Opting Against Ebola Drug for Ill African Doctor

International colleagues of the doctor who had been leading Sierra Leone’s battle against the outbreak had to decide whether to give him a drug never before tested on people.

Comments: 147

  1. Potential benefits to the patient > Potential risk to the patient.

    If the above is true, give the drug.

    The future of the organization, the future of other patients, the state of current affairs, what happens when the "word gets out"......all of this is frankly irrelevant.

    And it should be to the team who has taken an oath to protect their patient.

    Against a disease that has proved to be nearly uniformly fatal, it's hard to imagine a patient-centered reason why this drug wasn't given. Sure, hindsight is 20/20, but from any perspective, this seems like a travesty.

  2. Normally I'd agree with you logic. But this is a epidemic situation that involves many people no a isolated individual patient. So public health implications have to be included into your equation. The 'patient' here includes the larger public and that has to be considered to truly give patient centered treatment.

  3. If you are the first patient for an experimental drug, there is no data.

    Therefore your magic formula is useless. Any assessment of "potential benefit" is based upon pure conjecture, as is the corresponding assessment of "potential benefit".

  4. "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."

    The jury is still out on the efficacy of ZMapp in humans. If ZMapp doesn't work or ends up having terrible side effects and it had been given to Africans first, the conversation we would be having would be significantly different. We would be asking why we are testing drugs on Africans - why black people are being used as guinea pigs.

  5. In addition to the fact that the drug was first tested on two non-African patients, people (at least the ones with even a modicum of common sense) will understand why the drug needs to be deployed in Africa - because the drug is currently the best shot we've got at saving patients' lives. No offense, but the "guinea pigs" excuse to not give the drug is a load of rhetoric hogwash. What's important is not what public will thinks, but what the patients who are actually infected with the virus wishes are. Any reasonable person would know that potentially saving lives (by administering the drug) is infinitely more important than coverings our backs by refusing deployment of the drug just in case someone wrongly believes that we're using Africans as guinea pigs.

  6. Very well said and absolutely right. Great common sense approach.

    Thanks.

  7. It's been widely reported that there were hardly more than a dozen doses of ZMapp. This is stuff being "manufactured" by a 9-person lab in San Diego. So it can hardly be "deployed" to save the lives of more than a handful of people.

  8. American tax dollars paid for the development of the ZMapp drug I am comfortable with using the limited resources on consenting Americans. When it doesn't work, and that will happen, the debate will be even larger if we "test" our experimental drug on others. Catch 22?

    When and if we can get this very expensive antibody drug available to larger numbers, the debate becomes more interesting.

  9. No good can come of second guessing something like this. The people on the front lines made a decision. No one knows what would have happened if they had made it differently. Regarding ethical questions, it certainly makes sense to give limited doses to health care providers, who seem in all cases to be volunteers taking great risk. Giving the medicine first to the American doctor probably made sense because he was young and strong, meaning he was a good test subject.

  10. Dr. Khan was young too.

  11. This is not a "drug", it is a synthetic antibody. Everyday thousands of people in the world with immunodeficiencies are given passive immunity treatment, pooled antibodies from the population. There is NO risk in giving anyone this new anti-Ebola antibody cocktail. It will either work or not, but it is stupid to fret about it hurting an Ebola-infected person. The people leading this debate are ignorant of the most basic tenets of the immune response.

  12. Bill, think about your assumptions. Do you think that those thounsands of immunocompromised patients are given untested non-human antibodies? No. They are given antibodies that have been proven safe first.

    Sometimes treatments are given without safety testing for compassionate reasons. I know of at least one patient in this situation who died because the antibodies attacked a naturally occuring protein on the patient's lungs. The animals that the antibodies had been cultured from didn't have that protein, which is why the antibodies worked for them.

    ZMapp is cultured from animals and grown in tobacco plants. It was not tested in humans. It's completely possible that it could have provoked a fatal immune response in these patients. It didn't, thankfully, but it was a serious risk.

  13. Isn't that an enormous generalization? The human body is incredibly complex and there is still a great deal we don't know about it - not to mention the infinite variety among individual humans.

    Treatment with monoclonal antibodies is not universally safe. Each and every one of the patients receiving these treatments made the decision with their doctor that the potential benefits of treatment outweighed the very serious risks involved. I am one of them - I have to sign regular waivers because a lot of people have died from it. You're poking the immune system with a sharp stick to get a response. That process can go very wrong, even when the antibody is rigorously tested and FDA approved. ZMapp is neither.

    I think your point is that an Ebola patient has little to lose given the mortality rate and lack of alternative therapies, but that's not the same as "NO risk".

  14. It is scientifically and ethically appropriate to not administer untested drugs to sick people, just as it can be appropriate to do so. The drug could just as easily kill as cure, or do absolutely nothing. It's decision was made at the beginning of the possibility to do so, and I am troubled that hindsight is being applied to a wishful analysis.

  15. We Americans desire, and demand, a happy ending. Uncertainty of outcome is intolerable. Unfortunately, success has many parents but failure is an orphan.

  16. One should consider that, at least at the time, 40% of patients in this epidemic survived. So there might have been something to lose by treatment.

    In this particular case it was almost impossible to make an unchallenged ethical decision. As a physician i also suspect that the author exaggerates the "political" aspects of the decision-making and underestimates the consideration that they must have had that at the time of the decision he may well have been too ill to be the best candidate.

    Lastly, patients, even highly knowledgeable professionals, do not necessarily make •better• choices, only informed and autonomous ones. In a more ideal setting with wider availability he would have been offered only the choice of being randomized to treatment or non-treatment.

  17. I think it's potentially misleading to call ZMapp a "drug" when it's actually a monoclonal antibody preparation. The approach is not that dissimilar to the use of serum from recovered individuals who have developed natural antibodies to the virus, which has been done before. Encouraging results using monoclonal antibodies to treat Ebola in monkeys were published in 2012 and 2013 (both papers are linked to on the Science Magazine Ebola page: http://www.sciencemag.org/site/extra/ebola/). There would typically be more reason to be concerned about the potential toxicity of an untested drug compared to virus-specific antibodies.

    I find it impossible to fathom that no one asked Dr. Khan for his opinion about trying the available ZMapp.

    I also am somewhat mystified by this statement in the article:

    "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."

    I guess it's just intended to mean "less was known" in that it hadn't been given to a human yet? Because just as much was known otherwise (i.e. the published studies).

  18. Yeah, everything you said. I can't believe if they had this cocktail in hand they would NOT have given it to Khan. Regardless of his virus titers, there is NOTHING to lose in this situation by giving it to the doctor/patient, unless, of course, you just want to save the cocktail for the white patients.

