TIME Infectious Disease

CDC Received Over 90 Calls About Potential Ebola Cases Before Dallas Patient

The Dallas patient is the 13th patient in the U.S. tested by the CDC

On the afternoon of Sept. 28, U.S. Centers for Disease Control and Prevention (CDC) epidemic intelligence officers—sometimes referred to as disease detectives—received a call from Texas Health Presbyterian Hospital of Dallas concerned about a patient the hospital thought could be at risk for Ebola. This was at least the 90th call the team had received during the Ebola outbreak from hospitals concerned that one of their patients could possibly be infected. But until Tuesday, there had never been a diagnosed case.

CDC director Dr. Tom Frieden said in a press conference on Tuesday that “As long as the outbreak continues in Africa, we need to be on-guard.” The statement rings true since the U.S. now has its first patient, but the CDC has been awaiting the possibility that Ebola would make it to American soil for months.

On Sunday afternoon, an epidemic intelligence service officer took the hospital through a decision-tree of sorts that helps the CDC determine whether the patient is at a real risk for Ebola. Factors that are taken into account are where the patient had traveled in the past and what their symptoms were. Since the patient continued through the CDC’s algorithm with enough red flags, the CDC requested that the patient be isolated and that a blood specimen be sent to the CDC’s level 4 testing lab for confirmation.

MORE: Inside the CDC’s Emergency Operations Center Tackling Ebola

The Dallas patient is the 13th person that the CDC has actually tested for Ebola. “Every morning, Dr. Frieden is updated on all of the individuals that we have looked at and the numerous individuals under investigation,” a CDC spokesperson told TIME. There have been a few false alarms already, including patients in New York City and Miami—all eventually tested negative.

The CDC campus is in Atlanta, Georgia, and since early August, the headquarters has had its Emergency Operations Center on a Level 1 response—the highest possible level for a public health crisis. Just a couple days after the CDC kicked operations into high gear, the World Health Organization (WHO) declared the outbreak in West Africa a global public health emergency. In the Emergency Operations Center, several epidemic intelligence officers sit in rows of long tables tapping away at their computers facing a wall of computer screens that show where Ebola clusters are in West Africa, as well as graphs of the disease’s trajectory. The officers offer aid both domestically and to their colleagues in the field. Many have been traveling in and out of West Africa since the spring.

After the CDC determined that the patient, reportedly a man named Thomas Eric Duncan, was indeed at a very high risk for the disease, the hospital sent blood specimens for testing to both the CDC’s lab as well as a Texas Health Department lab. The specimens arrived at the CDC around 10 a.m. on Tuesday morning, and by Tuesday afternoon, both the CDC and the Texas Health Department had confirmed that the patient was in fact positive for Ebola. “We made sure the hospital spoke with the patient and their family first,” said a CDC spokesperson to TIME.

Once the patient was told they were positive, the CDC quickly informed the public by sending out a confirmation to media late Tuesday afternoon and holding a press conference an hour later. During that time, CDC disease specialists were already deploying to Dallas—landing on Tuesday evening to begin the process of tracking down and monitoring all the people that the patient with Ebola had come in contact with while infectious. It’s a process that will continue until the 21-day incubation period of the disease ends.

Though the Dallas patient is the first patient to have confirmed Ebola, the CDC has long said that an Ebola patient making it to the U.S. was always a possibility. However, due to the quality of health care in the United States, patients are not facing the same dire situations as patients in Liberia, Sierra Leone or Guinea, and Ebola in the states will likely have a much different prognosis.

TIME Infectious Disease

This Is the 21-Day Process for Stopping Ebola

Texas Hospital Patient Confirmed As First Case Of Ebola Virus Diagnosed In US
Dr. Edward Goodman, epidemiologist at Texas Health Presbyterian Hospital Dallas, and Dr. Mark Lester, Southeast Zone clinical leader for Texas Health Resources, answer questions during a media conference at Texas Health Presbyterian Hospital Dallas where a patient has been diagnosed with the Ebola virus on Sept. 30, 2014 in Dallas. Mike Stone—Getty Images

Experts are tracking anyone who could have come in contact with the first patient to be diagnosed in the U.S.

