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. http://www.cdc.gov/vhf/ebola/outbreaks/guinea/
(Accessed September 8, 2014)
[2] United States Embassy in Nigeria. Nigeria Malaria Fact Sheet. http://photos.state.gov/libraries/nigeria/231771/Public/December-MalariaFactSheet2.pdf
[3] Hildebrandt, Amber. 2014. Why Canada must approach the Ebola
outbreak as a natural disaster. CBC News Sept. 05. http://www.cbc.ca/news/canada/why-canada-must-approach-ebola-outbreak-like-a-natural-disaster-1.2754828
[Accessed September 8, 2014]