  19. I don't understand the molecular biology of this therapy but if they had asked Dr. Khan for an opinion would it then have been possible to not concur with that opinion? If so, the doctors would not have been the ones making the decision and they would be rightly criticized for that if died( and should be even if he lived). They were in no position to withdraw from the case and turn his car over to him. Yes, its a situation of damage control. But with the high probability of Dr. Khan death regardless of treatment, the implications to treating other cases should be considered.

  20. It is not clear to me as a physician, if the drug was available, why the patient was not asked whether he would be willing to take it. As long as he was mentally competent, he was perhaps more qualified than anyone else, to make the decision. When we are so careful today to not disenfranchise patients or be paternalistic, and we offer so many therapies that are experimental, and possibly dangerous, this decision is hard to understand. The suggestion that the decision was influenced by its effect on public perceptions is particularly troubling, if it led to putting politics above ones own patient.

  21. Your analysis implies a decision making environment where there is the time, organization, and infrastructure available for thoughtful, ethically guided decisions. In a US hospital you would have an ethics panel already in place, cognizant of the types of issues you raise (patient autonomy versus parents patriae, e.g, the health care provider as parent). But managing such a decision in a highly volatile west African treatment environment is a totally different situation. And the local ethical ethos - great suspicion of western medicine with resultant avoidance of life saving care - has to be considered. We once had a patient in cardiac arrest in Dakar - had to go to 4 different hospitals before we could find a CCU bed - doing compressions in the back of an ambulance the whole time. It's an incredibly austere treatment environment - so trying to apply the type of analysis you suggest is much, much more difficult. Decisions are made on the fly with the best data you have available at the time. That's just how it is.

  22. Your anecdote doesn't seem comparable. As many posters have said, a patient-centered response in which the doctors merely asked the Dr. would have been highly appropriate.

    Dr. Khan was accustomed to practicing and making decisions in the situation you describe. The environment makes little difference, really -- unless they were all in a panic. And perhaps, to some extent, they are and have been.

  23. I agree it seems that asking the patient whether he was willing is necessary. But only after the decision was made to recommend administering the drug. You shouldn't ask a patient his opinion on somethig you don't recommend. And in this case, because the patient was an esteemed doctor, asking him first would make it very difficult to then decide not to administer the drug. The issue here is who is responsible for the treatment, the doctor or the patient? I think, its the doctor.

    and because of the political situation, if the patient had asked for the treatment before the doctor's decision, and later died, the doctors would have the problem of saying he wanted it though we weren't sure he should. Since the patient can't corroborate the doctor's statement, there is a reasonable doubt how informed the patient was. As it is, the doctor's take sole responsibility for the treatment and so no accusation of coverup is possible.

  24. From what I understand the Ebola virus is anaerobic (ie cannot survive in the presence of oxygen). If this is true, then would it be worth a try to attempt some simple oxygen therapy? I believe there are a number of choices: from expensive exquipment such as hyperbaric chambers or decompression chambers (Mayo clinic offers hyperbaric oxygen therapy) ... to relatively cheap ozone generators ... to even cheaper hydrogen peroxide.

  25. The term "anaerobic" has no meaning when applied to a virus, which, unlike bacteria, never lives on its own but takes over a living cell. You are an example of some one who knows next to nothing but is willing to give the world the benefit of pure speculation as if it is wisdom.

  26. No doubt too good to be true. If this would work they'd be using it right now.

  27. "The term "anaerobic" has no meaning when applied to a virus, which, unlike bacteria, never lives on its own but takes over a living cell." Thank you for this part of your response. Because I am asking a question (not pretending wisdom), can you or someone who reads this give a reference that would elaborate on what you write? I understand that oxygen reaches every cell in the body. I also was under the impression that some oxygen therapies are under compression or ingested or injected so that they will reach cells efficiently. I am curious and appreciate any useful information. Thank you for your kindness.

  28. Now that we're learning more about the distribution of the ZMapp doses, the need for ethical guidelines is even more apparent. A dose got sent on behalf of a seventy-five year-old, but was not given to Dr. Khan, who was thirty-nine? And the decision was made for him, and not with him?

  29. The endless hand wringing over whether the first recipients of ZMapp were white, black or brown truly misses the point.

    One reason for Ebola's relentless spread in Africa is the lack of running water in individual homes, and the lack of indoor plumbing in many of the affected areas. For example, a recent news article profiled health workers who, before educating people about the importance of hand washing, collected rain water from a roof gutter to fill a demonstration tub. Also, a number of articles have discussed communal water taps. Until individuals have ready access to the easiest way to kill the Ebola virus (hot water and disinfectants), the virus will continue to be a common killer.

    The administration of ZMapp is a very small part of the story, and until people focus on the public health aspects of the story, we will be perpetually bombarded with alleged scoops about the supposed politics about distribution of ZMapp. If only a fraction of the money, time and energy spent on worrying about nonexistent racist overtones were actually refocused on the actual health problem itself, perhaps medical containment could be achieved.

    If ZMapp had been administered to the African physician, and if he had nonetheless died, similar conspiracy articles would have been generated about using Africans for experimental drug treatments. Although I greatly respect this individual reporter, this focus very much barks up the wrong tree, looking for a conspiracy where none exists.

  30. What a terrible, terrible decision to have to make. Unfortunately,this was the only possible decision. It has nothing to do with politics. Dr.Khan was known throughout the country. The population was already suspicious of the doctors, assigning to them responsibility for the deaths that were occurring. One can only imagine the negative impact on the efforts to control the spread of Ebola if he had received the antisera and died. My heart goes out to those who had to make this decision; and, of course, also to the people in the affected countries.

  31. But wait: now we have the negative impact of Dr. Khan NOT receiving the antiserum, and dying. What a disaster for Doctors Without Borders. They look like heartless people who cared more than a bit too much about politics in this life-or-death situation.

    Dr. Khan, of all people, should have had the option of learning about the experimental medicine.

  32. Maybe doctors need to remind themselves that no matter how much they and they public may wish to consider them closer to God than others, they're still just mortals regardless despite that perception. They're doing no one a service, especially themselves by actually falling into that trap of delusion.

    Let them stick to dispensing the knowledge and experience that they acquire as effectively and humanely as they can, but let them leave the raising of the dead to something else that's better suited to do that, and drop all the second guessing. If anything, going down that path may make them worse at what they're capable of doing out of future fear of not being able to live up to their assumed deified stature instead of focusing totally on their patient, who's not expecting them to be a god, just a good doctor.

  33. And just how, pray tell, do these ethicists wish that this drug be tested? With patients artificially administered Ebola in a clinically controlled setting?

  34. It was an grotesque violation of elementary ethics, basic humanity, and common sense for the physicians to make this decision without consulting their obviously informed and obviously competent patient.

  35. I'm unpleasantly surprised they didn't include Dr.Khan in their deliberations about whether or not he should receive the drug. They should have received his input. If necessary, he could have addressed their concerns about fallout from a failed outcome by agreeing to confidentiality with regard to his treatment.

