Posted on January 29, 2016 at 9:54 AM
The World Health Organization will hold an emergency committee meeting on the pandemic reemergence of Zika virus and the explosive increase in reported cases of congenital microcephaly in Brazil possibly linked to Zika on February 1. The virus is a mosquito-borne infection in the same family as West Nile and dengue. Until 2015, Zika had rarely appeared in the Western hemisphere. The WHO will decide whether the pandemic should be considered a public health emergency of international concern. Hastings Center Fellow Lawrence Gostin and Daniel Lucey suggested that “the very process of convening the committee [will] catalyze international attention, funding, and research.”
Much of the fear and uncertainty around Zika stems from a suspected association between pregnant women infected with Zika and risk of their babies being born with microcephaly, a birth defect characterized by an abnormally small head and brain damage. But much remains unknown about transmission and diagnosis. Christian Pettker, chief of obstetrics at the Yale School of Medicine, wrote in The New York Times, “Fear of these unknowns explains the severity of some of the responses from the medical community,” like telling women in areas with active Zika transmission to avoid pregnancy.
In a December 2015 article in the South African Medical Journal, Solomon Benatar, a bioethicist at the University of Cape Town and a Hastings Center Fellow, reviewed the ethical challenges presented by the 2014-2015 Ebola outbreaks in West Africa and offered lessons for future public health emergencies. Benatar’s account of the “interpersonal, public health and global” levels of ethical challenges offers a helpful framework for understanding what is at stake in the Zika pandemic and concerning other zoonotic (animal to human) diseases.
Interpersonal professional ethics demand engaging with questions about where and how experimental Zika vaccines will be developed, tested, and deployed. The Brazilian government and the National Institute of Allergy and Infectious Disease (NIAID) in the US have begun directing funds toward developing a vaccine. Zika vaccine candidates and public health interventions aim to benefit countries in the global south, where the virus is currently spreading. It seems to make sense to test drugs on consenting research participants in afflicted areas within this region. However, clinical research participants from middle- and low-income countries can be vulnerable to exploitation.
Notorious examples of this include the unethical placebo controls in AZT trials in Africa aimed at preventing mother-to-child transmission of HIV. Similarly, particular communities in Central and South America may recall being medically experimented on as part of research efforts supported by the US, e.g. the Guatemalan syphilis study and the Norplant study in Brazil. Hastings Center Fellow Ezekiel Emanuel et al have suggested that clinical research in middle- and low-income countries has historically created a greater risk of exploitation: “individuals or communities in developing countries assume the risks of research, but most of the benefits may accrue to people in developed countries.”
However, experts estimate that a Zika vaccine is possibly 3 to 10 years away. Right now health advisories from particular countries in Central and South America include aggressive mosquito control, travel postponement for pregnant women – and even that women delay their pregnancies. Monica Roa, programs director of Women’s Link Worldwide, an organization devoted to the human rights of women and girls, said on NPR that this last recommendation as “naïve and ineffective.”
As Benatar suggests, the field of public health ethics is not fully developed yet, but it asks questions related to the role of national governments, trust in those governments, and the strength and preparedness of local health systems. What additional responsibilities fall upon affected states – some of which, like Ecuador, limit access to contraception and ban abortion – to supplement these recommendations with informative public health campaigns? What additional responsibilities fall upon states to shore up the preparedness of health systems that might have to care for babies born with microcephaly and their families?
A WIRED article points out that elective abortion is illegal in Brazil, where increases in the Zika infection and congenital microcephaly have been most pronounced. Abortion is only permitted in Brazil to terminate a pregnancy resulting from rape, to save a pregnant woman’s life, or to prevent anencephaly or other malformations “incompatible with extrauterine life.” Roa suggests, “In the countries where the law doesn’t allow for [abortion], I think the debate [about reproductive rights] should be on the table and discussed in the context [of Zika virus infections].”
While public health ethics allows us to examine possible future directions for the responsible management of this pandemic, global health ethics asks, “How did we get here? What social and economic imbalances of power led to this outcome?”
Along these lines, Amy Vittor, an assistant professor in medicine at the University of Florida’s Emerging Pathogens Institute, wrote in The New York Times, “Indeed, the outbreak is a symptom of a larger problem that has gone unaddressed for the world’s poor. Lack of running water and waste management, in conjunction with urban crowding and poor housing, has given rise to the perfect set of conditions for the transmission of such mosquito-borne viruses. Mosquito control measures and heightened surveillance are absolutely critical in the immediate response, but to address the underlying conditions that give rise to epidemics such as Zika, we must address urban poverty.”