In 2014 We Prepared for Ebola. Then COVID Came. Now We’re Tired.
What happens when a health care system trains for one catastrophe, survives another, and quietly loses the energy to prepare for the next?
The Ebola numbers this week are probably wrong.
Not intentionally wrong. Not manipulated. Just incomplete in the way outbreak numbers often are early on, especially in regions where laboratory confirmation takes days, transportation is limited, and many people die before ever reaching a formal medical system. The current outbreak in Congo and Uganda has already pushed the WHO to declare an international public health emergency. Officials are now discussing nearly 750 suspected cases and 177 suspected deaths, but even WHO officials are acknowledging the outbreak likely began months before detection. Testing shortages, delays in specimen transport, and unsafe burials mean the real numbers are almost certainly higher than the official count.
And burial practices matter enormously with Ebola.
One of the cruel realities of Ebola is that the dead can remain highly infectious. Families naturally want to wash bodies, touch loved ones, hold funerals, gather. Those rituals are human. They are ancient. They are also how Ebola spreads. This week there were reports of clashes with authorities after families were denied access to bodies. One treatment center was reportedly attacked and burned after tensions over burial restrictions.
That is how outbreaks accelerate quietly at first. A few funerals. A few infections. A few people traveling before symptoms become severe. Then suddenly epidemiologists realize the visible outbreak is only the shadow being cast by a much larger one.
And reading those reports this week brought me back to 2014.
In August of 2014, Ebola felt like the monster at the edge of the map. Distant, terrifying, and unpredictable. About 1,100 people had died at that stage of the West African outbreak, and American hospitals suddenly realized that if even one patient arrived unrecognized, an emergency department could become a transmission event.
So we prepared.
And I mean really prepared.
Our Hospital Was Going to be the regional hospital for Ebola
I was at a large regional hospital. We were not a trauma center, which oddly made us more attractive as a potential Ebola intake facility. The thinking at the time was that trauma centers were already overloaded with catastrophic emergencies. Gunshots. Crashes. Strokes. Ruptured aneurysms. If Ebola arrived, a busy regional hospital with physical space and operational flexibility might actually be safer than a Level 1 trauma center already drowning in chaos.
So our hospital became one of the regional preparedness sites. As Chairman of Surgery I was tasked to get our department up to speed, as well as having to attend endless meetings.
Isolation rooms were identified immediately. Separate emergency department pathways were developed. Dedicated ICU beds were assigned. We even had a dedicated surgical suite identified for a potential Ebola patient should emergency surgery somehow become necessary.
PPE stations appeared everywhere.
Protocols multiplied weekly.
There were meetings upon meetings upon meetings.
Who transports the patient?
Who draws blood?
What elevator do they use?
Which hallway is cleared?
Where does contaminated waste go?
What if they need intubation?
What if they arrest?
What if the ventilator becomes contaminated?
Who cleans the room afterward?
Every one of these cases is important, critical, and had to have a decision ahead of any patient that might arrive. When facing these threats you want protocols in place. You do not want to have to think about.
Drill Baby Drill
For us this was not about oil, it was about every potential staff member from the person who greets you in the ER to the janitor needed to know what to do.
And because this was before everybody became an amateur epidemiologist on social media, most of us took it extremely seriously. We drilled constantly because everybody understood something simple: hospitals are systems, and infections spread when systems fail.
Not because doctors are stupid. Not because nurses do not care.mBecause systems break under stress.mSo we practiced. Putting on PPE. Taking off PPE.
Watching one another remove gloves so nobody accidentally touched their face. Simulating transfers. Simulating codes. Simulating contamination events.
Federal Money and Mandates Came into play
The federal government funded much of this preparation. Hospitals received money because preparedness was considered infrastructure. Nobody complained much about spending the money because the images coming out of West Africa were horrifying enough that preparation felt rational.
Then Ebola faded from the headlines.
And slowly the machinery of preparedness drifted into the background. And all of us took a collective sigh. The containment program put forth by the Obama administration kept Ebola contained. They had built new hospitals in Africa, sent morticians to help bury the dead, and set up testing facilities so that Ebola could quickly be diagnosed instead of waiting days.
We did have some come back from Africa with Ebola, the most famous being the nurses in Texas. But we dodged a bullet and after endless drills, quietly forgot those lessons.