U.S. health officials were working Wednesday to determine whether the first diagnosis of Ebola on American soil is an isolated case—or whether the patient may have infected others.

The Centers for Disease Control and Prevention (CDC) dispatched a nine-person epidemiology team to Dallas on Tuesday night. Their job is to contain any potential spread of the virus by working with local health officials to document whether the patient had contact with other people—who, where and when. How they’ll do this is less like the movie Outbreak and more of a labor-intensive process of interviews and monitoring.

The trail they will investigate starts Sept. 26, when a man came into Texas Health Presbyterian Hospital in Dallas for medical care. For two days, he had been feeling ill with fever and muscle aches—generally not concerning, which is why he was sent home. Two days later, he was worse, and was brought back to the hospital by ambulance.

It wasn’t immediately clear if doctors had asked the patient the critical question they should be asking all people who seek medical care for fevers, which is whether he had recently been outside of the U.S., and whether he had traveled to any of the countries in West Africa—including Guinea, Liberia or Sierra Leone—now battling the worst Ebola outbreak in the disease’s history. A Texas health official clarified Wednesday that a nurse had indeed asked the patient if he’d been to Africa and that he said he had, but hospital staff never factored that into their initial treatment.

MORE: How U.S. Doctors Can Contain Ebola

It turned out he had. Four days before he began feeling sick, the patient had been in Liberia before flying to the U.S. This time, based on his symptoms and his travel history, the doctors admitted him into an isolated room and called the state health department and the CDC’s 24-hour hotline; officials recommended testing the patient’s blood for the Ebola virus.

It tested positive, and now health officials from national and local agencies are on the scene. Their job is to contain any potential spread of the virus by documenting who, where and when the patient had contacted other people who might have been exposed via the patient. Because Ebola is only transmitted by droplets—in urine, blood or other body fluids—and only contagious when patients become symptomatic, those at highest risk are people who would have had the closest and most direct contact with the patient. Those who are exposed would also have to have direct mucous contact with infected fluids, such as via the eyes, nasal passages, or through a cut in the skin. So the passengers on the patient’s flights from Liberia to the U.S., for example, aren’t considered at high risk of exposure since he was not experiencing symptoms then.

MORE: Ebola in the United States: What You Need to Know

But the emergency medical personnel who brought the patient to Texas Health Presbyterian in the ambulance might be. They, and the man’s close family members, are being monitored for the virus’ longest incubation period—21 days—for any symptoms of Ebola, such as fever, nausea, vomiting or muscle weakness. If they don’t show any symptoms after that time, they’re likely in the clear.

Epidemiologists take a ring approach to tracing contacts of patients—starting with the circle of people with the most direct contact, such as family members or those who share close living arrangements. Each contact is asked about their own recent interactions with people, and this information is built into a contact tree of folks, not all of whom would be put on watch. Depending on how direct the contact with the patient was, even family members may not be quarantined but asked to refrain from traveling out of the city or country, for example, and avoiding public areas like movie theaters or shopping malls. A handful of children who were in the home with the patient are being monitored, local health officials said at a news conference on Wednesday, but they were allowed to attend school as usual.

MORE: Containing Ebola Is Extremely Labor Intensive, Former CDC Researcher Says

If anyone in the first circle of contacts develops symptoms, then doctors would step up their monitoring of the next ring of contacts, asking them to stay away from public gatherings for 21 days. This pattern continues until no one in a ring reports symptoms in the incubation period; that suggests they were not exposed and therefore don’t have the infection.

All of this, of course, depends on honest and accurate information from the patient and his contacts about where they have been and with whom—something that has been an issue in west Africa, where stigma against Ebola has led patients to flee health volunteers who are attempting to trace contacts, or fail to report people they have interacted with.

That shouldn’t be a problem here, CDC director Tom Frieden said. “We have identified all the people who could have had contact with the patient while he was infectious,” he said during a news conference. “We are stopping it in its tracks in this country. There is no doubt in my mind that we will stop it here.”

TIME Infectious Disease

Ebola in the United States: What You Need to Know

TIME answers your questions about Ebola in the United States

Ebola now has its first diagnosis in the U.S., and while concerning, it’s not entirely surprising. Given how interconnected our world is, the CDC has long said that it’s possible Ebola could make it here, though it’s unlikely it would spread widely. Here’s what you need to know, now that there’s a patient with Ebola in Dallas.

