The New Ebola Protocols

Year after year, the staff at Emory University Hospital prepared for a crisis that never arrived, fine-tuning the creepy details of a plan they hoped they would never have to activate. Isolation rooms. Hazmat suits. Protocols for the disposal of human waste teeming with lethal virus. They reminded colleagues of the biblical prophet who built a huge boat under skies of bluest blue, anticipating a tempest that few could see coming. “I have to admit to you, a lot of people sort of saw this like Noah’s Ark,” Dr. Bruce Ribner recalled in a recent interview. As head of Emory’s serious-communicable-disease unit, Ribner filled the role of Noah, the doomsday planner who was wrong, wrong, wrong about the weather–until the deluge arrived, and he was proved right.

Ebola is the deluge, and Emory was ready in August when the first U.S. health care workers became infected while fighting the West African epidemic and returned home for treatment. But Emory–now a go-to facility for U.S. Ebola patients–is one of a few exceptional cases. (Others include specially designated hospitals in Nebraska, Montana and Maryland.) Most of the world’s health institutions have been taken by surprise. As recently as late July, an official at the Centers for Disease Control and Prevention (CDC) deemed it a “very remote possibility” that a traveler from West Africa could carry the Ebola virus to the U.S. Two short months later, when a feverish visitor from Liberia named Thomas Eric Duncan showed up in a woefully unready Dallas emergency room, that remote possibility became a lethal reality.

Discovered in 1976 in what is now the Democratic Republic of Congo, the Ebola virus was, for nearly 40 years, a small problem in remote places. Its appearance last December in the borderlands of Guinea, Liberia and Sierra Leone stirred little international concern–which has proved to be a terrible mistake. This Ebola outbreak has rapidly escalated into a global public-health crisis, and now agencies ranging from the U.N. to the U.S. military are scrambling to catch up. The brutal pathogen had infected some 9,000 people in West Africa by the second week of October; an estimated 70% of them will die. And from the late Mr. Duncan, the virus had spread to at least two health care workers at Dallas’ Texas Health Presbyterian Hospital.

The two in Texas might seem like a tiny number compared with the thousands in Africa, but both figures loom large for people coming to grips with the disaster. As Dr. Tom Frieden, director of the CDC in Atlanta, explained at a news conference, “the care of Ebola can be done safely.” Successful treatment of Ebola patients at Emory and the tiny number of similarly prepared facilities proves that. But “it’s hard to do it safely,” he added, as the infected health care workers painfully learned. “Even a single inadvertent, innocent slipup can result in contamination.”

Or slipups, plural. The second infected worker, Amber Vinson, 29, was able to travel aboard Frontier Flight 1143 on the day before her symptoms emerged, even with a fever of 99.5°F. While it’s likely she was not yet contagious, officials were obliged to track down her fellow passengers and add them to a growing watch list of people who might have been exposed to the virus. Vinson is being treated at Emory.

If the response at Texas Health Presbyterian has been seriously flawed compared with the Emory gold standard, it is far better than what the world seems able to muster in West Africa. There, the virus “is running faster than us, and it is winning the race,” in the words of Anthony Banbury, head of the U.N.’s Ebola response. Health officials in Sierra Leone, for example, have given up on finding bed space for Ebola patients; instead, they are issuing instructions on caring for the contagious patients at home. In Liberia, where the disease is hottest, corpse-disposal teams are reportedly accepting bribes to permit families to bury their dead in traditional ceremonies–a common route of transmission for the epidemic.

In short, Dallas illustrates both the scale and urgency of the crisis in West Africa. If a large and modern hospital in a major U.S. city turns one Ebola patient into three–or perhaps more–how can the overburdened agencies in some of the world’s poorest nations hope to deal with caseloads in the thousands?

Ebola is a much more challenging problem than the world imagined, and–notwithstanding the Emory ark–we’re not ready for it. Worse, time is running out. According to Banbury, the world has fewer than 60 days to get the West African epidemic under control; beyond that, the deadly arithmetic of contagion becomes overwhelming. By early next year, the number of infected men, women and children could reach 1.4 million, epidemiologists predict. “This is the 9/11 of infectious diseases,” Dr. Leslie Lobel, an Ebola researcher at Ben-Gurion University of the Negev in Israel, told TIME. “We thought we conquered all infectious diseases 40 years ago, and we’ve been asleep.”

In a world knit together by airplanes and cargo ships, failure to control the epidemic in West Africa will mean more Ebola cases in the emergency rooms of America, of Europe, of Asia. “We can’t let any hospital let its guard down,” said the CDC’s Frieden. But keeping our guard up will exact both a financial and a psychic toll. Hospitals in places like Boston and Kansas City have already experienced the high cost of isolating feverish patients while awaiting tests that prove negative.

With the country on high alert, we can expect more panics like the one that diverted a United Airlines jet to a remote terminal at Los Angeles International Airport to evacuate a sick passenger. And more hoaxes like the one that diverted a busload of Los Angeles commuters after a man loudly announced that he was infected with Ebola. More of the conspiracy theories and overreactions that have sent a number of Americans in search of hazmat gear that they will almost certainly never need. More of the blame-shifting and political point-scoring that has erupted in Washington. And the specter of racial profiling looms as travelers to and from Africa come under increasing medical suspicion.

