12 Answers to Ebola’s Hard Questions

1) WHAT WENT WRONG AT THE CDC?

Everywhere he goes, Dr. Tom Frieden carries a stack of little white index cards. He uses them as a brain bank, a place to jot private thoughts in his tiny scrawl. As director of the Centers for Disease Control and Prevention (CDC), Frieden is the public face of the U.S. response to Ebola. And given the nationwide panic about the virus, it’s no surprise that one of the 4-by-6 cards is labeled “errors.”

The card is filling up fast. Frieden declared that U.S. hospitals were ready for Ebola, but the first hospital tested flunked badly. The CDC was forced to tighten protection guidelines for health care workers after two Dallas nurses contracted the virus. It allowed one of them to travel on a commercial flight despite her slight fever. At every turn, Frieden has sought to soothe an anxious public with assurances that Ebola won’t spread–only to watch fresh missteps undercut the case for calm.

Frieden has become the prime target for the health care system’s mistakes. He’s been flayed by critics and clobbered on Capitol Hill. Then, under pressure, President Obama installed Ron Klain, a longtime Democratic operative with no experience in public health, to coordinate the government’s response to the virus.

Frieden acknowledges some stumbles. “In retrospect, I wish I’d been very clear that this is going to be really hard and that there may be additional cases,” he says, sinking into a black desk chair in his office in suburban Atlanta. “Ebola is scary. I think people heard me say we would stop it. They didn’t hear me say there may be a few more cases.”

Despite the panic and the miscalculations, however, the fight to contain Ebola in the U.S. has been largely successful. Of the people the CDC has been monitoring, no new cases have been detected. Experts say the danger to the broader public is extremely low.

But as parents pull kids out of schools, airline passengers show up in homemade hazmat suits, and self-published Ebola survival guides climb the Amazon charts, Frieden bears the brunt of the hysteria. “He’s the best person I know to be in the position he’s in,” says Dr. Alfred Sommer, dean emeritus of the school of public health at Johns Hopkins University. “I also know he’s going to suffer for it.”

The timing hasn’t helped. Ebola has become the U.S. election season’s October surprise–a new chapter in the long-running story line about national competence. The Secret Service shortcomings, the rise of ISIS and the struggle to tame a lethal pathogen have congealed into the GOP’s closing message on the campaign trail: the Obama Administration can’t keep you safe.

Unlike medicine, politics is more art than science, and it has its own immutable laws–one of which says that when things go wrong, there must be blame. In this case, it’s falling on Frieden–a development his admirers consider unfair. “We’ve created this Colosseum mentality. We throw the Christians to the lions,” says former New York City mayor Michael Bloomberg, who hired Frieden as health commissioner of that city in 2002. “But if you were to drive out somebody like Tom, why would anybody take this job?”

Shouldering the Blame

The hub of the CDC’s response to Ebola is its emergency operations center in Atlanta, an open bullpen lined with clocks tracking the time in far-flung capitals. A map of the outbreak adorns one wall, with red and green circles marking cases and treatment centers in Guinea, Liberia and Sierra Leone.

It was in this room in late September that a staffer pulled Frieden aside to tell him the CDC was worried by incoming reports about a feverish patient in Dallas. Thomas Eric Duncan was one of more than 400 potential Ebola cases called in to the CDC. He remains the only one about whose diagnosis Frieden was warned in advance. Recalling his reaction, the CDC director sucked in his cheeks to mimic alarm: “Better get ready.”

He seemed up to the challenge. Frieden was born into a family of overachievers, the youngest of three sons to a cardiologist and a Russian history Ph.D. He followed his father into medicine after graduating from Oberlin, where he mixed premed coursework with a 200-page philosophy thesis on Wittgenstein. “He’s very hard-edged and no nonsense,” says his brother Jeffry, a professor of government at Harvard. (Indeed, before Frieden and I spoke, an aide instructed me to begin by stating the premise of my story in 30 seconds or less.)

Frieden began his career in public health as a community organizer in Tennessee, where he spent a summer conducting a census of a rural black population that lacked access to basic health services. Frieden biked door to door, visiting 500 households to inform them about a center that offered a pay-as-you-go model and free transportation. “His style then was what it is now,” says Barbara Clinton, who was head of that program. “He works very, very hard.”

