those with Ebola so that they don't infect others.

A major part of controlling an Ebola outbreak is to track down everyone who could be infected, which the WHO says has been a problem.

And why bring the military and police in? This is what the President of Sierra Leone said:

The police and the military will give support to health officers and NGOs to do their work unhindered and restrict movements to and from epicenters

There have been issues with people not trusting that medical workers can help them — and even some rumors that doctors are causing Ebola. News stories cite families hiding infected relatives, and the BBC reports that dozens of people who have tested positive for Ebola are now missing in Sierra Leone.

In some areas, medical workers have been unable to do their jobs because of security concerns. And workers "have been threatened with knives, stones and machetes, their vehicles sometimes surrounded by hostile mobs," according to the New York Times.

So security forces might be able to help.

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Ebola_death_rates_2

These death rates were calculated by adding up the records of cases and deaths from all known outbreaks. Individual outbreaks can vary, and Zaire ebolavirus is often cited as having death rates up to 90 percent.

Not all Ebola viruses are the same. As happens often with viruses, close relatives can have very different effects.

The current Ebola outbreak is of the Zaire ebolavirus species. This one has historically had the highest death rate of the five different species of Ebola virus.  The species was named after Zaire (now Democratic Republic of the Congo), where it was first found in 1976.

The World Health Organization and the US Centers for Disease Control have both said the risk that Ebola will spread beyond West Africa is extremely low. "The virus is difficult to transmit," Gregory Härtl, a WHO spokesperson, told Vox. "Yes, there was this case of a person with Ebola going to Nigeria on a plane, but in all of history, only one or two people with Ebola got on planes."

Still, fear-mongering headlines about the worst outbreak in Ebola history abound in the press: "Here are the 35 countries one flight away from Ebola;" "Global authorities on alert over Ebola outbreak;" "Deadly foreign diseases are 'potential major threat'."

So we called Art Reingold, the head of epidemiology at UC Berkeley's School of Public Health to make sense of the news. As a disease epidemiologist who has spent the last 30 years studying the prevention and control of infectious diseases around the world, he knows how and why viruses spread. Here's a transcript of our conversation, lightly edited for clarity.

Julia Belluz: How is this outbreak different from others in the past?

Art Reingold: This outbreak is certainly really bad. It's different from the ones we have seen in the past, which generally have started in and often been confined to villages or reasonably limited areas where most of the population is rural and scattered. We now have an outbreak in multiple countries, including urban areas. For this outbreak to be in West Africa is unusual; most have been in Central and East Africa. This represents a new set of challenges people haven't faced before. It is definitely going to be a real challenge to bring this outbreak under control.

JB: Because this is the worst Ebola outbreak in history—with three Western African nations affected—and because Ebola is so deadly, people everywhere are afraid. What is the actual risk that this virus will spread beyond West Africa?

AR: People should not be concerned about Ebola spreading to the US or other wealthy countries. It's transmitted entirely through exposure to bodily fluids. In settings with Ebola, there's bleeding in a variety of places and the virus is present in those excretions, and people need to come into contact with that to get the virus. The people at risk are the family members who are taking care of sick people, those who are preparing bodies for burial, and health-care workers.

JB: Some airlines are enacting travel bans since the outbreak. Are they justified then?

AR: The virus is not transmitted through coughing and sneezing, or through sitting next to someone on a bus or the like. The idea that the virus can somehow mutate and become more readily transmissible from person to person through coughing or sneezing—those are Hollywood scenarios. The idea that Ebola can become more readily transmissible through casual contact is unrealistic and not something we are concerned about. It's people whose job it is to deal with this virus—those working at the ministries of health, health care providers, those struggling with how to get the outbreak in the affected countries under control—that need to be concerned.

JB: What about a worst-case scenario, if it did spread?

AR: In high-income countries like in Europe and the US, we know how to prevent the transmission of Ebola. It has to do with making sure suspected patients are treated and isolated, and appropriate measures are taken for the health-care workers taking care of them. That's what worked in Africa in the past and it should be possible to prevent further transmission of the virus. For people in the US, it's really not a plausible scenario that we are going to start to have to introduce these measures. I would have no fear or concern about getting on an airplane and going to affected countries if I had work to do there.

