As Ebola flared unseen in the villages of Guinea late last year, CDC director Tom Frieden seemed to sense that something was wrong.
"Where's the next Ebola virus going to come from?" he wondered aloud last December. "There are 46,000 fewer people working at state and local health departments today than there were five years ago," he added. "Those are my biggest concerns."
Now, of course, those concerns are a matter of national crisis. As Ebola ravages thousands in West Africa, state and city health officials are scrambling to prepare for the possibility of more spillover cases here at home.
The CDC has tried to help, issuing guidelines for all-manner of Ebola care. But local decision makers, much as Frieden feared, are struggling to replace years of lean budgets with a few fat weeks of hurried training.
"All of us should be worried," said Jack Herrmann, the head of public health programs at the National Association of County & City Health Officials, a coordinating body for healthcare providers nationwide. "People look at some of the seemingly large numbers that we’ve invested in public health and ask does that make us safe. The answer is no. It’s not that simple."
In 2011, he said, by way of example, the CDC and the Department of Health and Human Services created a pooled grant program to fund emergency preparedness at the local level. They identified all the capabilities that a hospital would need to respond to anything, from hurricanes to Ebola. Then they issued grants to cover those skills.
Sounded great, Herrmann said, but officials soon told him it wasn't enough. They would have enough to fund training on say, 3 of the 15 capabilities one year, he said, and then 4 additional capabilities the next.
"What people don’t appreciate is that this isn’t a checklist kind of process," he continued. "There shouldn’t be any surprise that we’ve seen challenges."
The most famous setbacks came at Dallas Presbyterian Hospital, where on Sept. 25 a Liberian man walked in with Ebola and was nonetheless sent home. There, his symptoms exploded and the risk of infecting others skyrocketed. But while the CDC has been criticized for lax control, former Health and Human Services Secretary Mike Leavitt points out that treatment and prevention are ultimately local challenges.
"States and local governments, not just in Dallas, not just in Nebraska, not just in Bethesda, have got to be prepared for this," Leavitt said on MSNBC’s Daily Rundown. "As it spreads across Africa the likelihood of it returning to the United States is high and we need to be ready for that."
But what does “ready” even look like?
Nationally, according to Dr. Anthony Fauci of the National Institutes of Health, we need an expanded network of Ebola-ready hospitals, beyond the current four. “We want to make sure we have people who are pre-trained, predrilled over and over, and have the right protocols going,” he said on Sunday’s Meet the Press.
On the state level, officials are reviewing their own Ebola protocols, double-checking their standards against the latest from the CDC, according Tener Goodwin Veenema, a professor at John Hopkins University and the author of Disaster Nursing, a textbook on emergency preparedness. Each of these states, she added, is suffering from some kind of "apathy effect," the result of a post-9/11 boom and bust in funding for biological threats, one that’s left public health systems short of nurses, training, and equipment.
She said the past year has highlighted the struggle to maintain funding levels in between the outbreaks, so hospitals are ready the moment when the next global killer arrives—instead of days, weeks, or even years after. In the case of Ebola in particular, experts said, the vulnerabilities were obvious but the need was extensive, pushing officials to choose between cutting training or cutting personnel.
Often they had to cut both, and make due with what remained.
That's where Veenema comes in again. She's part of a team that's helping the CDC translate guidance into real-world trainings, covering screening methods, lab test standards, and the disposal of waste, among other things. But, she cautioned, everyone will have to remain flexible in the face of such a shape-shifting threat.
"The Ebola virus of the past is probably not this Ebola virus,” she said. “These pathogens mutate. They change. We think it incubates for 2 to 21 days, but I don’t know that we know that for sure. It could be 40 days."
One country that may hold lessons for local health officials is Nigeria, where the virus arrived in July, borne by a sick Liberian-American man who collapsed at the airport. Within weeks, the number of infections spiked to 20, with a fatality rate approaching fifty percent. Millions were at risk in the megacity of Lagos. But now, after six weeks without a case, the World Health Organization has declared the country Ebola-free.
"It's a huge accomplishment," said Sam Sturgis, a fellow at in the Atlantic’s City Lab, who has covered the containment effort in Nigeria.
But there are small takeaways, he added, most of the all the need for front-line workers to think Ebola first. Unlike their counterparts in Dallas, Lagos health workers were ready for Ebola to walk in the front door, and when they saw it, they quickly sounded the alarm, setting off the kind of coordinated response now being prepared in cities like New York in Chicago.
"We’ve come a long way," said Jack Herrmann of the National Association of County & City Health Officials. "But we’ve got a long way still to go."