Following medical school at Columbia, Frieden joined the CDC’s Epidemic Intelligence Service, a program that trains the agency’s disease detectives. He was assigned to New York City, then in the throes of a tuberculosis epidemic. He sent a team of researchers to canvass homeless shelters and crack houses, and pushed to confine TB patients who weren’t complying with recommendations. Within a year, the rate of infection plunged by as much as 80%.

After a six-year stint fighting TB in India, Frieden returned to New York in 2002, when Bloomberg hired him. At a post 9/11 moment when the specter of bioterrorism loomed over the city, Frieden chose tobacco as his signature public-health issue, convinced it would kill more people than terrorism ever could. Frieden imposed a ban on smoking in public spaces and hiked cigarette taxes to the highest rate in the country. To trim obesity rates, he barred restaurants from serving trans fats and forced them to post calorie counts. He even crafted a program that tracked purchases at the city’s pharmacies, gathering data that offers an early glimpse of emerging problems.

Frieden’s activist record may help explain why some Republicans are calling for his resignation, but the criticism transcends partisanship. After Amber Vinson became the second Dallas health care worker diagnosed with the virus, Obama seethed, according to an Administration official.

Frieden, it helps to remember, is a doctor, and his agency’s response to Ebola was grounded in years of science. “The protocols that were on the CDC website at least historically–maybe not in the last month, but historically–have worked well in the 24 African epidemics of Ebola,” says Dr. Anthony Fauci, director of the National Institute on Allergy and Infectious Diseases. “And as Frieden said publicly many times, we have dealt with Ebola since 1976 and put down every single epidemic.”

But that was Africa, where health care workers had experience with Ebola patients. In the U.S., it was almost inevitable that health workers would make mistakes on their first encounter with an unforgiving virus. “In Ebola cases, they have to be 100% right, 100% of the time,” says Dr. Julie Gerberding, Frieden’s predecessor at the CDC.

In some ways, higher health care standards may actually endanger nurses in the U.S. In Africa, the ratio of patients to caregivers permits little hands-on care. But Duncan’s nurses inserted catheters and ventilating tubes and drew blood regularly to monitor his viral load and immune-cell count, all while grappling with huge volumes of bodily fluid as they swapped soiled bedclothes and mopped vomit. The decision to allow one nurse to travel was rooted in the assumption that the hospital had trained her in wearing the proper equipment, so she–and the other passengers on the plane–were not at risk. Clearly, says a government official, “maybe it was too much to ask every hospital to be able to do that.”

That’s why medical experts–who knew there are no certainties in a fight against an invisible, unfamiliar foe–were baffled by Frieden’s categorical promises and especially by his assertion that every hospital in the U.S. could handle an Ebola patient. “There was perhaps a little bit too much emphasis on stopping [Ebola] in its tracks,” says one top government official. Another cringed upon hearing Frieden’s confident assurances: “When absolutes were coming out of the CDC, I said, ‘Oh my God, I wish he hadn’t said that.'”

Nobody knows how the nurses were infected; public-health officials suspect they contracted the virus amid the tricky process of removing protective gear. The CDC has since tightened its standards, insisting on full body coverage and adding a site manager to oversee infection control. To some, the changes suggest the original guidelines were too lax. “Absolutely irresponsible and dead wrong,” Dr. Sean Kaufman of Emory University Hospital told the New York Times.

But the CDC has also shouldered the blame for events beyond its control. The agency, which must be invited to assist with local health emergencies, does not provide care or control hospitals. In the federal health system, that role is reserved for the states. The CDC issues guidelines and protocols, and states are responsible for executing them.

At Home and Abroad

Although it is fed by politics, it is possible that Ebola hysteria will fade even before ballots are cast on Nov. 4. The last of Duncan’s community contacts in Dallas have passed through the 21-day incubation period without developing the virus. “We will get this problem put back in the box in the U.S.,” says Dr. Jordan Tappero, director of the CDC’s global protective division and deputy incident commander for the Ebola epidemic. “And we have to turn back to Africa.”

