Monday, September 08, 2014

Bioethics and the Ebola Crisis

As I write this the global north’s media hype about the Ebola outbreak in various West African nations is at its peak. Amidst wild speculations about the number of infected people there are also confirmed facts, such as about 3700 confirmed cases and about 1800 deaths.[1] No doubt numbers will increase. These cases occurred overwhelmingly in Liberia, Sierra Leone, Guinea and most recently Nigeria. It goes without saying that many more people have died of other preventable or treatable diseases in that same period of time in those same countries, yet the world’s gaze was transfixed on Ebola. Just for a reality check, in Nigeria about 215.000 people die per year entirely preventable deaths related to HIV/AIDS and another 300.000 die of Malaria.[2] Having said that, Ebola is a pretty terrible disease, even by the usual unpleasant standards of life-threatening diseases.

As can be expected of some mysterious disease emanating from the ‘dark continent’, a lot of attention seeking theatre accompanies the deadly performance of the actual virus. The actors are a mixed bunch of Christian missionaries busily trying to get their hands on the last available experimental agents while on private medical jet flights out of West Africa. As you would expect, toward the end of their performance they thanked their respective gods for their survival as opposed to state of the art medical care. Who else performed in the mass media’s bright lights? International organisations tried to grab the limelight. There were serious performers such as Doctors without Borders. They have treated patients in Ebola outbreaks for many years, without ever losing personnel in the process. Doctors without Borders provided us with sensible explanations for the ‘why now’ of the outbreak and the ‘why here’ with regard to where the outbreak is occurring. Essentially the outbreak is occurring in failing states with barely existing health care systems. Patients and their families – often with good reason – do not trust foreign or local medical staff. Quite understandably they are suspicious because mostly body bags leave government and other facilities tasked with attending to Ebola patients. Many of these people also don’t quite buy into the idea of viral causes of disease. Doctors without Borders asked for urgently needed specialist personnel from countries of the global north, staff able to undertake the necessary laboratory work, health care personnel for treatment, portable medical equipment necessary to isolate patients, and so on and so forth. That, of course, is so obvious, that it’s nearly boring. Theatre must be entertaining, and Doctors without Borders isn’t quite delivering on that front.

Steps in the WHO. After missing the outbreak for a fairly extensive period of time the world organisation responsible for global health decided that its first act after declaring this outbreak a pandemic, should be to host an expert meeting on experimental treatments and experimental preventative vaccines. It goes without saying that this haphazard meeting, convened within a week by WHO, and not really staffed by people who are experts on access to experimental agents, provided the necessary entertainment required by the media circuit. Endless media interviews were scheduled on the ethics of access to experimental agents all throughout August 2014, and it is here where the stage opened – finally – for bioethicists.

How did we perform? Did we stress that WHO’s choice of topic and the supposed urgency of its recommendation to provide access to experimental agents in Ebola regions amounted to pointless grandstanding in the face of a pandemic that requires a public health response, and not the tinkering with experimental agents? Some of us did, but it didn’t stop most of us from entertaining questions on the ethics of who should get experimental agents, whether it was ok that white religious activists with a health care background were prioritized over local dying health workers, and other reportedly important questions. In the rush to be seen to do something the WHO managed to convene said meeting without a single representative from a country affected directly by Ebola.

None of that mattered on the main stage of a pandemic veering out of control. Predictably riots broke out, patients ran away from hospitals or were violently freed out of isolation units by their worried families. Such on the ground mayhem would have also made for reasonably nice media theatre, alas, bioethicists decided to bring the full armament of analytical ethics to bear on crucial questions such as who should receive an experimental vaccine first. It is not that they were wrong in their concerns about the fact that these vaccines aren’t quite vaccines, they are chemicals that prevented infections in some monkeys. Even the drugs’ toxicity profiles were not established. So, in fairness there were ethical issues, but they were not the most pressing ethical issues. They were not particularly pressing because these vaccine candidates, even if they turned out to work, would not make a dent in the current pandemic. Did these issues occupy most of the mass media – bioethics collaborative performances? Sadly they did.

In supporting roles appeared health care professionals assembled by various nations, tasked with providing health care and laboratory services. They were doing the kind of work that Doctors without Borders has successfully undertaken for many years. Turns out our supporting actors are at the time of writing not quite ready for prime time, so as quickly as they drop in to West Africa, they are being airlifted due to some real or imaginary risk to them. The obvious point to be made here is perhaps this: Don’t send staff not up to the task, because the endless kerosene burned in private medical jets flying them forth and back is using up resources that could probably be put to better use. For instance, it could be used toward a down-payment for the creation of functioning primary care health care systems in the countries in question. Turns out, this allocation decision is an ethical decision, alas one not addressed by anyone currently pontificating on Ebola ethics.

What then are other relevant ethical questions to be addressed in the context of this pandemic? Here are a few that come to mind: What are the ethical obligations of citizens (and their representative governments) in the global north toward those affected now by this pandemic? Should they send health care personnel, possibly even military personnel, as the US President suggested in an interview? Or would it be sufficient to send a couple of experimental agents and wash their hands of the pandemic, as Canadian bioethicist Peter A. Singer seems to suggest in an interview. [3] Assuming that military or police force could assist in curbing the spread of the pandemic, under what circumstances and within which parameters should such deployments occur? What obligations of care do agencies have toward their staff? Do specialist technical public health workers in the global north have professional responsibilities to participate in Ebola related missions, given that they didn’t quite sign on for that sort of risk when they joined governmental agencies in the UK, Australia, Japan or elsewhere. What personal risks – if any – can they reasonably be expected to accept for themselves, both in terms of infection risk, but also in terms of violence that could occur if the local situation spins further out of control. Given that the existing health care infrastructure in the affected countries is disintegrating in front of our eyes, should others consider stepping in to provide the basic health services the local system was able to provide until – however insufficiently - the Ebola crisis hit?

There you go bioethics. Think of Ebola as primarily a public health challenge not a research ethics phenomenon and you might just be addressing questions that actually matter, ethically.

Udo Schuklenk

[1] Centers for Disease Control (U.S.). 2014. 2014 Ebola Outbreak in West Africa. (Accessed September 8, 2014)
[2] United States Embassy in Nigeria. Nigeria Malaria Fact Sheet.
[3] Hildebrandt, Amber. 2014. Why Canada must approach the Ebola outbreak as a natural disaster. CBC News Sept. 05. [Accessed September 8, 2014]

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