Public Health Disasters: A Global Ethical Framework

Advancing Global Bioethics 12

Michael Olusegun Afolabi

Public Health Disasters: A Global Ethical Framework

Advancing Global Bioethics Volume 12

Series editors Henk A.M.J. ten Have Duquesne University Pittsburgh, USA Bert Gordijn Dublin City University, Ethics Inst Rm C147, Henry Grattan Building Dublin, Ireland

The book series Global Bioethics provides a forum for normative analysis of a vast range of important new issues in bioethics from a truly global perspective and with a cross-cultural approach. The issues covered by the series include among other things sponsorship of research and education, scientific misconduct and research integrity, exploitation of research participants in resource-poor settings, brain drain and migration of healthcare workers, organ trafficking and transplant tourism, indigenous medicine, biodiversity, commodification of human tissue, benefit sharing, bio-industry and food, malnutrition and hunger, human rights, and climate change. More information about this series at http://www.springer.com/series/10420

Michael Olusegun Afolabi

Public Health Disasters: A Global Ethical Framework

Michael Olusegun Afolabi International Journal of Ethics Education, Center for Healthcare Ethics Duquesne University Pittsburgh, PA, USA

ISSN 2212-652X     ISSN 2212-6538 (electronic) Advancing Global Bioethics ISBN 978-3-319-92764-0    ISBN 978-3-319-92765-7 (eBook) https://doi.org/10.1007/978-3-319-92765-7 Library of Congress Control Number: 2018947385 © Springer International Publishing AG, part of Springer Nature 2018 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by the registered company Springer International Publishing AG part of Springer Nature. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

This book is dedicated to those who cherish the lamp of Truth, who swim against the tides of intellectual ease, who acknowledge the watery nexus of humanity, & seek answers through the lance of knowledge

Preface

In  the Fall of  2014, while undergoing doctoral studies at Duquesne University, I began noticing an overlap between the conceptual and ethical issues of traditional public health ethics and the themes of disaster bioethics, an area of academic overlap that had not undergone any scrutiny. This book is a culmination of my foray into this intellectual vacuum and an attempt to fill it. It presents a critical examination of the concept of public health disasters (PHDs) with some of the attendant ethical, sociocultural, transnational, and policy-related issues. Disasters, in all their shades and forms, occur in phases. But a critical phase of any PHD takes place when there is a rapid and an accelerated dislocation from a prior state of harmony. That is, a sudden change in the relational connection between human beings and specific elements of their environments such as microbes, the material and immaterial forces of nature, and other human beings (albeit infectious). Therefore, at the core of PHDs are different kinds of relational dissonances. The displacement, diseases, disappearance, destruction, disarray, and death that often accompany a public health disaster elicit varying degrees of ethical issues due to conflicting social, institutional, and individual interests and the need to follow one course of action (that may be favorable to some people) as opposed to another (that may be unfavorable to some people but congenial to others). Ebola viral and pandemic influenza outbreaks attest to the notion that the faces and potential victims of PHDs transcend geographical and national barriers. As such, limiting interventions and responses to the sphere of national boundaries is insufficient. Public health disasters as a class of global problems require a broad understanding of the underlying factors that influence the attendant social, cultural, ideological, biological, and geographic vulnerabilities. Such an understanding should inform the types of interventions and their ultimate success. Infusing a spectrum of context-specific ethical insights with anthropological, ecological, and sociological perspectives; this book develops a relational-based global ethical framework vis-à-­ vis engaging PHDs. The idea of a global ethical framework inevitably echoes the global bioethics debate. In this vein, this book shows that despite the complicated and controversial task of arriving at a comprehensive global ethic for bioethical problems writ large, it is possible to develop a theme-specific global bioethical lens. vii

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By filling an important knowledge gap in the extant bioethics literature, I believe that this book will be useful to bioethics scholars, public and global health policy experts, as well as graduate students doing research within the academic arena of global health, public health ethics, and disaster bioethics. I equally hope that it will intellectually provoke others to contribute to this emerging academic terrain. Michael O. S. Afolabi

Acknowledgments

I would like to thank Prof. Henk ten Have (Center for Healthcare Ethics, Duquesne University) for sending me the pdf copy of his book Global Bioethics: An Introduction prior to its appearance in print. The early access affirmed my intuitive leaning that my methodological approach in this book was apt and it “enhanced” my awareness of the current knowledge gaps in the global bioethics literature. I am grateful to people like Dr. Peter Osuji (Center for Healthcare Ethics, Duquesne University), Pastor Olugbenga Omoteso (Deeper Life Bible Church, GA), Prof. Stephen Sodeke (Tuskegee University, AL), Brother Samuel Akinola (Morgan State University, MD), and Pastor Joseph Adedokun (Deeper Life Bible Church, FL) who offered moral and spiritual solidarity while I rode the tides of a lot of unforeseen “storms” while researching, reflecting on, and writing this book. I am grateful to my family who had to put up with my prolonged absence from home. Christianah supported me with some intriguing musical compositions over the phone. Michele deserves “some apology” for she only recently reunited with me after more than a year of my physical absence. Ikeoluwa’s friendship, prayers, support, and understanding helped to keep me focused. Finally, my Lord and Savior, Christ Jesus—in whom are hidden all treasures of wisdom and understanding—ensured that my clarity of thought, analytical insights, and creativity remained with me throughout all the difficult challenges I faced that could have derailed and stunted the research that underpinned this book.

