Assignment for CBCS – Ethics of Intervention in

Disaster Management

Sistla Venkata Jyotsna

M2016PHHP004

DEVELOPING AND DEPLOYING

THERAPIES IN MEDICAL
DISASTERS-ETHICAL ISSUES
CONTENTS

1. Introduction and Issues

2. Strategy adopted
3. Ethical dilemas
4. Proposed ethical framework
5. Conclusion

INTRODUCTION AND ISSUES

The Ebola outbreak of 2013 was in terms of the scale and death toll, the largest of its kind since the
first reported outbreak in 1976. The epidemic ripped through communities in cities and villages,
causing a massive death toll, leaving health systems overwhelmed. The situation was compounded
by numerous systemic failures, such as

1. Lack of existing personnel

2. inadequate health infrastructure
3. Poor global response, slow recognition of the urgency of the situation by the WHO
4. Misguided attempts to stem the spread of the disease by establishing international
quarantine, which hindered transport of personnel and materials
5. Lack of research into development of therapies and vaccine to combat Ebola

Additionally, local customs related to burial ceremonies which exposed people to the virus increased
the exposure of communities to the virus, which spreads through contact with body fluids, resulting
in the disease spreading rapidly.

The dearth of research into development of therapies and Ebola vaccine development has been
attributed to a lack of financial incentives for pharmaceutical companies to develop vaccines for a
disease that was endemic to poor African countries which would not be able to afford the costs.
However, urgency grew as the scale of the epidemic was realized, and the subsequent infection of
foreign nationals from high income countries spurred the outpouring of funds and technological
support for vaccine development.

In addition to vaccine development, which would help in preventing subsequent infection spread to
unexposed, vulnerable communities, development of therapies for patients who were already sick
was also taken up by pharma companies.

Eventually 3 different drugs were developed by US pharma companies, one of which was
administered to the foreign nationals (2 American citizens and a Spanish priest) who had contracted
Ebola. Drug trials are currently ongoing, and some trials were conducted while the disease was still
raging on (Scientific American, 2017).

SOLUTIONS

The WHO constituted an expert panel to examine the current clinical trial protocols, to expedite the
availability of drugs and vaccines to combat a precarious situation. The panel, constituted in 2014
released a set of recommendations that stated in summary, that existing clinical trial protocols,
particularly randomization could result in a denial of care. In addition, the standard time required to
conduct the trial for safety testing would result in delayed availability of these lifesaving drugs and
vaccines. Mapp Biopharmaceutical was paid 43.7 million dollars as part of the strategy to expedite
research and development, and alternative trial designs, such as staggered introduction was mooted
for a more ethical and efficient approach.
However, it was not the increased availability of drugs and vaccines, but time-tested measures of
tracking down contacts, and providing timely supportive care in the form of fever reduction and
fluids, along with a strategy that worked with community leaders to provide education and
awareness about the disease, and customs and rituals that could result in its spread, that eventually
tipped the scales for the health workers.

ETHICAL ISSUES

Principles of justice – concerning distribution of drugs and vaccines

Principles of Beneficence – concerning the development of drugs and vaccines

Principles of respect of human dignity – the right to self-determination and full disclosure

PRINCIPLE OF JUSTICE

The fact that drug and vaccine distribution was not planned , and when planned, was concerned
with the issue of who would get the treatment first(Save the Greatest Number Who) points to a
basic lack of preparedness. The medical systems in the 3 countries affected were already in a
precarious state principally due to a lack of manpower. The fragile political state also contributed to
the weakened system, which collapsed in the face of the epidemic. However, although MSF had
been advocating the need for manpower as the priority in combating the disease, the measure of 21
day quarantines imposed on returning health workers was counter-productive to the need.

