key: cord-0037579-m6bwfubs
authors: Ambe, J. Radeino; Kombe, Francis K.
title: Context and Ethical Challenges During the Ebola Outbreak in West Africa
date: 2019-03-20
journal: Socio-cultural Dimensions of Emerging Infectious Diseases in Africa
DOI: 10.1007/978-3-030-17474-3_14
sha: 57fd1211784d9f2fdd81df1fee36ef19449b1bd2
doc_id: 37579
cord_uid: m6bwfubs

The philosophical discipline of ethics examines good, bad, right, wrong and how people live as individuals within a community. Bioethics investigates research in healthcare and medicine, examining public policy as it relates to healthcare and how resources are allocated. This includes: difficult, private, individual decisions, which occur in clinical settings; dilemmas during clinical trials; and controversies surrounding novel research. It is important to understand that ethical considerations related to health care ethics and those that pertain to public health are often seen from different perspectives. In public health, decisions are made within a context and a framework through principles which guide action that affect communities and populations. These decisions and actions are made with and involve, stakeholders to include: traditional, community and religious leaders; government officials; and private and commercial stake holders. The underlying principles of both public health ethics and bioethics are the same, namely equality, justice, beneficence, non-maleficence, veracity and fidelity. Health care ethics supports the rights of individuals. Under the same umbrella of health care ethics are medical ethics, clinical ethics and research ethics. These disciplines offer views that support the rights of individuals. Ethics in public health is very complex with a myriad of issues to include diverse groups of people in different situations, which have to be taken into account from the view of what is best for the population. Evaluating the components of a public health system, how resources are developed and the economic support available to communities is crucial. Access to care and the equitable and just allocation of resources are important factors; and questions about equal access for the poor, the socially disadvantaged and immigrants should be examined.

Public health ethics is seen from the view of communities and populations. The ethical considerations related to forced quarantine impinges on the rights of individuals to protect the wellbeing of the greater public, in an effort to curb an epidemic, a pandemic or to ensure that neither starts. In these situations, ethical conflicts are bound to occur because public health and the safety of the community often trumps individual rights. This chapter will examine the ethical questions pertaining to public health ethics that arose from the Ebola outbreak of 2014/2015. During the outbreak, it is said that the United States of America went through extraordinary lengths to give two tow of it citizens, experimental drugs, outfit a plane with an incubation pod and monitors; airlift them out of the "red zone" to a special, ward at Emory University hospital which houses the most sophisticated infectious disease unit in the United States. Many people were outraged that the individual rights of these two citizens appeared to be more important than that of the public. The fear of Ebola Virus Disease spreading in the country turned to hate mail hurled at doctors at Emory. (Usborne 2014) . The practice of forced quarantine will be a focus of the discussions as the risks of emerging and re-emerging infectious diseases increase with modern travel that transports people, to different continents within a few hours via airplanes, ships and trains that cross borders at exceedingly increasing speeds. With this "speed travel" comes the speed of rapid transport of communicable, infectious diseases, bio-hazards and toxic, biological agents; across borders. In the United States of America, rules and regulations that govern the use of quarantine are in place to safeguard the public against the transmission of infectious diseases to the general public.

This chapter attempts to explain differences between medical and public ethics, using quarantine, as an example. It also explains the differences between quarantine and isolation. There are existing laws, regulations, as well as, ethical considerations that affect health practice and practitioners when a forced quarantine occurs. Examples from the countries around the world are used for discussion purposes in an effort to express a global experience and to outline historical perspective.

Historically, international law played a key role in global communicable disease by providing guidelines for the control of diseases as well as playing a major role in the surveillance of global communicable diseases. During the nineteenth century, in lieu of a world global health body which could harmonize the different laws within European nations, international law dominated the field. There were inconsistent regulations on quarantine until the exchange of information and the establishment of international health organizations (Aginam 2002) . Communicable diseases shape global health since pandemics and epidemics know no borders. International law has been of importance since it reduces cross-border vulnerability to these diseases.

In 1377, the first known record of modern day quarantine was introduced in Dubrovnik, on Croatia. In 1424, the first lazeretto was opened in Venice because of the Plague. It was on the island of Santa Maria di Nazareth. In 1467, the system in Venice was adopted by Genoa (Tognotti 2013) . The origin of the word "quarantine" is said to be from Venetian Italian and a variant of the term "quaranta giorni" which was used as a designated period of 40 days that ships were isolated before crew and passengers could come ashore during the Plague and Black Death (CDC n.d.) . Quarantine is government enforced and can apply to humans, animals and can be used at borders or within countries. Clearly, this is the historical perspective of quarantine from a global north perspective. Isolation is when a sick person is kept separate from others. This differs from quarantine where people who have been exposed but are not ill, are separated from the general public.