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Contents

1 Public Health Disasters����������������������������������������������������������������������������    1 1.1 Introduction��������������������������������������������������������������������������������������    1 1.2 The Current State of Knowledge vis-à-vis Public Health Disasters��������������������������������������������������������������������������������������������    2 1.3 Conceptual Dynamics of Public Health Disasters������������������������������   8 1.4 Ethical Dynamics of Public Health Disasters ����������������������������������   11 1.5 Global Dynamics of Public Health Disasters������������������������������������   14 1.6 Methodology ������������������������������������������������������������������������������������   18 1.7 Conclusion����������������������������������������������������������������������������������������   20 Bibliography����������������������������������������������������������������������������������������������   20 2 Ebola Viral Outbreaks: A Ubuntuan Ethical Approach ����������������������   25 2.1 Introduction��������������������������������������������������������������������������������������   25 2.1.1 Nature & Risk Dynamics of Ebola Viral Disease ����������������   26 2.1.2 Socio–cultural Dynamics of Ebola Viral Disease ����������������   29 2.2 Ethical Issues Embedded in Ebola Outbreaks����������������������������������   34 2.2.1 Vulnerability ������������������������������������������������������������������������   34 2.2.2 Human Dignity & Rights Violations������������������������������������   37 2.2.3 Local & Global Justice���������������������������������������������������������   40 2.2.4 Rationing������������������������������������������������������������������������������   44 2.3 Ubuntu Moral Lens vis-à-vis the Quandaries of EVD����������������������   45 2.3.1 The Concept of Ubuntu��������������������������������������������������������   45 2.3.2 Ubuntu vis-à-vis the Quandaries of EVD ����������������������������   47 2.4 Conclusion����������������������������������������������������������������������������������������   51 Bibliography����������������������������������������������������������������������������������������������   53 3 Pandemic Influenza: A Comparative Ethical Approach����������������������   59 3.1 Introduction��������������������������������������������������������������������������������������   59 3.1.1 Biological Features of Pandemic Influenza Outbreaks������������������������������������������������������������������������������   60 3.1.2 Social and Global Features of Pandemic Influenza Outbreaks������������������������������������������������������������������������������   63 xi

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3.2 Responses to Pandemic Influenza Outbreaks�����������������������������������   66 3.2.1 Therapeutic Responses���������������������������������������������������������   67 3.2.2 Non-therapeutic Responses��������������������������������������������������   71 3.3 Ethical Issues Embedded in Pandemic Influenza Outbreaks������������   72 3.3.1 Uncertainty����������������������������������������������������������������������������   72 3.3.2 Human Rights ����������������������������������������������������������������������   75 3.3.3 Vulnerability ������������������������������������������������������������������������   78 3.3.4 Local and Global Justice������������������������������������������������������   80 3.4 A People-Centric Approach to Pandemic Influenza Outbreaks��������   81 3.4.1 Communitarianism: Conceptual Elaboration������������������������   81 3.4.2 Ethics of Care: Conceptual Elaboration��������������������������������   85 3.5 Conclusion����������������������������������������������������������������������������������������   90 Bibliography����������������������������������������������������������������������������������������������   91 4 Silent Public Health Disasters: An Anthropo-­ecological Approach��������������������������������������������������������������������������������������������������   97 4.1 Introduction��������������������������������������������������������������������������������������   97 4.1.1 Nature & Causes of Antimicrobial Drug-Resistance������������   99 4.1.2 Public Health Implications of Atypical Drug-Resistant Tuberculosis������������������������������������������������  102 4.1.3 The Nuances of Atypical Drug-Resistant Tuberculosis��������  107 4.2 Ethical Issues Embedded in Atypical Drug-Resistant Tuberculosis��������������������������������������������������������������������������������������  111 4.2.1 Uncertainty & Vulnerability��������������������������������������������������  111 4.2.2 Autonomy & Human Rights ������������������������������������������������  115 4.2.3 Harm & Social Justice����������������������������������������������������������  120 4.3 An Anthropo-ecological Approach to Atypical Drug-­Resistant Tuberculosis��������������������������������������������������������������������������������������  123 4.3.1 Clarifying an Anthropo-ecological Ethic������������������������������  124 4.3.2 An Anthropo-ecological Ethic vis-a-vis the Quandaries of ADR-TB ��������������������������������������������������������������������������  130 4.4 Conclusion����������������������������������������������������������������������������������������  134 Bibliography����������������������������������������������������������������������������������������������  135 5 Public Health Disasters During Earthquakes: A Solidaristic Approach��������������������������������������������������������������������������������������������������  143 5.1 Introduction��������������������������������������������������������������������������������������  143 5.1.1 The Nature of Earthquakes ��������������������������������������������������  144 5.1.2 Socio-geographical Dynamics of Earthquakes ��������������������  146 5.1.3 Public Health Dynamics of Earthquakes������������������������������  148 5.2 Ethical Issues Elicited by Earthquakes ��������������������������������������������  151 5.2.1 Anthropogenic Quandaries ��������������������������������������������������  152 5.2.2 Non-anthropogenic Quandaries��������������������������������������������  157

