26 August 2014

Ethical concerns about Ebola medication

Two American aid workers recovered from Ebola after being treated with an experimental drug, but Sierra Leone's most famous doctor was denied the same treatment.


When two American aid workers recovered from Ebola after being treated with an experimental drug, the grieving family of Sierra Leone's most famous doctor wondered why he had been denied the same treatment before he died from the deadly virus.

Sheik Umar Khan was a hero in his small West African country for leading the fight against the worst ever outbreak of the highly contagious hemorrhagic fever, which has killed 1,427 people mostly in Sierra Leone, Liberia and Guinea.

Country in mourning

When Khan fell sick in late July, he was rushed to a treatment unit run by Medecins Sans Frontieres(MSF) where doctors debated whether to give him ZMapp, a drug tested on laboratory animals but never before used on humans.

Staff agonised over the ethics of favouring one individual over hundreds of others and the risk of a popular backlash if the untried treatment was perceived as killing a national hero.

In the end, they decided against using ZMapp. Khan died on July 29, plunging his country into mourning.

Read: Doctor leading Ebola fight dies

A few days later, the California-manufactured pharmaceutical was administered to U.S. aid workers Kent Brantly and Nancy Writebol, who contracted Ebola in Liberia and were flown home for treatment. It is not clear what role ZMapp played in their recovery but the two left the hospital in Atlanta last week.

Khan is among nearly 100 African healthcare workers to have paid the ultimate price for fighting Ebola, as the region's medical systems have been overwhelmed by an epidemic which many say could have been contained if the world had acted quicker.

Khan saved hundreds

In their village of Mahera, in northern Sierra Leone, Khan's elderly parents and siblings asked why he did not get the treatment. Khan saved hundreds of lives during a decade battling Lassa fever – a disease similar to Ebola – at his clinic in Kenema and was Sierra Leone's only expert on hemorrhagic fever.

"If it was good enough for Americans, it should have been good enough for my brother," said C-Ray, his elder brother, as he sat on the porch of the family home. "It's not logical that it wasn't used. He had nothing to lose if it hadn't worked."

Doctors who knew Khan and who were involved in the difficult decision, however, said it was based on sound ethical reasoning.

Ebola, which is passed on by direct contact with the bodily fluids of infected persons, strikes hardest at healthcare providers and carers who work closely with patients.

Read: WHO chief says Ebola can be stopped

Victims suffer vomiting, diarrhoea, internal and external bleeding in the final stages of the disease, leaving their bodies coated in the virus. To treat the sick, doctors require training and protective clothing, both of them scarce in Africa.

The outbreak – the first in West Africa – was detected five months ago deep in the forests of southeastern Guinea. But it was not until 8 August that the World Health Organisation declared an international health emergency and promised more resources.

He knew the risks

By decimating healthcare staff in countries that had only a few hundred trained doctors before the outbreak, Ebola has now left millions vulnerable to the next crisis, experts say.

"Dr. Khan knew the risks better than anybody ... but if you work for months in overcrowded facilities, 18 hours a day, anyone will make a mistake," said Robert Garry, professor of microbiology and immunology at Tulane University in New Orleans, who worked with Khan for a decade.

"The whole international community needs to look back and say we dropped the ball. We should've reacted faster to this."

To many in his impoverished country, Khan was a saviour for his pioneering work with Lassa fever, a disease endemic to the jungles of eastern Sierra Leone that kills 5,000 people a year. When Ebola struck, he became a figurehead for that fight, too, hailed by President Ernest Bai Koroma as a "national hero".

Doctors involved in treating Khan were aware that – given sporadic violence against healthcare workers by a frightened local population – a misstep could prove costly.

Read: Fear hampers fight against Ebola in West Africa

"Now you can look back at that and say it was a mistake," said American doctor Daniel Bausch ofTulane University, who worked with Khan and advocated giving him ZMapp at the time.

Ethical concerns

"But there was a very tense atmosphere on the ground," he said. "If he had died from the drug, or even if it was perceived that he had, it could have had dangerous ramifications."

Doctors also had ethical concerns about giving Khan priority treatment that hundreds of other infected people could not receive, since only a few doses of ZMapp had been manufactured.

The president of Medecins San Frontieres – which has spearheaded the response to Ebola at clinics in Sierra Leone, Guinea and Liberia – said its doctors could not sanction use of a drug on Khan whose effects were unknown.

"We didn't know what the consequences would be. We didn't know how sick he was and we didn't know how efficient it would be," Joanne Liu told Reuters.

Khan, who had initially appeared to be recovering, was never told that the drug was available. Two weeks after his death, the World Health Organization approved the use of experimental drugs to tackle Ebola, on Aug. 12.

Read: Ebola emergency turns spotlight on experimental drugs

However, the manufacturer of ZMapp, California-based Mapp Biopharmaceutical, said supplies of the drug are exhausted after the last doses were used in treating three African healthcare workers in Liberia last week. Like the two Americans, they are also recovering.

Read more:
Ethical questions around who gets Ebola drug
Ebola health workers face 'hellish conditions'
SA health workers urged to be on the lookout for Ebola symptoms




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