Ethically Sound: Ethics and Ebola

Host:

As healthcare workers returned home in 2014 and 2015 from fighting the Ebola epidemic in western Africa, actions by state governments to prevent potential spread of the disease ran the gamut—from mandatory monitoring to travel bans and quarantine. These measures raised the question: Is the nation prepared to ethically respond to public health emergencies? 

Welcome to Ethically Sound: A podcast of the Presidential Commission for the Study of Bioethical Issues. I’m Hillary Wicai Viers.  Today, we’re talking to Dr. Barbara Atkinson, a member of the Bioethics Commission and Founding Dean of University of Nevada Las Vegas School of Medicine. But first, let’s hear from Dr. Patricia Henwood, President & Co-Founder of the PURE Initiative. 

Dr. Henwood:

I treated more than 100 Ebola patients while working in Liberia.   I quietly cried in my face mask and goggles while holding the hand of a child as they took their last breath, in the same treatment unit where their parents and siblings died…one by one…over the previous week.  Often touted as heroes while working in West Africa, at times myself and many of my colleagues felt like pariahs once we were back in the United States. 

Navigating the vague and varied restrictions put in place by local public health agencies, at times it felt more challenging to coordinate my return home than to actually do the Ebola-related work in Liberia.  What did the words ‘prolonged periods,’ mean?   Did the requirement to avoid ‘congregate gatherings’ include a grocery store? Or my office?  Though asymptomatic, I chose to spend time with only a few people during my 21-day monitoring. This was not driven by fear of making my friends, family and colleagues sick, but rather my concern that my siblings, nieces or parents would be sent home, from work or from school, because they were visiting with me.  Faced with the potential employment and personal burdens imposed by unnecessary quarantines and movement restrictions, healthcare workers are less able to fight outbreaks like Ebola at their source. That only serves to hamper our collective efforts to control the spread of epidemics, and to help save lives, at home and abroad.

Host:

That was Dr. Patricia Henwood, President & Co-Founder of the PURE Initiative, which examines the use of point-of-care ultrasounds in resource-limited environments. 

The Ebola epidemic that spread through three countries in western Africa in 2014 was the worst on record, claiming more than 10,000 lives. As the crisis deepened, public anxiety and demand for action mounted around the world. Like Dr. Henwood, health care workers from the US and other countries travelled to the affected regions to set up clinics and train local providers. Scientists furiously began to work on a vaccine. When the first case of Ebola was diagnosed in the United States, [state] governments began implementing measures to protect the health of the public, instituting travel bans and quarantining health care workers returning from fighting the Ebola epidemic. In some cases, these movement restrictions were not scientifically grounded—consequently, some of proposed and enacted state quarantine policies were ineffective and overly restrictive. Fear of infection led to discrimination, with people in America who had ties to the affected countries being told to ‘take yourself back to Africa with your Ebola virus.’  The response to the Ebola outbreak demonstrated the need for integrating ethics into preparedness planning before the next epidemic. In February 2015, the Bioethics Commission released Ethics and Ebola: Public Health Planning and Response, in which it clearly stated that the U.S. has an ethical responsibility to prepare for and respond to global public health emergencies. The Commission urged policy makers and public health officials to integrate ethics into decisions made in response to rapidly unfolding epidemics. Specifically, it called on governments and public health organizations to use the least restrictive measures on personal liberties necessary—on the basis of the best available scientific evidence. It also included recommendations aimed at mitigating the stigmatization and discrimination associated with public health emergencies. 

You can download Ethics and Ebola: Public Health Planning and Response, and all the Commission’s reports at bioethics.gov.

Here today to talk about the Ethics and Ebola report is Bioethics Commission Member and Founding Dean of University of Nevada Las Vegas School of Medicine, Dr. Barbara Atkinson.

Dr. Atkinson, welcome to Ethically Sound. 

Dr. Atkinson:

Thank you, I’m happy to be here. 

Host:

The Bioethics Commission heard from U.S. health care workers who, when they returned from fighting the Ebola epidemic in Western Africa, were placed under quarantine, travel bans, and other restrictions. As you deliberated restrictive public health measures, what were some of the factors that you and fellow Commission members considered? 

Dr. Atkinson:

You can ethically restrict people, quarantine them for instance if there’s a potential harm to others. But, you have some duties, if that’s the case. So, there are a variety of factors to look at, but you want to be sure to just use the least restrictive measure and to be sure that there’s scientific evidence to show that it’s necessary, and really, the take home from the Ebola epidemic was that there was no evidence that if a person was asymptomatic that there was any reason to restrict them. The virus isn’t spread until after symptoms occur. [For] other viruses, that might not be the case, or other bacteria, that might not be the case, but in this one it was well-known.

