Ethics of fighting Ebola

I can't think of too many people better qualified to break down the ethics of fighting Ebola than Peter Singer.

In this respect, Ebola is – or, rather, was – an example of what is sometimes referred to as the 90/10 rule: 90% of medical research is directed toward illnesses that comprise only 10% of the global burden of disease. The world has known about the deadly nature of the Ebola virus since 1976; but, because its victims were poor, pharmaceutical companies had no incentive to develop a vaccine. Indeed, pharmaceutical companies could expect to earn more from a cure for male baldness.

Government research funds in affluent countries are also disproportionately targeted toward the diseases that kill these countries’ citizens, rather than toward diseases like malaria and diarrhea that are responsible for much greater loss of life.

The most accurate way to judge the efficacy of a vaccine is through a double blind trial. One group of patients suffering from the malady are given the potential vaccine, the other set a placebo, and neither the doctors nor patients know who received what. When dealing with a shortage of vaccines and a disease as deadly as Ebola, the usual rules may not apply. That may be okay.

But, when facing a disease that kills up to 70% of those who are infected, and no accepted treatment yet exists, patients could reasonably refuse consent to a trial in which they might receive a placebo, rather than an experimental treatment that offers some hope of recovery. In such cases, it might be more ethical to monitor carefully the outcomes of different treatment centers now, before experimental treatments become available, and then compare these outcomes with those achieved by the same centers after experimental treatments are introduced. Unlike in a randomized trial, no one would receive a placebo, and it should still be possible to detect which treatments are effective.

Cultural filters

Facely Camara, a young radio journalist, was eager to fight Ebola in his native Guinea. In mid-September, Camara joined a convoy of health workers and government officials heading to Womé, a village in Guinea’s densely forested southeast, where he intended to cover an Ebola-centered education and disinfection campaign for Zaly FM, a popular station. Before he left, his friends and relatives applauded him on Facebook: “A super Mr. Journalist,” they called him. “The future of the family.”

By the time the group returned, many of its original participants, including Camara and two other radio reporters, were corpses in the back of a rescue truck. They were killed not by Ebola but by a hostile mob reportedly suspicious of the government’s public-health interventions in Womé, and of its actions in the region generally. All three murdered journalists were trainees at Search for Common Ground, a conflict-resolution nonprofit that has worked in Guinea, Sierra Leone, and Liberia for more than fifteen years. Aly Badara, who helps to coördinate S.C.G.’s Guinea efforts from the city of Nzerekore, told me by phone that “when the group arrived and started talking about Ebola, they were hit with sticks and stones.” Several of the victims—there were at least eight—had their throats slit with machetes, and were then stuffed into the village school’s septic tank. As Badara explained, the attacks were borne of distrust rooted in years of conflict and exclusion, both real and perceived: “In that part of Guinea, there is no faith between those people and their government.”

The mass killing in Womé presaged a concern that the Ebola outbreak is evolving from a public-health crisis into “a crisis for international peace and security,” as the World Health Organization’s director general, Margaret Chan, called it last month, from Geneva. This past spring, as Ebola spread across the region, S.C.G., which operates on four continents, began generating its own inventive community-by-community responses to the virus, to better tailor communications to local fears, strengths, and histories. The core of their approach has been to recruit not only standard public-health actors but also small-town preachers and soap-opera stars, taxi-drivers and town criers, local reporters and cameramen. What would it look like, they’ve asked, to fight Ebola with culture makers?

Sarah Stillman reports on efforts in Africa to disseminate critical information about Ebola through cultural, rather than governmental, channels, like embedding such information in popular music lyrics. When people have a historical distrust of government, alternative means of distribution of public health care information are needed.

I was tempted to hold up the U.S. as an example of a place where people are more receptive to logic, but then I thought of the anti-vaxxers and anti-GMO movement and remembered that we're all crazy.

The psychology of charitable donations

One of the better Planet Money episodes in recent memory: Why Raising Money for Ebola is Hard. Doctors Without Borders in Africa is overwhelmed with the latest outbreak. Donations would help, but they are at a trickle.

As Atul Gawande and many others have noted, containing Ebola in its current form is actually quite straightforward.

This relatively weak transmissibility makes the standard public-health technique of contact-tracing effective in halting the disease. Track down the people who’ve been in contact with a sick patient; measure their temperatures and check on them daily for twenty-one days; if any turn up with a fever or looking sick, put them into isolation. Once you get anywhere upward of seventy per cent of the contacts under such surveillance, the disease stops spreading.

Thiss podcast dissecting why so few people donate to help fight Ebola helps to unpack the donor psychology behind fundraising for disasters:

• The Planet Money episode notes that 90% of donations for disaster relief occur within 90 days of the disaster. But that's contingent on the disaster being sudden, massive, and prominent in a short period of time. Sudden and dramatic disasters, like 9/11 or the Haiti earthquake, are ideal for spurring a massive influx of donations. But a disease that starts with one person and spreads slowly like Ebola can't concentrate world attention the same way, no matter how many people it spreads to over time. The bitter irony is that when this round of Ebola first broke out, donations would have had the greatest leverage because the disease could've been isolated contained much more easily then.

• People react to visible evidence of severity. Slow building disasters like Ebola lull people into complacency. People have a finite store of charity, and Ebola hasn't generated any iconic horrific imagery to push donors over their emotional tipping point.

• People don't understand exponential math that well. This outbreak of Ebola may have an R0 or “R-nought” of 1 or even as high as 2. That means it could spread at an accelerating rate. “Should the outbreak continue with recent trends, the case burden could gain an additional 77,181 to 277,124 cases by the end of 2014.” That's still not as intuitive to most people as the tens of thousands of people who died in Haiti the first day of the earthquake.

• People don't like to contribute to preventative measures, they want their money to make things better immediately. For example, as noted in the podcast, it's almost impossible to raise money to head off a famine that everyone can see coming. People won't donate until people are actually starving.

• Africa is far away from America and many other first-world countries. Disasters close to home draw more donations. Out of sight, out of mind. I suspect most Americans don't personally know anyone who has been killed by Ebola.

• Given the irrational lumpiness of charitable donations for disasters noted above, when massive galvanizing disasters do occur, we should capitalize on the spike in charity and allow the organizations on the receiving end of that aid the freedom to hold back some of the funds to allocate to future disasters. Charities would operate more like insurance, or an endowment. The Red Cross tried this after 9/11, but donors erupted in outrage and the head of the Red Cross had to resign.

Not to be glib, but it almost feels like Ebola could benefit from a staged dramatic event to serve as a catalyst to mobilize world sympathy. Or Ebola needs its version of the Ice Bucket challenge, a meme which spurred a vast outpouring of donations for ALS without any precipitating disaster. 

Wisdom of the crowds doesn't seem to apply when it comes to allocation of charitable donations.

GiveWell doesn't have any article about the most worth charities combatting Ebola, but Vox linked to a list from the U.S. Agency for International Development. Among the list is Doctors Without Borders/Medecins Sans Frontieres (MSF), and they've posted a page on their efforts to combat Ebola. That's my choice. GiveWell says of MSF: “We have a positive view of MSF and have recommended them for disaster-relief donations in the past.”