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A scarce drug and an ethics debate

In the light of Ebola, is it wise to offer unproven drugs? If so, who should get them first?

By: New York Times | Published: August 17, 2014 12:02:00 am


With hundreds of Africans dying from the outbreak of Ebola, some commentators have said it is wrong that extremely scarce supplies of an experimental drug went to two white American aid workers.

But other commentators wonder: What if the first doses of the drug — which had never been used in people and had not even finished the typical animal safety testing — had been given to African patients instead?

“It would have been the front-page screaming headline: ‘Africans used as guinea pigs for American drug company’s medicine’,” said Dr Salim Abdool Karim, director of Caprisa, an AIDS research centre in South Africa.

A history of controversy about drug testing in Africa is just one of the complexities facing public health authorities as they wrestle with whether and how to bring that drug and possibly other experimental ones to the countries afflicted with Ebola. Who should get such a scarce supply of medicine? Health workers? Children? The newly infected who are not yet as sick?

The World Health Organization, which has declared an international health emergency on Ebola, will convene a meeting of ethicists early next week to discuss this delicate and difficult predicament involving the drugs. The US government is also forming a group to consider the same issues, said Dr Anthony S Fauci, the director of the National Institute of Allergy and Infectious Diseases.

At least two of the countries affected by the Ebola outbreak, Liberia and Nigeria, have asked for the drug, according to a spokesman for the Centers for Disease Control and Prevention.

The debate about who should get the drug, which is called ZMapp, may be mainly academic in the short term, because there is virtually no supply left, Fauci said. By the time some modest supplies are available in a few months, the epidemic may have run its course.

Supplies of ZMapp, which is made in tobacco plants, are being scaled up, but that is expected to take a few months.

ZMapp is reported to have helped the two aid workers, Dr Kent Brantly and Nancy Writebol, who were initially treated in Liberia and are now at Emory University Hospital in Atlanta. But experts say it is too soon to conclude it is truly effective.

According to federal officials, ZMapp was given to the two Americans because Samaritan’s Purse, the aid organisation that employed Brantly, found out about it and asked for it, not because of any favouritism to Americans.

Some bioethicists said they did not find it troublesome that the first doses went to health workers, be they American or African.

Health workers, they said, can best understand the risks in taking a drug not yet tested in people and give informed consent. Offering health workers priority is a way to encourage them to undertake the grave dangers of caring for people with such a deadly, contagious disease. And if nurses and doctors get better, they might go back to caring for other patients, in effect multiplying the benefit of the drug.

“There are very special commitments that we must make ethically to the health care providers that are willing to go in and serve,” said Nancy Kass, a professor of bioethics and public health at Johns Hopkins University.

A perception in the region of unfairness in distributing the medicine could also undermine the already shaky willingness of some Africans to trust Western relief efforts. Dr Armand Sprecher, a public health specialist for Doctors Without Borders, said it was unfortunate that the first doses went to Americans “because it confirms all the suspicions people have”.

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