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5.3 A Solidaristic Approach to Earthquakes ������������������������������������������  159 5.3.1 The Concept of Solidarity����������������������������������������������������  159 5.3.2 Anthropogenic Solidarity vis-à-vis the Quandaries of Earthquakes����������������������������������������������������������������������  161 5.3.3 Non-anthropogenic Solidarity vis-à-vis the Quandaries of Earthquakes����������������������������������������������������������������������  165 5.4 Selected Implications of the Solidaristic Approach to Earthquakes����������������������������������������������������������������������������������  167 5.5 Conclusion����������������������������������������������������������������������������������������  168 Bibliography����������������������������������������������������������������������������������������������  169 6 A Global Ethical Framework for Public Health Disasters������������������  175 6.1 Introduction��������������������������������������������������������������������������������������  175 6.1.1 The Relational Basis of Ethical Issues in Public Health Disasters��������������������������������������������������������������������  176 6.1.2 Relational Basis of the Human Quandaries of Public Health Disasters������������������������������������������������������ 177 6.1.3 Relational Basis of the Non-Human Quandaries of Public Health Disasters����������������������������������������������������  181 6.2 Moral Limits of Representative Approaches to Public Health Disasters��������������������������������������������������������������������������������  183 6.2.1 Limits of the Ubuntuan Ethic vis-a-vis Public Health Disasters ������������������������������������������������������������������  183 6.2.2 Limits of Ethics of Care & Communitarianism vis-a-vis Public Health Disasters ����������������������������������������  186 6.2.3 Limits of an Anthropo-ecological Approach vis-a-vis Public Health Disasters������������������������������������������  188 6.2.4 Limits of a Solidaristic Approach vis-a-vis Public Health Disasters ��������������������������������������������������������  189 6.3 Overcoming the Challenges of Developing a Global Ethic��������������  190 6.3.1 Framing a Global Ethic for Public Health Disasters������������  194 6.3.2 A Five-Relational Global Ethic vis-à-vis Public Health Disasters��������������������������������������������������������������������  195 6.3.3 A Relational Global Ethic vis-à-vis the Quandaries of Public Health Disasters����������������������������������������������������  198 6.4 Justifying a Global Ethical Framework vis-à-vis Public Health Disasters��������������������������������������������������������������������������������  202 6.4.1 Responsiveness to Local Realities����������������������������������������  203 6.4.2 Responsiveness to Global Realities��������������������������������������  205 6.4.3 Responsiveness to Microbial & Metaphysical Realities��������������������������������������������������������������������������������  206 6.4.4 Responsiveness to Scientific Concerns ��������������������������������  207 6.5 Conclusion����������������������������������������������������������������������������������������  208 Bibliography����������������������������������������������������������������������������������������������  209

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7 Theoretical & Pragmatic Implications of a Relational Global Ethical Framework����������������������������������������������������������������������  215 7.1 Summary ������������������������������������������������������������������������������������������  215 7.2 Translational Implications of a Global Ethic vis-à-vis Public Health Disasters ��������������������������������������������������������������������  221 7.2.1 Policymakers������������������������������������������������������������������������  222 7.2.2 Health Professionals�������������������������������������������������������������  223 7.2.3 Non-governmental Organizations ����������������������������������������  224 7.2.4 Bioethicists����������������������������������������������������������������������������  224 7.2.5 International Agencies����������������������������������������������������������  225 7.2.6 Members of Public����������������������������������������������������������������  225 7.3 The Global Ethical Framework vis-à-vis the UNESCO Bioethics Declaration������������������������������������������������������������������������  226 7.3.1 The Relational-Based Global Ethic vis-à-vis Solidarity & Cooperation������������������������������������������������������  226 7.3.2 The Relational Based Global Ethic vis-à-vis Social Responsibility & Health��������������������������������������������  227 7.3.3 The Relational Based Global Ethic vis-à-vis International Cooperation ����������������������������������������������������  227 7.4 Conclusion����������������������������������������������������������������������������������������  228 Bibliography����������������������������������������������������������������������������������������������  229 Index������������������������������������������������������������������������������������������������������������������  231

About the Author

Dr.  Michael  O.S.  Afolabi  earned a Ph.D. in Healthcare Ethics from Duquesne University, Pittsburgh, PA, USA. He has a background in biomedical sciences (Ladoke Akintola University of Technology, Nigeria); Innovation and Economic Development (University of Tampere, Finland); Research Ethics Evaluation (Three, France); and Clinical Ethics (Providence, USA). Dr. Afolabi combines his expertise in biomedical sciences and public health policy with bioethical rhetoric to pursue and proffer solutions to the ethical dilemmas elicited by individual, social, and institutional health issues. His approach to these issues from local and trans-national perspectives makes his work very relevant in contemporary global health. He has published a number of research articles in peer-reviewed journals and has shared some of his insights at academic conferences in Africa, North America, Asia, and Europe. His other areas of research interest include Neuroethics, Genethics, Healthcare Innovation, and Medical Sociology.

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Chapter 1

Public Health Disasters

Abstract  Public health disasters reflect the uncharted conceptual, ethical, and pragmatic intersections between public health ethics and the emerging discourse on disaster bioethics. This novel concept reflects public health issues with calamitous social consequences such as infectious disease outbreaks, the attendant public health impacts of natural or man-made disasters, and currently latent or low prevalence public health issues with the potential to rapidly acquire pandemic capacities. The attendant moral dilemmas that PHDs generate have local and global dimensions. For this reason, they demand a multifaceted ethically grounded and pragmatically oriented approach. This chapter presents the conceptual foreground to the ethical and pragmatic dimensions of these issues.

1.1  Introduction There is an increasing conceptual, ethical, and pragmatic intersection between the concerns of traditional public health ethics and the emerging academic discourse on disaster bioethics, an intersection that has not received any scholarly attention in the bioethics literature. This book describes this epistemic gap as “public health disasters” (PHDs). It seeks to untangle the attendant moral dilemmas as well as frame a global ethical framework (GEF) vis-à-vis engaging them and the associated pragmatic issues. Such a task is necessary for at least two reasons. First, the need for conceptual clarity on what constitutes PHDs, which also has the potential to serve as a rallying ground to draw attention to these distinct types of disasters in bioethical discourses. Whereas the term “Public health disaster(s)” may show up via scholarly search engines, yielding articles such as “Allocation of ventilators in a public health disaster”,1 “The lingering consequences of sepsis: a hidden public health disaster?”,2 “The ticking time bomb: escalating antibiotic resistance in

1  Tia Powell, Kelly C Christ, and Guthrie S Birkhead, “Allocation of Ventilators in a Public Health Disaster,” Disaster Medicine and Public Health Preparedness 2, no. 1 (2008). Pp. 20–24. 2  Derek C Angus, “The Lingering Consequences of Sepsis: A Hidden Public Health Disaster?,” Jama 304, no. 16 (2010). P. 1833.

