A Primer on Ebola: Ethics, Public Health, and Panic

by Craig Klugman, Ph.D.

Ebola is in the news a lot with the diagnosis of the first case on U.S. soil (excluding the 4 cases of health workers who were repatriated from West Africa after falling ill with the disease). Lots of information is flying around the internet and the news media. The ethics of outbreaks is not a new topic and has been written about extensively in this blog as well as elsewhere. Experts in public health ethics have addressed this issue thoroughly.

Below are some thinking points about Ebola to help put the situation into perspective and to provide some points for reflection.

1. It’s hard to get. Ebola is a virus transmitted through bodily fluids. You have to come into contact with the secretions or blood of an infected person and it enters your body through a cut or a mucous membrane. Ebola cannot be transmitted causally or through the air like influenza.
2. Ebola can only be transmitted when a patient has symptoms.
3. The infection rate in West Africa is high because (a) a shortage of trained health professions and medical supplies means caregivers lack adequate personal protection and can then act as disease vectors, (b) poorly funded public health systems means its hard to respond to the disease, (c) the funerary rites in many of these places include touching the deceased, washing the body, and even kissing the body.

4. Ebola has been in the United States before. In 1989, 1990 and 1996 Ebola was found in monkeys imported into quarantine facilities. In the 1990 case, four humans were found to have antibodies but were not sick.
5. The patient in Texas was infected in Africa, not the U.S. He showed no symptoms on the airplane over and thus no one on the plane was at risk.
6. Quarantine works. One of the oldest and most effective tools in preventing the spread of disease is quarantine. Ebola has an incubation period of 21 days (with an average of 8 days). A person suspected of having come into contact with the virus can be quarantined for 3 weeks and if no signs have developed enter general circulation and pose no risk to others. More information on quarantine and the ethics behind it can be found here.
   
7. Airports in West Africa are screening travelers. Using thermometers, travels through these ports are being examined to see if they are running a temperature—a high temperature is a sign of Ebola. Several nations have incorporated this step as well including Russia, Australia and India. Remember number 2 above, if a person has no symptoms then he or she is not infectious.

   This prevents people with symptoms from traveling and spreading the disease. Several years ago during the pandemic bird flu, screening passengers for symptoms was instituted at airports around the world. Don’t forget that flu is easily transmitted, unlike Ebola (see number 1). I went to south Mexico during this time (not a hot zone though northern parts of the country were) and I was subjected to a health questionnaire and brief examination on both entering and leaving the airport.

8. Most states, metropolitan areas, and hospitals have plans in place for dealing with infectious patients with dangerous diseases. In 2013 the Institute of Medicine released a toolkit to help localities create response plans to crisis based on ethical principles. I wrote about these plans in September and the work being done in Texas to prepare. The plans deal with using trained volunteers (such as medical and nursing students), distributions of drugs and vaccines (although for Ebola there is neither, only supportive care), and the establishment of alternative care settings where people who suspect they are can go instead of clogging the regular ER.
9. As the story of Ebola in Africa has demonstrated, disposal of the body of someone infected is important. Traditional funerary rites have permitted the virus to spread quickly through families and villages. Bodies must be buried in a safe fashion—meaning in sealed body bags washed in bleach, and then carefully handled or even better, burned. No one should expect to receive the body of a loved one who has died from Ebola—this is for your own protection. Public health ethics puts a priority on reducing morbidity and mortality by removing threats. This loss of personal liberty is more than balanced by the saving of many lives.
10. One of the foundational principles in the crisis management plans is transparency—that information should be made public. Thus, all crisis plans are public and usually go through a period of public commentary. Plans for distribution of resources and protection should be released as much as possible (thought it might be better to hide times and routes of equipment movement since such knowledge could make them subject more easily to piracy)

    However, this does not mean it’s okay to trample on individual patient confidentiality and privacy. Names of patients can and should be withheld. Details that will cause panic rather than help should be withheld. Releasing such information will cause more harm than good. All information that is necessary and will not cause harm or panic should be released.

    This also means that family should be informed before the public if possible. If a person is found to have Ebola, public health officials will obtain a list of people with whom he or she has come into contact (i.e. “contact tracing”). Those individuals will be contacted directly and screened and/or quarantined as necessary. For this Texas case, individuals are having their temperatures taken twice daily and quarantine has not yet been initiated. If people know they will be restricted, they may not show up. Approaches that maximize liberty until more information is known help preserve individual rights while forwarding public health aims.

    This is a better approach than publicly stating who the patient is, which could cause stigmatization for family and friends—suddenly ostracized by their communities. Actually, that’s a best-case scenario. The more likely scenario is a mob “going after” them, severely injuring these individuals physically and psychologically.

11. Some scholars have suggested relaxing research standards to try experimental vaccines and treatments on people with the infection. Unless the drug in question has completed a Phase 2 trial (meaning it has been checked for efficacy and safety), I would argue against using such interventions. The chances of causing additional suffering through unknown and perhaps dangerous side effects outweigh the potential hope for the miracle of a benefit. The indiscriminate use of research compounds also means that any examples of people surviving Ebola cannot be attributed to the drug. Three people received experimental doses of ZMapp. Two lived. Is that because the compound work or because the people received supportive care in a high tech medical environment? We’ll never be able to know because there was no clinical trial and the use was haphazard. There is no more of this drug either. Dr. Blumenthal-Barby discusses this issue well in her blog post.
12. To quote Douglas Adams, “Don’t Panic.” Panic and fear are the worst parts of any crisis. This single case is no reason for alarm or even concern. If the CDC hasn’t contacted you by now then you are not at any risk at all.