Michael T. Osterholm is director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

Ebola is spreading faster than anyone would like to admit, and the current, slow international response to the deadly disease is morphing into a modern tragedy. On Tuesday, the Centers for Disease Control and Prevention (CDC) in Atlanta confirmed the first case in the United States, in Dallas. If Ebola has already arrived on these shores, imagine how quickly it could be spreading in Africa.

Ebola’s dispersion on the African continent must be stopped soon. But right now there exists no realistic scheme to do so: Plan A is failing, there is no real Plan B and the best chance for a magic bullet—Plan C—is at best many months away.


Plan A—smothering the virus where it is currently an epidemic—hinges on having a sufficient number of Ebola treatment-center beds in African countries and necessary health-care providers for every Ebola virus disease (EVD) patient. In this ideal setting, each EVD patient is isolated and is no longer in a position to transmit the virus to family members or others in the community. Once patients are identified, public health workers begin to track down their contacts to ensure that if contacts become sick with EVD-like symptoms they are quickly provided a treatment-center bed, where they, in turn, can be isolated and the process repeats itself. This strategy has worked in containing every previous Ebola outbreak.

But Plan A is clearly not good enough this time. The truth is that we are failing miserably at containing Ebola, despite daily pledges by governments and philanthropic organizations to provide more health-care workers and additional financial and logistical support. It’s also despite the heroic work of a limited number of national and international volunteer health-care workers and public health professionals who are risking their lives daily so that others may live and the epidemic can be stopped.

Plan B—stopping any further spread—doesn’t exist, either for quickly stopping the transmission of the virus within Liberia, Sierra Leone and Guinea or for squelching it if it leaps to the slums of other large urban areas across Africa. Nigeria and Senegal, together with the CDC, succeeded in halting the virus’ spread after single introductions of the disease. If an infected person reaches a crowded area where health-care services are limited, however, it could spread exponentially.

In the end, the only guaranteed solution to ending this Ebola crisis is to develop, manufacture and deliver an effective Ebola vaccine, potentially to most of the people in West Africa, and maybe even to most of the population of the African continent. This is Plan C, and it is still a long way off. While the U.S government has done more than other international players to support the possibility of developing an effective vaccine, current efforts still fall short of what is needed to implement an effective vaccination strategy.

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How bad is the Ebola epidemic? It’s bad, but the honest answer is we don’t know just how bad.

So far, the reported number of deaths from Ebola in Africa is 3,044, and the World Health Organization believes the actual death toll could be three times that many. Just last week, the WHO estimated that as many as 20,000 EVD cases would likely occur in the three affected countries by early November. Meanwhile, the CDC projected a worse-case scenario of 1.4 million cases in Liberia and Sierra Leone by the middle of January unless effective interventions are implemented. These widely varying estimates by the world’s two leading public health agencies illustrate how little we know about the future course of this crisis, and demonstrate the need to scrutinize the statistical models used to estimate future case numbers. Any such estimates are only as good as the imprecise assumptions statisticians use to create the models. I don’t even try to predict the number of Ebola cases and deaths over the next few months except to conclude that there will be a lot of them—more than we should ever imagine.

The optimists tell us the disease is under control. Bill Gates, whose foundation has donated $50 million to respond to the epidemic, said earlier this week, “There’s a pretty clear road map of what needs to be done. … What’s taking place now is quite impressive.” Tony Banbury, the WHO official who oversees the emergency operations center for the Ebola crisis, declared this past week, “The United Nations is moving at lightning speed to bring a response on the ground to meet the challenges posed by this terrible disease.”

But this kind of rhetoric is not being translated into action, according to Joanne Liu, the international president of the NGO Doctors Without Borders . The promised surge of aid is still largely a promise, with beds and medicine in short supply. Liu said this week. “[E]verybody in their intentions is moving fast, but in the field we are moving at the speed of a turtle.” Tragically, every credible report from the front lines of the Ebola battle supports Liu’s more pessimistic assessment.

Plan A continues to fail today for one simple reason. Donor countries and organizations are operating on “program or bureaucracy time,” while the epidemic is unfolding on “virus time.” Thirty days of planning to deliver on-the-ground support might be considered lightning speed to a foreign aid officer, but it is an eternity for a virus being transmitted by physical contact between many people living in intensely crowded conditions. Each day of delay is also another day of hell for newly infected Ebola patients and their exhausted health-care providers.

Think of fighting a forest fire. Imagine waiting days before the necessary resources arrive; it means the blaze has expanded by the hour. And stopping a 100-acre fire is a lot different than containing a 100,000-acre fire. Every day the global response to Ebola falls far short in terms of treatment beds, health-care providers, public health workers and even adequate food and safe water is another day the epidemic grows substantially and becomes that much harder to contain. What might have been an adequate response last month now becomes much less effective.

We’ve seen increased finger-pointing about who didn’t and still hasn’t provided critical leadership or necessary resources. This debate will play out for years to come. But no one individual or group of individuals is to blame; instead, almost everyone involved is. And, unfortunately, far too many leaders, organizations and agencies still don’t understand the concept of virus time or the desperate need for command and control leadership in the affected countries.

Imagine if the only plan for Minneapolis to respond to a rapidly spreading fire were to call the New York City fire department for mutual aid. Leaders in both cities would speak proudly of the caravan of fire trucks and firefighters making their way westward. In the meantime, downtown Minneapolis would quickly become an inferno. That’s essentially the international response to the West African Ebola epidemic. World leaders have never prepared themselves or the global community for the public health actions necessary to combat this type of situation.