© Springer International Publishing AG, part of Springer Nature 2018 M. O. Afolabi, Public Health Disasters: A Global Ethical Framework, Advancing Global Bioethics 12, https://doi.org/10.1007/978-3-319-92765-7_1

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1  Public Health Disasters

Neisseria gonorrhoeae is a public health disaster in waiting”,3 “Australia’s new coal mine plan: a “public health disaster””,4 and “Public Health Disasters: Be Prepared”5; none of such articles offers conceptual clarity as to the term’s clear meaning(s) and nuances. There is, therefore, the need to address this lack of conceptual homogeneity. Secondly, while a GEF may help address public health disasters in particular, its global nature has the potential to contribute to the critical reexamination of some of the precepts of extant frameworks such as the UNESCO Declaration on Bioethics and Human Rights (UDBHR) in relation to some of the moral quandaries generated by PHDs. Also, a global ethical framework will contribute to the ongoing scholarly debate about the normative value and approach to global bioethics. To engage the theme of this chapter, the current state of knowledge in the disaster bioethics and public health ethics literature needs to be examined in order to tease out extant the epistemic gap(s). This will be followed by an elaboration of the conceptual dynamics of PHDs and how these relate to the six Ds (destruction, death, disease/disorders, displacement, disappearance, and disarray), an elucidation of some of the attendant ethical issues, the global dimensions of these issues, and the methodological angle that this book adopts.

1.2  T  he Current State of Knowledge vis-à-vis Public Health Disasters Disaster bioethics makes up an emerging area in bioethical thought. The concept of disaster and the extent of the attendant humanitarian obligations, for scholars like Gordijn and ten Have, is still under philosophical rumination.6 Hence, Hearn describes disaster bioethics as an emerging area of academic inquiry.7 Consequently, there is only a sparse amount of published literature focused on elaborating the ethical issues that disasters bring about. Some of the major works on this theme include Zack who emphasizes issues such as uncertainty as one of the core moral quanda-

3  David M Whiley et al., “The Ticking Time Bomb: Escalating Antibiotic Resistance in Neisseria Gonorrhoeae Is a Public Health Disaster in Waiting,” Journal of Antimicrobial Chemotherapy 67, no. 9 (2012). Pp. 2059–2060. 4  Chris McCall, “Australia’s New Coal Mine Plan: A “Public Health Disaster”,” The Lancet 389, no. 10069 (2017). P. 588. 5  RJ Kim-Farley, “Public Health Disasters: Be Prepared,” American journal of public health 107, no. S2 (2017). P. S120. 6  Bert Gordijn and Henk Ten Have, “Disaster Ethics,” Medicine, Health Care and Philosophy 18, no. 1 (2015). Pp. 1–2. 7  James D Hearn, “Disaster Bioethics: Normative Issues When Nothing Is Normal,” Journal of Bioethical Inquiry 12, no. 1 (2015). Pp. 151–152.

1.2  The Current State of Knowledge vis-à-vis Public Health Disasters

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ries that arise in disaster situations.8 George Annas’ worst-case scenarios perspective underscores how useful policies and practices may need to override individual interests.9 Scholars like da Costa recognize the importance of human rights in disaster contexts and argue that human rights can enhance individuals’ resilience to face disasters.10 However, such an approach fails to deal with the morally thorny issue of balancing conflicting rights based on competing needs and interests, especially those due to the presence of overwhelming needs and insufficient human and material resources.11 If human beings die very easily,12 then disasters, by definition, accelerate the process of human death and other possible associated types of  destruction  (e.g. emotional trauma, loss of limb, loss of businesses etc.). The unexpected nature of natural disasters often shapes the damage and human suffering that ensue as well as the disparity between human needs and resources available to immediately confront the utilitarian goal of doing the most good or benefit(s) for as many people as possible with a minimal level of harm.13 In disaster scenarios, the ethical goal generally entails finding some means to minimize the damaging social consequences. As such, actions that will lead positive social consequences are preferred14 and usually pursued. This is important considering the significant physical, psychological, social, and environmental kinds of harm that are associated with disasters15 and which must be engaged from a broad perspective. Different levels of efforts—at the micro, meso and macro level of concept and praxis—which seek to address the disruption associated with disasters are integral to recognizing the risks and responsibilities16 associated with disaster scenarios. Engaging these tasks demands some training and re-training of actors within and outside the healthcare sector.17 This is because on the one hand, professionals work Naomi Zack, Ethics for Disaster (Rowman & Littlefield Publishers, 2010).  George J Annas, Worst Case Bioethics: Death, Disaster, and Public Health (Oxford University Press, 2010). 10  Karen da Costa, “Can the Observance of Human Rights of Individuals Enhance Their Resilience to Cope with Natural Disasters?,” Procedia Economics and Finance 18 (2014). Pp. 62–68. 11  Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke, “Disaster Bioethics: An Introduction,” in Disaster Bioethics: Normative Issues When Nothing Is Normal (Springer, 2014). Pp. 3–4. 12  Atsushi Asai, “Tsunami-Tendenko and Morality in Disasters,” Journal of Medical Ethics 41, no. 5 (2015). P. 365. 13  Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna, “Evidence and Healthcare Needs During Disasters,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke (Netherlands: Springer, 2014). PP. 95, 100–101. 14   Vasil Gluchman, “Disaster Issues in Non-Utilitarian Consequentialism (Ethics of Social Consequences),” Human Affairs 26, no. 1 (2016). P. 52. 15  Keymanthri Moodley, “Ethical Concerns in Disaster Research—a South African Perspective,” in Disaster Bioethics: Normative Issues When Nothing Is Normal (Springer, 2014). P. 192. 16  Bruce Clements, Disasters and Public Health: Planning and Response (Butterworth-Heinemann, 2009). P. 14. 17  Lisa Schwartz et  al., “Ethics and Emergency Disaster Response. Normative Approaches and Training Needs for Humanitarian Health Care Providers,” in Disaster Bioethics: Normative Issues When Nothing Is Normal (Springer, 2014). Pp. 33–40. 8 9