    It doesn't look good. The other doctors got it, he didn't.

    I'm sure this recollection of events isn't entirely voluntary, but inspired by questions from Dr. Khan's family who know the drug was instead sent off to foreign doctors.

  36. I am not a medical specialist but it sounds like the risks of the treatment were not greater than the potential benefit, and the team on the ground made the wrong decision. It happens. That said, the team on the ground are also doctors risking their lives and working crazy hours in pretty horrific conditions to save as many lives as they can, certainly more than any of us sitting on our computers and reading about it are doing.

  37. But the thing is that no one knows whether the risks are greater than the benefit. It did not kill two people, who were given the drug after the decision not to give it to Dr. Khan. It was a dicey call, and one with potential implications both political and healthwise. It's a shame that he couldn't be transported to Switzerland, but I guess we can understand the thinking of the transport company too. Terrible decision to have to make about a terrible disease.

  38. No one should imagine that the fact that two patients given the drug (and other treatment) have survived is proof of the efficacy or usefulness of the drug. The drug clearly didn't kill them on the spot, and that is about as much as we know. Whether it might harm or help others who have not received it is still unknown.

    Many people are familiar with approved drugs that have been shown to work, and have less exposure to drugs that harm or are ineffective. Sadly, this is the case for many early candidates. Two or three patients are just not enough to be informative about whether someone else would have had benefit or detriment from treatment with this one. Dr. Bausch may be an enthusiast, but he may also not see all the drugs that fail.

    I don't know who exactly should get these drugs, but they should get them as part of a randomized trial so that future patients will have real information about the good and bad of each therapy. The real waste is to fail to learn everything we can from the first patients. The tragedy would be to treat a bunch of patients on some ethical protocol and to fail to learn whether the treatment helps or harms.

  39. The Spanish priest died after receiving ZMapp. A totally experimental drug.

  40. It makes far more sense to prioritize treatment for medical providers, whatever their race. Not to do so reduces the number of highly trained caregivers available, and perhaps the willingness of caregivers to put themselves at risk. Hospitals have closed for lack of caregivers.

  41. It is important to realize that there are a number of situations in which enhancing the immune response to an infection is harmful or lethal - certain forms of leprosy, tuberculosis. gram negative septic shock etc. Administration of anti-endotoxin monoclonals to septic shock patients increased mortality. Testing of drugs is done to decide whether the logic that lead to the development of the drug is correct or incorrect. Sometimes it is incorrect.

  42. any of the infections you listed are viral, and not bacterial?

  43. Antibody-mediated enhancement can happen with some viral infections, such as Dengue, and has been reported (seemingly mostly by one research group) for certain antibodies against Ebola in laboratory culture experiments (e.g. http://jvi.asm.org/content/75/5/2324.abstract). So it's certainly a valid concern. However, the antibodies being studied as Ebola therapies do appear to have a proven track record of neutralization of the virus (as opposed to enhancement) and the monkey study results are consistent with those results.

  44. My understanding of triage during, say, a flu pandemic is that doctors and nurses get vaccinations first so that they may contribute their work to limiting the effects of the pandemic. If they were lost or decimated, then the effectiveness of containing the pandemic would be greatly diminished.

    Seems logical that Dr. Khan should have been given ZMapp. The other factor: he had, what? a 90% chance of dying untreated.

  45. The goal of triage is to save as many people as possible with limited resources. Doctors believed that Dr. Khan's viral levels were too high for ZMapp to work. Giving it to him would have wasted one of only five doses of a potentially life-saving treatment. In triage, you prioritize the patients who you can do the most good for -- which sometimes means not trying to save those with a small chance of survival. Sometimes that can seem heartless and cruel, but it saves lives.

  46. Three doses are recommended for ZMapp protocol.

  47. If the doctor, Sheik Umar Khan, was such an expert in the field and in this particular outbreak, he ought to have known about this treatment. He also ought to have been consulted.

    This article does not actually say whether or not he was asked. It does not actually say that timely arrival and use of the treatment was actually possible. That it was available later in another country far away is not the same thing. An intense drama is suggested, but not exactly shown.

    Another way to discuss this is, where and how is it best to fail with an experimental drug? Which is worse, fail in a media glare on a national hero, or quietly fail on a couple of unknowns on the far side of the world away from the media?

    It could have failed. Many do. As I understand the odds, most first human trials have serious problems of failure or side effects, which is why it is such a big step.

  48. "This article does not actually say whether or not he was asked. "

    I think It does ...

    "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."

  49. Ebola is the best disease for trying an untested treatment. The chances of dying are very great. There is a possibility the treatment may help. On a case by case basis ask if the patient or the family will give consent. Keep track of the degree of illness of each patient and the outcome. This is a perfect way to get the patient trials necessary for approval. The patients don't have anything to lose and possibly everything to gain. Most people faced with probable death will be willing to try the untested serum because they hope it will give them a chance. Testing it in Africa is certainly better than bringing two missionaries with Ebola back to the US and offering them the serum in a covert operation. Let the FDA oversee the trials and possibly save the lives of Africans with Ebola. At the same time they can gather data for final approval or rejection of the serum.

  50. But there aren't enough doses to have an adequate trial.

  51. A clinical trial is done in multiple phases and is controlled rigorously. The FDA has no jurisdiction in Africa.
    What covert operation?

  52. I think it's obvious that they did the best they could. Hindsight is easy, especially for people who don't have to make the hard decisions. To blame those stuck in an impossible situation but just trying their best to do the right thing is arrogant and ungrateful. If they'd given the drug to Dr. Khan and he had died anyway what would the accusations have been? That Americans are reckless with their drugs?

  53. Given a disease with certainty of rapid death there is nothing to loose trying an experimental treatment.

  54. You are so right!

  55. USA pledged $184 million in foreign aid to Libera in 2013. Sierra Leone, nearly $100 million. Now they're demanding we manufacture and send them doses of a drug that isn't even approved for use on Americans. Anything else we can do for you, your majesty? Maybe we can do them a favor like Obama wants to do for the Hondurans and grant them "refugee" status?

  56. They REQUESTED available supplies of the drugs/treatments.

  57. Shocking that the patient was not consulted about this treatment option.

  58. I will listen to the comments of anyone that is on the ground volunteering with Ebola patients.

  59. Andrew I think it might be easier to listen just to the opinions of the people on the ground, than it would be to consider those of the world's best medical, bioethical, pharmaceutical (and all the other) professionals — the ones with the most comprehensive experience in research and treatment of Ebola; but I don't think it would be best. The decision on how to best distribute a cure for a terrible infection is hard. The decision on how to best distribute a small amount of an experiemntal treatment is even harder.

    To me the real fulcrum of this piece is the opinion of Dr. Khan on whether or not Dr. Khan would want to take an experimental treatment. He was given no choice. I do not understand if the decision to give Khan no choice was a medical, cultural, racial or political one. I would bet on "all of the above," but I'd like to know more.