Can I get Ebola?
No one is immune to Ebola, but that being said, the only way Ebola is transmitted is through bodily fluids like vomit and diarrhea and blood. You really have to be up close and personal with an Ebola patient to be at risk for contracting the disease, which is why, so far anyway, Ebola has spread primarily among family members of the infected as well as those caring for them. It’s not easy to catch Ebola, especially since it does not spread through the air.

But I heard it could spread through the air.
A renowned infectious disease expert named Michael Osterholm wrote an opinion piece in the New York Times that said airborne Ebola is possible if the virus mutates enough. As TIME reported in the past, anything is possible with viruses, but there are many other mutations that are more likely than a change in the mode of transmission—meaning how you catch it. For instance, a virus could become more virulent—more contagious—or could develop incubation periods that are longer than the current estimate of 21 days. But in general, scientists are not very concerned about that.

What’s the likelihood it will spread in the U.S.?
Not very, though the patient’s direct contacts must be screened. On Tuesday, director of the CDC Dr. Tom Frieden said in a press conference: “The bottom-line here is I have no doubt that we will control this case of Ebola so that it does not spread widely.” The CDC has consistently said that given the quality of the U.S. health care system, it’s very unlikely that there will be significant spread of the disease on U.S. soil. Any hospital in the U.S. with an isolation unit—which is most of them—has the ability to isolate a person with Ebola as well as treat them with supportive care. Even though Ebola has no cure, monitoring patients’ heart rates and providing fluids and electrolytes can go a long way. For instance, if a patients’ potassium plummets, doctors in the U.S. can replenish it fairly easily. That’s a different situation from West Africa, where health care workers are dealing with a significant lack of resources and less sophisticated equipment.

But could there be more cases?
It’s certainly possible. This is not the first time Ebola has crossed borders via air travel. Nigeria’s outbreak started when a Liberian-American man infected with the disease traveled from Liberia to Nigeria. That same patient was en route to Minnesota. In a press conference on Tuesday, Dr. Frieden said: “As long as the outbreak continues in Africa, we need to be on-guard.” The CDC has been working for months with U.S. hospitals to make sure they feel prepared to handle any cases of Ebola by informing hospitals about the warning signs, as well as what kind of protective equipment they should wear.

Are the people on the plane at risk?
That’s highly unlikely. Ebola is only contagious when a person starts exhibiting symptoms of the disease, like a fever. And even then, a person can only contract the disease from direct contact with bodily fluids. The patient with Ebola in Dallas did not start exhibiting symptoms until four days after landing in the U.S., which means it’s extremely unlikely people on his plane are at any risk.

Why did the Dallas hospital originally send the patient home?
Though we don’t know the hospital’s reasoning, we do know that Ebola presents similarly in the beginning to other diseases, like malaria for instance. It’s possible the health care workers thought it was something else. After all, Ebola has never arrived in the U.S. before. The CDC said they are also unsure how the patient got infected. A health care worker traveling home from Liberia would likely set off more red flags. The CDC has still been prepping the U.S. health system for the possibility, which is why we’ve had so many false alarms.

Should I be freaking out?
The CDC and the Texas Department of Health are confident that Ebola will be contained in the U.S., and if the current patient’s health is similar to that of other infected people evacuated into the U.S., they have a better shot at survival. The disease’s high mortality rate in West Africa is largely due to the state of the health care systems in Sierra Leone, Liberia and Guinea, as well as overcrowding and lack of resources.

So what’s the bottom line?
The Ebola outbreak as a whole is terrifying, with over 3,000 dead and the worst yet to come, according to reliable predictions. The new case is a reminder that an infectious disease outbreak like Ebola truly is a global health emergency.

TIME Infectious Disease

White House Urges Calm After First Confirmed U.S. Ebola Case

Tourists visit the south side of the White House on Sept. 30, 2014 in Washington.
Tourists visit the south side of the White House on Sept. 30, 2014 in Washington. Mark Wilson—Getty Images

"You can't get Ebola through air. You can't get Ebola through water. You can't get Ebola through food in the U.S."