On July 20th 2017, a Liberian national, by the name of Patrick Sawyer, flew to Lagos, the former administrative and current commercial capital of Nigeria from Monrovia with a brief stopover in Lomé in Togo. Although there are no accurate statistics on the population of Lagos, in 2016, the National Population Commission of Nigeria, stated that the population of Lagos was over 21 million. Lagos became the largest city on the continent of Africa, surpassing Cairo back in 2012 (World Population Review n.d.). Patrick Sawyer arrived in Lagos with the intention to proceed to Calabar, Nigeria, for a government conference. Some reports state that he was seeking the healing ministry of one of the Nigerian pastors, in Calabar, because he knew he was sick and possibly had Ebola Virus Disease (EVD). Mr. Sawyer's actions were reported to have been deliberate; as he reportedly evaded health warnings and the health protocols for the spread of infectious disease and lied to the staff at the hospital about not having contact with anyone who had EVD. Patrick Sawyer had nursed his sick sister who was confirmed to have EVD. She later succumbed to the disease. According to Patrick Sawyer's wife, he evaded contact with people at the Monrovia airport. In an interview with Mrs. Sawyer, she stated that her husband travelled to Nigeria because of the better health system. He knew he was ill and wanted to be treated (Mai-Duc 2014). Patrick Sawyer was the index case, (the first known case) of EVD in Nigeria. Professionally, Patrick Sawyer was a lawyer and the National Public Health Officer for Arcelor-Mittal, headquartered in Luxembourg. Patrick Sawyer was a naturalized American citizen with his family residence in the state of Minnesota, although he was consulting for the government of Liberia, at the time (Mai-Duc 2014). Information regarding Mr. Sawyer's education and social status is worthy of note, as it rules out the case of a person who may not know or understand the lethal and highly infectious nature of EVD. Against this backdrop, one can only assume that Patrick Sawyer, as the public health officer knew he was not supposed to travel and therefore should have quarantined himself to avoid exposing others to risk of contracting EVD.

Patrick Sawyer underscored the tension that might arise in balancing selfdetermination and autonomy of individuals and protecting the greater good of the society at large. Considering the social, health and psychological impact the Sawyer case had in Lagos and Nigeria at large, there is no doubt that the potential benefits for self-quarantine would certainly have outweighed by far, the individual rights of Mr. Sawyer. However, the debate on whether or not one should self-quarantine themselves is more complex than what many can imagine. For example, in the event that a person does not self-quarantine, important questions may arise about the ethical considerations for having that person under mandatory quarantine in an effort to protect the public from the spread of an outbreak? In the event that mandatory quarantine is considered, questions may equally arise regarding infringing and violating their individual rights? At face value, these questions and considerations may sound simple, yet too complex to resolve!

On August 20, 2014, the Liberian government, led by President Ellen Johnson-Sirleaf, imposed a 21 day quarantine in an effort to contain the EVD outbreak, on a sprawling area known as West Point. The Liberian government were at a loss as to how to contain the outbreak and the decision to cordon off this community, a week after the government had declared the outbreak a public health emergency, did not go well with the international community. West Point, a lower socio-economic slum of about 800,000 people, came under strict military enforced quarantine after a holding center for suspected Ebola disease victims was ransacked. Seventeen suspected EVD patients escaped; mattresses and infected materials were stolen. The government of Liberia felt the need for barbed wire and wooden checkpoints to go up around West Point. In a Time magazine interview, President Johnson-Sir leaf cited the attack on the holding center as the reason for the quarantine. She further went on to say that the attack "put the entire community at risk, hence the government had to protect them from themselves." (MacDougal 2014). President Johnson-Sirleaf was making reference to the residents of West Point.

West Point residents struggle to eke out a living by trade and barter such as, selling their catch of fish for the day, to people in wealthier neighborhoods. Contrary to international advice, President Johnson Sirleaf, imposed mandatory quarantine enforced by the military. The Liberian government got caught up in the fear and the turmoil of the Ebola epidemic which led to violent clashes. There were many scuffles with the police and West Point residents threw bottles and stones at the authorities, attempting to escape the makeshift checkpoints. Liberian security forces opened fire on the rioting crowd and killed a 15-year-old, Shakie Kamara, 3 wounding two other teenagers in the resulting melee. There was no autopsy performed on Shakie Kamara and the Ministry of Defence forces took possession of his body (MacDougall 2014). The quarantine imposed area was cordoned off for a total of 10 days (Butty 2014 ). On Friday, August 30th, the quarantine was lifted amongst much jubilation.

