Follow the Soapbox
New York Times
AUG. 12, 2014

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.

Photo Dr. Sheik Umar Khan Credit Reuters “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.

Dr. Marie-Paule Kieny, the World Health Organization’s assistant director general, announced that the agency would endorse the use of drugs untested in humans to combat the Ebola virus in West Africa.
Publish Date August 12, 2014. Image CreditSalvatore Di Nolfi/European Pressphoto Agency
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.



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