EDITORIAL THE MORAL CHALLENGE OF EBOLA
The Ebola epidemic continues largely unabated in West Africa, and the first few cases have spread to the United States and Europe. Especially in Guinea, Liberia, and Sierra Leone, Ebola poses an existential threat. The dread, despair, and death from Ebola are rampaging in these countries with their grossly inadequate health care and public health systems, precarious economies, and besieged governments. In these developing countries of West Africa, as well as in the developed countries where the infection has spread, Ebola poses a moral challenge to both individuals and societies. Foundational moral considerations should play a key role in public health decision-making to bring Ebola under control in an expeditious and just manner, as well as to prepare for the inevitable infectious disease outbreaks of the future. This article uses 4 key principles of public health ethics and policy to illustrate the fundamental role of ethical analysis in responding to public health emergencies. Although much of the focus is on containing Ebola, the principles discussed are applicable to other diseases and other types of public health threats.
1. A PROPORTIONATE RESPONSE IS ESSENTIAL Epidemics cause great public anxiety, especially when, as with Ebola, they involve a gruesome hemorrhagic fever with a high fatality rate and no vaccine or demonstrably effective treatment. In such situations, the impulse of some public officials is to be
6 | Editorial
extremely aggressive, such as by imposing a large-scale quarantine, requiring intensive medical surveillance, or banning travel from countries with high rates of infection. Although such an inclination is understandable, overaggressive policies are invariably ineffective in bringing epidemics under control, and the most common result has been to spread panic. In 2003, Severe Acute Respiratory Syndrome (SARS) was a new disease for which there was no vaccine or effective treatment. It seemed to be spreading out of control in highly populated regions of East Asia, with a related outbreak in Toronto, Canada. In Taiwan, 131 132 people were placed in quarantine, but there were only 2 confirmed cases.1 Officials later realized that the excessive quarantine was counterproductive by causing panic. In Canada, to prevent the entry of travelers with SARS, the Toronto and Vancouver airports used thermal scanning on 2.4 million arriving passengers without detecting a single case of SARS.1 India and Thailand quarantined foreign visitors from countries with SARS outbreaks, even if they had no symptoms or known exposures.1 All of these efforts were dismal failures. In the 2014 Ebola outbreak in the United States there have been several ill-advised calls to impose a travel ban on passengers from Guinea, Liberia, and Sierra Leone. Even the excessive measures used for SARS in 2003 did not involve a travel ban; instead, the World Health Organization issued travel advisories for individuals
traveling from countries with SARS. In the United States, if existing measures had been performed to any reasonable degree, the index case would not have left Liberia; even if he did, he would have been correctly diagnosed when he first sought medical care in Dallas; even if he had been initially misdiagnosed, when he later returned for treatment he would have received care with effective infection control. Only a series of blunders allowed this single case to threaten wider disease. Finally, although public health experts overwhelmingly believe a travel ban would not help prevent new cases of Ebola from entering the United States,2 further isolation of the 3 countries would cause Ebola to spread to neighboring countries in Africa, destroy the remnants of the local economies, and lead to a humanitarian disaster with an even greater threat to the United States. The countries in West Africa do not need further isolation; they need health care workers and modern health care facilities. Public officials in the United States should demonstrate courage and not impose superficially appealing—but ultimately counterproductive—measures.