Within minutes of confirmation from the Centers for Disease Control and Prevention (CDC) of the first confirmed case of Ebola on U.S. soil, the White House communications operation sprang into overdrive. Their message: don’t panic.

Seeking to combat the inevitable national concern over the deadly infectious disease which has ravage West Africa for more than six months,the Obama administration took to social media to raise awareness that while the virus is potent, it is relatively hard to contract.

“You can’t get Ebola through air. You can’t get Ebola through water. You can’t get Ebola through food in the U.S.,” the administration said in a rapid-response graphic shared on the White House website and Twitter, Facebook, and Instagram accounts. “America has the best doctors and public health infrastructure in the world, and we are prepared to respond.”

WhiteHouse.Gov

President Barack Obama was informed minutes before a scheduled meeting of the National Security Council on the efforts to combat the spread of the Islamic State of Iraq and Greater Syria (ISIS), an official said.

Lisa Monaco, the President’s Counterterrorism and Homeland Security Advisor, has been coordinating the administration’s homeland preparedness response to Ebola, and White House chief information officer Steven VanRoekel has returned to the U.S. Agency for International Development to work on the response, but Obama has not appointed a point-person to oversee the government-wide effort to combat Ebola.

CDC Director Dr. Tom Frieden briefed Obama by phone Tuesday afternoon on the diagnosis, as well as the “stringent isolation protocols under which the patient is being treated as well as ongoing efforts to trace the patient’s contacts to mitigate the risk of additional cases,” the White House said.

Earlier in September, Obama traveled to CDC headquarters in Atlanta for a briefing on the disease, announcing the deployment of hundreds of U.S. medical personnel and 3,000 American troops to assist in the response in Africa, while various federal agencies have worked to raise awareness at U.S. ports of entry and medical facilities.

In an interview with NBC’s Chuck Todd in early September, Obama said Americans shouldn’t consider the virus a “short term” threat, but warned that unchecked it could be a greater issue.

“Americans shouldn’t be concerned about the prospects of contagion here in the United States short term, because it’s not an airborne disease,” Obama said on Meet the Press. But he warned that the U.S. must make the disease a “national-security priority.” “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,” he said. “It becomes more easily transmittable. And then it could be a serious danger to the United States.”

Senior Advisor Dan Pfeiffer was appearing on CNN’s The Situation Room in a pre-arranged interview Tuesday evening, but urged calm. “America has the best doctors and public health infrastructure in the world, so we’re ready to deal with it,” he said, adding that the U.S. has “been prepared for this possibility for a long time.”

TIME Infectious Disease

CDC Confirms First Case of Ebola Diagnosed in the U.S.

Outbreak has claimed more than 3,000 lives in Africa

Health officials confirmed Tuesday that a patient in Dallas has Ebola, marking the first such diagnosis of the deadly disease ever to occur on U.S. soil.

Until now, the only cases of Ebola in the U.S. have been Americans who were infected abroad and were brought back for treatment. The death toll from the worst Ebola outbreak ever, which has hit several countries in West Africa, surpassed 3,000 last week.

The patient, who has not been identified, had traveled to the U.S. from Liberia, leaving Liberia on Sept. 19 and arriving in the U.S. on Sept. 20. The patient had no symptoms when departing Liberia or when first landing in the U.S., but began developing symptoms for the deadly virus four days after arrival. On Sept. 28, the patient was placed in isolation at Texas Health Presbyterian Hospital in Dallas. The patient’s specimens tested positive for Ebola on Tuesday afternoon.

U.S. Centers for Disease Control and Prevention (CDC) director Dr. Tom Frieden said that the medical team’s priorities are to care for the patient, as well as to track down everyone the patient came in contact with while the patient was infectious. A patient with Ebola is only contagious once an infected person starts presenting symptoms. The CDC and Dallas Health and Human Services will identify all the contacts and monitor them for 21 days, which is the incubation period for the disease. If any of the contacts comes down with a fever, they will be isolated and cared for. The CDC says it has just started the contact tracing.

Frieden acknowledged that it’s possible someone with close contact with the patient could come down with the disease, but is confident the U.S. healthcare system can handle that possibility. “The bottom-line here is I have no doubt that we will control this case of Ebola so that it does not spread widely,” said Frieden during a news conference.

