The End of Ebola? Lessons at the Epidemic's One Year Anniversary

"That's the anthrax building," a colleague told me several years ago, pointing to a squat reddish-brown brick building in the middle of Fort Detrick, for many years the U.S. Army's center for biological warfare research. Cinderblocks now sealed up all of the doors and windows. Inside, anthrax -- a deadly pathogen -- still lurks. Outside, we are generally spared. For years, the U.S. had developed stores of anthrax spores as biological warfare, but destroyed these in 1969. Yet after 9/11, someone sent letters containing the pathogen to various journalists and senators. Many observers feel that the culprit remains unknown.

This building sits as a silent testimony to the history of dangerous pathogens and their possible, though fragile containment.

In recent days, as the one year anniversary of the first announcement of Ebola has approached, and this outbreak has diminished -- some say the end is very near -- I have been thinking of this building.

One year ago, the current Ebola epidemic was announced to the world. Since then, we have learned and accomplished an enormous amount. The U.S., Western Europe and China worked together to address and curtail the threat, and scientists discovered that a new drug, favipiravir, shows promise. These are important achievements.

But there are also critical lessons to be learned. Major gaps emerged in world responses to the disease, and profound questions remain. This was at least the 23rd outbreak of Ebola, since the first one was documented in 1976. More may occur. This outbreak was the largest recorded, for reasons that we still do not entirely understand. Moreover, as the world becomes ever-more interconnected, infectious diseases that pop up in one corner of the globe can increasingly travel within 24 hours to countries all over the globe. In recent years, we have thus seen the spread of SARS, Avian Flu, Swine Flu, HIV and other epidemics.

Gaps in responses to Ebola emerged at multiple levels -- governments, internationally and domestically, at federal and state levels, industry and non-profits. Fear led to both over -- and under-reaction.

Doctors Without Borders (Medecins San Frontiers or MSF) was far more prepared and able to respond the epidemic than were far vaster government bureaucracies. Indeed, initially when MSF argued that the epidemic was unprecedented, WHO argued otherwise, and delayed, losing valuable months. WHO's slow and deficient responses resulted partly from funding cuts, but also from having hired personnel at local levels who lacked appropriate expertise.

Only when a patient entered this country did the U.S. respond fully. Nationally, the development of treatments and vaccines had started years ago, but stalled, due to absent or unclear funding. One potential vaccine was just sitting on a shelf.

At state levels, the U.S. was unprepared to deal with health care workers or others who may have been exposed, but were without symptoms. Governor Christie and others -- motivated perhaps by political agendas -- implemented overly restrictive rules for quarantine, unsupported by scientific evidence, and overly restricted citizens' civil liberties, causing potential negative effects, stigmatizing brave health care providers who had risked their lives to help others.

Medical centers were slow to obtain appropriate equipment, and when they did so, often didn't train staff to use it. Health care providers remained anxious and uncertain.

A few doses of ZMapp, a potential treatment that until now had only been used in monkeys, were administered to humans -- but at first only to Westerners, not the Africans who comprised the vast majority of cases. Yet transparency and openness in administration of such possible experimental interventions is crucial. Even now, as Ebola cases decrease, we still need to determine which trials of interventions should be stopped, but coordination and oversight is lacking.

Going forward, we need to be better prepared for further outbreaks of this and other infectious agents. Education and communication about risks of infectious disease is vital. To develop new treatments and vaccines, we need to develop and establish private-public partnerships and more coordination, and provide more on-going support for basic research through the National Institutes of Health and the CDC. We must determine appropriate protocols for when and how much quarantine makes sense, based on the actual risks. Maybe someday in the future, Ebola will be sealed and contained in a building. But in the modern age, even such containment is only temporary.

At the end of Camus' novel The Plague, as the epidemic has vanished from his town, Dr. Rieux finally pauses and reflects. "As he listened to the cries of joy rising from the town, [he] remembered that such joy is always imperiled... that the plague bacillus never dies or disappears for good..."