2. A PUBLIC HEALTH CRISIS OFTEN EXACERBATES INEQUALITY Although a virus can infect rich and poor alike, economic position clearly affects a person’s chance of survival. To begin with, more affluent people are likely to be in better health before an epidemic,
American Journal of Public Health | January 2015, Vol 105, No. 1
EDITORIAL
to have received regular health care, and to be able to travel to safer regions or to leave a country suffering from an epidemic. When disease strikes, the poor often suffer more and are treated less favorably—even by their own government. In Liberia, the government imposed an area-wide quarantine on the West Point section of the capital city, Monrovia, where 60 000---120 000 people lived in deplorable, unsanitary, slumlike conditions. Barbed wire and live bullets confined these desperate people. There was little or no health care available, and highly infectious dead bodies lay on the streets for hours and sometimes days. After 10 days, the scheduled 21-day quarantine was halted. Although Ebola cases were reported in many parts of Liberia, only in the poorest section of Monrovia was a draconian and counterproductive area quarantine imposed.3 Public health crises also tend to fall more harshly on the poor and powerless in the United States. One need only think of the images of New Orleans in the aftermath of Hurricane Katrina in 2005, where minority, sick, and vulnerable people were literally left behind by public health and government officials. Such heedless public policies fail to consider the principle of social justice—an essential component of public health ethics.4 To take but one application of this principle, wealth or “social worth” should not be considered in the allocation of scarce resources or in the distribution of the risks and benefits of public health interventions.5 In fact, a public health emergency requires special efforts to protect vulnerable people, such as individuals with physical or intellectual disabilities, pregnant women, and young children.6
3. RESPONSE TO INFECTIOUS DISEASE REFLECTS A NATION’S CORE VALUES A nation’s response to an epidemic depends on more than health care equipment and personnel; the response also reflects the nation’s core values. In an epidemic many individuals may be asked to endure personal inconvenience or to make sacrifices to protect the health of others. This situation is exemplified by quarantine, where many possibly exposed but currently asymptomatic individuals are separated from the rest of society and kept from work, social activities, and family contacts.7 During the SARS epidemic in 2003, the jurisdictions most affected were Canada, China, Hong Kong, Singapore, Taiwan, and Vietnam. Hundreds of thousands of people were quarantined,1 but the people overwhelmingly supported the effort and complied. For example, in Toronto, 30 000 people were placed in quarantine for 10 days, but only 27 people required court orders.1 The nations affected by SARS are known for their communitarian values and social solidarity. By contrast, the United States is known for libertarian values, rugged individualism, distrust of government, willingness to invoke legal rights, and a belief that health care is a matter of personal responsibility.8 Thus, it is fair to ask whether Americans would be as willing to enter into quarantine voluntarily, especially when, in the case of Ebola, quarantine would last 21 days. Already, of the first people placed in quarantine for Ebola, there were some highly publicized instances of noncompliance. Another important element of public health response is the
January 2015, Vol 105, No. 1 | American Journal of Public Health
willingness to follow the edicts of public health officials. In the United States, since the anthrax incidents in 2001, public health has become increasingly associated with national security and bioterrorism. One consequence is that public health recommendations have become viewed through the lens of partisan politics. For example, during the H1N1 influenza epidemic in 2009, political party affiliation was closely associated not only with trust in the government’s public health pronouncements but also with the likelihood of taking the H1N1 vaccine. Although 80--90 million Americans received the vaccine, about 70 million doses went unused and had to be destroyed.9
4. THE WORLD’S PUBLIC HEALTH SYSTEM IS ONLY AS STRONG AS ITS WEAKEST LINKS Liberia, one of the countries most devastated by Ebola, is among the poorest countries in Africa. A recent civil war and endemic poverty left Liberia’s health care system in a perilous state even before the outbreak of Ebola. A country of 4.4 million, Liberia had only one doctor for every 100 000 people before the epidemic.10 Deaths of numerous doctors and nurses, and the refusal of some health care workers to report to work because of a lack of personal protective equipment, further decimated the health care system’s capacity to deal with Ebola as well as other illnesses. As a result, only about 18% of Ebola patients have received care in a hospital, well below the Centers for Disease Control and Prevention’s (CDC’s) estimate of 70% needed to receive care in a hospital to prevent
the further spread of disease.11 In the absence of open and functioning hospitals, most Ebola patients have been cared for at home by relatives and friends who lacked the necessary training and supplies. The result was that Ebola often spread to caregivers. By contrast, Liberia’s wealthier neighbor, Nigeria, responded quickly and effectively to its initial Ebola cases and limited the death toll to 8. It was critical to stop Ebola before it could take hold because Nigeria is Africa’s most populous nation (177 million, including 21 million people in the capital city of Lagos). Among the resources used by Nigeria were an existing disease operations center, health educators to inform the public, health workers trained in epidemiology to do contact tracing, isolation rooms at hospitals, air conditioning in hospitals that permitted hospital staff wearing personal protective equipment to work longer shifts, laboratories that could perform Ebola testing in a matter of hours, and experience in treating Lassa fever, cholera, and other infectious diseases.12 If Guinea, Liberia, and Sierra Leone had health care systems like Nigeria, then Ebola would not have become an international scourge. Thus, public health infrastructure cannot be disassociated from economic development.