The CDC said that they do not know how the individual was infected, but the patient must have had close contact with someone infected with the disease. The CDC is sending disease specialists to Texas. The CDC has long acknowledged that it’s possible for Ebola to reach the U.S., though concern for widespread infections is low given the quality of U.S. health care. “As long as the outbreak continues in Africa, we need to be on-guard,” Frieden said.

TIME Infectious Disease

Ebola Outbreak Contained in Nigeria, Officials Say

After a total of 19 cases and seven deaths

The Ebola outbreak in Nigeria appears to be contained, health officials said Tuesday.

The U.S. Centers for Disease Control and Prevention (CDC) said that due to a very rapid local and international response, the country may have fully contained its Ebola outbreak. The 21-day incubation period for the disease has passed.

Nigeria saw its first confirmed case of Ebola on July 17 when a Liberian-American man collapsed at a Nigerian airport after traveling from Liberia. The man infected the health workers who treated him, and the country experienced a total of 19 cases and seven deaths. Unlike in other countries like Guinea, Sierra Leone and Liberia, where it took months for Ebola to be recognized, the Nigerian government quickly declared a public health emergency when it discovered the traveler may have come in contact with 72 people at the airport and hospital.

The Nigerian government coordinated the outbreak response with state and national networks and rolled out a massive public education initiative, with trained “social mobilizers” who were deployed to do house to house visits in areas where an Ebola contact resided. Nigeria also recently worked to eradicate polio, and the country tapped into those strategies as part of their response.

Still, if there’s a lesson to be learned from Ebola thus far, it’s not to overestimate containment. As TIME reported last week, there was a period in April when it appeared Guinea’s outbreak had subsided. In actuality, there were several unreported and hidden cases that re-ignited the outbreak with an even greater wave of infections.

TIME Infectious Disease

5 Reasons We May Never Know Ebola’s True Impact

Ebola Liberia
A Medecins Sans Frontieres (MSF) worker is sprayed and disinfected as he leaves a high risk zone of MSF's Ebola isolation and treatment center in Monrovia, Liberia, Sept. 29, 2014. Jerome Delay—AP

In this unprecedented Ebola outbreak, measuring and predicting the virus' true impact is nearly impossible

The U.S. Centers for Disease Control and Prevention (CDC) published a report in mid-September estimating that if current trends in the Ebola outbreak continue without a ramped up effort, then Ebola cases in West Africa would double every 20 days. In that situation, Ebola cases could reach up 1.4 million by January.

It’s a worst-case scenario estimate, but that’s only one caveat behind the 1.4 million figure, which remains muddled by research limitations and assumptions. While health experts and a CDC official told TIME that it’s common in public health surveillance projects to report overestimates, the fact that this is the worst Ebola outbreak in history adds additional levels of uncertainty in forecasting an unprecedented epidemic.

Here are five reasons why we may never know Ebola’s true impact, despite health experts’ best efforts to fully understand the virus’ deadly potential:

1. Most Ebola cases aren’t reported

CDC researchers believe that for every 1 reported case of Ebola, there are 1.5 additional cases that go unreported. They estimated that without additional intervention, 550,000 Ebola cases will be reported by January, a lower bound that doesn’t account for the cases that go unreported. By correcting for underreporting, they arrived at the upper bound of 1.4 million.

“Underreporting is always an issue with communicable diseases,” says Thomas Gift, an economist at the CDC. “We believe the actual incidence of disease is higher than what shows up in case reports.”

In West Africa, a lack of on-the-ground healthcare resources has meant that many Ebola patients haven’t been treated by doctors, or, in some instances, they have been turned away by doctors, which has resulted in an incomplete headcount of afflicted people.

2. Adjusting the projected numbers accurately is extremely difficult.

“It’s always difficult with these models to try to capture what’s really going on on the ground,” says Dr. Eden Wells, an epidemiology professor at the University of Michigan. “Given the data they used, it’s the best projection they could get at the time.”

