Wednesday, 8 October 2014

Quarantine ethics

It was recently reported that residents of slums in Liberia and Sierra Leone have been placed under military-enforced quarantines: nobody in, nobody out.

The ebola crisis has been reasonably visible in western media, and there was some discussion of the uncomfortable fact that the lives of several white aid workers were saved by an antidote too scarce to be widely deployed. But I am surprised that there hasn't been a bigger western reaction to the tactics that seem to be in use to control the disease in the African countries it is affecting.

I've read that the ebola crisis is a reminder of the dangers of allowing the WHO to become too weak to mount an effective and timely response. And I've read quite a lot about how the scale of the problem is hugely exacerbated by the weakness of the healthcare systems in the countries involved. There is widespread mistrust of healthcare workers, poor systems of communication....oh and a long term lack of financial motivation for pharmaceutical companies to come up with drugs and vaccines for resident diseases.

Only now the rest of the world is worried about ebola getting on a plane and becoming our problem too, so we have finally mobilised and decided to send help their way. Only, what kind of help are we sending? Obama is sending 3,000 military personnel, the UK 750 troops. Its reported that the purpose here is to provide logistical support and erect healthcare facilities to 'boost the number of beds'. But I can't help worrying that it all sounds a bit, well, violent.

The virus is reported to have something like a 70% mortality rate and, in the absence of effective vaccines or sufficient infrastructure to support the administration of treatments of the Zmapp type, the most that medical staff seem to be able to do for the affected is to isolate them, keep them hydrated, and try to find out who they have been in contact with. The soldiers aren't going to be setting up any drips, so I'm guessing they'll be more in the role of enforcing isolation and imposing restrictions on the people who have been contacted.

Basically, if you've got symptoms you're probably going to die, and all the healthcare workers can really do is make a guess about which of your loved ones are going to die also. It's not surprising that people are reluctant to come forward. So we send in soldiers, "specialists in logistics to assist in patient transportation". I fear that these soldiers are not headed over there to help the victims, but only to fence them in.

With high rates of transmission, low rates of reporting and no cure, hoping to contain the virus by relying on victims to report who they have had contact with seems pretty hopeless. When there is no hope of saving victims, the game becomes all about containment. But there are two goals in this, which trade off against each other viciously. On the one hand, we want to save as many potential victims as possible. On the other, we want to maximise the completeness with which the containment is carried out. So where do we draw the lines, and how deep do we dig them?

Anyone familiar with the zombie/deadly virus disaster genre will see the horrific humanitarian consequences.  To save humanity you have to seal off the area. Everyone inside is doomed. All the uninfected innocents trapped inside face a futile scramble to escape, and most are lost along the way. By some fluke or act or heroism, some particularly worthy innocent is saved.......along with various more corrupt exceptions and, inevitably, some infected along with them (which paves the way for the next film in which the containment zone gets bigger).

As you watch these films you feel the injustice, the despair, the abandonment of those written off.
 Now imagine all this in real life. The Liberian West Point quarantine was lifted after deadly clashes "led to running battles between residents and the security forces". A 15-year-old boy caught in the violence died after suffering bullet wounds to both legs. Many residents sneaked out of West Point by paying bribes to soldiers and police officers. Prices of food and basic goods doubled, causing living conditions in the slum to degrade further.

Many experts have pointed out that quarantining a slum is an ineffective response to the Ebola crisis. But why aren't more people shouting about the ethical failings of a policy which imprisons and imperils so many innocents? What would we say if these were white people condemned to die, selected for death by economic situation rather than by symptoms? How would our tactics differ if such a crisis occurred in the western world?


john clarke said...

"The soldiers won't be setting up any drips"

That is likely exactly what they will be doing. These "soldiers" consist of a Field Hospital of doctors nurses and trained medical assistants. They are all non-combatants and won't be doing much rifle pointing. There is also a hospital ship and I believe some helicopters. Medical military personnel are only allowed to use a weapon (tiny rather ineffective pistol) in defence of themselves or their patients. What they will really need is thousands of disposable protective bio suits. They will copy the type of set up run by the MSF treatment centres.

These "soldiers" are the only people our government can send out, whether they really want to go into this hazard or not. I do not think there will be thousands of NHS people volunteering, the government is not able to send NHS people to this situation on our behalf unless they volunteer.

The charity MSF has sent several teams of volunteers, at least one of their doctors has already died. We get newsletters from them as we donate to that fantastic organisation by direct debit.

The idea of sending an infantry regiment of front-line soldiers is obviously absurd. Please try and have some sympathy for families of the young male and female "soldiers" being sent to this dangerous situation (from Yorkshire).

Ellen Clarke said...

Hmm, well obviously some of the people being sent from the UK and the US are medical personnal, which is wonderful and heroic and just whats needed. But I dont think the whole 750 from the UK are from the York field hospital (see here ) , nor the whole 3,000 US personnel. As I said, the reports say many of them will be doing 'logistical' work. And I'm not the only person who has wondered if some of that work will involve containment(see here and here

I don't think that it does any disservice to army personnel themselves to point out that quarantine brings up a mares nest of issues involving personal liberty and medical ethics. Do you?

John Clarke said...

Obviously Liberian style miltary containment of a slum area was unethical. In MSF treatment units the known cases are quarantined from the staff and locals without the disease. Whilst in the quarantine area they are fed and kept hydrated to give them the best chance of recovery. Fit young adults and children do have a chance. Unfortunately this system will break down and likely has, when the volunteer staff get overwhelmed by numbers. They need logistical staff to bring food,water, IV stuff, local information, drugs for other conditions, bags for sealing corpses and grave digging.
They likely need more of these logistics folk than the ones entering the treatment area to do the feeding, IV's and assessing. I realise you know this already probably but logistics isn't only crowd control. How do you feel about the ethics of the MSF treatment centres?

Ellen Clarke said...

Good! I just sent them a donation (good call. But I bet they feel awful if they have to isolate mothers from their children, for example, or deal with people resisting going to the clinic, or trying to leave. Presumably there will be a few misdiagnoses too, in which uninfected patients are transported to clinics where they contract ebola and die. They're all horrible dilemmas that stem from the fact that isolation, at the end of the day, isn't done for the sake of the patient. Harms are done to individuals for the sake of the greater good.