Ebola: An Epidemic and its Ethics

By: Larry Zhang, Senior Editor

One word has seemingly occasioned a collective outrage from thousands within the medical world, with millions more everywhere else.

Ebola.

The current 2014 West Africa Outbreak is the largest epidemic of its kind, already claiming 3,439 lives out of the total 7,492 cases in West Africa and the U.S., as of Oct. 1st (World Health Organization). Just last week, the Centers for Disease Control and Prevention (CDC) confirmed its first case of travel-related Ebola within the U.S., affecting Thomas Duncan, who recently died at the Texas Presbyterian Hospital in Dallas. And although the chances of a national outbreak are exceptionally low, the government has been taking some notable precautions in the battle against Ebola. But just how far will it weigh the medical ethics of those involved?

Before the ethics are discussed, it is important to note the origins of the current epidemic. Originating in Guinea, Africa, back in 2013, the 2014 Ebola virus disease (EVD) epidemic has since spread to Liberia, Sierra Leone, Nigeria, Senegal, the United States, and most recently, Spain. Unfortunately, the outbreak of 2014 easily represents Ebola’s most critical resurrection since its initial discovery in 1976, where the virus first affected a victim who had been touring an area near the Ebola River (of which the virus obtains its name). Since then, 2,078 deaths have been laboratory confirmed, but officials estimate that the numbers have been largely underrepresented due to lack of investigative equipment and the local communities’ unwillingness to report suspected cases.

To provide background, Ebola itself is caused by, surprise, an ebolavirus. Symptoms include fever, sore throat, muscle discomfort, and headaches, followed up by vomiting, diarrhea, and decreased functioning of the liver and kidneys. Although the physical effects of Ebola are well documented, much of the world is still at odds with how Ebola is acquired. To clarify, the virus is only contracted through direct contact with the blood and other bodily fluids of an infected human or other animal. The virus is also suspected of being carried via fruit bats without being infected themselves. However, Ebola has yet to be proven airborne, so contact not involving the bodily fluids is not indicative of contraction. The search for a cure is no less critical though, as an estimated 50-90 % of infected victims are at risk of succumbing to the disease. As of now, there are no specific treatments for the disease, but attempts at developing a vaccine are confirmed.

Without a particular treatment, however, the control efforts at curbing the disease’s outreach have been largely varied in success. Currently, reducing the risk for acquiring Ebola largely focuses on reducing wildlife-to-human contact, human-to-human contact, and more careful containment procedures. The safety of those directly at-risk, health workers, is also of utmost priority. Community engagement in combatting the outbreak as well as raising public knowledge and awareness is also a critical concern to prepare individuals at-risk of contracting Ebola or near those at-risk against the virus. Numerous health organizations such as the CDC and WHO have been doing their best, but is this truly “best” enough?

The truth is, people in many of these affected countries have recently become immensely opposed to both the efforts of their governments and hospitals. Difficulties in control efforts have been exacerbated largely due to instances of violence. Protesters, for instance, believe that the virus is a hoax and that the government is responsible for Ebola’s diffusion. Many of these people have even been attacking local hospitals. Other factors contributing to the spread of the ebolavirus can be attributed to the widespread poverty of affected areas, many of which have limited or no access to clean water and soap to effectively combat the disease. Moreover, many of the hospitals and prevention centers themselves are often understaffed. They are without basic supplies, contributing to the lack of health worker safety. In fact, ten percent of all deceased victims have been health workers. Yet despite all the seemingly negative factors of the epidemic, there may exist one crack of light in the darkness–a new drug.

ZMapp, an experimental drug developed by San Francisco-based Mapp Biopharmaceutical, was recently administered to treat two Americans infected with Ebola, while thousands of Africans have already succumbed/continue to succumb to the fatal disease. The decision has sparked worldwide controversy, despite U.S. officials justifying the move. The two health workers, Kent Brantly and Nancy Writebol (both members of the U.S. charity Samaritan’s Purse), were recently treated with ZMapp while still in Liberia and have since shown improvements following the treatment. This has prompted a meeting involving the World Health Organization on experimental usage of such drugs in West Africa, but so far, no attempts at all have been recorded on aid regarding citizens of Africa.