The projections were based on data from only one day in only one country—Liberia—Gift said. Researchers used a model to predict the number of beds in use in Liberia on Aug. 28, 2014—the occupied beds were a measure of reported cases. They then surveyed experts at Ebola treatment clinics in Liberia to estimate the actual number of beds in use, weighing that estimate by the proportion of those who stay at home (and are therefore “unreported” cases) who eventually arrive in hospitals: a measure of both reported and unreported cases.

Gift added that while on-the-ground conditions made it difficult to collect more frequent data, there was also an urgency in releasing information about the outbreak. “Why didn’t [researchers] do more to get a range of confidence? Partially because this was designed to provide a tool to be used by people to assess the potential impact of intervention while the outbreak is going on,” Gift says.

3. The projection, based on a slice of data from Liberia, was applied to all of West Africa.

Liberia has been the most hard-hit country in the Ebola outbreak, with more than 1,800 deaths and 3,400 confirmed cases, according to the CDC. Sierra Leone and Guinea have suffered significant death tolls as well, though far fewer than Liberia. “Notable regional differences in underreporting might mean that using one [assumption] across an entire country is inappropriate,” the report said. This could, in theory, result in an overestimate.

“The 2.5 correction factor”—meaning that for every one reported case, there are potentially 1.5 unreported cases, according to the CDC’s modeling—”seems to have been correct for that day,” Gift says. “But [that] might change over time.”

Still, the fact that an Ebola outbreak has never been this widespread—and thus never modeled so extensively—allows the study some liberty in deciding its parameters, the report said.

“The purpose is to show that this epidemic was not going to show signs of peaking on its own. In historic outbreaks, there were a few hundred cases, and the epidemic diminished. That didn’t happen this time,” Gift says.

4. Much of the data coming from West Africa is likely inaccurate or incomplete.

A recent World Health Organization report said that in Liberia, “data were being reported from 4 different and uncoordinated streams, resulting in several overlaps and duplicated numbers.” The report added that many deaths were not being properly documented.

Last week, the New York Times similarly reported a discrepancy between the number of reported deaths in Sierra Leone and the number of buried victims, a fact that further complicates researchers’ efforts to measure Ebola’s true impact.

5. Projecting all the way to January is difficult.

“It’s a bit like weather prediction,” says Marisa Eisenberg, an epidemiology professor at the University of Michigan. “There’s a lot more uncertainty if you’re going all the way out to January versus the end of October.”

The obvious difficulty is that the report is based on the assumption of no significant additional intervention, which, with each passing week, is changing. A shorter-term projection of Ebola cases was provided by the WHO in a report published last week in the New England Journal of Medicine. The projection’s limited time span indicates a more realistic prediction of Ebola cases, even though it also assumes “no change in the control measures for this epidemic.” If Ebola cases were to double every 20 days without additional measures, as the CDC reported, then the WHO’s estimate indicates that there will be about 150,000 cases by January, a markedly more conservative figure.

Still, experts believe there is value in examining the CDC’s “worst-case scenario” of 1.4 million cases. Overestimation offers a safety net in ensuring adequate assistance is provided. If anything, it also adds an urgency to prove wrong the study’s chilling caveat: that this is what could happen if no additional resources are used to battle the deadly disease.

“[The researchers] are trying to cover their bases, and make sure they don’t under-deploy resources,” Eisenberg says. “If you’re going to be wrong in one direction or the other, it’s better safe than sorry.”

TIME Infectious Disease

The 5 Biggest Mistakes in the Ebola Outbreak

Members of a burial team wearing protective suits bury an Ebola victim in Freetown, Sierra Leone.
Members of a burial team wearing protective suits bury an Ebola victim at King Tom Cemetery, which is bitterly resented by residents of the adjoining slum, called Kolleh Town, in Freetown, Sierra Leone, Sept. 21, 2014. Samuel Aranda—The New York Times/Redux

Experts weigh in on how the outbreak got this out of control

The U.S. Centers for Disease Control and Prevention (CDC) recently projected that if trends continue unimpeded, cases of Ebola could pass the million mark by January. While that’s an unlikely scenario, many are still wondering: How on earth did it get this bad? We canvassed experts for some clues.