Doctors Without Borders and other NGOs on the front lines tried to warn the public health community as early as March that this Ebola outbreak was very different and would require unprecedented response resources. No one listened then, and the virus continued to spread unfettered across the three countries. Once it got a foothold in crowded, poverty-stricken West African cities, it was like igniting gasoline.

The U.S. government has in recent days taken a leadership role in responding to this international crisis. President Obama has urged a comprehensive, rapid response. His willingness to deploy military troops to support critical transportation, logistics and supply chain needs is an important step. (But again, the president’s promises of a month ago have been slow to become reality, and in many instances have not yet been acted upon.) CDC Director Dr. Tom Frieden has issued clear and compelling warnings over the last six weeks about the dire consequences of our ineffective response. CDC professionals are also providing valuable support in trying to track and stop new cases.

But the international public health community had never seriously planned for a “black swan” event such as this epidemic, so having an alternative to Plan A was never considered. You might call the recent quarantine restrictions employed by the governments of Liberia and Sierra Leone as an attempt at Plan B. But these measures have largely failed to control the disease’s spread, while they have been a humanitarian disaster.

For the affected countries, sadly, it’s already too late for a Plan B. Regardless of whose case estimates you believe, those put forward by the WHO or the worst-case numbers put forward by the CDC, the number of cases in these countries will increase substantially in the coming months. Everything in my 40 years of experience as a public health official and infectious disease researcher tells me this virus has a high likelihood of spreading to other African countries. And unlike in Nigeria and Senegal, it might not be so easily contained this time. What is our plan to fight this Ebola war on multiple African fronts when we can’t handle the current battles in West Africa?

We know how the disease will likely spread in the months ahead. Each year, thousands of young West African men and boys are part of a migratory work population not too dissimilar from U.S. migrant farm workers. Crop-friendly rains wash over West Africa from May to October, forming the growing season. These young men typically help with harvesting in their home villages from August to early October, but afterward head off for temporary jobs in artisanal gold mines in Burkina Faso, Mali, Niger and Ghana; cocoa nut and palm oil plantations in Ghana and Cote d’Ivoire; palm date harvesting and fishing in Mauritania and Senegal; and illicit charcoal production in Senegal, Mali, Cote d’Ivoire, Ghana, Burkina Faso and Niger.

This migration is about to begin, even for young men whose villages have been recently hit by EVD. These workers find daily laborer jobs at $5 per day, half of which they remit to their families back home. Like their ancestors before them, they use little-known routes and layovers through forests to avoid frontier checkpoints. They usually have ECOWAS ID cards, providing free passage to all the member states of the Economic Community of West Africa States. It takes one to three days to travel from the EVD-affected countries to these work destinations. There is no need for Ebola to hop a ride on an airplane to move across Africa: It can travel by foot.

Densely populated African cities such as Dakar, Abidjan, Lagos and Kinshasa—teeming with jam-packed slums as far as the eye can see—could be most at risk. This is the nightmare scenario. It is all too real, and yet no international, coordinated plan exists for how to respond to what would likely be an even more catastrophic event. Ask the world's intelligence and security experts what an Ebola epidemic unleashed on Africa’s megacities could mean for the continent’s stability. We need a Plan B, or hundreds of thousands of people may die.

And what of Plan C? The use of effective, safe vaccines has been a foundation of modern public health. We even eradicated one of the Lion Kings of infectious disease —smallpox —with an effective vaccine. Unfortunately, not all infectious agents can be relegated to the history books through vaccination. We are still searching for effective and safe vaccines for diseases such as AIDS, malaria and TB. But I feel certain that a safe and effective Ebola vaccine is on it way.

Will it come soon enough? On virus time? And on the scale that the disease demands? Only a month ago, the primary discussion around developing, approving, manufacturing and distributing an effective and safe Ebola vaccine was to protect a few thousand health-care workers and prevent the few remaining community-acquired Ebola cases that continued to occur. But it’s now a different ballgame. This epidemic could grow much, much larger and become what we call an endemic disease —one that doesn't go away. Science recently published two must-read articles, by Jon Cohen and Kai Kupferschmidt, about the grim reality of trying to find and produce an effective vaccine: Their conclusion was that government bureaucracy, a lack of adequate funding and battles between government and private-sector companies have prevented progress.

The first critical mistake public-health officials often make amid such outbreaks is failing to consider another black-swan scenario. At the moment, they are focused only on meeting the vaccine need in the three affected countries. If this virus makes it to the slums of other cities, the epidemic to date will just be an opening chapter. Africa contains more than a billion people, and is growing faster than anywhere else in the world. If world leaders don’t make it a priority now to secure up to 500 million doses of an effective Ebola virus vaccine, we may live to regret our inaction. It’s that serious.

Securing 500 million doses of an effective Ebola virus vaccine is going to require a partnership between government and vaccine manufacturers that puts it on the same footing as our response to an emerging global influenza pandemic. This will require mobilizing people and resources on a massive scale—it has to be the international community’s top priority.

In the words of Sir Winston Churchill, “It’s no use saying, ‘We’re doing our best.’ You have got to succeed in doing what is necessary.” It’s time to do what is necessary to stop Ebola. Now.