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ing in disaster situations face urgent choices which usually  diverge from their ­normal and accustomed duty-related or deontological ethos.18 On the other hand, nonhealthcare-based actors will have varying desires to render help to victims of disasters, desires which they will hardly be able to adequately translate into positive “clinical outcomes” in the absence of prior and proper training. Although disasters are by nature sudden, they are not completely void of the influence of human agency, hence, human culpability. Scholars like Dranseika share this view and argue that humans causally contribute to the negative outcomes of even such paradigmatic natural disasters as earthquakes, typhoons, and volcano eruptions.19 This remark underscores the notion that some disasters may be either preventable or their overall impacts limited when relevant and carefully orchestrated human actions are taken before they occur or during ongoing disaster episodes. Whereas scholars like Bhan20 usually emphasize this preventive approach, there has been little articulation of specifics in relation to accomplishing such a task. A possible reason for the difficulty in articulating a preventing approach, at least on a broad scale, to public health disasters involves the complex interplay between pre-disaster factors, the causal linkages between human and non-human parameters, and the biologically nuanced roles that microbial organisms play in their onset. However, if disasters generally and public health disasters, in particular, reflect a dissonance in the relational nexus that people have with others (locally and globally), the relationship nexus between humankind and microbes and the relationship between human beings and the divine (gods, God, spirits et cetera); then, failure to engage ways of repairing these multifaceted relationships support the culpability claim advanced by Dranseika. Some ethical issues have been identified in the arena of disaster ethical inquiry. These include issues of human rights,21,22 varying degrees of vulnerabilities23,24

 Pierre Mallia, “Towards an Ethical Theory in Disaster Situations,” Medicine, Health Care, and Philosophy 18, no. 1 (2015). P. 3. 19  Vilius Dranseika, “Moral Responsibility for Natural Disasters,” Human Affairs 26, no. 1 (2016). Pp. 73–74. 20  Anant Bhan, “Ethical Issues Arising in Responding to Disasters: Need for a Focus on Preparation, Prioritisation and Protection,” Asian Bioethics Review 2, no. 2 (2010). Pp. 143–145. 21  Annas. Pp. 5–25. 22  da Costa. Pp. 62–65. 23  Ruth Macklin, “Studying Vulnerable Populations in the Context of Enhanced Vulnerability,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna (Springer, 2014). Pp. 159–163. 24  Sneha Krishnan and John Twigg, “Menstrual Hygiene: A ‘Silent’need During Disaster Recovery,” Waterlines 35, no. 3 (2016). Pp. 265–268. 18

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c­ onflicting ethical options,25,26 limited human and material resources,27,28,29 justice30 and the design as well as the implementation of triage.31,32,33 Another significant moral feature of disasters is the high degree of uncertainty.34,35,36 The unpredictable nature of uncertainty in disaster situations clearly limit responses and available options, practically and ethically. As such, scholars like Lepora and Goodin note that an approach involving ethical compromise37 will be inevitable when dealing with the quandaries and challenges posed by disasters. Due to the nascent nature of the moral reflections on the ethical dynamics of disasters, the ethical approaches have generally been speculative, tentative or lacking. Perhaps, a striking approach is that of Kalokairinou who contends that a virtue ethics approach which creates a virtuous disposition in persons responding to disaster situations constitutes a richer and more efficient way of dealing with the associated moral dilemmas.38 Put another way, Kalokairinou seems to be saying that if all the potential relevant actors for particular kinds of disasters may be identified before  Mallia. Pp. 4–8.  Andrew Shortridge, “Moral Reasoning in Disaster Scenarios,” Journal of medical ethics 41, no. 9 (2015). P. 780. 27  O’Mathúna, Gordijn, and Clarke. Pp. 3–4. 28   Sara Kathleen Geale, “The Ethics of Disaster Management,” Disaster Prevention and Management 21, no. 4 (2012). Pp. 445–447. 29  Claritza L Rios et al., “Addressing the Need, Ethical Decision Making in Disasters, Who Comes First?,” Journal of US-China Medical Science 12 (2015). Pp. 20–23. 30  Anushree Dave et  al., “Engaging Ethical Issues Associated with Research and Public Health Interventions During Humanitarian Crises: Review of a Dialogic Workshop,” Bioéthique Online 5, no. 2 (2016). 31  Henk ten Have, “Macro-Triage in Disaster Planning,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke (Springer 2014). Pp. 13–16. 32  Hu Nie et al., “Triage During the Week of the Sichuan Earthquake: A Review of Utilized Patient Triage, Care, and Disposition Procedures,” Injury 42, no. 5 (2011). Pp. 515–519. 33  Michael Y Barilan, Margherita Brusa, and Pinchas Halperin, “Triage in Disaster Medicine: Ethical Strategies in Various Scenarios,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna (Springer, 2014). Pp. 49–52. 34  Fatimah Lateef, “Ethical Issues in Disasters,” Prehospital and Disaster Medicine 26, no. 4 (2011). Pp. 289–291. 35  Sven Ove Hansson, The Ethics of Risk: Ethical Analyses in an Uncertain World (Palgrave Macmilan, 2013). Pp. 1–112. 36  Gordijn and Ten Have. Pp. 1–2. 37  Chiara Lepora and Robert E Goodin, On Complicity and Compromise (OUP Oxford, 2013). Pp. 15–28 38  Eleni M Kalokairinou, “Why Helping the Victims of Disasters Makes Me a Better Person: Towards an Anthropological Theory of Humanitarian Action,” Human Affairs 26, no. 1 (2016). Pp. 26–29. 25 26