1. The response was far too slow
There was a period in April when it appeared that the Ebola outbreak had subsided, prompting a collective sigh of relief. Guinea’s Ministry of Health even said that country’s caseload appeared to be under control. But the outbreak didn’t subside. Instead, it barreled through interconnected towns and villages in more-populated areas of Guinea, Liberia and Sierra Leone. And after the outbreak’s perceived lull, however, came one of the largest flare-ups. Some scientists say that during that time, their warnings were ignored.

One such scientist is Robert Garry, a Tulane University virologist who had visited a hospital in Sierra Leone caring for some of his colleagues, including Dr. Sheik Humarr Khan — one of the first doctors to die of the disease in Sierra Leone. Garry then warned various groups, including the State Department, that the outbreak was highly concerning. No one, he says, really listened to him. “Their response was cordial, but nothing really happened,” says Garry. “I was really concerned about the lack of attention. I caught a lot of flack for saying I didn’t think the numbers [of reported cases and deaths caused by Ebola] were accurate. Some of us realized this was not going to be controlled.”

In a recent paper published in the New England Journal of Medicine, Peter Piot, director of the London School of Hygiene and Tropical Medicine and one of the original researchers to discover Ebola in 1976, writes: “Ebola has reached the point where it could establish itself as an endemic infection because of a highly inadequate and late global response … It was not until five months and 1,000 deaths later that a public health emergency was declared, and it was nearly another two months before a humanitarian response began to be put in place.”

2. A lack of cultural sensitivity
Patricia Omidian, a medical anthropologist, was sought by the World Health Organization (WHO) to spend time in Liberia to help Ebola response workers better understand the communities they were serving. “I think the biggest mistake that occurred very early was that primary health care was ignored and communities were not included in their own health issues,” she says. “Programs were rolled out and people were told what not to do. No effort was made to ensure engagement and increase trust.”

Omidian’s work included explaining some of the cultural practices among Liberians, including burial rituals that involve a lot of physical contact, putting mourners at risk of contracting the virus. “This disease attacks the best of [Liberians'] culture — that of touching and caring and kindness,” says Omidian.

3. We don’t have deployable medical teams
The CDC, WHO and U.N. have important jobs when it comes to containment practices like tracking down people who may have come in contact with infected patients, and using technology to predict disease spread. However, none of those groups actually treat patients, or have doctors and nurses they can deploy. This is something that Dr. Jack Chow, professor of global health at Carnegie Mellon University and a former WHO assistant director general, says needs to change.

“The Obama mission to Liberia, which is relying on the military at the last minute, shows that the U.S. and other industrial countries haven’t built up comparable deployable medical units on the civilian side, and need to do so to prepare against future ‘flashdemics’ — high-velocity, high-lethality outbreaks,” says Chow. “In addition to building an international epidemic response force, we need to conceptualize ‘global health defense’ to include bolstering the health systems of the poorest countries.”

4. A lack of approved drugs and cures
The scarcity of drugs and vaccines is not due to a lack of innovation. Drugs have been in development for years, but since pharmaceutical companies have had no financial incentive to fund them, researchers have hit walls. “People like me and others who have worked for years in vaccines and countermeasures are frustrated,” Thomas Geisbert, a professor of microbiology and immunology at the University of Texas Medical Branch in Galveston, said in an earlier TIME article. The supply of ZMapp, the drug that was given to a few health care workers, is exhausted. It comes from a small pharmaceutical company with nine employees, and the drug grows in a tobacco plant — requiring scientists to wait for a new crop to grow just for a new batch. Thankfully, clinical trials for other drugs have kicked off.

5. Treating Ebola as a “West Africa” problem
“It’s crucial countries not be lumped together,” says Nigerian Minister of Economy and Minister of Finance Ngozi Okonjo-Iweala. “The media writes about Africa and West Africa, but there needs to be differentiation. This will end up hurting the economies of countries that have no problems. Ghana never had any cases, Burkina Faso never had any cases.” Okonjo-Iweala was also the former managing director of the World Bank, and has seen how stigma damages economies.

“We should stick to the specific countries so as not to cause massive economic damage,” says Okonjo-Iweala. “We have worked very hard to get the private sector to invest in Africa for the continent to grow based on the fact that we are a continent with a lot of vigor and good rates of return on investment. If you scare away investors by lumping the continent into one big mass, what good does it do? It will take another decade to recover.”