PRINCIPLES OF BENEFICIENCE

The process of encouraging research and development was from a predominantly utilitarian
perspective, with Mapp Biopharmaceutical being given 43.7 million dollars to fund its development.
The pharmaceutical industry devotes billions of dollars into drug development that generates the
most profits(high volume and low margin) rather than rare drugs which can’t be paid for by poor
countries that are most in need. No form of disease surveillance and research was facilitated in the
African countries known to harbour these haemorrhagic fevers, and WHO itself spends a paltry
amount in research. The responsibility of preparedness lies on governments and international
organizations, the former by committing resources and the latter by providing capacity, as a very
broad definition of their roles. However, both these roles were abdicated citing the dearth of
resources, and the market was expected to fill the gap. However, when the healthcare market is
treated as a market like any other commodity, the best of care and the most efficient allocation of
resources will lie in the centre of the bell curve, rather than the outliers i.e., the rare diseases.

PRINCIPLES OF RESPECT OF HUMAN DIGNITY

The initial imposition of draconian measures of closure of borders, cordon sanitaire, and mandatory
quarantines, coupled with a lack of information led to a situation fraught with dangers, as cities
erupted with protests and patients went into hiding due to fear of being used as guinea pigs or
worse. It was only when community elders were brought into the discussion with the health
workers, and their help enlisted, that communities began to appreciate the magnitude and urgency
of the situation, and also the reasons behind the measures being taken, which led to cooperation,
eventually leading to the decline of the epidemic.

ETHICAL FRAMEWORK

The debate of who is responsible for managing the healthcare of a populace has returned in the
sphere of public health, with arguments for and against government provision and regulation and
other views suggesting a partnership approach. However, in the case of democracies, governments
are elected(ideally) from the voting populace, and hence, have to take on a central role in providing
healthcare, and ensuring readiness. Accepting faulty axioms of partnerships for better health leads
to a situation where major stakeholders give better excuses than solutions.

The ethical framework needed to assure the development of a resource centre must base its
principles on achieving justice and human rights, including the right to health.

A rights based approach, with a realist approach to social justice, can lead to pragmatic strategies
developed to ensure that the inverse care law does not operate in disaster conditions, particularly
emergencies.

A rights based approach would recognise the right to life and personal liberty, and aid in developing
strategies that operate on evidence based community participation to ensure awareness. It would
also ensure the availability and support to personnel, in the form of training and equipment. It
would ensure a rational approach to controlling the disease spread, abandoning the practice of
harsher, and no more efficient measures.

A realist based approach would identify the inherent failure of the healthcare market, and would
lead to government led initiatives to engage with past experiences, learn from those experiences,
and combine them with technical expertise available through globalization. It would seek to identify
the pros and cons of various processes of distribution and provisioning and aid in choosing the best
approach, tailor made to the country and/or region. It would seek to identify cultural and social
barriers to accessing healthcare, and seek solutions through the communities.

CONCLUSION

Preparing for public health emergencies needs to be integrated into the system, with clear ethical
standards to ensure quality and efficiency. International organizations and governments need to
formulate clear, ethical policies to manage epidemics, with preventive countermeasures based on
reliable scientific evidence instead of knee-jerk reactions.

REFERENCE

Breman, J. G., & Johnson, K. M. (2014). Ebola then and now. New England Journal of Medicine,
371(18), 1663–1666. doi:10.1056/nejmp1410540

Folayan, M., Haire, B., & Brown, B. (2016). Critical role of ethics in clinical management and public
health response to the west Africa Ebola epidemic. Risk Management and Healthcare Policy.
doi:10.2147/rmhp.s83907

Gostin, L. O. (2014). Ethical allocation of drugs and vaccines in the west African Ebola epidemic |
Milbank memorial fund. The Milbank Quarterly, 92(4), 662–666. doi:10.1111/1468-0009.12089

Scientific American. (2017). Untested Ebola drugs begin trials in west Africa. Retrieved January 31,
2017, from https://www.scientificamerican.com/article/untested-ebola-drugs-begin-trials-in-west-
africa/

WHO. (2016, January 15). Ethical considerations for use of unregistered interventions for Ebola virus
disease (EVD). Retrieved January 31, 2017, from World Health Organization,
http://www.who.int/mediacentre/news/statements/2014/ebola-ethical-review-summary/en/