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a given disaster so that certain virtues are infused into them, then they will more likely than not act virtuously during disasters. If this interpretation is true, then responding ethically to disasters will entail a long-term moral endeavor that will need to involve every segment of the society. How such a task may be counted worthy of pursuit in an increasingly pluralistic, secularized, and post-modern world remains the major setback to this approach but it does not render it void of logical credence. Perhaps, partly because the scholarly discussion on disaster bioethics has only recently begun,39 some scholars believe that the best that can be attained in handling disasters is a non-ideal ethical approach.40 Unlike the field of disaster bioethics, reflection on public health ethics goes a few years back, and are greater in volume. Some of the seminal writings in this line of ethical reflection include Harris and Holm who emphasize the moral duty of not infecting others. For them, failure to act on this obligation translates into deliberately harming others. Yet, a system of compensation may be necessary to motivate people to comply.41 Kass argues that a public health ethics approach needs to reduce morbidity or mortality and minimize any existing social injustices while adopting fair procedures.42 Callahan and Jennings contend that ethics and public health cannot be advanced without taking into consideration the values of the general society as well as that of the particular communities where the public ethical course of action is needed.43 This echoes Rhodes age-long remark that the practice of medicine is inseparable from the values of the society in which its practice occurs.44 If contemporary public health is bereft of national boundaries and is inherently global,45 then engaging the ethical issues generated by public health inevitably needs an approach that is local and context specific, globally sensitive, and nuanced. The absence of a global health policy response further highlights the necessity of such an approach.46 Roberts and Reich posit that an elaboration of consequences, fostering the flourishing of communities, balancing of conflicting rights and a quest for justification are cardinal features of public ethical analyses, as well as the need to understand moral alternatives.47 Whereas moral values are integral to decision making in the  Gordijn and Ten Have. Pp. 1–2.  Dónal O’Mathúna, “Ideal and Nonideal Moral Theory for Disaster Bioethics,” Human Affairs 26, no. 1 (2016). Pp. 8–9. 41  John Harris and Soren Holm, “Is There a Moral Obligation Not to Infect Others?,” British Medical Journal 311, no. 7014 (1995). Pp. 1215–1216. 42  N. E. Kass, “An Ethics Framework for Public Health,” American Journal of Public Health 91, no. 11 (2001). Pp. 1776–1777. 43  Daniel Callahan and Bruce Jennings, “Ethics and Public Health: Forging a Strong Relationship,” ibid.92, no. 2 (2002). P. 172. 44  Philip Rhodes, The Value of Medicine (Allen and Unwin, 1976). Pp. 86,117. 45  Annas. P. xxiii. 46  Annamarie Bindenagel Šehović, Coordinating Global Health Policy Responses: From Hiv/Aids to Ebola and Beyond (Springer, 2017). P. 1. 47  Marc J Roberts and Michael R Reich, “Ethical Analysis in Public Health,” The Lancet 359, no. 9311 (2002). Pp. 1055–1059. 39 40

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context of public health, pursuing the welfare or interests of the larger society will often engender tensions in individualistic societies.48 Yet, there is no evidence to show that moral tensions that are tied to the balancing of conflicting interests and priorities are exclusively felt in non-communally structured societies. This partly explains why justice and the need to pursue justice in multiple ways remains a recurring decimal in public health.49 Hence, it is not surprising that the dilemmas central to public health ethics revolve around how to ethically weigh and balance individual against population health needs50,51 how to balance health-related harms amidst members of society at the individual and collective planes of differing interests52,53 as well as how to ethically justify any one course of action that is chosen or suggested for public health policy and implementation.54 A recent and interesting issue relates to the obligations of healthcare workers to infectious disease patients as well as to patients during infectious disease outbreaks.55 An examination of the disaster bioethics and public health ethics literature clearly brings to the fore the observation that the idea of public health disasters has not received academic attention. As such, this novel area of bioethical inquiry— which reflects the intersection of disaster bioethics and public health ethics— demands critical scrutiny and exploration. This conceptual lacuna invariably explains the absence of a moral framework for addressing the moral perplexities of PHDs. It is against this backdrop that this book seeks to elaborate the concept of public health disasters, fashion a GEF for addressing the attendant moral quandaries, and, ultimately, contribute to the scholarly conversation on global bioethics.  Ronald Bayer and Amy L Fairchild, “The Genesis of Public Health Ethics,” Bioethics 18, no. 6 (2004). Pp. 473, 492. 49  Nancy E Kass, “Public Health Ethics from Foundations and Frameworks to Justice and Global Public Health,” The Journal of Law, Medicine & Ethics 32, no. 2 (2004). Pp. 232–234. 50  Stephen Holland, Public Health Ethics (Polity Press, 2007). Pp. 1–15; Public Health Ethics, 2nd ed. (Polity Press, 2015). Pp. 1–10. 51  Marcel F Verweij and Angus Dawson, “The Meaning of ‘Public’ in Public Health’,” in Ethics, Prevention and Public Health ed. Marcel F Verweij and Angus Dawson (Oxford: Clarendon Press, 2009). Pp. 13–16. 52  Harris and Holm. Pp. 1215–1216; Charles B Smith et al., “Are There Characteristics of Infectious Diseases That Raise Special Ethical Issues?,” Developing World Bioethics 4, no. 1 (2004). Pp. 1–3. 53  Leslie P Francis et al., “How Infectious Diseases Got Left out–and What This Omission Might Have Meant for Bioethics,” Bioethics 19, no. 4 (2005). Pp. 307–311; Michael J Selgelid, PM Kelly, and Adrian Sleigh, “Ethical Challenges in Tb Control in the Era of Xdr-Tb [Unresolved Issues],” The International Journal of Tuberculosis and Lung Disease 12, no. 3 (2008). Pp. 231–234. 54  Callahan and Jennings. Pp. 169–170; Stephen Peckham and Alison Hann, “Introduction,” in Public Health Ethics and Practice, ed. Stephen Peckham and Alison Hann (Bristol: Policy Press, 2010). Pp. 1–5. 55  Michael Millar and Desmond TS Hsu, “Can Healthcare Workers Reasonably Question the Duty to Care Whilst Healthcare Institutions Take a Reactive (Rather Than Proactive) Approach to Infectious Disease Risks?,” Public Health Ethics (2016).; Aminu Yakubu et  al., “The Ebola Outbreak in Western Africa: Ethical Obligations for Care,” Journal of Medical Ethics 42, no. 4 (2016). Pp. 209–210. 48