  60. This is an insolvable problem, and that's why we have clinical testing. Only in hindsight does it look like giving the drug would have saved Dr. Khan, but it could just as easily (or likely, for that matter) have resulted in a provably adverse reaction which would have killed him. Can you imagine what *that* would have been spun as? "Western doctors give unproven medication to African guinea pig who dies."

    We go through super rigorous trials for medications precisely because there are few silver bullets that have zero side affects, never mind being efficacious for the purpose it is intended. With so little clinical data this may as well have been resolved with a coin-flip -- you simply have not enough data and the stakes are too high to even think you can rationally and justifiably settle on an answer to the dilemma that withstands scrutiny or hindsight bias.

  61. They're playing games with Ebola. It isn't measles. The odds are that he would not have recovered (as he didn't!!) from the disease. At least try something. But that's the "western" philosophy - ask the African doctors what they would have done!

  62. Actually, ZMapp would probably not have saved Dr. Khan, just as it did not save the Spanish priest. His viral levels were just too high. In hindsight, witholding the drug from him saved one more dose for a person with a higher chance of survival. Perhaps another person will live because he died.

    In the moment, though, I agree that this decision was impossible. Sitting in the comfort of my living room with the benefit of distance and hindsight, I can argue that witholding the drug was probably the right call. However, sitting next to a dying colleague trying to make a decision without any way to predict the outcome -- I would not want to be that doctor.

  63. It seems that the greatest concern of the so-called "ethical" treatment team of Doctors Without Borders and the World Health Organization began their deliberations with the premise that if the drug failed and the patient died then there would a political price to pay for "killing' a national hero. Instead of going pubic, and trusting the sick doctor, his family and general public with good information up front about the possible good and bad consequences they decided not to even tell the patient. They kept their deliberations secret.
    The result of this archaic, faulty and absurd reasoning may have cost more than just the life of a prominent physician. What is now lost is public trust that in the future more secret and untried drugs exist and are being kept from the public domain. And the secret is being kept for political reasons not medical or ethical considerations. Had the public known that there was a possible cure even at the risk of death would they have truly rejected use of ZMapp? We all know the fatality rate from Ebola. Wasn't it worth one admiral life to allow a chance for life no matter how slim?
    What other medical secrets are out there? What other drugs are being tested or not tested because of politics or money? This death begs the questions what else is avoided for fear of political repercussion? How many others will suffer and die unnecessarily while there are possibilities, even slim ones, that can save the lives of thousands? Ethics?

  64. Yes, but the fact that a dose of the drug was available was kept secret from Dr. Khan and his family. Thus, Jay makes a valid point that other patients may now suspect that there is a treatment that could help them, but that they are not being informed about. I understand that increasing mistrust of the Western medical establishment was what Doctors Without Borders wanted to avoid, but they may have done just the opposite here.

  65. Richard Manhattan 6 hours ago = Thank you for pointing out that the studies were published and accessible. I read a great deal, but not not those publications, however in the future they are now on my most important list. In Sierra Leone and other African nations how many people in small villages would have known of these studies? At least here we have a chance to find out. But, this still begs the question why make the research public and allow choices? Who truly knew that this was under consideration save a privileged few?

  66. Administering an untested drug is an unmeasured risk. Having Ebola is a measured risk, and an extremely high one. Based on the chronology of the Times account, withholding the drug is not irrational. But failing to discuss the option with the late Dr. Khan is disheartening. He may well have weighed the risk of his own life against the potential salvation of other lives. In other words, he may have chosen to be an experiment.

  67. I propose a 2 sided test, anyone can do this in a spreadsheet.

    1000 trials of Blacks (Africans and otherwise) no antibody intervention.
    X + 3 known trials of Europeans (continental and otherwise), 3 known antibody interventions.

    If the NYT reporter can tell us X (zero?) excel will tell whether these have been shown to be two distinct populations, and produce the probability that they are different.

    If they are different and the probably is significant, you can treat any justifications (such as severally offered by subjects in this article) for any results of any individual trial that conforms with its population as noise.

  68. It's been acknowledged that the experimental drug developed and made in America was not specifically put aside for future use by citizens of America. That said, the lives of the two American missionary workers were certainly no less valuable than that of any of the other human beings suffering with ebola, and the missionaries were actively devoting every resource available (physical, mental, emotional, financial, etc.) to attempt to help those most in need--free gratis. For God's sake, please stop apologizing and/or offering uncalled for, asinine excuses to the American public and to the rest of the world for daring to save the lives of two freaking American citizens with the technology and expertise of their own darned country. It's absolutely absurd.

  69. 1. They had a good reason not to use the untested drug on the local hero with an uncertain outcome.
    2. Point most people who scream "Racism" don't get. The west does NOT have to provide anything to Africa. Whatever is provided is provided at our expense, is an act of good will, and is something the receiving party should be thankful for.

  70. I disagree with you. We have a duty to help our neighbors, be they here in the US or a little further away, in Africa.

    And you know what else? The comment that "the receiving party should be thankful for" help that it's morally imperative to offer shows what is wrong with the whole idea of "charity."

    It's a way to make the giver feel good and the receiver to grovel.

  71. It may be more blessed to give than to receive but it is still up to the giver and not up to you.

  72. Providing the chance for Dr. Khan to receive the medication is more than an act of good will. It doesn't only benefit him, it benefits us. The world is becoming smaller and smaller with air travel and it's not uncommon for Americans to travel abroad or for others to travel to this country. That means infectious diseases can be spread at a faster rate and wider area than in the past. Dr. Khan was a physician experienced with Ebola; if he had lived, he might have provided the US and the rest of the world with knowledge gained firsthand. Your comment is redolent of short-sighted selfishness.

  73. It's a necessity and we must rise above politics and everything. As we know, more than a thousand are already gone. At least the Doctors wjo got infected during treatment of Ebola patients should be given their drug though not tested before and that risk can be taken for the shake of humanity.

  74. Hesitate, hesitate, hesitate. If he had Ebola you treat him. Period.

  75. This epidemic is the perfect opportunity to run a controlled trial to test if it works. If there is enough of these drugs, we should inform people of the risks and then start monitoring who gets better. Perhaps, it would provide the definitive proof on whether they can save lives, and if so, which ones?

  76. What no one seems to be acknowledging here is that there is no vast supply of this experimental drug. The few available doses were made in a lab, not a manufacturing facility. "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." There is no ZMapp left so everyone suggesting that it be used now is not paying attention to the facts of the matter.

  77. That was an incredible decision. How could these doctors decide not to give the treatment due to the danger that the drug might do harm to the patient. They took their chances with Ebola. Ebola forgives nobody as shown by their choice.

  78. I remember reading that the American doctor who got ZMapp also received a unit if blood (which would contain antibodies) from one of his patients, a young boy who recovered from Ebola. Perhaps this blood transfusion and not ZMapp is the reason he survived. Also, this treatment could be made more widely available.