Thomas Eric Duncan, a 42 year-old man from Liberia, although feeling ill, flew to Texas in the United States. He went to Texas Presbyterian Hospital. After arriving at the hospital and complaining about symptoms, he was given antibiotics and some other medications and released from the hospital. He had no medical insurance. Thomas Duncan vomited on the sidewalk outside his apartment and was again taken to the same hospital. Upon arrival this time, he was admitted. Tests were run and they came back positive for Ebola Virus Disease.

Thomas Duncan's family and the staff of Texas Presbyterian Hospital faced a 21 day quarantine because they had been exposed to Thomas Eric Duncan who came from Liberia with EVD. There was a series of events that led to the fear that not only was Thomas Duncan discriminated against, but also the African community, many of whom had to be quarantined.

Reports suggest that Thomas Duncan was treated unfairly and unfortunately died on October 8, 2014 however, there is no empirical evidence to prove it. According to the Washington Post newspaper, some Ebola patients were rushed to advanced medical facilities contrary to what happened with Thomas Duncan. Duncan's family stated that he did not receive the expected standard of care owing to his lack of medical insurance, his race and poor background. The family stated that they requested for everything that they thought would save his life and a family member asked if he could donate blood, but this request was not heeded by the hospital staff. The hospital made an out of court settlement with the family on the strength that Duncan should have been admitted the first time he was taken to the hospital. (Moyer 2014) . Had Duncan been hospitalized and quarantined appropriately, by staff who were wearing PPE, others would not have been exposed to EVD or infected with EVD and the questions would not have arisen.

The Director of the National Institute of Allergy and Infectious Disease which is part of the National Institutes of Health (NIH), stated that the hospital made a mistake by not admitting Duncan during his first visit. However, he stressed that he did not think that Duncan was treated differently compared to others (referring to allegations of Duncan being black, poor and uninsured (Moyer 2014) . In this case, the ethics pertaining to economic support and the delivery of care would need to be questioned (Kominski 2014) . According to the director, some of the staff who had cared for Thomas Duncan became infected because some of their skin on their necks and face was exposed. They also did not wear shoe covers which made them vulnerable to the deadly infection of Ebola virus disease (Jaffe 2014) . Two nurses, Nina Pham and Amber Vinson, both exposed to Thomas Eric Duncan, tested positive for EVD. The two nurses were just two out of one hundred workers who had contact with Thomas Eric Duncan at Texas Presbyterian Hospital.

On October 17, 2014, a Carnival cruise ship with 4000 passengers headed back to the United States after not allowed to dock in Cozumel, Mexico. This happened because a laboratory technician who handled Thomas Eric Duncan's biological samples was on board the ship. Although the laboratory technician showed no symptoms, she was to self-monitor. After 3 days of the cruise, the lab technician and her husband self-quarantined. On arrival at Belize, the United States requested permission for her to board a flight back to the United States, however the Belizean government denied that permission. Other passengers were allowed to disembark. The laboratory technician and her spouse self-quarantined from Thursday until the ship docked in Texas the following Sunday. Nevertheless, the nation of Mexico isolated this ship by not allowing it to dock on their shores. Belize, refused passage for this passenger to board a flight back to the United States. In addition, some students who had been on the ship were kept out of school. This is an example of how people can be stigmatized as a result of suspected contact with EVD (Bever 2014) .

Ethical conflicts were inevitable especially in the United States of America. The reason for this is the history and environment of the United States which allows for the expression of individual rights. Quarantine puts healthy people who are not yet exhibiting symptoms of a communicable disease into a very confined and restricted environment. Most people who enter quarantine usually never become sick (Wynia, 2007) .

In the Autumn of 2014, states to include Maine, New York and New Jersey took onstricter standards for returning health care workers than was required by the United States federal government. On October 22, 2014, Governor Christie announced enhanced Ebola preparedness plans for the state of New Jersey. Two days later, Governors Christie (New Jersey) and Cuomo (New York) passed mandatory quarantine for health care workers returning from working with patients with EVD in West Africa. The former U.N Secretary General, Ban-Ki Moon cautioned against these restrictions because healthcare workers were critical to the efforts in curbing EVD. (Sherwood and Jenkins 2014) . Kaci Hickoxarrived at Newark Liberty International Airport, on October 24, 2014, from Sierra Leone where sheworked with Médecins sans frontiers (MSF) during the EVD outbreak. She passed through the new screening for all travellers from West Africa, as she transited to a connecting flight enroute to Maine. Her temperature was taken with a temporal scanner which showed elevated temperature readings however when taken orally her temperature was normal. She had been questioned aggressively for several hours by several people upon arrival at the airport; taken with several police cars in tow, sirens and lights on, and held illegally,in a tent on hospital grounds, against her will (Sherwood and Jenkins 2014) . Kaci Hickox was forced into mandatory quarantine in New Jersey and held against her wishes for three dayswithout legal counsel. Two tests for EVD were found to be conclusively negative.

