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Tom Sabulis

Fighting Ebola

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Moderated by Tom Sabulis

Even with Ebola patients leaving Emory University Hospital on Thursday, the threat of the virus spreading remains real in vulnerable communities. Today, two global health experts to write about the larger implications of Ebola and other infectious diseases on world populations. Emory doctors urges education as an antidote to fear in the general population, and a doctor at Duke University warns against the rush to use experimental or unproven drugs to fight back.

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Global health beyond Ebola

By Jeffrey Koplan and Carlos del Rio

Ebola virus news stories provide a jolting reminder of the power of infectious diseases. With expanding populations, a global economy and ease of air travel, diseases know no geographic boundaries and can spread quickly if effective disease surveillance, control and prevention programs are not in place.

Concerns about this disease are understandable since the majority of Americans know very little about infectious diseases, public health measures, and the work of global health researchers and practitioners. With Ebola virus at the forefront of media coverage and general discussion, it is important to note that community knowledge is a powerful deterrent to fear. Education can help dispel myths and support practical prevention tools for this and other serious communicable diseases.

Emory has embraced the importance of global health with active educational and research efforts throughout the university and an internationally recognized Global Health Institute. Researchers at Emory seek new and better vaccines and medications, study how to reduce rates of infectious and non-communicable diseases, identify environmental hazards and behavioral risk factors, and study the basic sciences, including genetics and immunology, to improve health in the U.S. and beyond.

Yesterday was influenza A (H1N1), today is Ebola, tomorrow will be another infectious disease that may yet be discovered. However, global health challenges go beyond infectious diseases, as non-communicable or “chronic” diseases such as cancer, heart disease, and diabetes have become global threats to longevity and quality of life.

Addressing global health issues is a multi-national endeavor that has a broad impact. While it is a moral imperative that we help populations around the world become and remain healthy, we must also remember that healthy populations are good for development, business, civil order and national security. A healthy population provides a nation with the necessary stability to compete in a dynamic, interconnected world.

Global health affects us all. Rather than reacting through panic and fear to just one current disease threat of the moment, the best approach to preventing and limiting the spread of communicable and non-communicable diseases is preparedness, research, training and partnership.

In the United States, facilities providing health care and public health departments should maintain their surveillance efforts and be on the lookout for patients with symptoms of potentially serious infectious diseases, particularly when these individuals have recently traveled to infected areas. All hospitals should prepare to use their existing facilities to isolate patients, when appropriate, using current Centers for Disease Control and Prevention protocols for infection control. Funding for new scientific research and public health are also essential if we are to prevent and fight serious global diseases.

Public health practitioners, physicians and nurses must share information readily with colleagues to create a strong team approach and help educate the public for a better understanding of health threats and how to prevent and control them. And we must continue to work with partners in other countries in a shared international effort. That’s why it’s called global health.

Dr. Jeffrey Koplan is vice president of Global Health at Emory University. Dr. Carlos del Rio is chairman of the Hubert Department of Global Health at Emory University’s Rollins School of Public Health.

Prescribe caution with unproven drugs

By Philip M. Rosoff

Amid reports of protesters breaking into a holding center in Liberia this weekend and carrying away Ebola patients, the current outbreak in western Africa threatens to transform from a local and contained problem to a pandemic with potential worldwide ramifications.

To combat the spread of this deadly disease, which is easily passed from person to person through close contact with blood or bodily fluids, several Western companies are in the early stages of developing vaccines and therapeutics. Though none of the drugs has been tested in humans for safety or efficacy, the ongoing epidemic is pressuring regulatory authorities to quickly advance this process.

Last week, the World Health Organization issued an emergency bulletin stating that because of the circumstances surrounding the Ebola crisis, if certain conditions are met, “it is ethical to offer unproven interventions with as yet unknown efficacy and adverse effects, as potential treatment or prevention.”

One company — Mapp Biopharmaceutical Inc. — has created a biologic drug called Zmapp that in the laboratory appears to neutralize the Ebola virus, thus showing promise as an effective treatment. However, it had never been given to humans until it was administered to three Ebola patients — two Americans and one Spaniard — who contracted the disease while working with others sick with Ebola, and more recently to three African patients, exhausting the supply.

It may seem reasonable to bypass normal regulatory pathways to demonstrate both safety and efficacy for this drug, and take the chance it might work. But despite these desperate circumstances, caution should be paramount when approving the use of an unproven drug.

First, desperation often gives rise to ill-considered choices by doctors and others caring for the very sick, their families and the patients themselves. Holding out the hope of a treatment, irrespective of how that hope is couched with caveats, is likely to prove irresistible to those frantic for any chance whatsoever, thus making the idea of informed consent meaningless.

Second, there are many examples of drugs that looked promising in non-humans only to prove ineffective and/or dangerously toxic when given to people.

Unfortunately, giving Zmapp to patients under these conditions will not permit us to find out if it is effective, overly toxic or completely ineffective and non-toxic. It would be a tragedy to discover later that we held out hope and poured energy into developing a drug that didn’t help anyone or, worse, hurt them.

Third, Western pharmaceutical companies have had a long and unsavory history of carrying out drug trials in African populations — typically in poor and undereducated people — only to take the data they generate to market medicines to be sold in wealthy countries and not benefit the people whose sacrifice made this possible. These practices have changed dramatically over the past 10 years or so, but memories die hard, and this is still a very sensitive issue. Thus, when Zmapp was given to three Westerners and not Africans, it recalled past discriminatory actions. There should be a proportionate distribution of both burdens and benefits of any intervention (and research).

Finally, even under the best of circumstances, it is unlikely there will be sufficient Zmapp — or some other medicine yet to come — to treat all infected with Ebola. Therefore, decisions must be made about who should receive the extremely limited supply.

No matter how this is decided, insufficient time and thought have been devoted to creating a fair and equitable system to distribute the (potential and questionable) benefits of this experimental therapy.

The outbreak of Ebola represents a tremendous challenge to fragile public health systems, to poor countries whose populations were already suffering from poverty and other ills, and to those charged with attempting to both treat the sick and prevent the spread of the virus. Nevertheless, we must not be so frightened that we fail to give due regard to difficult ethical questions raised by this harrowing situation.

It is bad enough that so many people are dying. We should not compound the grievousness of their plight and come to regret that they suffered even more for avoidable mistakes.

Dr. Philip M. Rosoff is professor of pediatrics and medicine at Duke University Medical Center.

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