Battling Ebola: Challenges, Ethical Dilemmas

Professor Ron Waldman answers questions about the “international public health emergency.”

Healthcare workers are struggling to fight the Ebola outbreak in West Africa. (Photo courtesy of the European Commission’s Humanitarian Aid and Civil Protection Department)
August 27, 2014

By Lauren Ingeno

The deadliest Ebola outbreak in history continues to spread across West Africa, killing more than 1,400 people and infecting at least 2,600 since March. The World Health Organization (WHO) has declared the virus epidemic an “international public health emergency.”

The global health community faces daunting economic, ethical and political challenges as it attempts to control the outbreak. Aid organizations struggle to find adequate health care personnel. Some want wider distribution of the unproven drug ZMapp, even though its effects remain unclear. A lack of adequate public health infrastructure heightens the problem.

Dr. Ron Waldman

Ron Waldman, a physician and professor in the Milken Institute School of Public Health’s Department of Global Health, worked for the Centers for Disease Control and Prevention for more than 20 years. An expert in infectious disease, he has coordinated emergency relief efforts in countries around the world.

George Washington Today sat down with Dr. Waldman to learn more about the global response to the Ebola outbreak and the implications of the crisis.  

Q: Have organizations like the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) responded to the Ebola outbreak in an effective and timely manner?
A: No, they did not respond in a timely matter at all. Doctors Without Borders, an organization that did respond rapidly, issued a statement in June, saying the outbreak was “out of control.” Its teams were exhausted and had no more people to send to the field. More than a month later, the World Health Organization launched a deployment plan and requested additional funding on July 31. It declared an international public health emergency on Aug. 8.

Q: Why was there such a slow response?
A: WHO is faced with many issues that it believes warrant emergency action. WHO was also looking at the history of prior Ebola outbreaks in which the virus was contained quite early. There was no way for these organizations to suspect that this outbreak would eventually reach this magnitude. Organizations are now trying to step up the pace, but they are struggling to find adequate numbers of health care personnel.

Q: What is contributing to the shortage of health care personnel?
A: One reason is that there are people who are uncertain about the situation. They have questions regarding evacuation procedures, personal protections or opportunities to receive adequate care should they become infected. Secondly, it is a really difficult time in the world, and there has been an incredible pull on the humanitarian community to deal with other situations.

Q: Is the inadequate response to the Ebola outbreak indicative of a greater problem? Does there need to be a greater global effort to respond to these types of crises?
A: Yes, it is indicative of a failure of the international community to address occurrences like this in a punctual and effective manner. No single organization is going to have the ability to respond to an urgent crisis in as rapid a fashion as this requires. The kind of response that is needed requires a level of cooperation and coordination that appears to be elusive.

But we also seem to be more concerned with responding to emergencies rather than strengthening the local systems prior to their occurrence. The most glaring defect that’s been exposed by this Ebola outbreak is the appalling weakness of the health systems in the countries where the virus is circulating. I think there needs to be a serious look at what’s happened, and why we’re leaving countries with health systems that are inadequate, understaffed, under-resourced and under-financed.

Q: How much longer will Ebola remain a danger?
A: It’s going to be very difficult to get a handle on this outbreak. I think that everybody feels that we won’t see the end of it during this calendar year.

Ebola doesn’t represent a huge threat to countries where the public health systems are strong. It represents a major threat to those countries where the public health infrastructure is weakest and most fragile. Ebola is not the only disease that is affecting people in these areas. Most people in these countries will continue to die from pneumonia, malaria, diarrhea and other common diseases. They won’t get treatment for those things now, because either clinics have closed in fear of Ebola or health care personnel are caught up dealing with the emergency.

Q: In West Africa, people’s distrust of health workers seems to be heightening the crisis. Why are some of these communities resistant to aid?
A: Let’s not forget the recent history of Sierra Leone and Liberia, countries in which the populations suffered brutal, unthinkable atrocities at the hands of those who had the reins of government. One can understand why people would be very reluctant to cooperate fully with the authorities, either local or foreign. There has been a lot of mistrust, and there has been inadequate communication between authorities and the population.

Q: What about the experimental ZMapp treatment? Was it ethical to use an untested drug on a select number of patients?
A: Yes, I believe that it was ethical. WHO convened a panel of experts who discussed the ethics of providing experimental treatments in situations like this, and they concluded that it would be ethical to use an unproven drug.

However, it would be better, I think, to be able to use the drug in a situation where one could learn the most about its effectiveness and its potential adverse effects. This way, it might be made available to more people more safely. We should try to find the best circumstances under which both “compassionate use” and “randomized clinical trial” conditions could be satisfied.

Q: What is your biggest fear regarding the near-term future of this outbreak?
A:  I think we should all be concerned about the possible spread of the disease to large urban areas, both within the three countries currently affected and in places like Senegal and Nigeria. It would be quite difficult to implement vital public health measures like contact tracing and quarantine in places like Lagos, for example. Panic, economic disaster and a breakdown of law and order could ensue. We need to get on top of the situation as soon as possible, and I hope it is not too late.