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Guest Host: Marc Fisher
As West African nations struggle to contain the spread of Ebola, public health officials and researchers in the United States are grappling with thorny ethical questions. Should nurses and doctors who return from West Africa face mandatory three week quarantines? How can research and development of an Ebola vaccine be expedited, while ensuring its safety and efficacy? We talk to a leading bioethicist about the conundrums of responding to Ebola.
- Arthur Caplan Director, The Center for Bioethics, University of Pennsylvania
MR. MARC FISHERFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. I'm Marc Fisher of The Washington Post, sitting in for Kojo. Later in this hour, measuring happiness and well-being. How social scientists develop new indexes for comparing quality of life in cities and regions around the world. But first, Ebola's ethical conundrums. As the disease continues to ravage the west African nations of Guinea, Sierra Leone and Liberia.
MR. MARC FISHERAnd as states across this country brace for possible cases in their communities, public officials and researchers are grappling with some thorny questions. Several states, in recent days, have adopted mandatory three week quarantines for health workers who returned from Ebola stricken regions. And just in recent hours, we've seen a modification of some of those policies. Critics say that some of these policies are perhaps effectively punishing health workers who are brave enough to put themselves at risk to help control the outbreak.
MR. MARC FISHERAnd to discuss the ethics of Ebola quarantines and other aspects of this disease, Arthur Caplan joins us by phone. He is the Director of the Division of Medical Ethics at New York University's Langone Medical Center. Welcome to the program.
DR. ARTHUR CAPLANHey, thanks for having me.
FISHERSo, I read a piece that you wrote, just two, three days ago, in which you recommended, seemed logical to me, that those health workers coming back from west Africa, who had been exposed, perhaps, to the Ebola virus, be not placed in some quarantined tent in an uncomfortable place in a hospital, but rather in a nice hotel with some good services. And that this should just be seen as part of the deal. You get to go overseas and treat the people with Ebola, and then you get to come back and have kind of a decompression period in a hotel. Is that basically your idea?
CAPLANYeah. It seems to me we can make it voluntary, but make it very, very attractive. If you go there, you get three weeks' pay, you had a nice environment. We honor you. Journalists can go there and interview heroes about their work. Remember, these people who go over there not only do they face Ebola, they're facing some hellish conditions in these countries there. Falling apart, they were very, very poor to begin with. They're really admirable. So, I don't really see the point of treating them like pariahs and putting them in a tent with no running waters, happened to Kaci Hickox. What I think we ought to do is treat them like heroes.
FISHERWell, and this battle over Kaci Hickox has gotten rather heated just over the last day or so. And she was quite angry about having been placed, against her will, in a quarantine in a New Jersey hospital. And now, the state of New Jersey is saying that she's going to be released today. So, the states are backing off from this harder position that Governor Christie of New Jersey and Governor Cuomo of New York took over the weekend. But even as they're doing that, just in recent minutes, Governor Martin O'Malley of Maryland announced that Maryland will now directly monitor the health of all people returning from those three countries in West Africa.
FISHERSo, there does seem to be this sort of patchwork quilt of solutions. Is what we're seeing here more political back and forth, or are there real ethical issues about what we owe the larger public in regard to these individuals coming back from the west African countries?
CAPLANWell, I think we have some politics and some ethics running at the same time. So, people assume the CDC or Washington is in charge when it comes to dealing with people who might potentially be threats to the public health. But in fact, it's states, and even counties -- in Dallas, Texas, it was the county health department that was running the show there. We still have a federal system, although whenever there's a big hurricane or an Ebola outbreak, people tend to forget all that and look to Washington. But Washington and the CDC run the borders. In terms of health, they don’t run what goes on within a state.
CAPLANSo, that's why you're seeing Maryland, Illinois, Florida, New York, New Jersey coming up with policies. I have to say there is politics. Governor Christie clearly, I think, had his eye on presidential politics. He came out, he said, I'm going to insist on this. I'm being tough. She's clearly sick. I'm not gonna change my mind, and within a day, he's changed his mind. She's going home, she's not sick. It's been quite a flip flop for him on this one. I think it's going to hurt him, politically, rather than help.
FISHERBecause it looks like he's flip flopping back and forth. You can join our conversation by calling 1-800-433-8850. Let us know how you think politicians are handling Ebola fears and risks. And do you have faith in the public health system's response to this disease? Let us know at 1-800-433-8850 or email us at email@example.com. And we're speaking with Dr. Arthur Caplan, the Bioethicist at New York University. And Dr. Caplan, when the first case of Ebola emerged in Dallas, I think it's fair to say that public health officials and political leaders seemed to be caught flat footed.
FISHERIs there, have you seen significant growth and maturity in their responses since then, or is it continuing to sort of drift in various different directions?
