Ethical Allocation of Drugs and Vaccines in the West African Ebola Epidemic

The West African epidemic of Ebola virus disease (EVD) is spiraling out of control, with an exponential increase in cases, projected to infect 10,000 people per week by December.1 Despite the rising death toll and regional spread, a major international response did not occur until 2 US aid workers and a Spanish priest were treated with the investigational drug ZMapp, a monoclonal antibody developed by Mapp Biopharmaceutical. Vaccines and drugs that have never been tested in humans, and are in scarce supply, could never have contained this outbreak. Nonetheless, what if good evidence emerged demonstrating their safety and efficacy? What would be an ethical method of allocating scarce beneficial resources? The apparent preference given to foreign aid workers over West Africans provoked a firestorm. Before discussing the ethical allocation of scarce drugs, we should ask a more fundamental question: Why did it take nearly 40 years after the first outbreak in 1976 to launch clinical trials? After more than 20 outbreaks of EVD and 5 months after its international spread, governments and industry have begun to ramp up research, with expedited regulatory processes and clinical protocols. On September 5, 2014, a World Health Organization (WHO) expert committee reviewed, and vowed to accelerate development of, promising drug and vaccine candidates, including blood transfusions from recovered Ebola patients and antibody treatments.2 Days earlier, the National Institutes of Health (NIH) launched vaccine safety trials, and preliminary clinical trial results for a GlaxoSmithKline vaccine are expected by November. The US Department of Health and Human Services promised Mapp Biopharmaceutical up to $42.3 million to develop ZMapp. Although these therapeutic agents offer some hope, with Ebola treatment centers currently overwhelmed, the global community must assist countries in building domestic health systems. Countries will require more human resources and technical assistance with, for example, transfusing whole blood, plasma, or serums derived from recovered Ebola patients. At the same time, the global community must help transport and deliver therapeutics to local facilities, while rigorously maintaining a cold-storage supply chain. Many factors have dissuaded investment in EVD countermeasures. Ebola outbreaks are sporadic, with an unpredictable market for interventions. These outbreaks typically occur in countries ranked lowest in economic development, which cannot afford the high price of patented medications. Rich countries have had other international funding priorities that better reflect the global burden of disease (eg, AIDS, tuberculosis, and malaria). But EVD has epidemic potential, and once it takes hold in highly congested, impoverished, capital cities, it can spread exponentially. The West African epidemic has provoked a public health crisis and a security threat, further weakening economically and politically fragile states. The UN Security Council should act boldly to ameliorate the crisis, with Secretary-General Ban Ki-moon framing the mobilization as “an international rescue call.”3