By Andrew Pollack
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A
scarce Ebola drug was obtained for the Rev. Miguel Pajares, who was taken to a
Madrid hospital last week. He died on Tuesday. Credit Emilio Naranjo/European
Pressphoto Agency
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The doctor who had been leading Sierra
Leone’s battle against the Ebola outbreak was now fighting for his own life,
and his international colleagues faced a fateful decision: whether to give him
a drug that had never before been tested on people.
Would the drug, known as ZMapp,
help the stricken doctor? Or would it perhaps harm or even kill one of the
country’s most prominent physicians, a man considered a national hero,
shattering the already fragile public trust in international efforts to contain
the world’s worst Ebola outbreak?
The treatment team, from Doctors
Without Borders and the World Health Organization, agonized through the night
and ultimately decided not to try the drug. The doctor, Sheik Umar Khan, died a
few days later, on July 29.
The doses of the drug that were not
used were eventually sent to Liberia, where other doctors made the opposite
decision — and two American aid workers became the first people in the world to
receive ZMapp. Both of them survived and are now being treated at Emory
University Hospital in Atlanta.
“It’s a little political; that’s what
it looks like to me,” Alhajie Khan, Dr. Khan’s brother, said of the decision.
“Why would you not give it to him? The guy who helped all of these people.”
The provision of ZMapp, which is in
extremely limited supply, to foreign aid workers has raised broad ethical questions
about the disparities in treatment between white outsiders and the Africans who
form the overwhelming majority of victims in the epidemic.
Those concerns were heightened further
after Spanish officials confirmed that they had obtained a supply of ZMapp for
a third patient, a 75-year-old Spanish priest who died Tuesday after having
been evacuated to Madrid from Liberia.
The previously untold story of Dr.
Khan, recounted by two doctors involved in discussions about whether to use
ZMapp, offered an unusual glimpse into the wrenching ethical dilemma of when
and how experimental drugs should be used to combat the Ebola epidemic in West
Africa. Had the treatment team decided differently in his case, the first
person treated with the drug would have been African.
On Tuesday, the World Health
Organization endorsed the use of untested drugs to combat the outbreak, which
has already killed more than 1,000 people and continues to spread. But ZMapp
and other potential treatments are in such short supply that another
politically charged question remains: Who should get them?
Marie-Paule Kieny, assistant director
general of the World Health Organization, said at a news conference in Geneva
on Tuesday that several drugs and vaccines had shown some promise in animal
testing and might conceivably be used.
But none are “available in unlimited
supplies right now,” Dr. Kieny said. “I don’t think that there could be any
fair distribution of something which is available in such a small quantity.”
On Tuesday, Liberia’s government
announced that it would receive ZMapp after its president, Ellen Johnson
Sirleaf, requested the drug from the United States. It said the drug would be
used to treat two doctors who have Ebola.
That would be the first known use of
the drug to treat Africans, but it also might be the last for a while. The
manufacturer, Mapp
Biopharmaceutical, said that it had complied with a request from a
West African nation, but noted in a statement that the available supply of the
drug was now exhausted.
In the case of Dr. Khan, who has been
called “the arrowhead
of the fight” against Ebola in his country, the doctors involved said there was
no intention to save the drug for Americans. They said it was not known that
the American aid workers were sick at the time of the decision not to treat Dr.
Khan, around July 23.
Instead, they said, doctors feared stoking the considerable suspicion of
Western medical institutions in the country, which was already
making it harder to contain the outbreak.
“What they really didn’t want to do was
kill Dr. Khan with their attempt at therapy,” said Dr. Armand Sprecher, a
public health specialist at Doctors Without Borders. “If word got out that
M.S.F. killed Dr. Khan, that would have implications for outbreak control,” he
added, using the initials for the French name of the relief group.
Dr. Sprecher, who is involved in the
procurement and use of drugs for Doctors Without Borders but was not directly
treating Dr. Khan, said another factor was that Dr. Khan’s virus levels were so
high it was believed the drug would probably not work.
He said the treatment team never discussed the
option of using the drug with Dr. Khan himself, deciding it would do so only if
it decided to go ahead with the treatment.
“There
are an awful lot of people who are very traumatized by the whole event,” Dr.
Sprecher said in a telephone interview from Brussels on Tuesday.
At
the time the decision was made, less was known about ZMapp, which may have helped
the two American relief workers, Dr. Kent Brantly and Nancy Writebol, who were
initially treated in Liberia and then evacuated.
Dr. Sprecher said the Spanish
priest, the Rev. Miguel Pajares, had received the first of three recommended
doses of ZMapp. He said the drug sent to Spain had originally been obtained by
Doctors Without Borders and the World Health Organization for use in
emergencies. It was kept at the University Hospital of Geneva, which had the
authority to decide how the drug was used.
Father Pajares worked in a hospital in Liberia and
was the first European to return home after being infected with Ebola. The
Spanish Health Ministry confirmed that it had obtained ZMapp for him, but
hospital officials in Madrid, citing patient confidentiality rules, declined to
say whether Father Pajares had ultimately been treated with ZMapp. Officials
said he would be cremated in a sealed coffin, with no autopsy, to reduce the
risk of any further contagion.
Also
on Tuesday, the press in Canada reported that the country’s Health Ministry
planned to offer hundreds of doses of an experimental vaccine for use in
Africa.
Dr. Kieny of the W.H.O. said Tuesday
that intensifying public health measures to contain the outbreak was more
important than supplying drugs. “It is very important to not give false hope to
anybody that Ebola can be treated now,” she said.
A string of coincidences led to the
decision in Dr. Khan’s case, Dr. Sprecher said. A Canadian team setting up a
laboratory had taken some of the drug with it to Sierra Leone. It set up shop
next to the Doctors Without Borders treatment center in Kailahun, and let the
relief organization know the drug was available.
Dr. Khan was in charge of the Lassa
fever ward in Kenema, which had become the Ebola ward. But when he became ill
he was moved to Kailahun so he would not be treated by his own colleagues. Dr.
Khan was going to be airlifted to Switzerland, where he would receive better
care, making the drug less necessary, his treatment team reasoned. But after
the decision was made, and just before he was to depart, Dr. Khan began
vomiting and having diarrhea, and the transportation company refused to take
him.
Dr. Daniel G. Bausch, an associate
professor of tropical medicine at Tulane University who was involved in the
discussions, said that he disagreed with the decision and that if he were sick
with a life-threatening disease he would have wanted the drug, even if it had
not undergone safety testing.
He also said he thought Dr. Khan should
have been asked for his own opinion. “Dr. Khan was the perfect patient, I
think, to understand the complexities of that gray area,” he said.
Nonetheless, he said that it was a
close call and that he respected the decision of the doctors on the ground.
“There was considerable difference of opinion even within M.S.F.,” he said.
Dr. Bausch, who has been a consultant
to the W.H.O., said he had been a close friend of Dr. Khan and had recruited
him in 2004 to take over the Lassa fever ward at the hospital in Kenema, a
dangerous job given that the previous holder of the position had died from
Lassa fever.
Dr. Bausch was in Sierra Leone until
July 16. When he and Dr. Khan said goodbye to each other that day, Dr. Khan
felt well. But he became sick within hours and tested positive for Ebola virus
around July 21 or July 22, setting the stage for the decision.
"We were willing to try anything,”
said Dr. Khan’s sister, Umu Khan. “It was not right; we should have had a say.”
Nick Cumming-Bruce contributed
reporting from Geneva, Raphael Minder from Madrid, and Elena Schneider from
Washington.
Source: http://www.nytimes.com
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