The drug still remains in its early phases of experimentation, with no widespread production and its only testing having been on laboratory monkeys. To this day, there are still no specific cures Ebola despite the two outstanding cases of the Americans. The question that remains, however, is where is all of this regarding ZMapp in Africa? Why have the hardest-hit countries of Sierra Leone, Guinea, and Liberia, where thousands have succumbed, been completely out of the picture regarding drug treatment? Peter Piot, director of the London School of Hygiene and Tropical Medicine, who also co-discovered the virus in 1976, has expressed urge on making the drug more widely available. According to the Los Angeles Times, “the African countries where the current outbreaks of Ebola are occurring should have the same opportunity” regarding access to medicinal treatment.

On the other hand, U.S. experts have dismissed concerns on the justness of first offering the drug to two white Americans; G. Kevin Donovan, director of Georgetown University center for bioethics claims that “ Brantly and Writebol were good candidates for taking the risky drug, since their medical training would have helped them understand the extent of the danger.” He adds that because “these people are deliberately putting themselves in harms way”, they should be granted utmost priority regarding access to the drug. Yet despite this, those most in danger- the African health workers- have also been infected to an extreme degree. Umar Khan, Sierra Leone’s most effective doctor, succumbed on July 29th.

The President himself has also offered insight onto the controversy. “We’ve got to let the science guide us,” Obama said at a news conference following a three-day summit with African leaders. “I don’t think all the information is in on whether this drug is helpful. What we do know is that the Ebola virus – both currently and in the past – is controllable if you have strong public health infrastructure in place.” On the other hand, Liberian Assistant Health Minister Dr. Todd Nyenswah has raised eyebrows over the issue itself, stating “the population here is asking, ‘you said there was no cure for Ebola, but the Americans are curing it?'” Yet other officials argue that they don’t even know whether or not the drug works, a drug that has the potential to mitigate what has become the worst epidemic of Ebola in history.

As the epidemic grows, more and more countries have expressed interest in the potential of the new drug. Nigeria’s health minister, Onyenbuchi Chukwu, raised his concern at a news conference to the U.S. Centers for Disease Control regarding availability and access. CDC director Tom Frieden responded, “there are virtually no doses available”, along with the fact that ZMapp is “not going to be available anytime soon.” The World Health Organization stated weeks ago that it would meet with medical ethicists regarding the complex predicament of “the responsible thing to do” for a drug with limited experimentation and potentially devastating health effects. Even so, Mapp Biopharmaceutical has informed the government that it would take 2-3 months to produce even a “modest amount.” With the death toll rising, it is even more critical that ZMapp’s manufacturer finds ways to speed up production.

The ethics at large are indisputably at concern with activists and others involving the decision in which two white American aid workers were given the experimental drug. Still, others wonder what would have occurred if the very first doses of ZMapp, a drug having never been used on humans, were administered to African victims. Some claim an outrage would have surely ensued if Africans were used as “guinea pigs” for an experimental drug developed by an American company. Nevertheless, questions have surrounded African officials for a long time regarding drug testing. One question has remained: who should be the first to receive doses of a possibly lifesaving drug? The health workers who place their lives in danger by serving others, the children, the elderly, or to those who have the highest chance of survival, the newly infected?

With no remaining doses of the drug and estimated production times amounting to a few months, it is even more paramount that the actions of the U.S. government and organizations of other countries are executed with haste. As more and more African victims express distrust in Western relief efforts, the question regarding the fairness of medicinal distribution policies undoubtedly arises. Dr. Armand Sprecher, a public health specialist for the aid group Doctors Without Borders, conveyed that it was unfortunate that the first doses went to white Americans “because it confirms all the suspicions people have.” Another perspective exists as officials claim that Samaritan’s Purse was the first to receive the drug because it had asked for it first, not because of any bias to Americans against Africans. However, Maina Kai, a human rights activist of Kenya, senses a confirmation of the fact that “the life of an African is less valuable.”

In the long run, two questions exist: who should be given priority to these drugs, and are drugs themselves the most effective way to combat such a viral epidemic? All bioethicists agree that ZMapp should be administered to those in most crucial need, but debate on the importance of whose lives are at highest stake continue to cause controversy. Others argue that drugs are not the most effective strategy and that the bias should not be analyzed on drugs, but on public health and infrastructure in general. And then there remains the raised eyebrows on the value of an African ‘s life versus an American’s, as some believe this has been a central part of the ongoing debate. Only time can tell, however, if such questions can be answered through the potentially efficient and just executions of health policies from governmental organizations and relief agencies.

For any questions, comments, or concerns, please contact Larry Zhang at lzhang@atlasbusinessjournal.org