In late 2014, the rampant outbreak of Ebola in some of the most impoverished areas in Africa led the director of the Centers for Disease Control and Prevention to urge that “we have to work now so that this is not the world’s next AIDS” (Rettner 2014).
Ebola first emerged in Sudan (now South Sudan) and Zaire (now Democratic Republic of Congo) in 1976. Since then, there have been approximately two dozen outbreaks in various rural areas in Africa. The size, spread, and virulence of the most recent outbreak in 2014–2015, which reported more than 23,000 cases and killed over 10,500 people in Guinea, Liberia, and Sierra Leone as of April 2015
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(WHO 2015c), were the most severe on record (Sayburn 2014). As multiple cities were affected and that infected healthcare workers and others traveled to various parts of the world, there were also fears that the virus could quickly become a global epidemic if not managed properly.
The statement comparing HIV and Ebola was controversial, especially since there are important clinical differences between these two viruses. HIV has a long latency period that lasts up to 10 years, during which asymptomatic people can spread the virus to others. Ebola has a short incubation window of up to 21 days, and only symptomatic people can spread the virus. Nonetheless, the macro and international sociopolitical context within which the HIV epidemic evolved in the last few decades offers important lessons for the international community regarding how justice requires various parties—government agencies, NGOs, pharmaceutical companies, and researchers—to work together in combating the spread of Ebola and other tropical diseases affecting people in LDCs. Both viruses emerged in Africa with no vaccine, and both are fatal if left untreated.
HIV was initially considered a disease only affecting poor Africans or gay men, and the stigmatization and marginalization of these populations prevented domestic and international communities from acknowledging the macro conditions contribut- ing to and exacerbating the circumstances. It was only when the disease became more widespread in heterosexual people even in wealthy countries that research and development activities ramped up. Ebola has also been among one of the neglected tropical diseases. Dozens of small outbreaks for the past 40 years in rural Africa did not prompt significant public health research effort. Despite killing 50–90% of those infected with the virus, the “market condition” for Ebola simply provided little to no incentive for pharmaceutical companies to invest in developing a treat- ment, making this an orphan condition. It was only the dramatic fear brought on by the high susceptibility of healthcare workers—including international professionals working in Africa and subsequently treated in the west—and the perception of the global spread that recently motivated international pressures on fast-tracking research efforts. A few individuals were granted emergency access to ZMapp, the anti-Ebola virus three-antibody mixture that has gone through animal studies but not randomized clinical trials (RCTs) to evaluate efficacy and safety in humans (Pollack 2014).
Much of the recent ethics literature regarding ZMapp has been focusing on the ethical considerations regarding informed consent and balancing risks and benefits in using experimental drugs (Rid and Emanuel 2014). Distributive justice discus- sions have mostly been around the issue of allocating very limited doses of unproven compounds (Donovan 2014; Joffe 2014). There are also debates regarding whether the use of RCTs would be most appropriate in dire and emergency circumstances.
However, as we have seen in the HIV situation, economic, sociopolitical, and cul- tural contexts affect how an epidemic emerges, such that these factors need to be considered as government agencies, international organizations, and pharmaceuti- cal companies work together in finding ways to curb the epidemic and prevent the next outbreak. Stigma, health illiteracy, cultural practices, the general lack of health infrastructure, and the unavailability of effective treatment for Ebola have prevented
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many infected individuals from seeking medical attention. For every 100,000 peo- ple, Sierra Leone and Liberia only had 2.2 physicians in 2010 and 1.4 physicians in 2008, respectively (WHO 2015b). With much of the already weak infrastructure in these countries further damaged due to civil wars or conflicts, the usual systems of disease control used in previous outbreaks could not contain the spread of the virus.
Many have wondered why pharmaceutical corporations have not developed effective drugs for Ebola. It is noteworthy that ZMapp, which was the research result of collaborating biodefence companies that have been financially supported by various American federal agencies and the Public Health Agency of Canada (Kroll 2014), was not developed primarily as a treatment for infected patients in Africa. This is despite the fact that the virus was initially discovered in the region in the mid-1970s and that much of the key discoveries of how the virus spread were first conducted there. Rather, the antibody cocktail was developed because Ebola was considered a top-level threat for bioterrorism in the post 9–11 era.
At the height of the latest outbreak, there was political pressure from the interna- tional community to fast-track and ramp up R&D for this disease. The National Institute of Allergy and Infectious Diseases (NIAID) announced in February 2015 that the agency would partner with relevant research units in Liberia to test two experimental vaccines in that country (NIAID 2015). As the epidemic begins to ease, the study investigators anticipate that flexibility in the conduct and design of the trial will be necessary to address the changing nature of the outbreak.
I contend that these considerations regarding how to prevent the next outbreak need to go beyond study design. Assuming scientific success, larger questions of how these compounds may be developed and made available to those in LDCs in the long term need to be considered. As the fear of an imminent global epidemic fades, drug developers and international agencies may once again question if investment in an orphan drug would be financially worthwhile, and who may have the moral obligation to develop such treatment, since the principle of rescue does not require potential actors to make substantial sacrifice. Detailed discussion of this issue is beyond the scope of this chapter, but it is worth noting that drug availability is only a small part of disease prevention and treatment. As the high recovery rate of Ebola patients in the west has shown, infrastructure is important, such that the interna- tional community should not only focus on drug development. It also needs to con- sider how to support local actors in building capacity for the long run. While the United States spent hundreds of millions of dollars and deployed around 3000 troops to build treatment centers in Liberia in late 2014 and early 2015 (Onishi 2015), many of these treatment centers now sit empty as the number of new cases decreased drastically. Since LDCs facing Ebola also battle other deadly infections that continue to claim even more lives, the international community must not aban- don its effort in understanding the fundamental economic, cultural, and geopolitical issues that may have contributed not only to the latest outbreak but also people’s daily hardship. Many residents in the aforementioned LDCs already face HIV, malaria, water-borne diseases, TB, and other health problems that have become part of their everyday life. To prevent another epidemic, whether of Ebola or other viral diseases, we need to ask fundamental questions regarding what macro global and
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local conditions may contribute to the spread of diseases, how to make sure that the necessary and integrated infrastructure is available to tackle basic health needs, what conditions and populations should be targeted for pharmaceutical research, how such research should be supported and funded, and how proprietary regulations should be constructed to ensure that those in the most disadvantaged positions will not be denied access to essential medicines. It is only when we attend to these broader contextual issues that we can prevent the world’s next AIDS.
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