When Kacy was released, she went back to Maine where she was toselfquarantine, as mandated by the state, for a total of 21 days. Kaci Hickoxwent for a bike ride with her boyfriend defying state voluntary quarantine guidelines. The American Civil Liberties Union and lawyers for Kaci Hickox, filed afederal civil rights law suit stating her civil rights had been violated. Shesoughtboth compensatory and punitive damages. In October, 2014, a judge in the state of Maine overturned the state's forced quarantine and reversed a court order however ordered that Kaci Hickox self-monitor, take her temperature daily and get travel approved by state officials. Governor LaPage (Maine) stated that the judge put Kaci Hickox rights above public safety. (Nicks 2014) .

Systematic changes concerning quarantine in the state of New Jersey are intended to be a new guideline to be used for other states. These include the concern that forehead scanners can be inaccurate and an oral reading is preferable, right to communication, right to legal counsel prior to hearings, the right to privacy, as long these do not interfere with the needs of the public (Santora 2017).

A good quarantine strategy would take into consideration all members of the public to include those under quarantine. It would ensure that when a quarantine is imposed,people have access to liberty and due process (Santora 2017) , in addition to the basic necessities such as water and food. It would also be critical to ensure the people have access to health care that would curtail the spread of the communicable diseases to others within a population. The strengths of quarantine lie in the power of the state to impose it. However, the flip side of this is that it can be a weakness as it is important to have checks and balances such as a committee made up of multiple heads of institutions saddled with the responsibility of engaging those affected at various levels, rather than one person or entity making unilateral decisions. This would keep the balance of fairness. The United States has a federal law and institutions such as the Center for Disease Control (CDC) which have been authorized to take action in the event of quarantine. Africa now has an organization as the African Union and the CDC partnered to form the new Africa CDC (Africa CDC 2017). The strategy for Africa and quarantine is that it has to embody the African culture and must include stakeholder engagement. Failure to do so will result in a failed quarantine that could cost the public dearly.

It is important to consider community engagement during an outbreak and most especially when quarantine is considered necessary, such as the case of West Point. Unfortunately, most national governments easily engage the military to reinforce quarantine, without considering sensitizing the affected communities on the value and importance of the exercise. Lack of community and stakeholder sensitization can create tensions between the government and the affected community, human rights activities and civil societies who may resist a potentially beneficial intervention. Community engagement should be considered to avoid unnecessary tension. The World Health Organization Country representative for Liberia had previously advised that community consent was necessary prior to the quarantine of West Point. However, this was not sought by the Liberian government, thereby contributing to the civil unrest.

Professionals working in field of healthcare have an immense responsibility to act professionally whether they work with individual patients or with populations or communities. Professional ethics is part and parcel of the duty of professionals in the domain who are responsible for those who have entrusted the professionals with their health. This is a complex field to navigate most especially because there is no current framework for ethics in public health (Wilson and Mabhala 2009; Kass 2001) . There is a risk of the transfer of deadly infectious disease, as was seen with the Severe Acute Respiratory Syndrome (SARS) in 2013 and the 2014 EVD outbreak in West Africa. This risk, also carries with it the possibility of threats of bioterrorism, by nature (Tognotti 2013) .

In Africa, another ethical consideration of quarantine is related to the associated stigma of those who are quarantined. For example, survivors of EVD in West Africa were initially ostracized and shunned by their own community members, and in some cases by their own families. Survivors often experienced psychosocial trauma such as feelings of guilt, isolation and shame, as well as stigmatization. Survivors were also frequently attacked, evicted and threatened by community members. Many were excluded from their communities and their properties burned and destroyed because the communities believed they still harboured the deadly virus and could infect others.

