Bioethical Inquiry (2014) 11:417–420 DOI 10.1007/s11673-014-9587-3
Ethical Challenges Posed by the Ebola Virus Epidemic in West Africa Peter F. Omonzejele
Received: 19 September 2014 / Accepted: 9 October 2014 / Published online: 12 November 2014 # Journal of Bioethical Inquiry Pty Ltd 2014
Abstract This paper examines how people in West Africa are reacting to the Ebola virus disease, an epidemic presently prevalent in the region. Certain lifestyle changes are suggested. Additionally, the heart of the paper focuses on the request by governments to be allowed access to experimental drugs, such as Zmapp and TKM-Ebola, for their infected populations. The author argues that granting such a request would circumvent research ethics procedures, which could potentially constitute significant risk to users of the drugs. The Pfizer Kano meningitis trial of 1996 is cited as an example to buttress how unapproved drugs could prove fatal. Keywords Ebola virus disease . Epidemic . West Africa . Traditional rituals . Zmapp
Introduction Sub-Saharan Africa carries the burden of many diseases. The majority of HIV/AIDS cases are to be found there, and recently there emerged an outbreak of Ebola virus disease (EVD) in the West African region that presently has no cure. Ebola virus (EV) had its origin in monkeys, chimpanzees, and fruit bats and was first identified in the Democratic Republic of Congo in 1976. It damages the immune system and organs and leads to severe, P. F. Omonzejele (*) Department of Philosophy, University of Benin, Benin-City, Nigeria e-mail: [email protected]
uncontrollable bleeding inside and outside the body (WebMD 2014). The disease is contracted by direct contact with an infected person’s bodily fluids such as blood, sweat, vomit, or feces (Johnson 2014). EVD has so far claimed nearly 5,000 lives.
EVD Prevention Strategies and the Need for Some Lifestyle Changes It is not unusual for people to devise ways of removing themselves from harm’s way. This is in line with the principle of self-preservation. For instance, it would be most sensible for one to quickly jump out of the way if one sensed that an oncoming motorist was driving under the influence of alcohol in order to not to be knocked down. Hence, it is not unreasonable for people living where EVD is prevalent to take measures to protect themselves from being infected with the deadly virus. Some preventive measures have significantly changed lifestyle in the West African region. Let us examine the reasons for some of these suggested lifestyle changes and the implications of such changes for the spread of the deadly EV. Regular Hand Washing In Nigeria, it is considered proper for most people to eat their meals (except rice and beans) with their bare hands. With the use of a microscope, it is easy to see that one’s bare hands or improperly washed hands contain infectious bacteria and germs. In a study conducted by
researchers at Michigan State University, it was found that “only 5 percent of people properly washed their hands long enough to kill infection-causing germs and bacteria” (Jaslow 2013, ¶2). The researchers advised that: The “right way to wash your hands” is to wet your hands with clean, running water (warm or cold) and apply soap. Rub them together to make a lather while scrubbing them well, making sure you get the backs of the hands, between the fingers and under the nails. Keep this up for 20 seconds—the CDC recommends singing the “Happy Birthday” song twice—and after, rinse under running water, before drying with a clean towel or air dryer (Jaslow 2013, ¶6). People in the West African region have been told by experts and governments that regular hand washing would help curb the spread of EVD. But there is a slight problem. The above-mentioned study was undertaken in the United States, where pipe-borne water and air dryers are commonplace and taken for granted. In many West African communities, clean pipe-borne water is a rarity—especially in the rural areas—and most West Africans, be they in the rural or urban areas, have never seen an air dryer used for the purpose of drying one’s hands after washing. The implication of this is that regular hand washing may not be very effective in curbing the spread of EVD in that region. Perhaps the way to go is to resort to the use of cutlery: In fact, some homes, especially where parents are university graduates (particularly those trained in Western countries), have done this. Some others have resorted to the use of hand sanitizers and disinfectants.
Traditional Rituals, Handling of the Dead, and the Spread of EVD Life in West Africa is mostly communal. This is the reason why West Africans continue to keep tabs on happenings in their ancestral villages, no matter how far away they live from their ancestral homes. Communality is exemplified in how the events of marriages and deaths are conducted. For instance, in most African countries marriages are recognized only on “the payment of the so-called bride-price, known as the ‘labola’ in South Africa, ‘roora’ in Zimbabwe, ‘mahari’ in East Africa, and generally referred to as ‘head-money’ in West African countries” (Omonzejele 2008, 121). It is
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a community affair that involves all the age grades as they actively participate in the marriage arrangements and negotiations. In like manner, when a member of the community dies, the community participates actively in the burying of the dead, which involves traditional rituals beyond the scope of the bereaved family. Those rituals have health implications for the community, especially since the advent of the EVD outbreak. In fact, burial rites as undertaken in West African countries might have brought the Ebola virus to an epidemic level. Let me explain. In many West African communities, certain rituals are performed before the public show of a burial ceremony. Because ethical themes and values are very similar across Africa (Tangwa 2000), the example of an ethnic group in Nigeria can be used to explain how burial rites are performed in the West African region. Among the Esan people of Nigeria, when one dies, especially where that person is married, the first step is to take the corpse to the extended family head for purification. This entails the washing of the corpse. If the deceased person is a male, his wife/wives are made to drink from the water used to wash the man’s body. Because EVD is highly contagious, the wife/wives of the deceased husband, if he was infected with EV, could contract the virus. In addition, those who undertake the body washing of the corpse also might contract the virus. In turn, those who participate in the washing process interact with their friends and family members. The outbreak of EVD in Guinea, Sierra Leone, and Liberia may also have emanated from such practices. Nigeria was somewhat lucky that airport officials and security agencies were able to quickly track down both Patrick Sawyer of Liberia and the health workers who attended to him. If the Nigerian government had not been proactive, the outbreak of EVD in Nigeria would have been a calamity of epic proportion, owing to the large Nigerian population, poor public health infrastructure, and the burial and other traditional rites in that setting. Even so, Nigeria is not out of the woods. Another traditional burial rite undertaken in many African cultures is what may be referred to as “traditional autopsy” undertaken by local experts who are supposedly knowledgeable in that art. This entails opening up the corpse for two reasons: to remove the ailment that was the cause of death (it is not clear how grounded in science this is) and to detect whether the deceased was a witch. Reason number one is founded on the belief of reincarnation and the assumption that where
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the cause of death has been removed the person will not reincarnate with that malady in his or her next life. The second reason is used to determine the type of burial that will be accorded the deceased. The implication of this practice for the spread of EVD is enormous. Where a person who dies from EVD is opened up the Ebola virus can easily spread very quickly. There is a need to change how people manage their dead.