But the story abroad is getting grimmer by the day. The virus struck at the porous borderlands of three West African nations with little health care infrastructure and no experience combating Ebola. Every few weeks, cases double. The agency estimates that there may be up to 1.4 million cases at the heart of the epidemic by January. This outbreak has catalyzed the largest global response in the CDC’s history, with more than 1,000 employees working to stop it, including 150 people scattered across Sierra Leone, Liberia and Guinea.

Frieden says that what keeps him up at night is the speed at which the virus is spreading in West Africa. On the home front, however, the CDC director is still making promises. “There’s really no scenario, other than a mutation, that we end up with a widespread outbreak in the U.S.,” Frieden says. “It’s just not in the cards.”

–ALEX ALTMAN/ATLANTA. WITH REPORTING BY ALICE PARK/NEW YORK AND TESSA BERENSON AND ZEKE MILLER/WASHINGTON

2) I KEEP HEARING THE VIRUS IS MUTATING. COULD EBOLA BECOME AIRBORNE?

No. Ebola, like most viruses, mutates often, but that doesn’t mean the way it spreads between people will change. To be very clear: In the history of all viruses, scientists have yet to see a virus mutate so that it goes from spreading via droplets–meaning it is carried by infected bodily fluids–to becoming airborne. Unlike influenza–where the dried viral particles can travel long distances in the air–Ebola can’t survive without a fluid vehicle, such as saliva, sweat, blood, feces or vomit. Ebola apparently needs that liquid to jump from one person to another, and liquid can’t travel as far as dry particles in the air. For the virus to find an entirely new way of moving around would be unprecedented.

These characteristics of viruses have been confirmed to hold true in the case of Ebola by researchers at the Broad Institute who have been analyzing Ebola genes from patients who have died of the disease. Ebola has a genetic spine that is made up of RNA. Human genomes are built on DNA, so once Ebola infects a human cell, the virus has to translate its genes into DNA language so that it can insinuate itself into the human body and continue to replicate. All that copying results in lots of errors. But even while the virus is replicating–and making mistakes while it’s doing so–it’s not likely to disturb the most important genes that give it its identity. And those include the genes that make Ebola a virus that’s transmitted by droplets of body fluid.

–ALICE PARK

3) WHO CAN ORDER AN EBOLA PATIENT TO QUARANTINE? WHAT ARE THE PATIENT’S LEGAL RIGHTS?

When it comes to containing deadly and contagious viruses that pose a potential public health threat, health officials have a lot of leeway. Local, state and federal agencies have significant powers to order quarantines of those who have been exposed to deadly viruses and to isolate individuals who are carrying diseases like Ebola. The burden rests with public health officials to show sufficient justification to issue those orders, says Peter Jacobson, a University of Michigan professor of health law and policy, and a health agency is generally required to protect public health while being as unrestrictive as possible. While the orders can be challenged in court, judges often give the benefit of the doubt to health officials, especially during a public health emergency, experts say. Quarantines should not run for longer than the incubation period for a disease, however, which for Ebola is 21 days.

There are a few more rights for those under quarantine at a hospital vs. those who are quarantined at home. Under federal law, a hospital cannot disclose a patient’s name or identifying factors, says Polly Price, an Emory University law professor. If a person is restricted from leaving his or her own home, however, there are no legal provisions that explicitly guarantee their privacy.

Businesses like airlines and cruise ships could also theoretically quarantine a passenger or even deny them boarding, but they’re required to notify and seek guidance from the CDC in such an event.

How strict are these rules? If an individual decides to violate a formal quarantine order, it could be treated as a criminal offense, depending on the state. If someone violates a voluntary quarantine, officials can, in some cases, make that confinement order an official, legally binding one.

–JOSH SANBURN

4) WHAT’S THE STATUS OF ALL THE EXPERIMENTAL DRUGS AND VACCINES?

There are no drugs or vaccines approved by the FDA to treat Ebola, but scientists have lots of leads. And the FDA can, in extraordinary circumstances, allow an experimental drug–meaning one that has not been proved safe or effective in people–to be used on human patients.

That’s what happened with ZMapp, the cocktail of antibodies received by Dr. Kent Brantly and Nancy Writebol, the first two American aid workers to get infected. ZMapp had been tested in primates and looked promising. It didn’t cause any serious side effects, and it was effective in protecting the animals from Ebola infection. And indeed, both Brantly and Writebol survived Ebola and have been declared free of the virus. Because the drug isn’t approved, it’s in short supply. Production of ZMapp is now being ramped up.