Nigeria has had 19 cases, seven deaths and everyone else survived. As of Tuesday, the 21 days of incubation expired for people who treated the infected, so currently no one is being monitored. “We’ve worked hard as a continent to overcome this kind of stigma of disease,” says Okonjo-Iweala.

TIME Obesity

Are Diabetes Rates Really “Leveling Off”?

For the first time in several decades, we’re starting to see a slowing of new diabetes diagnoses, suggests new data published in JAMA.

The study authors examined data collected from more than 600,000 adults between ages 20-79 from 1980 to 2012—part of the Centers for Disease Control and Prevention (CDC)’s National Health Interview Survey. A broad view paints a grim picture: From 1990 to 2008, the prevalence of diabetes as well as new cases of the disease both doubled. But from 2008-2012, those rates of change leveled off. So while people are still being diagnosed with diabetes, the rate of growth is decelerating.

“It’s encouraging that we may be seeing this slowing and plateauing,” says Ann Albright, PhD, RD, director of the division of diabetes translation at the CDC and one of the study’s authors. The study cites a slowing of rates of obesity—one of the biggest contributors to type 2 diabetes, found one study—as a partial explanation for the results. Black and Hispanic adults, however, have continued to see a rise in new diabetes cases, and prevalence also grew among people with a high school education or less. These disparities, Albright says, could get worse.

“This data is telling us that we are doing some things right,” Albright says, which is especially important given that the population is aging, and baby boomers are hitting peak years for diabetes. Driving down diabetes prevalence is great, but the best way to get there is to curb new cases—not to have people in the diabetes pool die off early, she adds.

“[This study] is important to note, but it doesn’t mean we have this licked and we’re all done,” she says. “We still have a lot of work to do.”

TIME Infectious Disease

CDC: Cases of Ebola Could Double Every 20 Days

Members of a burial team wearing protective suits bury an Ebola victim in Freetown, Sierra Leone.
Members of a burial team wearing protective suits bury an Ebola victim at King Tom Cemetery, which is bitterly resented by residents of the adjoining slum, called Kolleh Town, in Freetown, Sierra Leone, Sept. 21, 2014. Samuel Aranda—The New York Times/Redux

A new CDC report predicts the enormous cost of delayed response to Ebola

If Ebola conditions continue without a scaled-up effort, the CDC estimates that cases of Ebola in West Africa will double every 20 days — and in an absolute worst-case scenario without any intervention, numbers could reach 1.4 million by Jan. 20.

Using a new Ebola Response prediction tool, the CDC has published results that show that if current trends continue unimpeded, Liberia and Sierra Leone will have approximately 8,000 total Ebola cases, or 21,000 if the tool accounts for underreporting, by Sept. 20. Liberia will account for about 6,000 of those cases.

The numbers are frighteningly high, but it should be noted that it’s a prediction of a hypothetical situation in which absolutely no intervention were to happen. That won’t be the case if many countries and the UN keep their promises. The model also shows that a big response could turn the outbreak around. In another hypothetical situation, the outbreak could ease up and eventually end if 70% of people with Ebola are placed in medical care facilities, Ebola treatment units, or somewhere where transmission could be contained.

“The model shows that a surge now can break the back of the epidemic,” said Dr. Tom Frieden, director of the CDC, in a press conference. “The importance of implementing effective programs rapidly cant be over-emphasized. The cautionary finding of the modeling is the enormous cost of delay.”

During the press conference, Dr. Frieden said the outbreak is very fluid and changing, but that he does not think West Africa will meet their worst case scenario predictions. “If you get enough people effectively isolated, the epidemic can be stopped…Even in dire scenarios, if we move fast enough we can turn it around. I do not think the most dire circumstances will come to pass,” he said.

The CDC report comes out on the same day the World Health Organization released their reports on the outbreaks at six months in all affected countries, and it appears that cases in Nigeria and Senegal have stabilized “for the moment.” Last week, President Obama announced a deployment of 3,000 U.S. military personnel and over $500 million in defense spending to go to West Africa, and the UN announced a new task force called the U.N. Mission for Ebola Emergency Response. The hope is that an exponentially increased response will prevent these possible scenarios.

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