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1.3  Conceptual Dynamics of Public Health Disasters At a glance, the concept of public health disasters suggests the idea of disasters linked to public health. Transposed to the realm of ethics, four distinct conceptual building blocks may be untangled from PHDs. These are “public health”, “disaster(s)”, “public health ethics”, and “disaster ethics/bioethics”. Defining each of these and combining the resultant ideas offer important insights into what PHDs may be and present a prism through which the attendant practical and ethical challenges may be seen. Public health is often described as the science and art of promoting health and preventing diseases for the whole society56 or a specific segment of society.57 Disasters are sudden, large-scale, chaotic events of acute onset, the end result of which are significant physical, social, psychological, and environmental harm.58 Public health ethics refers to ethical issues that come to the fore in relation to implementing public health schemes. Specifically, it constitutes the myriads of moral quandaries that may arise when weighing individual health needs against that of the collective society59 while pursuing social health goals and agendas. Lastly, disaster bioethics is an emerging area of academic inquiry60 engaged in raising and engaging bioethical perplexities that arise during disasters. Against this conceptual background, public health disasters may refer to one of three distinct phenomena. Firstly, public health issues with calamitous or devastating social consequences such as infectious disease outbreaks. Secondly, it may refer to the attendant public health impacts of natural or man-made disasters. Thirdly, PHDs may refer to currently latent, “silent”, or low prevalence public health issues with the potential to rapidly acquire pandemic capacities. Infectious diseases of current low-prevalence whose untreatable nature spell future calamity fit this category. A central and common denominator amongst all these three possible categories is the presence of all or some of the six cardinal features of disasters; that is, the so-­called six Ds. These are destruction, death, disease/disorders, displacement, disappearance, and disarray.61 In the context of public health, each of these Ds or a part/ whole combination has unsettling implications. Effective public health is a participatory and often coordinated course of activities which require cooperation amongst the different professional and non-professional actors in terms of a clear delineation of who does what and to what end. This affirms the idea that public health involves cooperative behavior and relationships that are forged on overlapping values and  Adetokunbo O Lucas and Herbert Michael Gilles, Short Textbook of Public Health Medicine for the Tropics (Arnold Publishers, 2003). Pp. 1–10. 57  Verweij and Dawson. 58  Moodley. P. 192. 59  Holland, Public Health Ethics. Pp. iv–ix. 60  Hearn. Pp.151–152. 61  Ahmad, Mamun, and O’Mathúna. P. 96. 56

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elements of trust.62 As such. stakeholders including professionals, policymakers, and patients (or potential patients) as well as the social context ultimately influence public health goals.63 However, the destruction, death, disease/disorders, displacement, disappearance, and disarray that characterize disasters and which can affect all public health actors will inevitably disrupt the participatory activities during public health disasters. It is important to specifically show how each of the six Ds plays out during PHDs. In relation to destruction, it is known that public health disasters often destroy social infrastructures including healthcare and other activities in the public sector. In developing economies where resources are usually limited and/or poorly managed, this will lead to the disintegration of healthcare systems. This may be exemplified by the closure of hospitals and clinics which invariably increases social suffering as well as the burdens of infectious diseases including tuberculosis, HIV/ AIDS, enteric and respiratory illnesses, cancer, cardiovascular disease, and mental health.64 The death-related disaster feature of Ebola virus outbreak has always been played out since the first outbreak in 1976. For example, the 2013–2015 episode recorded a 39.5% case-fatality rate and produced more than 11,000 deaths.65 Since some of the deceased were children, mothers, fathers, and other subsets of dear ones, it can be said that some type of emotional, financial or social disarray also accompany Ebola outbreaks as an exemplar of PHDs. During the Congo Ebola outbreak of 1995, healthcare workers and many people living in the community of the index case fled their homes amidst the confusion and rising death toll.66 This clearly illustrates the displacement-related disaster dimension of Ebola diseases, and it adds another conceptual justification for placing EVD under the category of PHDs. Scholars like Nancy Kass note that EVD ignites some of the worst fears in a globalized world, especially in terms of the ease with which it transcends borders.67 This implies that public health disasters are global or at least have some intrinsic tendency to become global. It is generally accepted that availability of effective and affordable drugs helps to ameliorate diseases.68 However, biological phenomena such as antimicrobial drug  James F Childress et  al., “Public Health Ethics: Mapping the Terrain,” The Journal of Law, Medicine & Ethics 30, no. 2 (2002). Pp 170–171. 63  Peckham and Hann. Pp. 2–5. 64  Jeremy J Farrar and Peter Piot, “The Ebola Emergency—Immediate Action, Ongoing Strategy,” New England Journal of Medicine 371, no. 16 (2014). P. 1545. 65  James M Shultz et al., “The Role of Fear-Related Behaviors in the 2013–2016 West Africa Ebola Virus Disease Outbreak,” Current Psychiatry Reports 18, no. 11 (2016). P. 101. 66  Yves Guimard et  al., “Organization of Patient Care During the Ebola Hemorrhagic Fever Epidemic in Kikwit, Democratic Republic of the Congo, 1995,” Journal of Infectious Diseases 179, no. Supplement 1 (1999). Pp. 269–270. 67  Nancy Kass, “Ebola, Ethics, and Public Health: What Next?,” Annals of Internal Medicine 161, no. 10 (2014). P. 744. 68  Michael O.S. Afolabi, “A Disruptive Innovation Model for Indigenous Medicine Research: A Nigerian Perspective,” African Journal of Science, Technology, Innovation and Development 5, no. 6 (2013). P. 446. 62