  79. The drug seems to have worked on several patients. Its balance of electrolytic enhancement, immune boosting and transportation of oxygen throughout the body are seem to be the perfect combination for ebola patients.

    Hopefully, it continues to go well for them.

  80. You may be thinking of a different drug.
    ZMAPP is a mix of monoclonal antibodies against Ebola proteins. Its mechanism of action could be as simple as neutralizing the virus by binding to it, interfering with its life cycle. Its likely buying your body the time it needs to mount its own productive response. Electrolyte management and transportation of oxygen are not related to an antibody treatment.

  81. Then why was it not given to Dr. Khan ?

  82. Because of hte fear that it woudl make him worse. It has not been tested on enough patients to know.

  83. Dr. Sheik Umar Khan - a true hero. Peace to his memory.

  84. Here are hard choices.

    A disease is contracted with a high fatality rate, so let’s assign a number that is scary but not without hope. Pick 60% as a fitting number.
    If you do nothing, 6 out of 10 will die while 4 survive.

    Let’s look at an experimental treatment that has not be tested in humans. Tests in other animals suggest humans might benefit. No likelihood of outcome can be assigned.

    Who should be the earliest recipients in an emergency? Flip a coin? Look at demographics of the stricken and pick a member representing the largest group? What about a person whose medical history is well known, but has a skin pigmentation different from the majority of victims?

    If there is only a small amount of the experimental drug available, would it not be better to use it on a person better able to describe her or his experience and whose health status is well known?

    If there is a larger supply available, use it on as many as possible. Those who are unavoidably not inoculated will be the control group. If you have doses for 20 and 40 need the drug, then 20, no matter how that horrible decision is made, will not be treated. As far as anyone can predict, the 20 untreated might fare better.

    When all choices are bad, do whatever good you can the best you can.
    When all choices are wrong by some viewpoint, do your best from your view, and record the results. Learn from it.

  85. The road to hell is paved with good intentions.

    But here, even the good intentions were tinged with paternalism.

    "...it was a close call and that he respected the decision of the doctors on the ground."

    How could they not have consulted the patient, himself a leading doctor on the ground?

    Another sad chapter in the history of paternalistic Europeans making décisions for their African counterparts without the latter's knowledge or consent. The road to...

  86. It was a medical decision made more by political concerns than by science.

    It was a medical decision made more by committee than by the best doctor.

    It was a medical decision made without the knowledge or consent of the patient (who could have been that "best doctor").

    In short, it was the worst kind of medical decision.

  87. The irony is two-fold:

    - it was *because* Dr. Khan was African that race entered into the equation at all;

    - the doctors hoped to avoid racial politics, yet it was *because* they viewed Dr. Khan first of all as "African" above all else that they put themselves into an ethical dilemma of their own making.

    At the end of the day, these doctors could not see beyond Dr. Khan's skin color or ethnic origins; they could not see the man, they could not see the MD, they could not see the prominent physician with as much experience and expertise as themselves.

    I doubt any one of them would have hesitated to take the drug himself.

  88. Of course, NEITHER of your two-fold points is supported by information in this article. Furthermore, the article implies that Dr. Khan's race and nationality were not factors in the decision.


  89. I amend my previous commment.

    While the article does not imply that race was a factor in the decision to not use the drug, you are correct that the desire to avoid potential in-country accusations of the drug CAUSING his death was the core of their dilemma.

    And, upon reflection, I do see the irony — that their objective to avoid a political backlash actually contributed to the current controversary.

  90. The decision should have been Dr. Khan's and MSF was wrong to withhold the information from him.

    If a choice must be made, there is good reason to give first refusal rights to medical personal who have risked their own lives to save people, no matter what their country of origin.

  91. Like most of the media fuss about drugs for Ebola infection this piece is blind to the fact that none of these drugs have been shown to be effective and their adverse effect profile in humans is completely unknown. Pretending that there is an ethical issue about not trying to administer any of them to Ebola patients is hardly an ethical issue. It may be justifiable as an act of desperation, but that does not mean they are of any value or that they ought to be more widely available at this time. Tough but those are the facts.

  92. If there was nothing more that could have been done to save Dr Khan then he should certainly have been given the drug as there would not have been a downside in those circumstances.
    Putting aside all the arguments over whether the drug should have been administered, one can only admire all these amazing people who voluntarily put their lives on the line to help others. Selfless and truly inspirational.

  93. There was a downside, mentioned in the article, that if the doctor died after taking ZMapp and word got out to the public, given all the misinformation, mistrust, and lack of understanding of how Ebola is spread, that news could be fatal for efforts to control the disease, and would raise the level of mistrust of Western health workers. That being said, I agree with Dr. Bausch that Dr. Khan should have been given the choice, and that he would have been the best person to understand all the implications of taking or not taking the drug, not only for himself, but for the community.

  94. I feel like a lot of commenters believe that ZMapp is a miracle cure. It's not. There's only been two studies done on it, both using small numbers of monkeys. All of the control monkeys died, but survival rates for the monkeys given ZMapp increased the earlier they were treated.

    In the first study, they gave ZMapp within minutes of exposure to ebola and all of the monkeys survived. This is an extremely idealistic scenario.

    If the drug is given 2 days after exposure to ebola, survival drops to 50%. If the drug is given as soon as clinical symptoms appear -- still very idealistic -- survival rate drops to 43%. The drug must be given over a nine day period to be effective, which is why giving it early is so important. Unfortunately, the drug must be kept at sub-zero temperatures and allowed to thaw over a period of 8-10 hours, which will further delay treatment. It's also going to make treating rural patients very difficult.

    At best, ZMapp might improve the odds for an ebola patient. Even if it were widely available and effective, ZMapp's not going to stop the spread of this disease. Right now, the most life saving treatment is prevention. It's the only thing that will stop ebola, now and in the future. Right now, focusing on an unproven drug is nothing but a distraction from the real work of saving lives -- the work that Dr. Khan died doing.

  95. When confronted to a lethal disease such as Ebola, patients, once informed thoroughly, ought to have the right to be used as guinea pigs. If nothing else, it would make them feel hopeful and helpful.

  96. Doctors have been too overconfident here in the Ebola outbreak. They say that they know how to control it; just avoid touching infected bodies and their fluids. But the problem is? This is extremely hard for ... nurses and health care workers.

    The fact is the Ebola outbreak is doubly dangerous ... because it targets precisely, health care workers.

    (Many of whom are careless about such things. And as more die, fewer capable ones are left.)

  97. That's why healthcare workers need proper supplies. PPE's( personal protective equipment) are vital. They're not careless. They had never dealt w/ Ebola in W. Africa before. They didn't know proper procedure or diagnosis techniques. The doctor's aren't overconfident. They realize they have a major epidemic to deal with.