CAPLANIt's drifting. I think, you know, when we hear talk about quarantine in a couple of states, it's clear to me that not only haven't they figured out where to put people, they haven't figured out how to enforce it. So, if someone, if you remember the news reporter, Nancy Snyderman, who imposed a kind of self-imposed quarantine. Remember her? And then she was wandering around Princeton, New Jersey seen in grocery stores, I guess. And downtown. And the question is, how do you enforce a state mandated quarantine?
CAPLANDo you put a cop outside in a cop car and watch them? Do you put the cop in a moon suit, if the person comes out against the will of the government? Do you shoot them, tazer them, tackle them, drag them back in? You need to know what you're going to do. I haven't seen much careful thought go into quarantine enforcement. And while I'm at it, I think tracing people and relying on them, particularly healthcare workers, to report and take their temperature and do what they're supposed to do, is just as effective as quarantine.
CAPLANBecause if quarantine is miserable, people are either going to sue their way out, as that nurse tried to do before they let her go. In New Jersey, or they're just going to sneak out.
FISHERSo, there's really no easy way to enforce this. And of course, there have been times in our history when quarantines were enforced rather harshly, whether it was to do with influenza or tuberculosis.
FISHEROver -- we're going back probably a century or so in those cases, and I guess, over time, people came to feel that quarantine was not only a violation of civil liberties, but impractical, as you mentioned. So, are we in a situation now where we have a society in which, even when quarantine is called for, we have no viable way to enforce it?
CAPLANWell, you could do it. You just have to lay out the rules. I suspect quarantine in place, at home, which seems to me more palatable than quarantine in a tent in Newark with no running water, is gonna be a little easier to enforce. But the easiest quarantines are the ship in the harbor. That's the historical ones. You've got them there, they're all isolated, you know, let the ship come in, and that's the classic case. In SARS, just that disease, some listeners will recall, that ravaged Hong Kong and Canada, they had quarantines. But there was tons of leakage.
CAPLANPeople were wandering all over the place. So, it's very tough, very tough to sort of penalize. I would say if you want to do it, make it voluntary and say, you know what, we've got a nice place for you. It's at the beach, maybe Atlantic City. We've got a lot of empty hotels there. There's a lot of food. You're gonna get paid. Here's some wine.
FISHERA new purpose for Atlantic City. Right?
CAPLANYep. Yeah, it's sort of a hotels for heroes, you know? Let's make it attractive and make it part of your decompression. When these people come back, it's like being deployed in a war zone. Not only are they facing Ebola, they're facing horrific conditions. So, rather than quarantine them and punish them and stigmatize them, why don't we reward them?
FISHERWell, okay, that's well and good, but that doesn't sound like it would be terribly easy to enforce and what we've seen so far is that whether it's the NBC reporter or the original case in Dallas, there are people who are told to stay in one place -- the family of the fellow in Dallas, rather. There are people who are told to stay in one place and they just don't. And if that tells us something about human nature, that people say well, I'm just going out to get a pizza. I'm not going to touch anyone.
FISHERThat's -- doesn't that tell us that we need some harsher enforcement methods?
CAPLANWell, you know, the fact is we know a lot about how hard it is to catch Ebola. And that's because Ebola's been around for about 40 years. And people know -- they don't know how to cure it and we don't have a vaccine against it, but we know about its contagiousness and it's rather hard to get. So, even when people are wandering around and why they aren't symptomatic, they're not going to make you sick. You can go to a bowling alley, you can go to a subway train, as long as you don't exchange a toothbrush with the person.
CAPLANOr have sex with them in the bowling alley, I think you'll be okay. That being said, public morays, panic, concern, I certainly would advise people who are coming back -- stay at home, don't wander around too much. Not because of anything about the infectivity of Ebola. The science doesn't back that up, but just because it helps, I think, make the public calmer. And let's face it, people coming back from the wars against Ebola, I don't think they want to do harm and I don't think they want to cause panic.
CAPLANSo, these are some of our best and brightest folks. If we reason with them and say we've got a nervous public, I think they'll do the right thing. You don't have to force them.
FISHERBut is it worth or is it right to ask people to hole themselves up, even in a lovely environment for three weeks, just to calm people's irrational fears?
CAPLANWell, our politicians seem to think so. They keep issuing those quarantine orders. But it may be. It may be. You know, it's three weeks. It's -- if you get to sort of stay in place and you get your pay and somebody's going to cover your salary and you're not going to lose your job and all the rest of it, then I think, yeah, we could probably do it. You know, we send people off for a couple of weeks for National Guard training. It's no picnic. There are a lot of other things that people have to do, even when they get out of the military.
CAPLANThey have to kind of spend some time here before they get to go home. It's not unprecedented, but let's make it doable. Let's not get into sort of this punishment aspect.
FISHERThe way you paint it, it's fairly enticing, so just sign me up.
CAPLANWell, you know, in a way, but it's what we want to do, because you might say, if we can make it enticing, then people will go back, other people will volunteer. And, you know, the battle is over there, and if we don't get it tamped down there through volunteers and money and support, then we're going to be talking about this next year.