There are also two possible vaccine candidates that are currently being tested in healthy human volunteers in the U.S., Mali and Switzerland. Researchers should know by December if the vaccines are safe–and the World Health Organization (WHO) is ready to test them further in Africa if they are, with first priority going to health care workers. The WHO is also making available to those infected the plasma, which contains Ebola-fighting antibodies, of surviving patients. Stations in Liberia will likely have the first doses of serum within weeks.

In the meantime, the FDA is contacting companies that have drugs or vaccines in earlier stages of development and working with them to find quicker ways to make those options available if they prove safe.

Since the only conclusive proof that these drugs work requires intentionally infecting volunteers with Ebola–and “we are not going to infect anyone with Ebola intentionally,” says FDA commissioner Dr. Margaret Hamburg–the agency has a so-called animal rule that allows companies with promising drugs to test them in animals to prove that they are effective in fighting the virus.

–ALICE PARK

5) CAN I GET SICK IF I TOUCH SURFACES THAT HAVE BEEN IN CONTACT WITH EBOLA?

It’s technically possible but highly unlikely, based on what scientists currently know. The vast majority of data on the transmission of Ebola shows it spreads when an infected person’s bodily fluids, like blood, sweat, vomit and diarrhea, come into direct contact with another person’s mucus membranes (as in the nose, mouth or eye) or broken skin. Although there hasn’t been a lot of research into whether Ebola spreads from surfaces, data available suggests the virus can survive on surfaces–remember, though, that the virus needs to be inside a liquid (in this case bodily fluids) to survive for long periods of time. The only confirmed case of a person getting Ebola from an object or material that can carry infection, was during a 2000–01 Ebola outbreak in Gulu, Uganda, when a patient who had never been directly exposed to someone with Ebola got the disease by sleeping with a blanket that had been used by an Ebola patient.

A 2007 CDC-funded study from infectious-disease researchers at the Tulane School of Public Health and Tropical Medicine sampled 31 objects and surfaces that were not visibly bloody, such as light switches, stethoscopes and bed frames inside an isolation ward that treated Ebola patients. All specimens tested negative for the virus, suggesting the risk of transmission from environmental surfaces was low.

The researchers concluded that their findings could also mean that the viral load–that is, the number of viral particles of surface contamination–is too low for detection, or that surfaces may be able to be contaminated, but are no longer infectious once cleaned. Emory University Hospital in Atlanta, which has experience treating patients with Ebola says it decontaminates its surfaces regularly, and the CDC stand by the data showing surface transmission may be possible–but is not considered a high risk.

–ALEXANDRA SIFFERLIN

6) SHOULD THE U.S. BAN ALL TRAVEL TO AND FROM SIERRA LEONE, LIBERIA AND GUINEA?

Disease experts say, resolutely, that stopping flights from West Africa or denying visas to people from Guinea, Liberia and Sierra Leone will only increase the risk that an infected and unknown traveler makes his way to the U.S.

It’s a devil-you-know rationale: by carefully screening and tracking travelers from West Africa before departure and after they arrive in the U.S., public-health officials are in a better position to respond to any Ebola cases that develop.

“To block people from coming into the U.S. from West Africa is not thinking about the loopholes,” says Koya C. Allen, an epidemiologist who studies disease transmission related to travel. If flights are halted, people will leak out through other means.

That’s why the Department of Homeland Security has ordered that all passengers arriving from or through Ebola-hit countries land at just one of five designated airports, where the CDC has long maintained quarantine stations and where enhanced screening processes are currently in place. And travelers entering the U.S. from Liberia, Guinea and Sierra Leone will now be actively monitored for Ebola-like symptoms by state and local health officials for 21 days upon arrival, the CDC announced on Oct. 22.

Sahotra Sarkar, a specialist in the history of science at the University of Texas, has worked with colleagues to develop a predictive model of how dengue fever spreads through travel. He says surveillance is the best response, not just in West Africa but especially at transit airports such as those in Dubai or Istanbul, to keep the disease from spreading to China or India.