JB: Can you put the Ebola risk of death into the context of other diseases?

AR: A few thousand people in history have died of Ebola. Compared to AIDS or malaria or diarrhea, this affects far fewer people. More people die of diarrhea in a day than Ebola has killed in history.

JB: So if the risk is so remote, why do you think people are afraid?

AR: It's a highly lethal virus and sixty to seventy percent of the people who get it die. Being fearful is a reasonable response. But elevating that to a fear of getting Ebola by the average person is where it becomes irrational.

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"I knew it was going to be hard but I did not expect this extent of challenges, in terms of lack of equipment and gaps in infection prevention and control measures," says Mauricio. "However, after the initial shock, I started to see those difficulties as opportunities for improvement."

This is Mauricio Ferri, a doctor fighting Ebola in Sierra Leone as part of a World Health Organization deployment. He and another doctor shared their stories in an interesting piece that's up on the WHO's website here.

The world is currently experiencing the worst Ebola outbreak in history — it's in West Africa and has killed about 672 people as of July 23.

But what would happen if the disease came to America?

The scenario isn't as far-fetched as it might sound. With air travel as common as it is, borders don't mean all that much when it comes to disease. It's entirely possible — though by no means certain — that at some point, someone infected with Ebola could get on a plane and land in the United States. And then what?

As it turns out, experts say, we'd probably be able to contain an Ebola outbreak here pretty quickly. But it's worth exploring why that is. The outbreak in West Africa is so severe for a number of key reasons, including a lack of resources, inadequate infection control measures, and mistrust of health workers. The United States, by contrast, has far better public-health infrastructure. And that makes all the difference.

So here's a detailed look at how Ebola in America might go down:

1) The first 24 hours: identify the outbreak

The most likely way for Ebola to arrive in the United States would be an infected person flying from West Africa who has Ebola but doesn't even know it. Ebola can hide in a person's body from two days to three weeks before symptoms emerge. And people don't transmit Ebola during that incubation time — they're only contagious once they show symptoms.

Once an initial Ebola patient starts feeling sick, the person will probably seem at first like he or she has the flu or traveler's diarrhea. (Some of the more famous symptoms of Ebola, like bleeding from orifices, don't tend to come on until later. And bleeding doesn't even happen in about half of cases.)

Although the patient would now be contagious, that doesn't mean that it's exceptionally easy to catch. Ebola doesn't spread through the air, and it's harder to catch than things like the flu. You can't get it just from being on the same plane or in the same public space. The only way to get Ebola is to touch a patient's bodily fluids, like vomit, diarrhea, sweat, saliva, or blood.

Now would be when speed and public awareness plays a big role, no matter where in the world an Ebola patient is. The patient or someone around her will have to figure out: (1) This is something that looks like the flu or diarrhea and (2) This person was just in a country that has Ebola.

If people realize that this might be Ebola early on, they should be able to avoid getting infected by keeping away from the patient's bodily fluids. But if that doesn't cross their minds for a while, people will be more likely to get the virus by accident. In that first day of symptoms, every hour counts.

2) The next step: isolate the patient

In US hospitals, any suspected case of Ebola would be treated as a potential risk until tests come back negative. This means that standard procedures to protect other patients and health-care workers from the patient's bodily fluids would be put into place.

Because Ebola doesn't spread through the air, hospital workers wouldn't have to wear respirators or what you might think of as full Outbreak gear. However, they would protect their body and face from fluids that might splash on them, using things like gowns or full body suits, masks, gloves, and goggles.

Anything that touches the patient would be sterilized or disposed of in a safe manner. And if the patient dies, the body would be carefully handled so that it won't be a danger to anyone, either.

Better adherence to these safety guidelines is one reason why the virus wouldn't spread as quickly in the United States as it has in West Africa. For example, over there, some health-care workers have gotten infected, most likely because the rules weren't followed as closely. And there's actually a reason for that — people who are supposed to wear protective suits in 100°F weather will get extremely hot and might cut corners, says Michael Osterholm, of the Center for Infectious Disease Research and Policy at the University of Minnesota. But US hospitals are more climate controlled, he says, and even that small difference makes a breach less likely.