  98. The cordon by itself is inhumane. Food, clothing, sanitary supplies and drugs (especially opiates and anti anxiety drugs) should be sent. Also radios, batteries, solar lights, lamp fuel and other survival and comfort items.
    The people within the cordon must feel they have contact with the outside world. They need to be instructed to quarantine themselves into smaller family units within the cordon. And they need a structured way to receive supplies. They need entertainment and pastimes to help them cope with the stress.
    The hardest question for all of the people will be how much care do they want from their own families when such contact can mean contagion of their loved ones.
    If survivors exist they can be paid well to give aid to others. They will be immune. The question is, in a survivor, how long does it take for the body to clear the virus?

  99. Dr. Khan's passing away during the Ebola outbreak will remain a sad incident. The complex ethical guidelines and political correctness are at times a hindrance to protecting public health. The speculation of whether or not ZMapp would have saved Dr. Khan makes little difference now. If he had received it at a late stage and not saved him, the drug would have been considered non effective. Also the drug cannot be credited with saving the lives of the 2 Americans who received it or can be credited with saving their lives for receiving at an early stage which would be optimal for any treatment against the fast growing deadly virus. At least now there is a standard of care established of which the ZMapp is a part, which can improve the survival chances of a person with Ebola infection. The death of Dr. Khan raises a number of issues on the over bearing regulation, influence and oversight by global organizations that can short circuit good medical practice at a local level. Dr. Khan had one life to live while serving poorest and diseased patients and the decision whether he lived or not should have been left to him and not to organizations who did not have all the answers. If I had the opportunity to be around Dr. Khan when he first found out that he maybe infected by Ebola virus or even likely to be infected by Ebola virus which had a higher probability in his case, I would have suggested he consider options backed by sound science and include natural broad spectrum antivirals.

  100. Please cite the studies involving "sound science" that have demonstrated efficacy against Ebola using "natural broad spectrum antivirals."

  101. What charities are best for sending money for helping the people within the quarantine areas?

  102. ZMapp does raise ethical questions. For example, what are the medical ethics of not providing proper medical care to Americans before we run out to the rest of the world with 50 health care workers from the CDC?

  103. The 50 workers from the CDC aren't involved in direct patient care. They coordinate and do data base management. They're also training groups for
    contact tracing.

  104. These CDC resources could be used in this country. For example. whooping cough is making a comeback here because our public health infrastructure for inoculations is faltering.
    Or, here in the US, 35,000 people die from gun violence every year. Or tobacco? Or auto deaths on the highway. (Need I go on...)

    Why isn't the CDC all over this? Well, they've gone off to Africa.

  105. We can't assist in a public health crisis because we haven't solved all our problems at home? That hamstrings us until the end of time! I mean, I understand your frustration about our crumbling infrastructure and violence, but 50 people for an acute crisis with potentially worldwide implications doesn't seem like a whole lot of resources. Our political problems won't be solved by not helping during this crisis. We can find 50 people for this.

  106. I'm confused. From what I was first told, Dr. Khan refused the medicine, wanting it to go to others instead of him. Why has this changed here?

  107. That wasn't Dr. Khan. He was never given the choice. Dr. Brantly asked that it be given to Nancy Writebol first.

  108. This is a doomed if you do and doomed if you don't issue. Had the African doctor been the first to be given the drug, and died afterwards, ZMapp would have been accused of using an African human being as guinea pigs. Ebola is a deadly disease. The only hope of survival is this drug. It appears to have worked on the two American health workers, but not on the Spanish priest, who died. However, we do not know the details of how and when it was administered. The age of the Spanish priest could have also been a factor. This is a run against time and a deadly disease, and risks have to be taken. Stating that a group is benefiting over another will not help to get a cure. Someone has to get it first. It has to be tested in someone first.

  109. I have read that one reason Ebola is so lethal is that increases vascular permeability leading to dangerously low blood pressure. There are drugs that can reduce vascular permeability including melatonin and NSAIDs. Have these been tried for helping Ebola patients?

  110. I am very surprised to read such a story in this time and age. Has no one learned the lessons from rights activists during the AIDS epidemic? Patients prefer and demand aggressive, experimental, treatment, when he is almost certain to die and where this death is painful and horrible.

    Whom we have not heard from in all the media is ebola victims' rights activists. What we need is an ACT-UP of ebola to counter the dominating voice of international health organizations.

  111. Yeah, those dictatorial international health orgs.

    Medecins sans Frontieres, WHO, CDC, USAMRIID, Red Cross, And so on--they're where the problem is.

    Good lord.

  112. There are many misguided comments here, most of them based on the assumption that the drug is effective and would have saved the doctor. There is no reason to believe this; it simply hasn't been tested. I hope that one day its effectiveness can be shown. The best reason for not giving it was the concern about using Africans as guinea pigs. Whatever the level of validity of this position, I do wish they had given the patient the opportunity to make the decision. He might have lived or died, but either way, we would not find ourselves in the kind of discussion that is reported in the article.

  113. We don't even know if Dr Khan was competent to make an informed decision.

  114. I'm puzzled: the question being asked is "why didn't they give the drug to the West African doctor"? Why is the same question not asked of the population? Why is it ok to distinguish doctors from patients, but not Americans?

  115. This is a stupid question. The drug was/is experimental. Untested on humans. You don't just go test drugs on a general population, especially not a population of vulnerable people who may not be very well educated. To try a new drug there is the need for informed consent. U.S. workers were in a better position to understand the consequences and to give informed consent. In effect, they were willing human "guinea pigs". Also, the drug was a U.S. developed drug and, as such, if it were used on Africans without prior human testing it could ignite a firestorm of anger if the patients dies after use of it. Better to try it on well-informed U.S. citizens who understand the consequences of taking an untested drug. What is needed in Africa are better sanitary facilities and basic care and protection for workers and isolation of patients. Also, proper disposal of contaminated materials. The WHO is trying to clear the air on this by saying basic facilities are needed to care for the ill. There is no magic pill.

  116. I agree with the opinion that health care workers should be given first priority when deciding to whom to give any drug that could help cure Ebola. They are the ones who are putting their lives at risk to help others. If not for the health care workers, who would take care of the general population.?

  117. In an outbreak like this emotions do not matter or fairness or trust or anything really. It comes down to who is at the right place at the right time to receive needed treatment. If this disease hits here there is not way to we will handle it. When it started in December is when action should have been taken to contain it. Now it may be too late and emergency efforts are underway. The dismay and disagrement will continue. This could be the world pandemic we have been warned against and it is up to our Government to protect our country.

