Ebola came to the U.S. and in many ways, it appears the U.S. wasn't ready.
Warning signs were missed at a Dallas hospital and a patient wasn't diagnosed until it was too late. Two nurses who cared for the now deceased patient became infected themselves. And with a growing list of those potentially exposed, including a school teacher in Ohio who had contact with one of the nurses, officials are racing to prevent the disease from spreading further. How did we get here?
While infectious disease and disaster preparedness experts note that there have been missteps at all levels, they say there were critical lapses in the national response that helped bring about the current situation. Those pitfalls, experts told CBS News, range from a lack of coordination to an overabundance of confidence in U.S. hospitals.
Miscommunication and an attitude of "smugness"
For months, CDC Director Thomas Frieden, while warning of Ebola's devastating spread in West Africa, repeatedly assured Americans that the U.S. health care system was prepared to handle Ebola should it come to the States.
"The attitude that has emanated from CDC is one of smugness," said Ken Isaacs, the vice president of programs and government relations at Christian relief organization Samaritan's Purse, which has been fighting Ebola in Liberia.
"'We have this under control. There's nothing to worry about. If you have a fever, go to your local health department. We will stop this in its tracks. This is not going to be a problem in the United States,'" he added, paraphrasing CDC rhetoric. "I think that making assumptions about capacities and abilities is dangerous."
In July, Frieden told reporters that "Ebola poses little risk to the U.S. general population."
In August, he told Congress: "We know how to stop Ebola with strict infection control practices which are already in widespread use in American hospitals."
Experts said Frieden and the CDC projected an overabundance of confidence in U.S. hospitals, which possibly helped to lull health workers into a state of complacency and which suggested, wrongly, that nearly every health department in the country was prepared to handle Ebola.
"It's a learning process. We, including Dr. Frieden, are learning a lot here, and our confidence in the hospitals was ill-founded," said Dr. Irwin Redlener, the director of Columbia University's National Center for Disaster Preparedness.
"I think it is and was unfounded, and unfounded in a way that people are probably surprised how much the hospitals have to learn and have to do."
Other experts agreed that the notion that every hospital in the U.S. should have been ready to handle Ebola was misguided.
"I don't think you have to turn every hospital into an Ebola unit," said Dr. Arthur Caplan, a medical ethics expert at New York University Langone Medical Center. "Turning the American health care system into an Ebola-savvy, Ebola-ready entity I think is not the best use of resources."
Hospitals should be able to "identify, isolate, and get the process going" when facing Ebola, said Dr. Amesh Adalja, an infectious disease specialist and representative of the Infectious Disease Society of America. "But these cases of secondary spread highlight the potential need for specialty centers, like a trauma unit."
Experts said there should have been more focus on creating such specialized "regionally designated centers" like Emory University Hospital, which has already treated three Americans diagnosed with the virus and where the second Texas nurse infected with the disease was transported Wednesday night.
As the situation in Texas progressed, Frieden's rhetoric evolved. After Thomas Eric Duncan became the first patient diagnosed with Ebola on U.S. soil late last month, Frieden continued to project confidence regarding the disease, telling CBS News, "we're stopping this in its tracks in the U.S."
Weeks later, after Duncan died and the first nurse, Nina Pham, became infected, Frieden admitted to reporters, "Stopping Ebola is hard... We have to rethink the way we address Ebola infection control, because even a single infection is unacceptable."
Limited education and training
Experts also said that while the CDC has provided the "gold standard" of information about Ebola to hospitals, its shifting recommendations have at times been unclear, fueling confusion.
"We're not really getting as much clarity as I think we should be getting," said Redlener.
"There could have been better communication about how to make sure infection control is done," said Adalja. "Understanding that it's not just about providing protocols and putting information out there, you have to make sure that it's actually being received and it's penetrating into the thousands of hospitals we have in the country."
Authorities at all levels are coming under criticism for what specialists say was a lack of training and practice for health workers.
"This is something that they need to be practicing and thinking about and preparing for, before a case happens," said Adalja. "And that may have been not emphasized enough and maybe people were lulled into a sense of feeling they were going to be prepared."
What's also been missing, said Caplan, is a public awareness campaign on par with Homeland Security's "If you see something, say something" efforts.
"I think people know what to do if they see an unattended package. Right?" said Caplan. "If they see somebody lying down, who's sick, what do they do?"
"If people still don't know what to do on the subway, or sitting next to someone on the train, or being nervous at the emergency room or whatever, that's not a good enough public education campaign."
Lack of coordination and structural woes
There's only so much that can be done from the federal level, experts acknowledged, because of structural issues inherent in a largely private health system overseen by a patchwork of local and state jurisdictions.
"So when a big disaster happens, it's really hard to get our collective act together," said Redlener, noting that many times an agency like the CDC can only make recommendations.
The complex state and federal bureaucracy has at times hindered coordination, leading some lawmakers and health experts to call for the creation of an "Ebola Czar" to lead the national effort against the disease.
"There needs to be somebody that can reach across different departments of the government, and coordinate the effort," said Isaacs, with Samaritan's Purse.
Experts also believe budget cuts and political fights have taken a toll on the national Ebola response.
"We've been starving NIH research for many years," said Caplan, referring to the National Institutes of Health. "Infectious disease hasn't gotten the funding it merits because it doesn't have a lobby."
There's also the lack of a surgeon general, with President Obama's nominee for the position currently held up in a Senate confirmation dispute.
"I'm still wondering where the surgeon general is, why one of the key voices for communicating to the American people isn't being heard," said Caplan. "Are we going to go through this whole epidemic without a surgeon general?"
Too late to Africa
Before Ebola ever reached the U.S., experts say it should, and likely could have been stopped early on in West Africa.
Over the summer, as the disease spread across borders and claimed hundreds of lives, the U.S. and the international community did not heed the "clear and clarion calls that this was an unprecedented event," said Isaacs. "There was a chance to stop the disease in June or July from becoming what it is now."
When help did come, in the form of CDC and World Health Organization advisers, international aid groups and later the U.S. military, it was slow to adapt to realities on the ground in countries with little infrastructure. And as in the U.S., there were many players and jurisdictions, which impeded coordination. In addition to an "Ebola Czar" at home, Isaacs said he would like to see an "Ebola General" leading the efforts in West African countries like Liberia, who can tighten coordination among the diffuse cast of characters fighting the disease.
In addition to containing the disease in the U.S., in the end, experts said, Ebola must be eradicated in the West African countries that it continues to plague.
"The war's going to be won in Africa," said Caplan. "It's not going to be won here."