3) Track down other potential patients

Detective work is a major part of controlling a disease like Ebola. Experts would interview the patient, her relatives, and other potential close contacts to monitor them and make sure that they don't spread the disease to others.

Officials will then suggest various options for these people, depending on the level of risk, including watching and waiting, isolation at home, and testing for infection.

Tracking down contacts has been especially problematic in West Africa in ways that unlikely to happen in the US. An editorial in the major medical journal The Lancet says "The geographical spread of cases and movement of people in and between the three countries presents a huge challenge in tracing those who might be infected." And the World Health Organization says that "low coverage of contact tracing" is one key problem it uncovered in a recent assessment the Ebola response in Liberia.

4) Keep patients in hospital until they're not a threat

It's important to remember that about 40 percent of the patients in this Ebola outbreak have survived. There's no specific pill or shot that will make an Ebola infection go away, but doctors can try to make the patient comfortable, give IV fluids, and treat symptoms.

To prevent Ebola from spreading, health authorities wouldn't release a patient from the hospital until it's clear that the person won't be a danger to others.

This might seem intuitive, but it hasn't always happened in West Africa. For example, the BBC reports that there are several missing patients in Sierra Leone — where some people don't trust that medical care will help them. That, obviously, increases the odds that the outbreak will spread.

The best case scenario and the worst case scenario

To sum up, the best case scenario is that someone coming back from, say, Guinea, realizes that he might possibly have Ebola as soon as he starts feeling sick. Everyone makes sure not to touch her vomit or diarrhea or other fluids. And the outbreak ends with just one patient.

The worst case scenario is that this person is ill for days and in contact with a whole lot of people before anyone realizes that something unusual is going on and brings her to a hospital. But it's still unlikely that Ebola will get farther than a local problem in one city or town. Even in the worst case scenario, "I don't think we’ll have a serious public health threat in any of the developed countries," Osterholm says.

For more on the basics of the Ebola outbreak, check out my previous story Ebola: what you need to know.

Update: Included more examples of bodily fluids that can transmit Ebola and removed a statement that Ebola can't be transmitted by cough or sneeze.

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Sheik Umar Khan was the top doctor fighting against Ebola in Sierra Leone. And he's one of several individual cases that have gotten extra media attention lately in an outbreak that has infected more than a thousand.

Liberian doctor Samuel Brisbane died of Ebola on July 26, according to the Associated Press.

And at least two Americans have caught Ebola in Liberia. They are Nancy Writebol and doctor Kent Brantly, who are receiving medical care, according to USA Today.

Subscribe to this StoryStream for more updates on the Ebola outbreak.

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The deadliest Ebola outbreak in recorded history is happening right now. The outbreak is unprecedented both in infection numbers and in geographic scope. And so far, it's been a long battle that doesn't appear to be slowing down.

The Ebola virus has now hit four countries: Sierra Leone, Guinea, Liberia, and recently Nigeria, according to the country's ministry of health.

The virus — which starts off with flu-like symptoms and often ends with horrific hemorrhaging — has infected 1,201 people and killed an estimated 672 since this winter, according to the numbers on July 23 from the World Health Organization.

Ebola is both rare and very deadly. Since the first outbreak in 1976, Ebola viruses have infected thousands of people and killed roughly 60 percent of them. Symptoms can come on very quickly and kill fast:

Ebolav3

Each bar here represents a different Ebola outbreak. The data is what the CDC has on record. Not every case or death always gets officially recorded, so there is always some wiggle room in numbers like these. 2014 is estimate of the current outbreak as of July 23, 2014 from the WHO.

Journalist David Quammen put it well in a recent New York Times op-ed: "Ebola is more inimical to humans than perhaps any known virus on Earth, except rabies and HIV-1. And it does its damage much faster than either."

So why is Ebola doing so much damage right now? Here's a primer on what's going on.

Why is Ebola back in the news?

Ebola tends to come and go over time.

The viruses are constantly circulating in animals, most likely bats. Every once in a while, the disease spills over into humans, often when someone handles or eats undercooked or raw meat from a diseased ape, monkey, or bat. An outbreak can then happen for several months. And then it becomes quiet again.