FISHERLet's turn to Marjorie in Washington. Marjorie, you're on the air.
MARJORIEHi, thank you for taking my call. I read an article a number of weeks ago by a virologist questioning the time frame of 21 days for quarantine, saying that that was based on a small outbreak in Zaire in 1976. And that, in fact, in a larger population, the quarantine time could be as beneficial -- as long as 31 days or even more. And so, I've never heard anybody, any of the doctors who are talking about the management of this talk about that. And why are we so focused on 21 days if there isn't a good scientific basis for limiting it to that?
CAPLANWe're focused on a good scientific base, because the 21 days comes out of the 40 years of experience since that first Ebola outbreak. So people know, low viral loads don't transmit. Why that's so, I don't know. But it turns out, you gotta get pretty -- enough virus in you to make you symptomatic and then it's the fluid exchange at that point because of the nature of the virus. It's not airborne, like the flu. That really is the key to transmission. So again, there are plenty of papers.
CAPLANYou can look them up online, in journals, that talk about Ebola transmission. It's not something that people are uncertain about. 21 days seemed to have been the outer limit for transmissibility and you had to be symptomatic, at least the flu and achy and painy at that point. So, that's where it comes from. I don't think it's -- it hasn't just been invented, due to this outbreak.
FISHERWe're speaking with Arthur Caplan of New York University about Ebola. And to turn from quarantine to some of the other ethical aspects of this situation, under normal circumstances new medical treatments and vaccines can take decades to develop and safely test in human subjects. Here where there's tremendous public and political pressure to compress that process quite dramatically and questions about how you go about testing a fairly untested vaccine and do you even both with control groups where people are getting or not getting the actual medicine when you have a large outbreak like this. What's the latest ethical thinking on that question?
CAPLANThere's a fight about it. One side is saying you have to go with a straight randomized trial using a placebo against the drug or vaccine that you want to use. That's the fastest way to learn if it works. It doesn't do us much good if we don't know whether something worked or helped.
CAPLANAnd by the way, we've thrown some things at some of the people with Ebola here who've gotten better, most of them, in fact all but one. But we don't really know whether any of the blood serum transplants or some of the medicines used did any good. I'm actually in the other camp but I wrote something just recently in the past couple days in the Lancet, one of the British publications, medical journals, that said no, I don't think placebo-controlled trials, at least in West Africa, are the way to go. Things are out of control. The death rate's too high.
CAPLANWhat you should do is try drugs and then compare groups to places where you don't have the drugs. You're not going to withhold them from anybody but just by supplies you're not going to have enough to give to everybody. So study one group and then watch the other group is if there seems to be more survival in one place or the other. That's less reliable than randomization but I think it'll give you a little bit of information And it seems to me in the middle of an epidemic you've got to bend the rules a bit.
FISHERAnd are you willing to bend those rules because this drug has shown significant promise or would you be equally willing if it was much earlier in the development stage?
CAPLANYeah, that's a great question. So my argument, and the colleagues who wrote this with me said, look, we don't have much on efficacy for Ebola. We haven't tested a lot of drugs or vaccines against it. And that, by the way, is a separate ethical issue, how did we get this far without trying things that have been around for awhile? But we do have safety profiles on a number of things because they've been around some drugs used against other things, viruses, other viruses that are out there. And when you have that safety profile, to me that's enough to then justify their use.
CAPLANYou know that a couple of these drugs have been used in children to fight viral infections, not Ebola but other things. And the safety profile's been pretty good. I think you can, in good conscience then try them in humans for Ebola and see if you get anywhere. So to me, passing the safety standard is probably sufficient in an epidemic whereas it probably wouldn't be under normal circumstances.
FISHERAnd last question before we go, there have been -- some patients have received these experimental treatments already. There's questions about whether that is what saved these folks or not. But is there a clear consensus on who should get the experimental treatments when they are in short supply? Do we have protocols that are established for picking those winners and losers?
CAPLANNot really. I suspect this is true. Drugs for treatment are going to work better when you get them right at the point of infection of the person, because there's less virus to have to deal with than someone who's really in the end stages, as much as we might want to rescue them. I think earlier in the Ebola person will be better for prevention. And vaccines, I think you're going to put the at-risk people first in line, health care workers, people who deal with dead bodies. Maybe family members of those caring for someone with Ebola, they're more likely to head to the front of the line to get preventative vaccines.
FISHERThanks very much, Dr. Arthur Caplan, director of the Division of Medical Ethics at New York University's Langone Medical Center.
FISHERAppreciate it. When we return after a short break, we'll switch gears and talk to the folks who rank cities and states across the country and around the world. How do they measure well-being? How do they decide who's living the better life? That's after a short break. I'm Marc Fisher and this is "The Kojo Nnamdi Show."
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