What Ebola Experts Learned the First Time—and What’s Different Now
Five friends and Ebola veterans sat down to talk about Bundibugyo. The operational details are where this gets scary.
On Friday night, I sat down with five friends to talk about the Bundibugyo Ebola outbreak now spreading in eastern DRC: Craig Spencer (an ER doctor who survived Ebola), Angie Rasmussen (a virologist who studies how the virus kills), Nahid Bhadelia, Megan Coffee, and Krutika Kuppalli (three infectious disease specialists who ran a biocontainment unit, built triage systems, and worked on WHO emergency declarations).
All of us, except Angie, deployed to West Africa during the 2014-2016 epidemic.
Here’s what came up that I haven’t written about yet. You can find my prior posts on Bundibugyo Ebola here:
Congo’s New Ebola Outbreak Has No Vaccine, No Treatment, and Has Already Crossed a Border
The Quarantine Powers We Gutted After COVID Are the Ones Many Want Now
The nursing math that determines who lives.
In an Ebola treatment unit, one nurse in full PPE can deliver 100 cc’s of IV fluid to one patient in one hour. Or one nurse can sit outside the unit and coach ten patients to drink a liter of oral rehydration solution each.
That tradeoff — IV versus oral — isn’t a clinical preference. It’s a workforce equation. During the West African epidemic, we prioritized oral rehydration because the math was the only thing that scaled. The nurses who can do this work need training, experience with high-consequence pathogens, and a specific mindset. Many of those community health workers have since lost their jobs due to cuts in USAID funding.
The testing bottleneck that kills people.
During the West African outbreak, one of the biggest operational problems wasn’t beds. It was patient identification. Blood would get drawn, sent to the lab, and come back four days later. Common names made it impossible to always match results to the right patient. People sat in suspected-case wards for seven days waiting. Some got infected with Ebola while waiting to find out if they had Ebola.
The fix wasn’t more beds. It was faster, more efficient systems: results within 24 hours, clear patient tracking, rapid triage. In this outbreak, only 20 of 240 suspected cases have been tested (as of Friday, May 17th). The bottleneck is already forming.
Ebola hides behind everything else.
Early Ebola looks like malaria. It looks like typhoid. It looks like labor. The treatment protocols during West Africa included empiric malaria and typhoid treatment for every patient, because co-infection was the norm, not the exception.
The cruelest overlap: pregnant women. Ebola triggers premature labor. Birth involves massive bodily fluid exposure. Almost any woman in labor checks positive on an Ebola screening checklist: fever, abdominal pain, and bleeding. Healthcare workers died on labor and delivery wards because they thought they were attending a birth, not an Ebola case.
In eastern DRC right now, healthcare workers with limited PPE are seeing patients with nonspecific symptoms in an area endemic for malaria. The early signal is indistinguishable from noise.
“Mild Ebola” exists. We don’t know how common it is.
Angie studies host response at the genetic level. Her work shows that host genetic background alone determines whether an animal survives Ebola — same virus, same dose, radically different outcomes. Some die with hemorrhagic disease. Some lose a little weight and fully recover.
During the West African epidemic, we saw this in our patients. One young man came in with flu-like symptoms, felt better within days, begged to be released, and then tested positive. We don’t know how many people in the real world have had mild Ebola and never sought care. That matters enormously for understanding true case fatality rates and transmission chains.
It’s not anti-science. It’s that science doesn’t work for them.
People keep framing infectious disease denial as “anti-science.” But when you talk to communities — in DRC, in the US — it’s more specific than that. They don’t think science doesn’t work. They think it doesn’t work for them.
The logic in the US: I pay taxes, research happens at universities, it gets sold to companies, they charge me prices I can’t afford. During Ebola in West Africa, communities watched $800 million go toward a treatment developed partly from a Congolese survivor’s blood, and then watched Congolese patients in subsequent outbreaks struggle to access it. One of the monoclonal antibodies was trialed in their community. The benefit went elsewhere.
This isn’t irrational. It’s an accurate read of who the system serves. And it’s the same dynamic driving distrust during hantavirus, a pattern where the world only pays attention when a disease threatens people from wealthy countries.
The World Cup arrives before the response does.
In weeks, the US hosts the FIFA World Cup. The DRC is playing in Houston. Argentina, the source of the current hantavirus outbreak, is playing in Dallas. Texas is setting up an infectious disease consult line between the state health department and UT physicians to field calls from clinicians statewide.
They need to be prepared for this: a patient walks into a Dallas ER with fever. What could it be? Texas is still traumatized by its experience with Ebola in 2014. CDC isn’t even testing for mpox anymore. The federal coordination that would manage this? Gone.
The Bundibugyo Ebola outbreak has all exacerbating factors as the West African outbreak — cross-border spread, migrant populations, urban populations — plus ADF militants, refugee populations, one of the biggest urban travel hubs on the continent, all on the heels of the World Cup.