Alison Thompson suggests that the Ebola outbreak is part of a larger emergency defined by a lack of public health infrastructure.
Amid the worst Ebola outbreak ever, the World Health Organization (WHO) has declared that it can be ethical to offer experimental pharmaceutical interventions. Normally, experimental drugs and vaccines are first tested on healthy volunteers. But, in the case of Ebola, a public health crisis of international significance, this is a luxury we don’t have time for.
Two American aid workers who contracted Ebola were recently treated with an experimental drug called ZMapp. And following the WHO’s declaration regarding experimental Ebola drugs and vaccinations, Canada has pledged to donate up to 1000 doses of the experimental Ebola vaccine called VSV-EBOV. Neither ZMapp nor VSV-EBOV has been tested on humans.
The allocations of these scarce, potentially useful experimental drugs should be done in a way that restores trust. This is particularly true in the case of experimental vaccines because of the history of vaccine boycotts in West Africa stemming from deep mistrust of Western intervention. There is strong suspicion, especially in Northern Nigeria, that vaccines are the vehicle for the West to sterilize or infect Africans with the HIV virus. So, introducing an experimental vaccine in this region that could cause harm is a very risky proposition and it could have far-reaching consequences for the efforts to control polio and other infectious diseases. Whether or not the usual prescription for trust-building, such as being transparent, listening to communities about their concerns and being responsive to them will be enough to allow people to place their trust in outsiders again remains to be seen. Trust can’t be rebuilt in a day, especially in the midst of a crisis.
No doubt, the WHO ethics panel will continue to grapple with the ethical questions about how to use experimental pharmaceuticals in the midst of a public health emergency. But while it is commendable that WHO has gathered ethics experts from around the world to advise their decision-making, they broke the most basic rule of public policy: nothing about us without us. None of the affected countries were represented on the ethics panel. This is a gross oversight, given the rampant mistrust of outsiders involved in the management of Ebola that characterizes Ebola outbreaks in general, and this one in particular.
However, international attention to the ethics of experimental pharmaceuticals in the Ebola crisis is a sideshow to the fundamental ethical problems raised by this Ebola outbreak. Why, after nearly 40 years of nearly annual Ebola outbreaks, don’t we have an effective drug or vaccine to combat the disease?
No doubt, many will point the finger at the global pharmaceutical industry for neglecting the research and development of treatments for tropical diseases that afflict the global poor in favour of drugs targeting first-world problems.
While the pharmaceutical industry makes for a convenient villain, the situation isn’t quite that simple. Although it’s true that the lack of an affordable and approved drug to combat the disease is contributing to the current Ebola outbreak, it’s not the only contributor.
Basic public health measures such as isolation, contact tracing and personal protective equipment to reduce direct contact with the infected are highly effective ways to contain the spread of the disease.
The president of Doctors Without Borders has called this lack of basic public health resources the “emergency within the emergency.” But it’s the other way around; Ebola is the emergency within the larger emergency defined by a lack of basic public health resources.
What gets labelled an emergency of international significance is partly based on whether the event is unusual or unexpected, and whether the public health emergency threatens to spread beyond national boundaries. Ebola meets these criteria.
A larger emergency has been going on for decades, but it hasn’t been considered to be internationally significant. Diseases related to poverty and political instability have been out of control much longer than Ebola. Deaths from malaria alone far outstrip those from Ebola. Extreme drug-resistant tuberculosis is a direct result of inadequate public health resources, and a lack of civic infrastructure means that accidents on the road are expected to become the biggest killer of African children between five and fifteen by 2015, outstripping malaria and Aids. Cancer and diabetes are also on the rise in Africa. Industrialized nations’ indifference to the plight of Africans and their failure to acknowledge their complicity with economic regimes that keep Africans poor and unhealthy perpetuate global health inequities that keep Africans sick and poor.
But we’ve known what the social determinants of health are for decades, and how to predict what will happen to people’s health when they live in poverty. There is nothing unusual or unexpected here. So we decide this isn’t an emergency.
The diversion of resources to contain the Ebola outbreak, and the complete collapse of a woefully inadequate public health infrastructure will result in many more deaths because people can’t access what little help was available to treat malaria, deliver babies safely or treat those injured in road accidents. And while this will be viewed as collateral damage, it is the central problem.
We need to be asking ourselves about what the moral criteria are for declaring something an emergency. Is it how many lives are at risk? Is it whether their lives are at risk because of unjust inequities in health? Is it because systematic oppression is the root cause of ill health? Because if these things have anything at all to do with what we consider worthy of our attention and resources here in Canada, we should have declared a public health emergency in Africa decades ago.
Alison Thompson is an Assistant Professor at the Leslie Dan Faculty of Pharmacy at the University of Toronto.