Right to Life Should citizens of more affluent countries be given priority by their countries and saved from the burden of disease by being airlifted out of a grave situation, whilst others are unable to get basic treatment and left to die? (Kass 2014) . This individualistic view examines considerations that focus on autonomy while public health ethics supports the rights of the community. Essentially, everyone has a right to life. While the experience of life differs dramatically between different contexts, there is a general appreciation that optimal quality of life should comprize of a healthy life, free from disease, including any form of physical and psychological distress. Against this backdrop, every human being, regardless of their socioeconomic background, ought to have an optimal life experience. Health care provides a means towards restoring the divergent quality of life to its optimal standard. Unfortunately, this was never the case during the EVD outbreak. The outbreak saw numerous cases where individuals from specific nationals received preferential treatment over others. Thus, individuals from well-resourced countries, those who were affluent or who came from wealthy families were more likely to receive the best quality of health care compared to the poor black persons from resource-poor countries where the health systems were already dilapidated and severely constrained. In fact, it is fair to say that the outbreak exposed the pathetic disparities that exist between the well resourced and poor resourced countries and individuals more profound.

Survivors of EVD were stigmatized, in part because cultural beliefs such as the concept of having been bewitched, brought by those who were afflicted, affected survivors and their families (Van Bortel et al. 2016) .It is clear that the African perception of a personhood or self, lies within how or where that persona can be found. Since there are no logs or manuscripts chronicling the journey of self, persona and humanness; disease and death, this can only be found in African philosophy and evidenced by the way the African people live and breathe, the essence of African "ness" and how they perceive themselves. Although traditional African societies have been eroded by the Western values, health had a high value and this value was what made other avenues in life possible (Tangwa 2000) . Quarantine within the West African context also falls right in the middle of treading within the delicate balance of tradition and cultural, vis-a-vis public health. For example, the way Africans perceive the concept of health and illness, death and the dying and personhood, as a whole differ, significantly from the public health construct, which borrows heavily from the western epistemology. Despite its good intentions, quarantine is likely to create tensions with individual rights as well as general African culture and traditions.

The Liberian government made several blunders, the first recorded one concerning quarantine was the case of Patrick Sawyer, outlined above. Sawyer was able to travel to Nigeria when he was supposed to have been on the no-fly list, under observation and in self-quarantine. This mistake which could have been corrected at several pointsprior to Sawyer's leaving Liberia and his arrival in Nigeria. This error, put the people of Lagos metropolis at high risk of EVD, causing the infection of 20 people out of whomeightdied.

In Monrovia, 17 patients escaped from a holding center for suspected EVD patients. After the escape, the Liberian government through the Ministry of Information, claimed the patients were rounded up and taken to the John Fitzgerald Kennedy Hospital; a claim which a doctor at the hospital denied. The quarantine of West Point was also a disaster with the use of force; batons, sticks and teargas as well as bullets, to control the rioting by the unarmed residents. This led to some human rights activist expressing dismay at the unjustified shooting of a teenager in an epidemic situation. This show of force was totally unwarranted (MacDougall 2014).

Public health ethics is geared towards communities and populations, unlike medical ethics which supports the rights of individuals (Kass, 2001) . Ethical considerations related to public health can be seen through two main views. These views are from that of the healthcare worker and the associated professionality of that worker. Ethical considerations in regards to public health and the practice of quarantine primarily centers on the loss of freedom for the individual being quarantined. West Africa is a region that is susceptible to emerging infectious diseases. It is crucial that the region examines its surveillance system, restrictions concerning biological specimens, and has a true model to ensure that fairness and equity prevails. The quarantine of West Point under military guard is an example of how leaders make decisions against international advice, out of fear and disregard for people of lower economic classes who are helpless and do not have a voice. The decision to impose a mandatory, military enforced quarantine at a time of such fear; interrupted livelihoods of people who were already at a serious economic disadvantage some of whom are yet to recover. A lot has happened in the field of Public health since the Ebola outbreak of 1976, in the Central African nation of Zaire (now known as the Democratic Republic of the Congo), in a remote rainforest and a village known as Yambuku, when Peter Piot discovered the Ebola virus and provided epidemiological evidence of the path of the virus. (Boseley 2014) . The examples shared in this chapter, show how an outbreak can spill over to neighbouring towns, villages and countries, like the situation with both Patrick Sawyer who flew to Lagos, Nigeria and Thomas Duncan who flew to Texas, United States.

Professionals, working in field of healthcare and public health have an immense responsibility to act professionally whether they work with and treat patients individually or if they are public health professionals dealing with populations of people in communities, regions or at a national level. Professional ethics is part and parcel of the duty of professionals in the domain who are responsible for those who have entrusted the professionals with their health. This is a complex field to navigate most especially because there is no current framework for ethics in public health. (Wilson and Mabhala 2009; Kass 2001) . There is a very real risk of the transfer of deadly infectious disease, as was seen with the Severe Acute Respiratory Syndrome (SARS) in 2013 and the 2014 EVD outbreak in West Africa. This risk, also carries with it the possibility of threats that are bioterrorist by nature (Tognotti 2013) .

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