Looking back, the mistakes are easy to see: Waiting too long, spending too little, relying on the wrong people, thinking small when they needed to think big. Many people, governments and agencies share the blame for failing to contain Ebola when it emerged in West Africa.
Now they share the herculean task of trying to end an epidemic that has sickened more than 9,000, killed more than 4,500, seeded cases in Europe and the United States, and is not even close to being controlled.
Many of the missteps are detailed in a draft of an internal World Health Organization report obtained by The Associated Press. It shows there was not one pivotal blunder that gave Ebola the upper hand, but a series of them that mounted.
Nearly every agency and government stumbled. Heavy criticism falls on the World Health Organization, where there was "a failure to see that conditions for explosive spread were present right at the start."
WHO — the United Nations' health agency — had some incompetent staff, let bureaucratic bungles delay people and money to fight the virus, and was hampered by budget cuts and the need to battle other diseases flaring around the world, the report says.
In a statement, WHO said the draft document has not been checked for accuracy and that the agency would not comment until it was finished. WHO's chief, Dr. Margaret Chan, did not respond to AP requests for comment, but told Bloomberg news service that she "was not fully informed" as the disaster evolved. "We responded, but our response may not have matched the scale of the outbreak and the complexity of the outbreak," she said.
Outside experts say the point now is not to grab necks or find fault, but to learn from mistakes.
"By the time we recognized this was serious, the genie was already out of the bottle," said Michael Osterholm, a Minnesota public health expert. "Nobody is to blame because everybody is to blame."
Ebola had caused two dozen smaller outbreaks elsewhere in Africa before it appeared in the western part of the continent earlier this year, "so people were caught off guard" by its rapid spread, said Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University. "We thought we would do what we usually do and that this would come under control, but that didn't turn out to be the case."
The first mistake came Jan. 11 at a hospital in Gueckedou, Guinea, where the grandmother of the first two children known to have died in this outbreak sought care. It was a rare opportunity — most people just seek help from traditional healers. But instead of detecting and stopping the disease, the hospital compounded the problem: Two new chains of transmission began, among patients and health workers, and in another village.
On Jan. 27, local health officials and Doctors Without Borders missed a chance to diagnose Ebola after seeing bacteria in blood samples — they concluded cholera might be the culprit. Ebola wasn't confirmed until March 21. By the end of the month, it had spread to Liberia.
In April, Doctors Without Borders warned that the outbreak was out of control, but a WHO spokesman insisted it wasn't. In May, the funeral of a traditional healer in Sierra Leone spread the virus to hundreds of people.
"It was a turning point. It refueled the epidemic in Guinea and it was the start of major epidemics in Liberia and Sierra Leone," said Dr. Peter Piot, co-discoverer of the Ebola virus and director of London School of Hygiene and Tropical Medicine.
Little went smoothly. WHO's Guinea office was accused of not helping a team of experts get visas to that country. Some $500,000 in aid was held up by red tape.
In early July, Piot "called for a state of emergency to be declared and for military operations to be deployed," he said.
It didn't happen.
Response falls short
In Guinea, the ministry of health at first would give WHO information only on lab-confirmed Ebola cases, hampering the investigation. Messages to the public about the lethal nature of the disease discouraged people from seeking treatment. When masked teams arrived to disinfect hot zones, people thought they were spraying toxic chemicals and attacked them.
Early international aid was mishandled. Guinean President Alpha Conde set up a panel with the ministers of health, communications and social affairs to fight the disease, but the minister of health couldn't formulate an effective strategy and little money was dispersed. Finally, a new committee of independent experts was appointed and funds began to flow.
In Liberia, early government messages stressed that Ebola had no cure, so sick people saw little reason to go to a hospital, and the disease spread even more. In August, the government quarantined a Monrovia slum, sparking clashes with security forces that killed a teen. Ultimately, health officials realized they couldn't track or limit Ebola spreading in the slum. Many bodies were dumped into nearby rivers.
In Sierra Leone, the government sent politicians to warn people about Ebola rather than relying more on charitable groups and medical professionals, said Joseph Smith, a community activist in the capital city of Freetown. Some feared it was a government conspiracy to use Ebola to wipe out opposition supporters ahead of a national census planned for December.
"They believed that the whole situation was a kind of lie," Smith said.
In Spain, where a nurse got Ebola after taking care of a patient who died of it, debate raged over whether protective gear protocols were being followed. Health workers protested about a lack of training; the government overhauled it and adopted new equipment standards.
Ebola comes to US
On Sept. 20, Ebola made a 5,700-mile trip to the United States, when a Liberian man, Thomas Eric Duncan, flew to Dallas. His infection was confirmed on Sept. 30. Two nurses who cared for him before he died now have the disease.
The Centers for Disease Control and Prevention has been harshly criticized by many who say it offered shifting advice on protective gear to hospitals and failed to assess correctly what risk Duncan's infection posed and to whom.
In fact, the CDC had been among the earliest responders when Ebola surfaced in Africa, sending five people to Guinea in late March and two more to Liberia in April. In late May, the situation seemed in hand and WHO advised CDC that its staff could leave.
But cases surged in June and five CDC workers returned to Guinea. In July, more went to Liberia and Sierra Leone, and to Nigeria after an Ebola death occurred there. By late August, 100 CDC staffers were tracing contacts, educating health workers, communicating with the public and training officials on how stop sick passengers from getting on planes.
Gregg Mitman, a University of Wisconsin medical historian who was in Liberia in June, said the response by CDC and others was slow, but noted that WHO and CDC had tight budgets. After the 2008 financial crisis, WHO lost more than 1,000 staff and was left with only two Ebola experts.
"We're always quick to blame ... and ask why wasn't the CDC on top of this earlier," he said. "But we're not looking at the longer picture of how have we supported public health infrastructure."
Redlener, at Columbia University, agreed.
"It shouldn't just be WHO that we blame," he said. "Nobody else, no other countries, were really rushing in to help."