  118. This is an ethical issue that needed to be dealt both privately and publicly. Privately, between the patient and his/her doctors as they were going into an uncharted territory with a drug of unknown effectiveness. What transpired is unknown to us and should be left out of public debate. The public debate is however the implication of giving a drug to a patient in Africa without adequate trails. It could lead to more harm then help and could further hinder efforts to contain the epidemic. We cannot ignore that in some villages they felt that Doctors without borders were actually spreading the epidemic. This is a brave fight with limited options by many dedicated individuals and although they may have made some mistakes it is clear that almost all of them were unintended and it is best we keep politics out of it. We should focus on how best to help them as they need a lot of help from us.

  119. Sridhar Chilimuri, you are so correct. This is one of those situations where, if Dr. Khan had been given the untested drug, and if then, he would still have died, those who used the untested drug on him would have been accused of using him as a human "guinea pig" and, thereby, killing him. It would have been a firestorm of a nightmare. Using the drug for the first time on U.S. workers diffuses the blame if the drug does not work. Also, if the drug had been used first on Dr. Khan and, due to the advanced stages of his infection, not worked, then, the drug would have been shelved for all time, perhaps. Maybe the drug worked on the U.S. workers, maybe it didn't. Maybe what worked was quicker recognition of the infection and better care from the outset. But, now the drug has the chance to be tried again. For certain. what is needed for any and all outbreaks of any disease in Africa and throughout, is better facilities for basic care and isolation, sanitation, and proper preventive measures for health care workers. Without proper equipment and basic facilities nothing can be done to help contain this or any epidemic.

  120. If you know anything at all about Doctors Without Borders, you would know that the people there care more about saving lives than anyone in the world. They are the ones with their feet on the ground in the places with the worst health conditions imaginable. I saw them in action in 1994 during the cholera epidemic in Rwanda and Zaire. The selflessness of the doctors, nurses and aid workers was astounding. DWB (MSF) would never allow anything but the health of a patient to be the guiding principle of whether to give an experimental drug or not. I hope that everyone who reads the article, and those who have commented, realize that DWB's main goal is to save lives. They probably have more resources in Africa than anywhere else in the world. It is sad to think that MSF might end up with a soiled reputation because of this. I am certain that the people involved in the decision are tortured by Dr. Khan's death, because they will never know if ZMapp might have saved him, or if given the drug, might have killed him. They were in a doomed if you do, doomed if you don't, scenario. I feel for them, Dr. Khan and his family. You can speculate whether ZMapp might have saved him, but there should be no doubt that the people at DWB wanted to save his life.

  121. I agree with you that they did what they felt best for Dr. Khan but I really think that the risk benefit ratio favored treating Dr. Khan. Perhaps it's easier to say this in retrospect, but his chances without the treatment were not great and if the treatment failed, they would have known that they tried everything possible.

  122. Was Dr. Khan in any position to say what he wanted, or his immediate relatives? If certain death was a real possibility then the people who opposed using this drug were playing God, and were dead wrong.

  123. There is a percentage of people who survive ebola. We don't know if the 2 Americans who got zmapp were helped by it or would have survived without it. What I don't understand is what's holding up production of a potentially life saving drug.

  124. "We were willing to try anything,” said Dr. Khan’s sister, Umu Khan. “It was not right; we should have had a say.”

  125. What did they have to lose? The disease was highly lethal with conventional therapy therefore the risk benefit ratio favored the experimental treatment. I don't get what they were thinking. R.I.P.

  126. The decision was political only in the sense that there were fears that should Dr Khan die after receiving ZMapp, it could have been considered as "testing" the drug on an African. "...(T)he already fragile public trust" was at risk. And that public trust was what they had to lose. rini10.

  127. You're likely right. It's sad that this concern took the choice away from him, though.

  128. Doctors Without Borders and the World Health Organization, the organizations to which Dr. Khan's treatment team belong, have shouldered the daunting responsibility of taming this out-of-control ebola epidemic. Their actions and decisions directly affect the people of the African nations already involved and also worldwide health — as well as the fate of Dr. Khan, the immediate focus of this article.

    For that reason, I contend that simple "politics" was not part of the equation as the doctors weighed their complex decision whether to treat Dr. Khan – their colleague and friend. If they give him the drug and he does not survive, the real risk is not political; rather, it could impede the effectiveness of the whole multi-nation ebola control operation, should the belief spread that their organizations make the situation worse. It's not just that their organizations would look bad, ultimately it could cost hundreds of lives, or more, if at-risk populations are less cooperative with epidemic control regimens.
    Also, remember that back when they made their decision, there was no clinical evidence of humans surviving ZMapp.

    And, as several comments point out, while this topic raises a possible question of ethics, the question is academic because only traditional epidemic control procedures will be the solution. Not only is the safety and efficacy of ZMapp not proven, currently it's made only in a lab, with zero prospect of manufacturing it in useful quantities.

  129. For the life of me, I do not understand the posturing and agonizing over who get's to receive a vaccine that in fact does NOT YET EXIST!
    Who should receive a vaccine when it becomes available the very FIRST people to receive it should be the Doctors, Nurses, and health care professionals who have the task of dealing with the ill.Next in line should be the Mother's with children, after that, I don''t know, and just hope that by than there will be sufficient vaccine for ALL to get taken care of.

  130. There are numerous issues identified here as part of the decision not to treat Dr. Kahn with Zmapp. Personal, medical, social and political factors included in this decision.

    Not mentioned is that the Ebola crisis won't be resolved by individual treatment decisions but by addressing PUBLIC health issues. Local people are reluctant to go to medical facilities and medical personnel in local communities are believed to spread the disease. Cultural practices increase exposure to the virus.

    There are always cultural, political and resource factors in public health decision making that affect hundreds or thousands of people. Changing behavior while respecting cultural norms present the ethical questions. Decisions regarding an unproven drug available in minuscule amounts will always be arbitrary.

  131. Doctors are heroes certainly! But they are hostages of the situation also. In my opinion the virus has spread because of the ambitions of pharmaceutical corporations. They want to get super profits from the sale of anti-virus.

  132. When you're up to your knees in alligators, it's hard to remember that the objective was to drain the swamp. The exigencies of Ebola are such that normal drug trials are difficult to undertake: the patient is usually unconscious or otherwise unable to give informed consent and death is imminent and probable without treatment.

    Certainly it would be nice to have trials, but it would be better to save lives. Best of all would be to have a supply of ZMapp large enough to offer it to all who suffer from this scourge, and to have the victims or their relatives understand that it may save their lives but it may not, and if it doesn't please don't blame the messenger. And since none of these things are likely to happen any time soon, the health care people on the ground are forced to make agonizing decisions about who lives and who dies. I very much doubt they make these decisions lightly or based on a whim. They do their best with the tools and information they have. You can't ask for more than that.

  133. The death of Dr. Khan is so painful - and now it's infuriating. Why didn't they let Umu Khan and the rest of his family make the decision? MSF and the WHO cared more for their public image than for the life of this great and singular man? Wasn't it MOST important to consult his relatives and have them make the decision? My heart hurts for the people affected by this epidemic and for the family of this fine man - it's one of those losses that cannot be made right.