CONCLUSION Ebola represents a moral challenge on both an individual and collective level. Do Americans and perhaps other peoples of the industrialized world have the understanding, compassion, equanimity, trust in government, selflessness, courage, and social cohesion to develop and comply with thoughtful public health
Editorial | 7
EDITORIAL
plans? Is it possible to set aside personal interests and political rancor to support evidence-based interventions? In an interconnected world it is impossible to prevent the spread of disease by simply walling off one’s country. The only effective and humane strategy is to attack the disease where it arises. Thus, as a matter of public health science, the Ebola crisis will not be over anywhere until it is brought under control in the West African countries where it began. Moreover, the risk of a new outbreak of Ebola or some other infectious disease spreading rapidly worldwide will remain until the public health infrastructure around the world is capable of effectively responding to the next public health emergency. If the moral imperative of providing life-saving health care for helpless people in desperately poor nations is insufficient motivation to act, then perhaps the interest in selfpreservation will be. j Mark A. Rothstein, JD
About the Author Mark A. Rothstein is with the Institute for Bioethics, Health Policy and Law, University of Louisville School of Medicine, Louisville, KY. He is also a Department Editor for the American Journal of Public Health. Correspondence should be sent to Professor Mark A. Rothstein, University of Louisville School of Medicine, 501 East Broadway # 310, Louisville, KY 40202 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This article was accepted October 20, 2014. doi:10.2105/AJPH.2014.302413
References 1. Rothstein M, Alcalde MG, Elster NR, et al. Quarantine and isolation: lessons learned from SARS: a report to the Centers for Disease Control and Prevention. 2003. Available at: http://stacks.cdc.gov/view/cdc/ 11429. Accessed on October 21, 2014. 2. Mouawad J. Experts oppose travel ban, saying it would cut off worst-hit countries. New York Times. October 18,
8 | Editorial
2014: A12. Available at: http://www. nytimes.com/2014/10/18/business/ experts-oppose-ebola-travel-ban-saying-itwould-cut-off-worst-hit-countries.html? ref=todayspaper&_r=0. Accessed on October 20, 2014.
Times. October 1, 2014. Available at: http://www.nytimes.com/2014/10/01/ health/ebola-outbreak-in-nigeriaappears-to-be-over.html?_r=0. Accessed on October 20, 2014.
3. Onishi N. Quarantine for ebola lifted in Liberia slum. New York Times. August 30, 2014: A4. Available at: http://www. nytimes.com/2014/08/30/world/ africa/quarantine-for-ebola-lifted-inliberia-slum.html?_r=0. Accessed on October 17, 2014. 4. Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford University Press; 2006. 5. Jennings B, Arras J. Ethical guidance for public health emergency preparedness and response: highlighting ethics and values in a vital public health service: a report for the Ethics Subcommittee, Advisory Committee to the Director, Centers for Disease Control and Prevention. 2008. Available at: http://www.cdc. gov/od/science/integrity/phethics/ docs/white_paper_final_for_website_ 2012_4_6_12_final_for_web_508_ compliant.pdf. Accessed on October 18, 2014. 6. Hoffman S. Preparing for disaster: protecting the most vulnerable in emergencies. UC Davis Law Rev. 2009;42 (4):1491---1547. 7. Rothstein M. From SARS to Ebola: legal and ethical considerations for modern quarantine. Indiana Health L Rev. 2015;12(1). Published ahead of print October 20, 2014. Available at http:// papers.ssrn.com/sol3/papers.cfm? abstract_id=2499701. Accessed on October 20, 2014. 8. Rothstein M. Are traditional public health strategies consistent with contemporary American values? Temple Law Rev. 2004;77(2):175---192. 9. Gerwin LE. The challenge of providing the public with actionable information during a pandemic. J Law Med Ethics. 2012;40(3):630---654. 10. Fox M. Ebola spreading “exponentially” as patients seek beds in Liberia. 2014. Available at: http://www.nbcnews. com/storyline/ebola-virus-outbreak/ ebola-spreading-exponentially-patientsseek-beds-liberia-n198516. Accessed on October 17, 2014. 11. Onishi N. In Liberia, home deaths spread circle of Ebola contagion. New York Times. September 25, 2014: A1. Available at: http://www.nytimes.com/ 2014/09/25/world/africa/liberia-ebolavictims-treatment-center-cdc.html?_r=0. Accessed on October 17, 2014. 12. McNeil Jr DG. Nigeria’s actions seem to contain Ebola outbreak. New York
American Journal of Public Health | January 2015, Vol 105, No. 1
The Ebola epidemic continues largely unabated in West Africa, and the first few cases have spread to the United States and Europe. Especially in Guinea, Liberia, and Sierra Leone, Ebola poses an existential threat. The dread, despair, and death from Ebola are rampaging in these countries with their grossly inadequate health care and public health systems, precarious economies, and besieged governments. In these developing countries of West Africa, as well as in the developed countries where the infection has spread, Ebola poses a moral challenge to both individuals and societies. Foundational moral considerations should play a key role in public health decision-making to bring Ebola under control in an expeditious and just manner, as well as to prepare for the inevitable infectious disease outbreaks of the future. This article uses 4 key principles of public health ethics and policy to illustrate the fundamental role of ethical analysis in responding to public health emergencies. Although much of the focus is on containing Ebola, the principles discussed are applicable to other diseases and other types of public health threats.