Inside the Ark

In August, a reporter for time visited Emory to get an idea of the work involved in setting up a truly safe center for the treatment of highly lethal and infectious diseases. The medical revolution wrought by vaccines and antibiotics lulled many physicians in the developed world into thinking of quarantines and isolation wards as bygone features of the medical dark ages. “A lot of people knew we had this program and just sort of said, ‘You are not going to have any activity there, you’re just wasting your time with all that,’ ” Ribner recalled at Emory. When the first Ebola patient arrived–a medical volunteer in Liberia named Dr. Kent Brantly–the effort was vindicated. “This is what we have been preparing for for 12 years,” Ribner said.

In those 12 years, the Emory team thought of everything. The ambulance serving the isolation ward is specially equipped and sanitized after each use. Ambulance attendants wear one-piece hazmat suits so they can’t absentmindedly scratch a nose. Similar suits garb the highly trained doctors and nurses who staff isolation rooms. Pressure and heat sterilize instruments, bedclothes–even feces and vomit.

The air in each isolation room is vented from the hospital through dedicated ductwork (though Ebola does not spread through the air), and the water in the toilets is treated with disinfectant before it is flushed through the pipes. The infectious-disease unit maintains its own lab to eliminate risk of contamination, and the unit keeps its atmospheric pressure lower than that of the surrounding hospital so that air can’t escape through an open door.

Emory even has a protocol for donning and doffing gear: it uses the buddy system, with a medical worker standing watch for any possible breach. “We feel very strongly that, especially during the doffing process, individuals who are not properly trained are at risk for self-contamination,” Ribner says.

When Nina Pham, a nurse at Texas Health, came down with Ebola after working with Duncan, CDC officials quickly organized a telephone briefing for hospitals across the country. Ribner and a colleague at Omaha’s University of Nebraska hospital were tapped to describe these state-of-the-art precautions for safe treatment of Ebola. Participants in the conference call reacted with stunned disbelief. “I really appreciate this helpful information,” one Southern California health care professional offered in response. “But practically speaking, I think what you just described would probably bankrupt our hospital.”

It’s now clear that the CDC and other federal agencies gave too little credence to the idea that far-flung hospitals and clinics might find themselves dealing with walk-in Ebola patients–a situation underscored by the Oct. 15 decision to transfer Vinson to Emory. What took Emory 12 years and stacks of money to perfect can’t be matched overnight on a shoestring. This lack of foresight was made worse, perhaps, by the limited federal jurisdiction over public health, which is largely the province of state governments.

Seen in this light, the failures in Dallas are understandable, though no less appalling and painful. Unconfirmed reports, publicized by a national nurses’ union, described untrained workers in various degrees of protective garb coming and going from Duncan’s room, and samples of Duncan’s virus-laden blood and waste moving through the same channels to the hospital lab as other, nonlethal test samples. In all, according to the CDC, 76 people who may have had contact with Duncan’s body fluids during his time at Texas Health Presbyterian are being watched for symptoms.

In Washington, Democrats blamed Republicans for cutting federal dollars that could have been spent on public health, while Republicans like Senator John McCain of Arizona called for an Ebola czar to bring order to the situation. The CDC’s Frieden dispatched a task force to Dallas, promised similar medical SWAT teams to respond to cases elsewhere across the country and weighed the idea of establishing Ebola treatment centers at selected hospitals in each major city. Needed improvements all, but each one fails to address the basic problem: no one knows where the next Ebola patient might turn up.

‘A Courageous Ask’

The solution, ultimately, is to knock down Ebola at the source. Scientists around the world are working on vaccines, and Ben-Gurion’s Lobel, for one, counts himself “somewhat optimistic” that success is on the horizon. “I would guess that we’re very close,” he told TIME. “Probably three to five years for a vaccine and drugs to handle this outbreak in a much better way.”

That leaves the current epidemic and a desperate need for volunteer doctors and nurses to go to West Africa and shore up the failing effort. People like Irish nurse Laura Duggan, who was preparing in early October to go to Sierra Leone to fight what she called “one of the biggest public-health emergencies of our time.” Duggan told TIME that similar news from Madrid, where a nurse contracted Ebola while caring for an infected missionary, had shaken her confidence. Her boyfriend, she said, was concerned that protective gear and safety protocols had failed to keep that nurse healthy. “That was my first little wobble,” Duggan said. “I kind of just went ‘Oh, God.’ ”

As of Oct. 10, 416 health workers have been infected with Ebola in West Africa, and 233 have died. Other local doctors and nurses have fled their posts. In a message to leaders of the International Monetary Fund and the World Bank on Oct. 9, Sierra Leone’s President Ernest Bai Koroma said, via video link, that his country would need 750 doctors and 3,000 nurses to treat the anticipated caseload. Finding that many qualified health care professionals willing to put their lives at risk is “a challenge,” says Eric Talbert, executive director for Emergency USA, a medical charity that is creating a 100-bed Ebola facility in Sierra Leone. “There is a significant fear factor. They are putting their lives on the line for people they have not met. It’s a courageous ask.”

After much thought, Duggan decided to stick to her plans. She left London on Oct. 13 to spend six weeks sweltering in protective gear while caring for Ebola patients in Kailahun, Sierra Leone, at a Doctors Without Borders facility. “It is my job, and something that I’ve been trained to do,” she said matter-of-factly, though clearly something much deeper, more admirable, lay behind her choice. If Ebola is to be defeated, the world will need thousands more like her–on the front lines and scattered throughout the frightened world.

–WITH REPORTING BY ALEXANDRA SIFFERLIN/ATLANTA, NAINA BAJEKAL/LONDON, ARYN BAKER/MONROVIA, ALICE PARK/NEW YORK CITY AND ALEX ALTMAN/WASHINGTON