  134. First off, what makes you think the good doctor was even awake?

    Second off, how come THAT family should get to make such a choice, and nobody else's does? remember--Dr. Khan was already receiving far, far better care than nearly anybody else. He already had a much, much better chance to be helped than nearly anybody else.

    Third...is it really a choice, if the only conceivable answer is yes? What else would a family say..."I never liked him anyway, so the heck with it?"

    Fourth: we Americans like to think we're smart shoppers. And not one in ten understands the moral questions here, and can set personal feeling aside. Not one in a hundred really listens when a doc tells them that a family member's gravely ill, and this is the longest of long shots. Not one in a thousand begins to understand the science involved.

    So if you're personally biased, unlikely to understand the moral issues, and extremely unlikely to understand enough of the science, how again are you making a free choice?

    Sorry, but this is one of a cascade of "decisions," people in advanced societies are faced with, in which their "right to decide of their own free will," is a bit of an illusion.

  135. Doctors are faced with these dilemmas on a daily basis, particularly during wartime and humanitarian crises, as to which patient receives a particular treatment, or not, during triage. We laymen don't have enough info on the health status of these patients at the time the experimental drug was available to second guess these tough decisions.

    That said, Dr. Khan is also a physician, and should normally have been consulted about his own treatment (if this wasn't the case).

    I just hope other countries are busily creating their contingency plans for dealing with this deadly disease, and a whole host of others, waiting to wreak havoc on humanity!

  136. The situation here is that you have 4 doses of a drug that theoretically might help a patient who receives it. You have thousands of desperately ill and dying patients. The decision on how to use this drug cannot be made on a patient level. No one can judge which life is more deserving. One can however make a judgment on how using the drug might help or harm the overall societal impact of the epidemic. If using it on an “undeserving” patient would hasten the end of the epidemic that patient should receive it. If using on the most “deserving” patient might prolong the epidemic and increase the total death toll that “deserving” person should not be offered the drug. Simple but not in line with the US model of maximal healthcare for each patient rather than healthcare for maximal social good.

  137. "the treatment team never discussed the option of using the drug with Dr. Khan himself" -- ??

    That is the very definition of condescending, patronizing treatment.

  138. First off, it's important to realize that there is no decision whatsoever about any of this that would not draw pretty much the same torrent of faux-political commentary, conspiracy theories, ignorance and just plain crackpottery.

    I say "faux-political," because real politics aren't as glib as a lot of this stuff, they don't rely on flashy solutions that only take a minute, and they're based on reality.

    "Pharmaceutical companies?" really? This is of a piece with attacking doctors and nurses and health care workers because "they're giving us the virus."

    Ignorance? ZMapp ain't a vaccine. ZMapp is a treatment--and one that is completely untested in humans. Hooray, looks promising, a few monkeys died slower. Hooray, the two in Atlanta appear to be doing well. BUT, we have no idea if the drug helped. We know that so far, ZMapp did not kill them.

    Oh, and we also know it's moot, because there ain't no more.

    The real takeaway from all this isn't that Dr. Khan should have been given the drug, because why not? The real takeaway is that a) his docs made the very best choice they knew to make, b) there's no getting around the ambiguity, c) very few of us are remotely qualified to even have an opinion, and d) that's the way advanced medical treatment is.

    If you'd like real politics and morality--consider why we'd rather send weapons to crackpot governments to serve our own purposes, than help WHO set up decent medical systems.

  139. It still seems troubling that Dr. Khan was not given a choice.

  140. This would be a complex ethical dilemma if the mortality rate was closer to 50%. Given that it is near 90% and the doctor was described as having high virus levels I find it inexcusable that he wasn't offered ZMapp. They buried him before he died. This was a horrible decision.

  141. This story says ZMapp is in "such short supply", "extremely limited", "such a small quantity" and is "now exhausted." When will the Times get the actual number??

  142. Many seem to consider the Zmapp "the solution" despite little evidence. The survival of the two patients may have been positively impacted by the drug, and most certainly was impacted by access to unlimited sanitary IV solutions, oxygen, a sterile modern hospital environment, modern medical equipment preventing opportunistic infections, and the full resources of a leading university hospital. Simply administering Zmapp in Africa in sub-standard, highly stressed medical "hospitals" with inadequate monitoring resources means patients die, and minimal information is captured.

  143. This drug is as much a leap forward as penicillin was in the 1940s. So, given a choice between a shiny new hospital or a new drug, it would have been better to bet on the drug.the best explanation i saw was that the drug was more or less effective depending on the viral load of the patient and that that had been a factor in the decision. But i would have risked using the drug in this case. The decision bit to give the doctor the choice was, in my opinion, immoral.

  144. Looking for the explanation of why more can't be made and production started on some emergency basis??? Is this a patent-related, intellectual property rights matter, that it's just too expensive to make, or what?

  145. Don't forget:
    --the MSF workers who treated Dr. Khan have risked their lives as he risked his, save he worked in his homeland, but MSF docs volunteered to go there;
    --little is known about ZMapp or other drugs that may/may not have benefit, save that 2 patients given ZMapp have survived in Atlanta and 1 in Spain didn't;
    --Dr. Khan died on 29 July, 15 days ago; the ZMapp-treat-or-not decision was made 6 days before that;
    --many Africans opposed the presence of health workers--had ZMapp been given Dr. Khan and he died anyway, the screams would be that he died a guinea pig.

    A November 2013 PLoS blog noted a confirmed Uganda Ebola case in July 2012. Was the problem cooking for 2 years? And practices like touching the deceased's body are cultural ritual in Africa, elsewhere. These are powerful methods of disease transmission.

    We all have fears; all are ignorant about something. Stir fear and ignorance into a disease mix: the result may be massively lethal. That's the tale in Africa's resource-scarce, subsistence-living environments.

    Amounts of drugs available? Quantities must be seen in when/where/how terms. These are not off-the-shelf drugs at CVS. They are manufactured in carefully monitored processes, then moved to where needed. Needs can change daily, or more quickly. Public health emergencies are matters of logistics, logistics, logistics. Don't make this a "no good deed goes unpunished" matter with attacks on MSF/other healthcare workers who put their lives on the line.

  146. Sorry but this whole article reads like an attempt at CYA. All of this agonizing about whether or not Dr. Khan should have been given the drug yet some how it made it's way to Spain without nearly as much ethical angst.

    There's also something very disturbing and patronizing in their concerns that Africans would feel they were being "experimented" on if the treatment didn't work. What African wouldn't understand the concept of risks associated with trying out an untested experimental drug in an effort to save a man's life? They didn't even give Dr. Kahn an opportunity to weigh in on his own treatment options.

    This article just underscores that the decision about who would and would not get the drug was driven by politics and this bizarre form of paternalism that is pervasive among Westerners working in Africa.