1. A PROPORTIONATE RESPONSE IS ESSENTIAL Epidemics cause great public anxiety, especially when, as with Ebola, they involve a gruesome hemorrhagic fever with a high fatality rate and no vaccine or demonstrably effective treatment. In such situations, the impulse of some public officials is to be
6 | Editorial
extremely aggressive, such as by imposing a large-scale quarantine, requiring intensive medical surveillance, or banning travel from countries with high rates of infection. Although such an inclination is understandable, overaggressive policies are invariably ineffective in bringing epidemics under control, and the most common result has been to spread panic. In 2003, Severe Acute Respiratory Syndrome (SARS) was a new disease for which there was no vaccine or effective treatment. It seemed to be spreading out of control in highly populated regions of East Asia, with a related outbreak in Toronto, Canada. In Taiwan, 131 132 people were placed in quarantine, but there were only 2 confirmed cases.1 Officials later realized that the excessive quarantine was counterproductive by causing panic. In Canada, to prevent the entry of travelers with SARS, the Toronto and Vancouver airports used thermal scanning on 2.4 million arriving passengers without detecting a single case of SARS.1 India and Thailand quarantined foreign visitors from countries with SARS outbreaks, even if they had no symptoms or known exposures.1 All of these efforts were dismal failures. In the 2014 Ebola outbreak in the United States there have been several ill-advised calls to impose a travel ban on passengers from Guinea, Liberia, and Sierra Leone. Even the excessive measures used for SARS in 2003 did not involve a travel ban; instead, the World Health Organization issued travel advisories for individuals
traveling from countries with SARS. In the United States, if existing measures had been performed to any reasonable degree, the index case would not have left Liberia; even if he did, he would have been correctly diagnosed when he first sought medical care in Dallas; even if he had been initially misdiagnosed, when he later returned for treatment he would have received care with effective infection control. Only a series of blunders allowed this single case to threaten wider disease. Finally, although public health experts overwhelmingly believe a travel ban would not help prevent new cases of Ebola from entering the United States,2 further isolation of the 3 countries would cause Ebola to spread to neighboring countries in Africa, destroy the remnants of the local economies, and lead to a humanitarian disaster with an even greater threat to the United States. The countries in West Africa do not need further isolation; they need health care workers and modern health care facilities. Public officials in the United States should demonstrate courage and not impose superficially appealing—but ultimately counterproductive—measures.