Then COVID arrived.
And suddenly we discovered we had prepared for containment, not scale. I had moved to California and was in two hospital systems. While many there remembered the Ebola scare, what we did not believe was how many COVID patients would arrive at our doorstep.
Ebola was terrifying because it was lethal. COVID was devastating because it was everywhere.
The Ebola model assumed a small number of highly isolated patients. COVID turned every hallway, every ICU, every emergency room, every recovery area, and eventually every exhausted nurse into part of the infectious disease system simultaneously.
At first some of our Ebola preparation helped. We understood isolation. We understood PPE. We understood exposure reduction. We understood negative pressure rooms and contamination zones.
But none of us were prepared for the volume. Nobody was.
Anticipating Covid since February there was no Federal Preparation
The PPE disappeared almost immediately. Masks became precious. Gowns were reused. Equipment designed for single use suddenly became multi-day use because there simply was no replacement available. And then we discovered something that should have frightened every policymaker in America: much of our PPE manufacturing had been outsourced overseas, particularly to China. When the entire world needed protective equipment simultaneously, supply chains collapsed almost overnight.
We had protocols to reuse N-95 masks. Usually involved baking the masks in an oven at 350 degrees for an hour. We didn’t have enough. And what was available in the public was quickly bought out by people.
The patients came in waves. We didn’t just get a few in our Emergency rooms, we got dozens a day. We saw them coming and we had to stop all elective surgeries. There was no room in the hospital and we thought we would need the ventilators. And we did.
Hospitals hemorrhaged money. ICUs overflowed. And health care workers aged visibly in real time.
Brutal Burnout
That is the part I think the public still underestimates. COVID did not simply overwhelm hospitals physically. It exhausted them psychologically. The people who attended all those Ebola preparedness meetings in 2014 were already burned thin by 2021. Some retired. Some left medicine entirely. Some simply stopped believing the country had the attention span necessary to sustain preparedness.
I remember during the height of COVID I would go to the hospital, change into scrubs, get into what look like spacesuits, and start rounding on ICU patients. We had, at one time, over 200 ICU patients in one hospital, most on ventilators. You are never used to people dying in the ICU, some die, but this was a scale that we could not imagine. Every patient who lived and got off the vent we celebrated. And the too many who died slayed us.
Yes, sometimes we danced, made silly videos, and yes our parking lots were empty because we were not allowing visitors. We held the hands of patients dying, holding up iPads so families could give the last words.
Then many of us would go home and on Facebook have people tell us that the hospitals were empty, this was just the flu, and I’d just come home after 12-18 hours working trying to save. Many died.
We were overwhelmed. A medical school classmate of mine, Howard Markel, described flattening the curve. By getting people to shelter in place we could take the strain off our hospitals. Most states instituted it - I remember when California was ordered to shelter in place. The first time I saw the 405 without traffic. We did it, I would go to work with no one else on the street.
Many of my colleagues, both physicians, nurses, respiratory techs, and others retired, quit, or moved into something else.
Here We Go Again
And now here we are again. Another viral outbreak.
Another round of discussions about surveillance, isolation, travel screening, testing delays, and public health response.
Except this time the system feels older.More brittle. More cynical.
During Ebola in 2014 there was still a broad assumption that preparedness was worth funding even if the disaster never fully materialized here. COVID changed that politically. Now every discussion about preparedness immediately becomes a culture war argument about spending, mandates, expertise, and distrust.
But viruses do not care about ideology. They care about opportunity. And outbreaks are always easier to stop early than late.
National Defense is Being Prepared
In January of this year we exited from the World Health Organization, and with it was 15% of the WHO funding. I’ve heard that the WHO was a lot of wasted money. Perhaps that is true, but so is the Defense Department that has all of those planes, missels, tanks, and other equipment just sitting around. The $600 toilet seats, the $150 hammers. We don’t blink an eye.
More people have died in war from infectious disease than any spear, bullet, bomb, or weapon ever killed.
Like the shiny firetruck at the fire station. No one thinks it is a waste of time. You hear about a fire on the other side of town, and you are happy to be prepared. If that fire comes closer to you then you want more fire trucks.
That is how we need to look at being prepared for any world wide epidemic.