Ebola can completely disappear from humans for years at a time. For example, there were zero recorded cases of Ebola in 2005 or 2006.

The current outbreak has been going on since late 2013 or early 2014 and has been getting extra attention in the news recently as several doctors have caught the disease, including a Liberian doctor (who died) and Sierra Leone's top Ebola doctor (who is undergoing treatment).

Where is the current Ebola outbreak?

Ebola_map

This map is up to date as of June 20, 2014. CDC/VSPB

The current outbreak started in Guinea sometime in late 2013 or early 2014. It has since spread to Sierra Leone, Liberia, including some major capital cities. And one infected patient traveled to Nigeria on a plane, according to the Nigerian Ministry of Health.

Why is this particular outbreak so deadly?

For starters, this outbreak concerns the most deadly of the five Ebola viruses, Zaire ebolavirus, which has killed 79 percent of the people it has infected in previous outbreaks. (The virus is called that after the formerly named Zaire, which, along with Sudan, experienced the first Ebola outbreak back in 1976.)

Ebola_virus_species_death_rates

These death rates were calculated by adding up the records of cases and deaths from all known outbreaks. Individual outbreaks can vary, and Zaire ebolavirus is often cited as having death rates up to 90 percent. Data in this chart doesn't include the most recent 2013-2014 outbreak.

There are also social and political factors contributing to the current disaster. Because this is the first major Ebola outbreak in West Africa, many of the region's health workers didn't have experience or training in how to protect themselves or care for patients with this disease.

What's more, an NPR story suggests that people in these countries tend to travel more than those in Central Africa (where outbreaks usually occur). That may have helped the virus disperse geographically, and it made it difficult to track down people who might be infected.

Meanwhile, as an editorial in the medical journal Lancet noted, social stigmas and a lack of awareness may lead people to not seek medical care (or even avoid it). Another often-cited problem is that some people have had direct contact with victims' dead bodies during funerals and preparations for burial, which can spread the disease.

Some people are afraid that medical workers are causing Ebola, and workers "have been threatened with knives, stones and machetes, their vehicles sometimes surrounded by hostile mobs," according to the New York Times.

The humanitarian group Doctors Without Borders has noted 12 villages in Guinea that might have Ebola but aren't safe for workers. In Sierra Leone, a protest against a clinic led to the police using tear gas. And a World Health Organization assessment in Liberia noted problems with tracing patients' contacts with other people, "persisting denial and resistance in the community," and issues with "inadequate" measures used to prevent and control infections, weak data management, and "weak leadership and coordination," according to a statement released on July 19.

In many ways, how well a country can deal with an Ebola outbreak comes down to basic health-care practices and public education. With enough resources poured into the effort, people should be able to contain this outbreak. So far, however, these countries are really struggling.

Does Ebola really make people bleed from their eyes?

Yes. Bleeding from orifices is one of the more unusual and memorable symptoms of viral hemorrhagic fevers like Ebola. In later stages of the disease, some people bleed from the eyes, nose, ears, mouth, and rectum. They may also bleed from puncture sites if they've had an IV.

External bleeding can be one of the main symptoms that can help people realize they're dealing with a case of Ebola, since other signs — first fevers and headache, then vomiting and diarrhea — can be caused by any number of illnesses. Internal bleeding can happen, as well.

But it doesn't always happen. For example, this study of a 1995 outbreak found external bleeding in 41 percent of cases. And bleeding didn't correlate with who survived and who didn't.

What actually kills people is shock from multiple organ failure, including problems with the liver, kidneys, and central nervous system.

Symptoms come on abruptly after an incubation period of 2 to 21 days. And people generally die between day 6 and 16 of the illness.

Why is Ebola so deadly?

One of the main things that seems to make Ebola viruses especially deadly is that they seem to be able to evade much of the human immune system. Among other problems, white blood cells from the immune system are often seen to die off in patients. And if the body can't fight fully back, the virus can just keep taking over.

Scientists are still figuring out exactly how this happens, and they have several promising leads. One is that the virus is making proteins that act as decoys, interfering with the body's ability to fight back.

How hard is it to catch Ebola?

Ebola is relatively hard to catch compared to some other viruses like measles, SARS, or the flu because it doesn't like to hang out in the air.