2. A PUBLIC HEALTH CRISIS OFTEN EXACERBATES INEQUALITY Although a virus can infect rich and poor alike, economic position clearly affects a person’s chance of survival. To begin with, more affluent people are likely to be in better health before an epidemic,
American Journal of Public Health | January 2015, Vol 105, No. 1
EDITORIAL
to have received regular health care, and to be able to travel to safer regions or to leave a country suffering from an epidemic. When disease strikes, the poor often suffer more and are treated less favorably—even by their own government. In Liberia, the government imposed an area-wide quarantine on the West Point section of the capital city, Monrovia, where 60 000---120 000 people lived in deplorable, unsanitary, slumlike conditions. Barbed wire and live bullets confined these desperate people. There was little or no health care available, and highly infectious dead bodies lay on the streets for hours and sometimes days. After 10 days, the scheduled 21-day quarantine was halted. Although Ebola cases were reported in many parts of Liberia, only in the poorest section of Monrovia was a draconian and counterproductive area quarantine imposed.3 Public health crises also tend to fall more harshly on the poor and powerless in the United States. One need only think of the images of New Orleans in the aftermath of Hurricane Katrina in 2005, where minority, sick, and vulnerable people were literally left behind by public health and government officials. Such heedless public policies fail to consider the principle of social justice—an essential component of public health ethics.4 To take but one application of this principle, wealth or “social worth” should not be considered in the allocation of scarce resources or in the distribution of the risks and benefits of public health interventions.5 In fact, a public health emergency requires special efforts to protect vulnerable people, such as individuals with physical or intellectual disabilities, pregnant women, and young children.6
3. RESPONSE TO INFECTIOUS DISEASE REFLECTS A NATION’S CORE VALUES A nation’s response to an epidemic depends on more than health care equipment and personnel; the response also reflects the nation’s core values. In an epidemic many individuals may be asked to endure personal inconvenience or to make sacrifices to protect the health of others. This situation is exemplified by quarantine, where many possibly exposed but currently asymptomatic individuals are separated from the rest of society and kept from work, social activities, and family contacts.7 During the SARS epidemic in 2003, the jurisdictions most affected were Canada, China, Hong Kong, Singapore, Taiwan, and Vietnam. Hundreds of thousands of people were quarantined,1 but the people overwhelmingly supported the effort and complied. For example, in Toronto, 30 000 people were placed in quarantine for 10 days, but only 27 people required court orders.1 The nations affected by SARS are known for their communitarian values and social solidarity. By contrast, the United States is known for libertarian values, rugged individualism, distrust of government, willingness to invoke legal rights, and a belief that health care is a matter of personal responsibility.8 Thus, it is fair to ask whether Americans would be as willing to enter into quarantine voluntarily, especially when, in the case of Ebola, quarantine would last 21 days. Already, of the first people placed in quarantine for Ebola, there were some highly publicized instances of noncompliance. Another important element of public health response is the
January 2015, Vol 105, No. 1 | American Journal of Public Health
willingness to follow the edicts of public health officials. In the United States, since the anthrax incidents in 2001, public health has become increasingly associated with national security and bioterrorism. One consequence is that public health recommendations have become viewed through the lens of partisan politics. For example, during the H1N1 influenza epidemic in 2009, political party affiliation was closely associated not only with trust in the government’s public health pronouncements but also with the likelihood of taking the H1N1 vaccine. Although 80--90 million Americans received the vaccine, about 70 million doses went unused and had to be destroyed.9
4. THE WORLD’S PUBLIC HEALTH SYSTEM IS ONLY AS STRONG AS ITS WEAKEST LINKS Liberia, one of the countries most devastated by Ebola, is among the poorest countries in Africa. A recent civil war and endemic poverty left Liberia’s health care system in a perilous state even before the outbreak of Ebola. A country of 4.4 million, Liberia had only one doctor for every 100 000 people before the epidemic.10 Deaths of numerous doctors and nurses, and the refusal of some health care workers to report to work because of a lack of personal protective equipment, further decimated the health care system’s capacity to deal with Ebola as well as other illnesses. As a result, only about 18% of Ebola patients have received care in a hospital, well below the Centers for Disease Control and Prevention’s (CDC’s) estimate of 70% needed to receive care in a hospital to prevent
the further spread of disease.11 In the absence of open and functioning hospitals, most Ebola patients have been cared for at home by relatives and friends who lacked the necessary training and supplies. The result was that Ebola often spread to caregivers. By contrast, Liberia’s wealthier neighbor, Nigeria, responded quickly and effectively to its initial Ebola cases and limited the death toll to 8. It was critical to stop Ebola before it could take hold because Nigeria is Africa’s most populous nation (177 million, including 21 million people in the capital city of Lagos). Among the resources used by Nigeria were an existing disease operations center, health educators to inform the public, health workers trained in epidemiology to do contact tracing, isolation rooms at hospitals, air conditioning in hospitals that permitted hospital staff wearing personal protective equipment to work longer shifts, laboratories that could perform Ebola testing in a matter of hours, and experience in treating Lassa fever, cholera, and other infectious diseases.12 If Guinea, Liberia, and Sierra Leone had health care systems like Nigeria, then Ebola would not have become an international scourge. Thus, public health infrastructure cannot be disassociated from economic development.
