When the world tolerates impoverished healthcare systems, the risks associated with contagious disease escalate exponentially.
It is called "the hot zone": a region of over-exploited forest terrain in which three West African countries – Guinea, Liberia and Sierra Leone – meet. But it is not just borders that join them. They also share decades of political turmoil, historical injustice and extreme poverty – the root causes of this century's most frightening epidemic thus far: Ebola.
Their shared sub-tropical forest, or what remains after ravaging by global mining and timber companies, is central to the contagion horror. It is also at the heart of an intensifying bioethics debate on research and development of Ebola vaccines and treatments.
An investigation by the World Health Organization (WHO) has shown how the changed forest ecology has driven fruit bats – the species that hosts the Ebola virus – closer to human settlements and their forest-animal food chain.
The latest sign that the virus had found a new home in which to adapt and propagate was in December 2013 when a young boy in a remote Guinean village contracted a mysterious illness characterised by fever, black faeces and vomiting. He was dead within 48 hours. But it was a sign that no one read, because there was no professional health service able to recognise the symptoms.
Guinea and its neighbours are among the world's poorest countries and it is this circumstance, and its public health consequences, that have been preoccupying Professor Michael Selgelid, director of the Centre for Human Bioethics at Monash University – one of six WHO Collaborating Centres for Bioethics worldwide.
Professor Selgelid, an international authority on ethical issues associated with infectious disease control, has been centrally involved in WHO's deliberations on Ebola.
Ethics and wealth
For Professor Selgelid, the current Ebola tragedy is an injustice on many levels.
"The disease has been around for 40 years, so we should have already done more research and development of Ebola medications. This was presumably not done because Ebola has historically affected poor countries, which are not an attractive target for private, profit-driven pharmaceutical companies, on whom we rely too heavily for medical R&D."
However, as it spreads, Ebola has been mutating. "The more individuals of a species that a pathogen infects, the better adapted it becomes to that species. Ebola could, theoretically, become more transmissible and this could be disastrous for rich as well as poor countries," Professor Selgelid says.
In early August 2014, Professor Selgelid participated in WHO's Emergency Committee meeting that led to Ebola being declared a "public health emergency of international concern" and developed relevant recommendations.
Since then, Professor Selgelid has been advising WHO on ethical issues surrounding the use and study of unregistered Ebola vaccines and treatments that have not previously been tested in humans. Such was the scale of the emergency that a WHO ethics panel (on which he served) agreed unanimously that experimental drugs should be used without delay.
"Normally you would not even consider using unregistered medications, but there are therapies and vaccines in the development pipeline that show promise. We decided we should use them, plus take this opportunity to learn as much as possible about their safety and efficacy – because this is important for both the current and future epidemics," Professor Selgelid says.
"From an ethics and humanitarian perspective, we should have conducted more studies during and after the earlier, small-scale outbreaks. We should not have waited for Ebola to become a global emergency to get this research happening."
The Ebola crisis has, for Professor Selgelid, amplified numerous fundamental issues that bioethics has to address, such as the rights of the individual versus the common good in the context of infectious diseases and public health.
Similar issues arise in the context of public health surveillance, another area of Professor Selgelid's research.
"Surveillance is the public health radar … collecting and analysing data for public health purposes. Although surveillance raises ethical issues, such as privacy and the need to balance individual rights and the greater good of society as a whole, there are no international guidelines for public health surveillance ethics." Professor Selgelid is working with WHO to develop such guidelines.
Professor Selgelid's exploration of infectious disease ethics also includes the threat of bioterrorism, and this dovetails with his professional interest in dual-use scientific research – research done with good intent, but with the capacity for harm. The 20th century's physics revolution, which produced nuclear fission, is one example, but more recent cases have emerged from biology and genetics.
Photo: Brad Collis
"Discoveries are occurring that could have vast benefits for human health, but at the same time could also be used to develop a new generation of biological weapons," he says. He points to the example of a potential biological control for mouse plagues in Australia. Researchers inserted a gene into the mousepox virus genome, hoping the altered virus would make infected mice sterile. However, the researchers found the genetic modification created a super strain of mousepox; the altered virus killed mice that had been vaccinated against mousepox. They published this research in full detail, including descriptions of materials and methods. Others noted that bioterrorists could potentially use this published "recipe" to create and unleash vaccine-resistant smallpox as a biological weapon.
From an ethics and humanitarian perspective, we should have conducted more studies during and after the earlier, small-scale outbreaks.
Other examples of dual-use research have involved the artificial synthesis of polio, the reconstruction of the 1918 flu, and the creation of bird flu that was airborne-transmissible between ferrets. Such cases raise questions about what research should be done and, Professor Selgelid adds, what research should be published.
Despite its importance, dual-use research has received relatively little attention from bioethicists. For Professor Selgelid this reflects what was historically a more general bioethics "awareness gap" regarding infectious diseases in general.
He wonders if this was because infectious diseases are subconsciously considered a "problem of others" – the plight of poor countries. As a bioethicist, he finds himself grappling not only with science's immediate moral parameters, but also with attitudes and culture.
"From an academic perspective, this is why bioethics is so fascinating. It pulls together science, philosophy, history, economics, politics, culture, and you must apply this to infectious disease because with such an interconnected world, pathogens can readily spread."
Professor Ross Upshur, head of Clinical Public Health at the University of Toronto, says Professor Selgelid's work shows that ethical issues are ubiquitous in the interplay between humans and pathogens.
After completing his first degree in biomedical engineering at Duke University, in the US, Professor Selgelid completed an undergraduate philosophy curriculum at the University of California, Irvine, and a PhD in philosophy at the University of California, San Diego. His dissertation focused on ethical, legal and social implications of genetics: "I then did postdoctoral research on ethical issues raised by the AIDS epidemic in southern Africa, in particular exploring reasons why wealthy developed nations should do more to help improve health care in poor countries."
He now brings this experience and insight to the Ebola crisis, informing the debate and policies needed for the world not only to end the current epidemic, but also to prevent its spread – and its reoccurrence.
"The Ebola outbreak underscores the importance of ethical issues in the response to communicable disease outbreaks," says Professor Upshur, who has worked with Professor Selgelid advising WHO on the West-African Ebola crisis.
"What is surprising is how this gets forgotten and needs to be rediscovered with each new outbreak."
For example, many ethical challenges such as whether healthcare workers have an obligation to care for people infected with Ebola, whether to use measures including isolation, quarantine or travel restrictions, and how to best allocate scarce resources in emergencies have been evident in outbreaks such as SARS and H1N1 influenza.
"It is hoped that an outcome of Professor Selgelid's research would be a means to integrate a systematic approach to ethical issues into outbreak management," Professor Upshur says.