There’s a precedent for forbidding access to the U.S. for travelers with infectious diseases. In 1987 President Ronald Reagan banned people infected with HIV/AIDS from coming into the U.S. But there is little evidence the ban was enforced or even could have been–or that it curbed the spread of the virus in the United States. Obama eliminated that particular ban in 2010.

–BILL SAPORITO

7) IF YOU SURVIVE EBOLA, DOES IT MEAN YOU CAN NEVER GET IT AGAIN?

Possibly. Scientists currently do not know of any case in which a person got Ebola more than once. But that’s because doctors still don’t know much about how the human immune system responds, since so few survivors have been studied from the beginning of infection to the end. Researchers do know that even several years after being infected, monkeys that survive can still fight off another Ebola infection.

For now, experts think that the immune response in people is similar to that generated when you catch chicken pox. Just as the body makes antibodies and produces other immune cells that can recognize and destroy the chicken pox virus, the body does the same to fight Ebola. These responses remain in immunological storage, in a sense, ready to be called into action again if the virus reappears.

But unlike the flu, which many of us get over and over again in a lifetime, Ebola is a new virus that the body is not likely to have seen before. That makes it harder for the immune system to rev up and fight it quickly and effectively the first time. How strong a response the body mounts depends on a lot of factors, including age and overall health before infection. So far, it looks like younger patients are better able to fight off Ebola, since their immune systems are more aggressive and nimble at recognizing and attacking a novel enemy.

–ALICE PARK

8) HOW LIKELY IS A MAJOR OUTBREAK OUTSIDE WEST AFRICA?

Slim. Aside from a few isolated cases outside Africa, Ebola outbreaks have been located on that continent, where the virus was first discovered, starting with Zaire in 1976.

There’s no reason to think that will change anytime soon. Weak health care systems in that part of the world stymie efforts to stop the spread quickly, which can result in more cases–and more people leaving outbreak areas to seek medical care or safety elsewhere. Countries bordering Liberia, Sierra Leone and Guinea and those with strong trade and ties to the affected regions are at increased risk, according to the WHO, which is working closely with those countries to improve their capacity to detect and contain cases. That’s what happened in Senegal and Nigeria–two countries now officially free of Ebola.

Even when a case turns up in a country outside West Africa, as happened recently in the U.S. and Spain, the chances of a full-blown outbreak are very small. As long as the proper training has taken place, countries with robust health care systems are much more equipped to contain and manage infectious diseases. The WHO recently said that a major Ebola outbreak isn’t likely to happen in the U.S. or Europe, and the CDC agrees. Because Ebola is spread so intimately, travelers are at “very low risk,” and the risk of an outbreak in the U.S. is also very low.

–MANDY OAKLANDER

9) HOW DO HOSPITALS SAFELY DISPOSE OF THE BODILY FLUIDS OF AN EBOLA PATIENT?

You can’t just toss ebola-infected materials into the trash. Critical to containing the virus is safe disposal of the fluid-soaked waste used in the treatment of an Ebola-infected patient, which is classified as a hazardous material by the Department of Transportation and subject to all kinds of requirements.

CDC guidelines state that medical waste–things like garments, sheets, gowns, cleaning supplies or anything that comes into contact with the patient or their bodily fluids–must be sterilized before they are removed from the hospital. Hospitals can do this in an autoclave, a pressure chamber that uses steam sterilization or by incineration. Both kill the virus. Most hospitals have at least one of these capabilities on-site, like Emory University Hospital, which has treated several Ebola patients. Hospitals that do not have such capabilities would have to triple-pack the waste in watertight containers and then have it carted away by contractors.

Fecal waste can be flushed down the toilet, since U.S. sewer systems are designed to deactivate infectious agents through disinfection with chlorine and bleach and bacterial breakdown of sludge–though medical-waste laws vary by state. When William Dunne, administrative director of UCLA Health System’s emergency preparedness, safety and security, helped develop the disposal plan for UCLA Hospitals, he learned that the local water-treatment system wouldn’t allow the flushing of Ebola waste. Their plan is to give patients toilets with individual containers, then bag, solidify and treat all waste with bleach solutions and discard it as part of the hazardous-waste process. Blood samples would be packaged and sent to the local health department and the CDC, and any left over would be discarded as biowaste.

–MANDY OAKLANDER

10) WHAT’S THE NEXT EBOLA?

