Why do two white Americans get the Ebola serum while hundreds of Africans die?
The ethics of drug distribution.

By Arthur L. Caplan August 6
^{Arthur L. Caplan is the director of the Division of Medical Ethics at NYU Langone Medical Center’s Department of Population Health.}


[img]http://www.washingtonpost.com/wp-apps/imrs.php?src=http://img.washingtonpost.com/rf/image_908w/2010-2019/WashingtonPost/2014/08/05/Foreign/Images/Ebola_Americans-00461.jpg&w=480[/img]
^{Nancy Writebol in Liberia, where she contracted Ebola before being brought to an Atlanta hospital. (AP Photo/Courtesy Jeremy Writebol)}

What should happen if a massive viral outbreak appears out of nowhere and the only possible treatment is an untested drug? And who should receive it? The two American missionaries who contracted the almost-always-fatal virus in West Africa were given access to an experimental drug cocktail called ZMapp. It consists of immune-boosting monoclonal antibodies that were extracted from mice exposed to bits of Ebola DNA. Now in isolation at an Atlanta hospital, they appear to be doing well.

It’s an opportunity the 900 Africans who’ve died so far never had. Is there a case to suspend ethical norms if lives might be saved by deploying an experimental drug?

The reasons for different treatment are partly about logistics, partly about economics and, partly about a lack of any standard policy for giving out untested drugs in emergencies. Before this outbreak, ZMapp had only been tested on monkeys. Mapp, the tiny, San Diego based pharmaceutical company that makes the drug stated two years ago: “When administered one hour after infection [with Ebola], all animals survived…Two-thirds of the animals were protected even when the treatment, known as Zmapp, was administered 48 hours after infection.”

But privileged humans were always going to be the first ones to try it. ZMapp requires a lot of refrigeration and careful handling, plus close monitoring by experienced doctors and scientists—better to try it at a big urban hospital than in rural West Africa, where no such infrastructure exists.

And because of the drug’s experimental nature, it’s unclear that it should go to anyone else. Even if the drug is cooled correctly, success in a few monkeys (less than 20) tells us little about what will happen in a lot of humans who’d had the infection for more than two days. No one knows how much drug to give, how often, what other pre-existing medical conditions might influence its efficacy or even what route is best, be it IV, pill, syrup, or even surgically right into the liver. With an untested drug, there is always a chance you will kill the first human subject who might otherwise have lived. And the two Americans who got it in Africa had been infected for more than a week, making its efficacy completely unknown. Still, because they are a small group in such a carefully controlled setting, they are better candidates for the drug than others might be.

But it’s about more than logistics. Drugs based on monoclonal antibodies usually cost a lot—at least tens of thousands of dollars. This is obviously far more than poor people in poor nations can afford to pay; and a tiny company won’t enthusiastically give away its small supply of drug for free. It is likely that if they were going to donate drugs, it would be to people who would command a lot of press attention and, thus, investors and government money for further research—which is to say, not to poor Liberians, Nigerians or Guineans.


The medical missionaries got the experimental drug because the evangelical Christian International Relief organization they work for, Samaritan’s Purse, reached out to the CDC and the NIH to find out if there was any drug to give to them. They were referred to Mapp Pharmaceuticals and evidently struck some kind of deal to get the drug to their employees who were in Africa at the time. (Technically, African health ministries could make a similar request.) The FDA has little oversight over what goes on abroad, and the federal government has no program to consider appeals for use—much less payment—of experimental drugs that have only been tried on animals. Without an organization pushing, no one might have received access to any sort of treatment. The chance of a poor African getting an experimental drug is about the same as Donald Trump contracting Ebola (which is apparently his greatest current fear).

Even if logistical and economic obstacles could be surmounted, is there a case for giving Zmapp to Africans still dying from Ebola? Many Africans were infected more recently than the Americans now being treated in Atlanta, so they better fit the conditions in which the drug was tried in the monkey lab.

But there is no accepted set of rules for a sick person to request compassionate access to drug that is experimental, expensive, and in short supply. And access to experimental drugs remains a long shot full of risk. While the American Ebola patients gave their consent, and while most people would want to do something rather than nothing, the decision about gaining access is more in the hands of the drug manufacturer than the would-be subject. The dying may feel more cavalier about entering a drug experiment—the rewards (life) could justify the risks (since death approaches anyway)—but a company may still withhold a drug from a willing volunteer for fear that it will fail and reduce investor interest or increase attention from malpractice attorneys.

An ethical case can surely be made for an organization that puts health-care workers in harm’s way to acquire access to experimental drugs and bring staff home to get the best possible care. But that is neither a fair nor just policy for deciding what to do when an emergency arises and rationing is the only option. This Ebola outbreak has taught us two things: that we need to act quickly to shut down emerging epidemics wherever they occur, and it is long past time to have a transparent public policy about what to do when not everyone gets a chance to live.

hushmail: all dis long grammar to what end??

Abeg money z not a problem when lives r at stake

they shld release d drug first later then discuss d economics of it

azpekuliar: Well the world is only 50 WHITE victims away from an Ebola cure, so hang in there fellow Africans...

MissMeiya:
Pretty much.

jpphilips: Let me give you my opinion as succinct as possible, the article is creating a picture of western hegemony over Africans, I don't buy into that, except the writer is trying to create some kinda sensationalism in the article.

What I can deduce from the events of 2nd August is a true picture of the failure of African leadership, please leave America out of it.
The Ebola virus was discovered in 1976 close to the Ebola river in west Africa, between 1976 to 2014, which is the unfortunate year for the last outbreak, the world has witnessed 25 outbreaks of this deadly virus, within which all the west African countries including south Africa have had a fare share of loses, my question is this; WHY IS IT ONLY THE USA LOOKING FOR A CURE?

All the cases of Ebola in the united states were all animals imported from the Philippines that were affected, Overall, Ebola has not directly killed a United states citizen on American soil. why is it the Americans that are the fore front of finding a cure? why not Africans who are worst hit?

Are Africans really poor?

I don't think so, Nigeria as at 2014, with the biggest GDP in Africa rivals one fifth of the Euro zone economy, home to the richest black man in the world to the tune of $25b, now this will shock you! Bill and Mellisa foundation that happens to be the conduit for funding research for infectious diseases in Africa through charity, was actually started with $94m, this amount has grown over the years due to successes the organization has achieved.

The Zmapp trial drug was developed from a grant of $25m, is it what African countries cannot afford? is it anywhere near the billions they loot on a daily basis?

Is that what Nigerian billionaires and Govt cannot afford? the South African Oppenheimer family was worth over $9b the last time I checked, I ask again, why is it only the USA that is interested in finding a cure to a disease that does not directly affect them?

Most African countries are laden with natural resources are they giving it to America free? Nigerian Brent crude, South African gold and Zaire copper stand today as the most priced raw materials on the international market, why would America give us the Ebola Serum free?

I have heard comments from people in Liberia and Nigeria accusing the sans frontier as the people who gave them the virus, same people who are risking their lives to save theirs (most of them have been mobbed in the past).
Africans don't deserve a penny nor good will from anyone, the black man by their actions have proved to be the most ungrateful fvctards ever lived.

Africans want the Ebola serum, but they cannot fund the research, Isn't that wishful thinking?



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