In order to contract Ebola, someone must touch the blood or bodily fluids (including sweat, urine, and semen) of a person or animal who's infected (alive or dead). People can also catch it through indirect contact with victims' fluids, such as via bedding or medical equipment.

People generally aren't infectious until they get sick.

Ebola's limited transmission ability is one of the main reasons why outbreaks can often be stopped within weeks or months. What it takes is public education and good health-care hygiene like isolating patients, sterilization procedures, and the use of gloves, masks, and other protective gear.

481845187

A view of gloves and boots used by medical staff, drying in the sun, at a center for victims of the Ebola virus in Guinea. AFP/Getty Images

What are the chances of Ebola spreading to the US?

The Ebola viruses known today don't spread from person-to-person well enough to have much risk of causing a wide pandemic across several continents. The risk of Ebola coming to the US is still very low.

And if a case did appear in the USA, it "would not pose a major public health risk" Michael Osterholm, biosecurity expert and director of the Center for Infectious Disease Research and Policy at the University of Minnesota told USA Today. Why? Because it would be quickly tracked down and controlled.

How do you treat Ebola?

Patients are treated for symptoms, including IV fluids for dehydration. It's important to remember that some people do survive an Ebola infection.

Hopefully, in the future there will be more options. For example, researchers are working to find drugs, including a recent $50 million push at the National Institutes of Health. And scientists are working on vaccines, including looking into ones that might be able to help wild chimpanzees, which are also susceptible to the disease.

Update: Removed a statement that Ebola cannot be caught from a cough or sneeze.

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The deadliest Ebola outbreak in recorded history is happening right now. And now the Liberian government has confirmed that a senior doctor working to fight the disease, Samuel Brisbane, has died, the Associated Press reports. That makes him the first Liberian doctor to die of Ebola in the current outbreak.

In addition, an American doctor has been infected. Kent Brantly, a 33-year-old working for American aid organization Samaritan's Purse, has been treated and is in stable condition, according to USA Today.

This news comes just days after an announcement that the top Ebola doctor in Sierra Leone, Sheik Umar Khan, had been infected.

Brisbane's death is an unfortunate blow in a long battle that doesn't look like it's slowing down.

Liberia is one of several countries battling the current outbreak, which is unprecedented both in the number of cases and in its geographic scope. It's now hit four countries: Sierra Leone, Guinea, and Liberia have been joined by Nigeria, which this week saw its first case, after an infected Liberian man flew to the Nigerian city of Lagos, which is also Africa's largest city. There are also fears the disease has spread to the country of Togo, where that man's flight had a stopover.

And the virus — which starts off with flu-like symptoms and often ends with horrific hemorrhaging — had as of July 23 infected 1,201 people in Sierra Leone, Guinea, and Liberia, and killed an estimated 672 since this winter, according to the numbers from the World Health Organization.

Ebola is both rare and very deadly. Since the first outbreak in 1976, Ebola viruses have infected thousands of people and killed about one-third of them. Symptoms can come on very quickly and kill fast:

Ebola_cases

Each bar here represents a different Ebola outbreak. This data is what the CDC has on record. Not every case or death always gets officially recorded, so there is always some wiggle room in numbers like these. 2014 is estimate of the current outbreak as of July 23, 2014 from the WHO.

Journalist David Quammen put it well in a recent New York Times op-ed: "Ebola is more inimical to humans than perhaps any known virus on Earth, except rabies and HIV-1. And it does its damage much faster than either."

So why is Ebola doing so much damage right now? Here's a primer on what's going on.

Why is Ebola back in the news?

Ebola tends to come and go over time.

The viruses are constantly circulating in animals, most likely bats. Every once in a while, the disease spills over into humans, often when someone handles or eats undercooked or raw meat from a diseased ape, monkey, or bat. An outbreak can then happen for several months. And then it becomes quiet again.

Ebola can completely disappear from humans for years at a time. For example, there were zero recorded cases of Ebola in 2005 or 2006.

Where is the current Ebola outbreak?

Ebola_map

This map is up to date as of June 20, 2014. CDC/VSPB

The current outbreak started in Guinea sometime in late 2013 or early 2014. It has since spread to Sierra Leone and Liberia, including some major capital cities. It's the first time Ebola has ever reached a state capital.