CONCLUSION Ebola represents a moral challenge on both an individual and collective level. Do Americans and perhaps other peoples of the industrialized world have the understanding, compassion, equanimity, trust in government, selflessness, courage, and social cohesion to develop and comply with thoughtful public health
Editorial | 7
EDITORIAL
plans? Is it possible to set aside personal interests and political rancor to support evidence-based interventions? In an interconnected world it is impossible to prevent the spread of disease by simply walling off one’s country. The only effective and humane strategy is to attack the disease where it arises. Thus, as a matter of public health science, the Ebola crisis will not be over anywhere until it is brought under control in the West African countries where it began. Moreover, the risk of a new outbreak of Ebola or some other infectious disease spreading rapidly worldwide will remain until the public health infrastructure around the world is capable of effectively responding to the next public health emergency. If the moral imperative of providing life-saving health care for helpless people in desperately poor nations is insufficient motivation to act, then perhaps the interest in selfpreservation will be. j Mark A. Rothstein, JD
About the Author Mark A. Rothstein is with the Institute for Bioethics, Health Policy and Law, University of Louisville School of Medicine, Louisville, KY. He is also a Department Editor for the American Journal of Public Health. Correspondence should be sent to Professor Mark A. Rothstein, University of Louisville School of Medicine, 501 East Broadway # 310, Louisville, KY 40202 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This article was accepted October 20, 2014. doi:10.2105/AJPH.2014.302413
References 1. Rothstein M, Alcalde MG, Elster NR, et al. Quarantine and isolation: lessons learned from SARS: a report to the Centers for Disease Control and Prevention. 2003. Available at: http://stacks.cdc.gov/view/cdc/ 11429. Accessed on October 21, 2014. 2. Mouawad J. Experts oppose travel ban, saying it would cut off worst-hit countries. New York Times. October 18,
8 | Editorial
2014: A12. Available at: http://www. nytimes.com/2014/10/18/business/ experts-oppose-ebola-travel-ban-saying-itwould-cut-off-worst-hit-countries.html? ref=todayspaper&_r=0. Accessed on October 20, 2014.
Times. October 1, 2014. Available at: http://www.nytimes.com/2014/10/01/ health/ebola-outbreak-in-nigeriaappears-to-be-over.html?_r=0. Accessed on October 20, 2014.
3. Onishi N. Quarantine for ebola lifted in Liberia slum. New York Times. August 30, 2014: A4. Available at: http://www. nytimes.com/2014/08/30/world/ africa/quarantine-for-ebola-lifted-inliberia-slum.html?_r=0. Accessed on October 17, 2014. 4. Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford University Press; 2006. 5. Jennings B, Arras J. Ethical guidance for public health emergency preparedness and response: highlighting ethics and values in a vital public health service: a report for the Ethics Subcommittee, Advisory Committee to the Director, Centers for Disease Control and Prevention. 2008. Available at: http://www.cdc. gov/od/science/integrity/phethics/ docs/white_paper_final_for_website_ 2012_4_6_12_final_for_web_508_ compliant.pdf. Accessed on October 18, 2014. 6. Hoffman S. Preparing for disaster: protecting the most vulnerable in emergencies. UC Davis Law Rev. 2009;42 (4):1491---1547. 7. Rothstein M. From SARS to Ebola: legal and ethical considerations for modern quarantine. Indiana Health L Rev. 2015;12(1). Published ahead of print October 20, 2014. Available at http:// papers.ssrn.com/sol3/papers.cfm? abstract_id=2499701. Accessed on October 20, 2014. 8. Rothstein M. Are traditional public health strategies consistent with contemporary American values? Temple Law Rev. 2004;77(2):175---192. 9. Gerwin LE. The challenge of providing the public with actionable information during a pandemic. J Law Med Ethics. 2012;40(3):630---654. 10. Fox M. Ebola spreading “exponentially” as patients seek beds in Liberia. 2014. Available at: http://www.nbcnews. com/storyline/ebola-virus-outbreak/ ebola-spreading-exponentially-patientsseek-beds-liberia-n198516. Accessed on October 17, 2014. 11. Onishi N. In Liberia, home deaths spread circle of Ebola contagion. New York Times. September 25, 2014: A1. Available at: http://www.nytimes.com/ 2014/09/25/world/africa/liberia-ebolavictims-treatment-center-cdc.html?_r=0. Accessed on October 17, 2014. 12. McNeil Jr DG. Nigeria’s actions seem to contain Ebola outbreak. New York
American Journal of Public Health | January 2015, Vol 105, No. 1