Circumventing Research Ethics in the Search for New Drugs Poses Significant Risks Despite lifestyle changes, the hard fact is that EVD continues to spread and kill many people in the West African region. In light of this reality, some governments have resorted to appeals to the United States to make experimental drugs, such as Zmapp, available to them. If those requests are granted, the usual phases of research required before making a drug available for human use would be circumvented. It is important to examine the ethical implications of making unapproved drugs available in the midst of an epidemic. There are clinical trial phases pharmaceutical companies must go through to ensure safety before a drug is licensed for human use: In other words, there are established research ethics procedures for bringing a drug to the market. However, in desperation, some West African governments, such as Nigeria, have requested the experimental drug Zmapp be made available for the treatment of EVD. In the Nigerian Vanguard on August 8, 2014, it was reported on the front page that: The United States of America, yesterday, dashed the hope of an early cure for Ebola Virus victims in Nigeria when it refused to share the trial drug with Nigeria. US President Barak Obama says it would be premature to share the experimental drug with Africa. The Federal Government had earlier reached out to the United States Centre for Disease Control and Prevention, CDC, in Atlanta, to request for the drug for treatment of EVD affected persons in Nigeria, but President Obama turned down the request, saying, it would be far more beneficial to focus on prevention instead (Ogundipe et al. 2014, ¶1–¶2). The moral question is: In an epidemic, as with EVD in West Africa, is it morally right to circumvent research
ethics procedures to make unapproved (experimental) drugs available to a desperate population whose need is compelling? To answer this question we need first to understand what constitutes a “compelling need.” It is compelling need that would make one wish to attempt or access the unorthodox. It is unlikely that anyone would wish to access an unapproved drug in normal times. This means that the requests for EVD experimental drugs by West African governments are desperate ones, made because of the lack of an alternative. A compelling need includes the things a person has to have in order to survive in the plain biological sense. But, wider than this, it will also cover those needs which a person requires to have met in order to enjoy a full life as defined by the community (Omonzejele 2011, 119). This implies that there is a link between a lack of alternative and a compelling need. One could reasonably conclude that the circumstances in which West African governments make the request for experimental EVD drugs fit the notion of a compelling need. Despite this, I intend to argue that bypassing research ethics procedures for EVD drug use (even in an epidemic) poses significant risks. A comparable case to EVD that readily comes to mind (though in a smaller way) is the 1996 Pfizer Kano meningitis trial in Nigeria. In that study, which was condemned by most bioethicists, Pfizer tested Trovafloxacin (Trovan)—an antibiotic—“amid a terrible epidemic in a squalid, short-staffed medical camp lacking basic diagnostic equipment” (Stephens 2000, A1). According to Macklin (2004), the trial resulted in the death of 11 children, and 200 became deaf, blind, etc. The problem with fast-tracking the use of a drug on humans for whatever reason is that this often circumvents research ethics guidelines. In the Pfizer Kano meningitis trial, a crucial question was whether proper consent was given by the research subjects or by their parents. It seems not (Omonzejele 2012). According to Macklin, “[a]n undisputed criterion for determining that research is in fact exploitative is failure to provide the information necessary for properly obtained consent” (2004, 100). How does the EVD epidemic compare with the Pfizer Kano meningitis trial? First, the Pfizer study and the EVD cases are situated in the same region (that is, West Africa), which means the economic, social, and public health infrastructure are
similar. Second, both concern an epidemic in which there is compelling need and a lack of alternatives. Third, both circumstances appear to constitute a trial and not a treatment (assuming unapproved drugs were made available to those West African countries requesting them to combat EVD). This means that if the Pfizer Kano trial was unethical, then making experimental drugs available to West African populations who are in the midst of the EVD epidemic cannot possibly pass the research ethics test. This is because, as clearly demonstrated in the Pfizer Kano meningitis trial, circumventing research ethics in the quest for new drugs carries enormous risks.
Conclusion The most important lesson to be drawn from the EVD epidemic is the need for African governments to significantly improve their public health infrastructure. The current “fire brigade approach” to health care and health care delivery is ineffective and often unproductive in terms of material and human life. In the words of U.S. President Obama in his address to 50 African leaders at the U.S.–African Summit in Washington, Ebola virus “is controlled if you have a strong public health infrastructure in place.” According to Obama, “the countries affected are the first to admit that what’s happened here is the public health systems have been overwhelmed. They were not able to identify and then isolate cases quickly enough” (Ogundipe et al. 2014, ¶6). Public health should not just be considered to refer to government superstructure, but it must also involve attitudinal and behavioral changes in daily life and in traditions
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among people living in the West African region. The key to averting epidemics is the development of this kind of public health infrastructure!
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