How could it happen? Some of the underlying causes that are believed to have contributed to the magnitude of the Ebola epidemic in West Africa are: ? The substandard health care in the affected countries. Prior to the outbreak there were approximately one doctor per 10 000 inhabitants in Guinea, and even fewer in Sierra Leone and Liberia (compared to Sweden's 33 doctors per 10,000 inhabitants). The mortality among healthcare workers infected with the virus was also high, which aggravated the situation. ? There is a deep mistrust of the government and authorities in the affected countries, which made it difficult to implement the preventive measures and procedures needed to contain the virus. Rumours that this was just another "con trick" from those in power to attract humanitarian assistance funding's. In this enabling environment, several other rumours were also mounted, which aggravated the situation further. ? Traditional burial practices and ceremonies in West Africa enabled an extensive spread of the virus. Among other things, the diseased person is touched by the mourners and relatives while washing the body in preparation for the funeral. Also, when long-distance funeral guests travelled back to their communities, they brought the infection back with them. ? The negligence by the World Health Organization (WHO) during the first months of the Ebola outbreak, when the disease spread slowly in Guinea, and then gained momentum as is was carried across the borders into Sierra Leone and Liberia. Even WHO's own experts have acknowledged that the epidemic could had been contained, with relatively small means, had they acted sooner. ? The inability of the international response to adapt to the cultural and social contexts of the affected countries. For instance, an independent expert review of WHO's actions during the outbreak concluded that the response, once initiated, was too technical and medical in nature and lacked cultural, psychological and sociological expertise. Similar views have been expressed also by a number of other actors and observers, including Doctors Without Borders (MSF). This situation created a significant resistance among the population towards the response. ? Migration and porous borders in the region resulted in the reciprocation of the infection across borders, which contributed to increased spread as well as complicating contact tracing. This allowed the Ebola virus to be exported from Guinea to the neighbouring countries. ? Environmental degradation and climate change has also been discussed as contributing factors to the magnitude of the outbreak. For instance, changes inland use, deforestation and increased human activity in the presumed natural habitat for the reservoir of the virus, fruit bats. Could it happen again? One concern that has surfaced is whether an additional Ebola outbreak could emerge in West Africa? And does the virus still linger? Indications that the Ebola virus is endemic (that is, naturally occurring) among fruit bats in West Africa have been proposed in scientific publications. Bats are hence assumed, to be the likely source of infection of the first human case (the index case) in West Africa in December 2013. Therefore, there is indeed a possibility that the virus can strike again in this region. Genetic analyses suggest that the virus has migrated from Central to West Africa. However, how long the virus has been present among bats in the region is largely unknown. Repeated reporting have shown that Ebola survivors may be long-term carriers of the virus, and some survivors have also infected their relatives. This means that the disease may reoccur in West Africa, or elsewhere in the world for that matter. One example is a Scottish nurse and an American doctor, who both carried the virus although they had been declared free of the infection. Ebola - a security issue As the Ebola outbreak in West Africa grew in magnitude it transitioned from being merely a medical-humanitarian health crisis to a social and security crisis as well. Riots, looting and attacks against medical facilities and aid workers took place in e.g. Monrovia, and Margaret Chang, the Director-General of WHO, warned that the already hard-hit West African States might become "failed states". In addition, in September 2014, MSF appealed for a military intervention to deal with the situation. Furthermore, UN Security Council declared the Ebola outbreak as "a threat to global peace and security." In parallel, the creation of UNMEER (United Nations Mission for Ebola Emergency Response) took place, which is the first ever peace operation in support of an infectious disease outbreak. The concerns regarding global security were also reflected in public debate regarding the potential for the use of Ebola virus for terrorist purposes. An editorial in Washington Post rhetorically asked: "The world is experiencing virulent outbreaks of Ebola and Islamic radicalism. What if the two converge into one? ". What have we learned? A number of conclusions and lessons can be drawn from the Ebola outbreak and clustered in four main themes: ? Many experts has accentuated the risk for new epidemics that can threaten the world. Concerns are high that the next time we will see something new and more infectious than the Ebola virus, for example an airborne virus such as SARS, MERS or influenza. Therefore, it is desirable to establish a global and effective monitoring and response system that can detect natural infections as well as epidemics that may be a result of use of biological weapons. ? The Ebola outbreak has also raised questions about how to prioritize current research of vaccines and therapies for infectious diseases, since the market forces drives the development. The Ebola virus is a striking case in point in this regard. Until the West Africa outbreak, Ebola cases have been rare and have usually only affected poor people in Central Africa. Therefore the economic incentives to develop therapies and vaccines have been limited. Until recently, research regarding filoviruses (the virus family Ebola belongs to) has essentially only been conducted by defence actors. ? There is a need to fundamentally reform and restructure the WHO in order to be able to meet future global crises and needs. The key words in this context is to prioritize local ownership and sensitivity to cultural contexts.? Civilian-military co-operation was critical for the international Ebola response. Most of the participating nations in the response used military assets, such as logistic support and military medical personnel. There seem to be a consensus that only military organizations can mobilize the unique capabilities needed at a short notice and to operate in a sustained fashion. Therefore, it has been argued that military resources indeed must be involved in any future response system for serious infectious disease outbreaks. One challenge with this is however the risk for mission creep, an undesirable state where additional tasks are given the military that are not balanced with the extra resources needed for carrying out these tasks. The lessons from the Ebola outbreak in West Africa that can be drawn are paramount for future infectious disease response. When analysing the Ebola virus crusade through West Africa, one sees that the virus does not appear to have acquired any new characteristics or skills. What was new was instead the context in which the virus appeared, where new game rules applied. In the future, human activities such as further exploitation of natural resources, coupled with the effects of climate change, may act as further triggers for new infectious disease threats. In sum, this calls for a holistic approach in order to be able to understand such threats and act accordingly.