What happened seemed to be that the people who were making the decisions at a state level were really responding to the fear of the public. They really weren’t responding to the scientific facts of the matter. The public was very, very worried about the lethal nature of this virus and so, they responded in a political way which was to segregate people. And one of the nurses that we discussed actually was put in a tent at the Newark airport for a few days, and then she was going back home to Maine, and the Maine governor quarantined her for 21 days. Totally unnecessary on both fronts.

Not that you don’t want to be careful, but what happens when you do things like that is it causes other people to decide they don’t want to be a nurse that goes and takes care of people who have Ebola, because they would then know not only would they be away from their families during the time when they’re actually treating patients, but they would have another three weeks of quarantine after that. So, there are a variety of factors that have to be considered and this was not one that was handled particularly well. 

Host:

What role did lessons from the history of epidemics, such as the HIV/AIDS pandemic, play in influencing the Bioethics Commission’s analysis and recommendations? 

Dr. Atkinson:

So, we actually did consider other epidemics and what happened with them. One of the things with the HIV/AIDS epidemic was that there was a travel and immigration ban that was placed on anybody coming into the United States who was known to have HIV or AIDS. Once a regulation like that gets put in place, it takes a long time to get it removed, and that ban wasn’t lifted until 2010 which was long after there was good treatment for HIV/AIDS. So, one of the things, again, it was fear that really caused people to decide to do a ban like that, but there was no reason to think that a travel ban actually does anything to prevent disease spread.

TB is another one that’s been a long-time issue in the United States. There used to be TB sanitariums where people went to try to recover. Part of it was the recovery, but part of it was keeping the people away from others. Now, people can’t be guaranteed to protect their families and the general public can be quarantined, but in general, there’s good treatment for TB. You just have to convince the patient to actually take the antibiotics that are necessary. So, in general, it’s rarely used as a quarantine. But it just demonstrates the fear factor in all of the epidemics, and I think we’re seeing a little of that now as we actually are dealing with the Zika virus. That’s the newest one to come along. It’s not lethal in the same way that the others have been, but it’s lethal to fetuses in some cases. And so people are still trying to understand the science of Zika, but I think this report is very good as a road map for how to handle the communications and the response to this virus as well. 

Host:

How did your background as a doctor influence your thinking on this issue? 

Dr. Atkinson:

I think it really made me go back to the scientific basis of the illnesses. You know, every one of these epidemics is very different; the way it’s transmitted is different, the outcome is different. And whatever the public health response is, it has to first deal with the real facts of the issue. And that didn’t happen well. Sometimes it doesn’t happen well because the facts aren’t known at the time of the start of an epidemic, but once they’re known then the remedies have to match the facts. And Ebola had actually been around for quite a long time in Africa. There had been other epidemics that had been cured basically in other countries. So, people did know how it was transmitted and that it’s only transmitted by touching fluids that come from a patient who’s actively infected.

It just was very frustrating as a physician that there wasn’t better information coming out that really would communicate the risk or the lack of the risk. There were surveys done that showed that the public was very worried about it and were actually worried that their families might actually get Ebola, and the chances of that, scientifically, were miniscule. And I just hope that with new epidemics as it goes forward, that we get better communication right at the beginning and that it’s more continuous and that then we can convince people to believe it. Because I think that’s always the hard part is you can communicate, but if people aren’t listening, it’s difficult. 

Host:

You’ve already touched on Zika, but how can the Bioethics Commission’s report be used to inform the response to current and future public health emergencies? 

Dr. Atkinson:

I think it lays out the real ethical pieces that need to be considered. It lays out communication, communication, communication first. Then, the scientific basis for the epidemic and then the ethical issues to be considered. And those really are the harm principle, the principle of least infringement, the principle of beneficence and non-malfeasance, reciprocity, and justice and fairness. And if you really look at the definitions of each of those, and you think about how it can be related to what needs to be done in any particular epidemic, then I think you have the framework for how to go about handling it.

It’s important to think about the ethical issues really before an epidemic happens, and it’s really a global issue at this point, too, that if we know that there’s an epidemic starting somewhere in the world, it’s time to start finding a vaccine for it the minute we know it first is occurring. And that didn’t happen with Ebola. Ebola, as I said, had been around quite a while and we hadn’t really begun working on a vaccine for it until recently, and now luckily there’s vaccines and trials for both Ebola and Zika. Zika was one that did get started early. But the planning for how to communicate it and for what to do to protect the public has to start really at the very first sign of any new epidemic. And I think that’s starting to happen better than it used to. 

Host:

Dr. Atkinson, thanks for being with us today. It was a pleasure. 

Dr. Atkinson:

Thank you. 

Host:

You’ve been listening to Ethically Sound: A podcast of the Presidential Commission for the Study of Bioethical Issues. Thank you for joining us. You can check out our full series online at bioethics.gov.