Why is this particular outbreak so deadly?

First, this outbreak concerns the most deadly of the five Ebola viruses, Zaire ebolavirus, which has killed 79 percent of the people it has infected. (The virus is called that after the formerly named Zaire, which, along with Sudan, experienced the first Ebola outbreak back in 1976.)

Ebola_virus_species_death_rates

These death rates were calculated by adding up the records of cases and deaths from all known outbreaks. Individual outbreaks can vary, and Zaire ebolavirus is often cited as having death rates up to 90 percent. Data in this chart doesn't include the most recent 2013-2014 outbreak.


There are also social and political factors contributing to the current disaster. Because this is the first major Ebola outbreak in West Africa, many of the region's health workers didn't have experience or training in how to protect themselves or care for patients with this disease.

What's more, an NPR story suggests that people in these countries tend to travel more than those in Central Africa (where outbreaks usually occur). That may have helped the virus disperse geographically, and it made it difficult to track down people who might be infected.

Meanwhile, as an editorial in the medical journal Lancet noted, social stigmas and a lack of awareness may lead people to not seek medical care (or even avoid it). Another often-cited problem is that some people have had direct contact with victims' dead bodies during funerals and preparations for burial, which can spread the disease.

A World Health Organization assessment in Liberia noted problems with tracing patients' contacts with other people, "persisting denial and resistance in the community," and issues with "inadequate" measures used to prevent and control infections, weak data management, and "weak leadership and coordination," according to a statement released on July 19.

On June 23, the humanitarian group Doctors Without Borders sent out a distress call. As the only aid organization treating people with Ebola, the group said it was "overwhelmed," that the epidemic was out of control, and that it couldn't send workers to new outbreak sites without getting more resources.

In many ways, how well a country can deal with an Ebola outbreak comes down to basic health-care practices and public education. With enough resources poured into the effort, people should be able to contain this outbreak. So far, however, these countries are struggling.

Does Ebola really make people bleed from their eyes?

Yes. Bleeding from orifices is one of the more unusual and memorable symptoms of viral hemorrhagic fevers like Ebola. In later stages of the disease, some people bleed from the eyes, nose, ears, mouth, and rectum. They may also bleed from puncture sites if they've had an IV.

External bleeding can be one of the main symptoms that can help people realize they're dealing with a case of Ebola, since other signs — first fevers and headache, then vomiting and diarrhea — can be caused by any number of illnesses. Internal bleeding can happen, as well.

But it doesn't always happen. For example, this study of a 1995 outbreak found external bleeding in 41 percent of cases. And bleeding didn't correlate with who survived and who didn't.

What actually kills people is shock from multiple organ failure, including problems with the liver, kidneys, and central nervous system.

Symptoms come on abruptly after an incubation period of 2 to 21 days. And people generally die between day 6 and 16 of the illness.

Why is Ebola so deadly?

One of the main things that seems to make Ebola viruses especially deadly is that they seem to be able to evade much of the human immune system. Among other problems, white blood cells from the immune system are often seen to die off in patients. And if the body can't fight fully back, the virus can just keep taking over.

Scientists are still figuring out exactly how this happens, and they have several promising leads. One is that the virus is making proteins that act as decoys, interfering with the body's ability to fight back.

How hard is it to catch Ebola?

Ebola is relatively hard to catch. Unlike measles or the flu, it's not spreadable over the air through casual contact.

In order to get Ebola, someone must touch the blood or bodily fluids (including sweat, urine, and semen) of a person or animal who's infected (alive or dead). People can also catch it through indirect contact with victims' fluids, such as via bedding or medical equipment.

People generally aren't infectious until they get sick.

This limited transmission ability is one of the main reasons why Ebola outbreaks can often be stopped within weeks or months. What it takes is public education and good health-care hygiene like patient isolation, sterilization procedures, and the use of gloves and masks.

481845187

A view of gloves and boots used by medical staff, drying in the sun, at a center for victims of the Ebola virus in Guinea. AFP/Getty Images

What are the chances of Ebola spreading to the US?

