In 2017 we’ll be seeing Ebola again. Probably a small outbreak or two, but another full-on pandemic is entirely possible. We survived the Ebola pandemic of 2014-2015, but we didn’t defeat it. We didn’t learn enough, or change enough things, to prevent another pandemic. Nothing new was put in place. With a few exceptions, we are just as vulnerable to an Ebola pandemic now as we were in 2014.

Knowing how the Ebola pandemic began and ended makes it clear why Ebola isn’t gone for good. 

Ebola is a zoonotic disease. It has an animal reservoir – probably bats, although that hasn’t been proven. When humans come in contact with wild animals in some parts of Africa, they can be exposed to the virus. In 2013, the Ebola pandemic began with an outbreak triggered by a human infection mostly like resulting from contact with bats. An 18-month old boy was patient zero. He died of Ebola not long after playing in a bat-infested hollow tree.

The virus then spread rapidly from person to person over land borders and occasionally by air. It overwhelmed national health systems in Guinea, Liberia, and Sierra Leone. Most Ebola victims did not get medical care of acceptable quality; some did not get medical care at all and were simply confined in wards in a futile effort to stop the spread of infection. This led people who suspected exposure to avoid medical care instead of seeking it out.

The fear of medical care, combined with traditional burial practices centering on washing and preparing the dead body for local burial, allowed the virus to outpace any governmental ability to implement infection control. As a result, for months, the virus spread largely unchecked despite futile efforts to stop it.

A combination of two factors finally brought the pandemic to a halt. First, communities changed the way they interacted with sick and dead people, which slowed the spread of the virus. Second, international donors built and then ran Ebola treatment centers, which both provided decent medical care and helped stop the virus from spreading.

What has changed?

Patient zero, the toddler boy who died of Ebola in Guinea, had easy access to a tree full of bats because, to quote the World Health Organization, “Much of the surrounding forest area [around his village] has, however, been destroyed by foreign mining and timber operations. Some evidence suggests that the resulting forest loss, estimated at more than 80%, brought potentially infected wild animals, and the bat species thought to be the virus’ natural reservoir, into closer contact with human settlements.” Experts have also suggested that climate change has affected plant and animal habitats, bringing wild animals in closer contact with humans in Sub-Saharan Africa.

Climate change hasn’t stopped. In fact, it is worse now than it was in 2015. Deforestation in Africa hasn’t stopped either. In fact, palm oil companies took advantage of the distraction of Ebola to increase their land grabs in Liberia. The factor that brought us patient zero – human contact with wild animals as a result of animal habitat loss – has intensified, not been resolved.

Health systems have not improved either. The foreign-run Ebola treatment centers helped bring an end to the epidemic, but they didn’t strengthen national capacities. While they did train hygienists, educators, and other health workers in infection control, there has been little increase in capacity among Ministries of Health. In addition, there simply aren’t enough physicians in West Africa to contain an Ebola pandemic and maintain any level of normal medical care. That is a problem that takes decades to solve. The Ebola treatment centers supported by DFID and USAID were designed to fight a pandemic, not prevent the next one. A future pandemic will require foreign intervention once again to stop it.

The real questions is not, will we see Ebola again? The question is, when we see more Ebola infections, will they add up to an outbreak – or a pandemic?

A new Ebola infection could arise from contact with an animal that carries Ebola, or it could be transmitted sexually by an Ebola survivor. March 2016 saw an Ebola flare-up in Guinea and Liberia linked to an initial sexual transmission. Authorities caught the situation early enough to isolate and observe people had been exposed, as well as distribute an experimental vaccine. However, there were a number of near-misses that could have led to disaster. For example, the disease was spread from Guinea to Liberia by one individual who avoided contact with authorities and eventually died of the disease. If you miss enough potentially infected contacts, your flare-up turns rapidly into an epidemic and then pandemic.

There are a few factors that have improved since 2014. Communities have not entirely forgotten what they learned about sickness and the handling of bodies. They are more likely to cooperate with public health authorities now than they were three years ago. Finally, we now have a major tool to stop outbreaks; a highly effective vaccine has been developed for one strain of the virus. The vaccine is 100% effective for ten days after administration; there is no data yet on whether its protection will last for longer periods. The vaccine will be most useful deployed early to stop an outbreak – which means its effectiveness depends on good disease surveillance systems.

When Ebola transmits again, which is a certainty – from forest animals, or from survivors – we will have to hope those improvements are enough.

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