A Moral Ailment That Allows Ebola To Fell The Poor

[FWS]

Cure a moral ailment that allows Ebola to fell the poor

By Clive Cookson
The Financial Times
August 8, 2014

Medical staff are shunned, believed by many to spread not cure Ebola, writes Clive Cookson

Until last week media coverage of the growing Ebola epidemic in west Africa, which the World Health Organisation has declared an international emergency, stated simply that there was no vaccine and no treatment for the disease, with its 60 per cent mortality rate.

All that could be done for patients, we were told, was to keep them well hydrated while making sure no one came into contact with their body fluids. That is arduous work for the hospital staff struggling to contain the outbreak with inadequate protection in poorly equipped clinics. The virus has infected and killed dozens of local doctors and nurses.


Then came news that two US health workers infected in Liberia were receiving an experimental Ebola drug called ZMapp. It may have saved their lives – and word slipped out about a few other drugs and vaccines in development in North America, which could perhaps be rushed into the field.

With the official death toll rising inexorably towards 1,000 and the real total considerably higher, the existence of potential Ebola medicines gives the medical debate about how to stop the outbreak an unexpected ethical dimension. The WHO responded with admirable speed to convene an “ethical review of experimental treatments for Ebola”.

At a meeting next week the organisation will turn to ethicists, rather than epidemiologists, for advice. The main questions are whether medicines that have never been tested on people should be used in this outbreak; and, if so, who should receive the limited quantities available.

It is important to inject a dose of realism into the debate, which is in danger of exaggerating the pharmaceutical prospects for fighting Ebola. People who a week ago did not know there were any drugs in the pipeline should not imagine now that they could save west Africa. Even if one of them can reliably kill the virus, the quantities available will be far too few in the near future to treat the general population.

The processes by which these experimental drugs and vaccines are made could not be scaled up fast enough to treat many people, even with unlimited funding. For example ZMapp, the combination of antibodies received by the American patients Kent Brantly and Nancy Writebol, is produced in genetically engineered tobacco plants. These biological products cannot be mass produced as quickly as chemicals such as the anti-flu drug, Tamiflu.

The epidemic can be stopped by directing sufficient resources to a more conventional public health campaign involving strict isolation of suspected cases, rapid diagnosis (reliable tests for the virus are available but they require a high-containment lab) and barrier nursing of patients by properly equipped staff.

The WHO’s declaration of a health emergency should help. Ebola is a super virus only when judged by its lethality. Contact with bodily fluids can be deadly, but the virus is not unusually contagious. It does not spread through the air as flu does, and genetic evidence shows there is no sign of it mutating into something more dangerous.

Those who should receive any available supplies of Ebola drugs are the doctors and nurses who have been treating patients under appalling conditions, whether they are local African staff or volunteers from western organisations such as Médecins Sans Frontières.

Health workers are particularly vulnerable to infection, and also have the professional training needed to assess the risks and benefits of taking an unlicensed medicine to treat such a lethal virus.
"Doctors and nurses are widely shunned, believed by many to spread Ebola rather than cure it"

As some observers pointed out, providing a potential cure to two Americans and airlifting them out of the country, while making none available to their African medical colleagues, did not look fair. Even if supplies of unproven drugs were unexpectedly magnified, it would be unwise to prescribe them to the general population at a time when many Africans are deeply suspicious of modern medicine.

Doctors and nurses are widely shunned, believed by many to spread Ebola rather than cure it. If the drugs caused additional deaths, or were believed to do so, that mistrust would intensify. And western scientists must avoid any appearance that they are using people in developing countries as guinea pigs for their experiments.

The Ebola epidemic is a critical test for the future of public health interventions in Africa. International agencies and charities have seen considerable success recently in campaigns to control Aids and HIV, tuberculosis, malaria and previously neglected diseases such as river blindness, even in countries where poverty and civil strife have left the health infrastructure in tatters. Handled well, Ebola would provide a boost to what has already been achieved. Handled badly, it would be a serious setback.

The dearth of properly tested drugs or vaccines for the most lethal haemorrhagic fevers such as Ebola and Marburg disease is a sign of the low priority given until recently to the development of treatments for combating infection. The world is now waking up; David Cameron, UK prime minister, last month warned that we could soon be “cast back into the dark ages of medicine” without better antimicrobial drugs.

The pharmaceutical industry, which has little market incentive to develop new antibiotics only to see them unused and held in reserve, has no more reason to work on cures for infections in the developing world. Fear of bioterrorism has provided some US government funding for research. But a more robust mechanism is needed to develop treatments for these lethal germs, put them through clinical trials and build up supplies for use in an emergency. Even if the science is conquered, a moral and political challenge will remain.