The Ebola viruses known today don't spread from person-to-person well enough to have much risk of causing a wide pandemic across several continents. The risk of Ebola coming to the US is very low.

How do you treat Ebola?

Patients are treated for symptoms, including IV fluids for dehydration. It's important to remember that some people do survive an Ebola infection.

Hopefully, in the future there will be more options. For example, researchers are working to find drugs, including a recent $50 million push at the National Institutes of Health. And scientists are working on vaccines, including looking into ones that might be able to help wild chimpanzees, which are also susceptible to the disease.

Updated. This article was updated on July 27 to include news on Brisbane's death and Brantly contracting the virus. It was also corrected on July 28 — originally, Brantly's name was listed as Keith, not Kent, as a result of an update written by Danielle Kurtzleben. On July 28, updated the first chart with newest case count numbers.

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The deadliest Ebola outbreak in recorded history is happening right now. The outbreak is unprecedented both in the number of cases and in its geographic scope. And so far, it doesn't look like it's slowing down.

The outbreak has now hit three countries: Guinea, Sierra Leone, and Liberia. And the virus — which starts off with flu-like symptoms and often ends with horrific hemorrhaging — has infected about 600 people and killed an estimated 367 since this winter, according to the numbers on June 26 from the World Health Organization.

On June 23, the humanitarian group Doctors Without Borders sent out a distress call. As the only aid organization treating people with Ebola, the group said it was "overwhelmed," that the epidemic was out of control, and that it couldn't send workers to new outbreak sites without getting more resources.

Ebola is both rare and very deadly. Since the first outbreak in 1976, Ebola viruses have infected roughly 2,400 people and killed about one-third of them. Symptoms can come on very quickly and kill fast:

Ebola_outbreaks

Each bar here represents a different Ebola outbreak. This data is what the CDC has on record. Not every case or death always gets officially recorded, so there is always some wiggle room in numbers like these. 2014 is estimate of the current outbreak as of June 24, 2014 from the WHO.

Journalist David Quammen put it well in a recent New York Times op-ed: "Ebola is more inimical to humans than perhaps any known virus on Earth, except rabies and HIV-1. And it does its damage much faster than either."

So why is Ebola doing so much damage right now? Here's a primer on what's going on.

Why is Ebola back in the news?

Ebola tends to come and go over time.

The viruses are constantly circulating in animals, most likely bats. Every once in a while, the disease spills over into humans, often when someone handles or eats undercooked or raw meat from a diseased ape, monkey, or bat. An outbreak can then happen for several months. And then it becomes quiet, again.

Ebola can completely disappear from humans for years at a time. For example, there were zero recorded cases of Ebola in 2005 or 2006.

Where is the current Ebola outbreak?

Ebola_map

This map is up to date as of June 20, 2014. CDC/VSPB

This outbreak started in Guinea sometime in late 2013 or early 2014. (The majority of cases have been in that country.) It has since spread to Sierra Leone and Liberia, including some major capital cities. It's the first time Ebola has ever reached a state capital.

Why is this particular outbreak so deadly?

First, this outbreak concerns the most deadly of the five Ebola viruses — Zaire ebolavirus, which has killed 79 percent of the people it has infected. (The virus is called that after the formerly named Zaire, which, along with Sudan, experienced the first Ebola outbreak back in 1976.)

Ebola_virus_species_death_rates

These death rates were calculated by adding up the records of cases and deaths from all known outbreaks. Individual outbreaks can vary, and Zaire ebolavirus is often cited as having death rates up to 90 percent. Data in this chart doesn't include the most recent 2013-2014 outbreak.


There are also social and political factors contributing to the current disaster. Because this is the first major Ebola outbreak in West Africa, many of the region's health workers didn't have experience or training in how to protect themselves or care for patients with this disease.

What's more, an NPR story suggests that people in these countries tend to travel more than those in Central Africa (where outbreaks usually occur). That may have helped the virus disperse geographically, and it made it difficult to track down people who might be infected.

Meanwhile, as an editorial in the medical journal Lancet noted, social stigmas and a lack of awareness may be preventing people from seeking medical care (or even actively avoiding it). Another often-cited problem is that some people have had direct contact with victims' dead bodies during funerals and preparations for burial, which can spread the disease.