Ebola is by no means the only infectious disease that has the ability to spread on a mass scale, nor is it the only one for which we don’t have an approved drug or vaccine.

One of the more worrisome diseases among the public-health community is bird flu, a respiratory virus that has the ability to cause pandemics. Many viruses that originate in animals eventually make their way to humans–and once they do, some are transmissible from human to human. That hasn’t happened with bird flu yet, but if it did, it would likely be a disaster much greater than the current Ebola outbreak, according to Dr. Robert Belshe, a professor of infectious diseases, allergy and immunology at Saint Louis University who is working on a vaccine. “Ebola is a very different virus, but if you take a step back and ask, ‘What are the public-health consequences of these two viruses?,’ they are sort of similar,” he says.

Another infectious disease that concerns experts is the Middle East Respiratory Syndrome (MERS), which was first reported in Saudi Arabia in 2012 and made its way west in May 2014, when two people brought the disease to the U.S.

Despite years of work from infectious-disease experts to develop vaccines for some of these diseases, financial incentives for the pharmaceutical industry to bring drugs to market are mostly nonexistent. “Pharmaceutical manufacturers in the U.S. are wary of incurring substantial research and development costs for infectious-disease drugs that are primarily utilized by individuals in developing countries,” says IBISWorld health care analyst Sarah Turk.

–ALEXANDRA SIFFERLIN

11) THERE HAVE BEEN ONLY A FEW CASES OUTSIDE WEST AFRICA. WHY ARE PEOPLE FREAKING OUT?

The almost-zero probability of acquiring something like Ebola often doesn’t register at a time of mass paranoia–and that may just be human nature. “There are documented cases of people misunderstanding and fearing infectious diseases going back through history,” says Andrew Noymer, an associate professor of public health at the University of California at Irvine. “Stigmatization is an old game.”

While there was widespread ignominy surrounding diseases like the Black Death in Europe in the 1300s, for instance, the Ebola frenzy seems more akin to how we grappled with HIV/AIDS in the 1980s. Like the first cases of HIV/AIDS, Ebola is something novel in the U.S. It is largely unknown to Americans, and its foreign origins may help spark fearful reactions. The fatality rate for those who do contract it is also high, and the often gruesome symptoms provoke strong, instinctual responses. “It hits all the risk-perception hot buttons,” says University of Oregon psychology professor Paul Slovic.

Humans essentially respond to risk in two ways, either through a quick gut feeling or longer gestating, more reflective decisionmaking based on information and analysis. Our gut can often trump reflection. Even though we know that things like the flu will likely contribute to the death of thousands of people this year, or that heart disease is the leading cause of death in the U.S., we’re more likely to spend time worrying about the infinitesimal chances that we’re going to contract a disease that has affected only a handful of people outside West Africa.

“Statistics are human beings with the tears dried off,” Slovic says. “We often tend to react much less to the big picture.”

–JOSH SANBURN

12) IS THERE ANYTHING I CAN DO TO HELP?

There is. Aid groups and organizations with programs already in place in Sierra Leone, Guinea and Liberia need money to make sure they have a consistent flow of resources to treat patients and protect health care workers. Doctors Without Borders/Médecins Sans Frontières (MSF) and the International Red Cross have been active in the region, and both accept monetary donations, through doctorswithoutborders.org and ifrc.org/en/get-involved/donate, respectively.

The nonprofit CDC Foundation, to which Facebook founder Mark Zuckerberg recently donated $25 million, accepts monetary donations on its site, cdcfoundation.org. The group is also looking for donations of items including protective equipment, ready-to-eat meals, generators, vehicles and motorcycles.

“There is definitely a need for more well-trained, well-managed medical and support staff to safely and efficiently care for patients,” said an MSF spokesperson. Both MSF and the Red Cross say they are not recruiting health care workers because the required skill sets are so specific and require extensive training that the nonprofits do not currently have the bandwidth to perform on top of what they are currently doing in the area. MSF is calling on foreign governments to recruit, train and deploy more physicians and medical staff to the region.

Health care workers with experience dealing with infectious diseases can volunteer through USAID (usaid.gov/ebola/volunteers). Finally, $10 donations can be made to WHO by texting EBOLA to 27722, which will support relief efforts in West Africa.

–ALEXANDRA SIFFERLIN