In many ways, how well a country can deal with an Ebola outbreak comes down to basic health-care practices and public education. With enough resources poured into the effort, people should be able to contain this outbreak. So far, however, these countries are struggling.

Does Ebola really make people bleed from their eyes?

Yes. Bleeding from orifices is one of the more unusual and memorable symptoms of viral hemorrhagic fevers like Ebola. In later stages of the disease, some people bleed from the eyes, nose, ears, mouth, and rectum. They may also bleed from puncture sites if they've had an IV.

External bleeding can be one of the main symptoms that can help people realize they're dealing with a case of Ebola, since other signs — first fevers and headache, then vomiting and diarrhea — can be caused by any number of illnesses. Internal bleeding can happen, as well.

But it doesn't always happen. For example, this study of a 1995 outbreak found external bleeding in 41 percent of cases. And bleeding didn't correlate with who survived and who didn't.

What actually kills people is shock from multiple organ failure, including problems with the liver, kidneys, and central nervous system.

Symptoms come on abruptly after an incubation period of 2 to 21 days. And people generally die between day 6 and 16 of the illness.

Why is Ebola so deadly?

One of the main things that seems to make Ebola viruses especially deadly is that they seem to be able to evade much of the human immune system. Among other problems, white blood cells from the immune system are often seen to die off in patients. And if the body can't fight fully back, the virus can just keep taking over.

Scientists are still figuring out exactly how this happens, and they have several promising leads. One is that the virus is making proteins that act as decoys, interfering with the body's ability to fight back.

How hard is it to catch Ebola?

Ebola is relatively hard to catch. Unlike measles or the flu, it's not spreadable over the air through casual contact.

In order to get Ebola, someone must touch the blood or bodily fluids (including sweat, urine, and semen) of a person or animal who's infected (alive or dead). People can also catch it through indirect contact with victims' fluids, such as via bedding or medical equipment.

People generally aren't infectious until they get sick.

This limited transmission ability is one of the main reasons why Ebola outbreaks can often be stopped within weeks or months. What it takes is public education and good health-care hygiene like patient isolation, sterilization procedures, and the use of gloves and masks.

481845187

A view of gloves and boots used by medical staff, drying in the sun, at a center for victims of the Ebola virus in Guinea. AFP/Getty Images

What are the chances of Ebola spreading to the US?

The ebola viruses known today don't spread from person-to-person well enough to have much risk of causing a wide pandemic across several continents. The risk of Ebola coming to the US is very low.

How do you treat Ebola?

Patients are treated for symptoms, including IV fluids for dehydration. It's important to remember that some people do survive an Ebola infection.

Hopefully, in the future there will be more options. For example, researchers are working to find drugs, including a recent $50 million push at the National Institutes of Health. And scientists are working on vaccines, including looking into ones that might be able to help wild chimpanzees, which are also susceptible to the disease.

Update: Incorporated the newest case counts from the WHO on June 26.

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The Ebola virus, which is resurgent in West Africa, is almost always fatal. At least 145 people have died in the recent outbreak, mostly in Guinea. But a lucky few survive — only to be shunned upon their recovery by a society that refuses to believe they're no longer contagious.

"Thanks be to God, I am cured. But now I have a new disease: the stigmatization that I am a victim of," a Guinean doctor who survived Ebola told The Associated Press. "This disease is worse than the fever." The doctor refused to give his name "for fear of further problems the publicity would cause him and his family."

Terror of the disease — and confusion about how to protect against it — can manifest itself in more dangerous ways than ostracization. In Liberia, homes of some of the infected have been attacked, and in Guinea, Doctors Without Borders had to temporarily abandon a clinic that was under threat.

Health workers are trying to reduce the stigma against Ebola survivors through their own example. Corinne Benazech, a representative in Guinea for Doctors Without Borders in Guinea, told the AP that "The patient never leaves alone," and health workers make a show of shaking hands with survivors as they leave the isolation ward. The country's minister of health also awards patients a certificate stating that they are no longer contagious. The one exception is a male patient's semen, where the virus can linger even after recovery, so men who survive Ebola are given a three-month supply of condoms.

Read more at the Associated Press.

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