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resistance negate the telos of public health—fostering positive health outcomes69— and engenders increased morbidly and mortality. Beyond limiting the effectiveness of combination drug regimens,70 drug resistance influences the further dispersal of resistance within and amongst communities and between economic and geographic divides,71 exhibiting an unsettling ripple effect. This feature clearly entails the disease/disorder and death parameters of disasters, and the physical as well as psychological suffering that comes with it (as in most disease states)72 comes with different kinds of social, personal, and economic disarray. If drug resistance has the conceptual dimensions to be classed as a type of disaster, then non-apparent or silent forms of drug resistance will be more “disastrous”. Atypical drug-resistant tuberculosis (ADR-TB) belongs to such a class. Indeed, scholars like Viens and Littmann recently mused that antimicrobial drug resistance constitutes a slowly emerging disaster.73 Pandemic influenza can also be described as a public health disaster. One-third of the world’s population was estimated to be infected and had clinically apparent illnesses during the 1918–1919 influenza pandemic.74 201,200 respiratory deaths (ranging from 105,700–395,600) with an additional 83,300 cardiovascular deaths were estimated to have occurred.75 The global mortality rate for the 1957–1959 influenza pandemic was moderate relative to that of the 1918 pandemic but was approximately 10-fold greater than that of the 2009 pandemic.76 Deaths resulting from pandemic influenza, the attendant disruption of personal and social flourishing due to control measures such as quarantine, as well as disarray due to the oft-­ associated panic77 put influenza outbreaks in the category of PHDs. The preceding analysis shows that Ebola virus and pandemic influenza outbreaks are diseases of significant public health concern that may bring about devastating social

 Lucas and Gilles. Pp. 1–3.   Giovanni Battista Migliori et  al., “Drug Resistance Beyond Extensively Drug-Resistant Tuberculosis: Individual Patient Data Meta-Analysis,” European Respiratory Journal 42, no. 1 (2013). P. 170. 71  Richard Wise et  al., “Antimicrobial Resistance: Is a Major Threat to Public Health,” British Medical Journal 317, no. 7159 (1998). P. 810. 72  H Tristram Engelhardt, “Ideology and Etiology,” Journal of Medicine and Philosophy 1, no. 3 (1976). Pp. 256–259. 73  AM Viens and Jasper Littmann, “Is Antimicrobial Resistance a Slowly Emerging Disaster?,” Public Health Ethics 8, no. 3 (2015). Pp. 255–262. 74  Jeffery K Taubenberger and David M Morens, “1918 Influenza: The Mother of All Pandemics,” Review of Biomedicine 17, no. 1 (2006). P. 70. 75  Fatimah S Dawood et al., “Estimated Global Mortality Associated with the First 12 Months of 2009 Pandemic Influenza a H1n1 Virus Circulation: A Modelling Study,” The Lancet: Infectious Diseases 12, no. 9 (2012). Pp. 687–688. 76  Cécile Viboud et al., “Global Mortality Impact of the 1957–1959 Influenza Pandemic,” Journal of Infectious Diseases 213, no. 5 (2016). P. 738. 77  Mark Davis et al., ““We Became Sceptics”: Fear and Media Hype in General Public Narrative on the Advent of Pandemic Influenza,” Sociological Inquiry 84, no. 4 (2014). Pp. 499–503. 69 70

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c­ onsequences. Their disaster dynamics are tied to the destruction, death, displacement, disappearance, and disarray that they cause. The public health consequences of man-made or natural disasters which exhibit all or some of the six Ds may also fit into the class of PHDs. For instance, cholera constitutes a common post-earthquake event, which was observed in the 2010 Haiti earthquake.78 Rapidly occurring or accelerated levels of physical and psychological trauma, and other mass causality events are other characteristics of earthquakes. Destruction of homes and water supply systems, the disintegration of families and disappearance of people,79 as well as human displacements are also features of earthquakes.80 Hence, while earthquakes are not diseases or disorders, their capacity to cause destruction, deaths, displacement, disappearance, and disarray (the disaster dynamics) and pose significant public health issues justify their categorization as PHDs. The high index of untreatability associated with a typical drug-resistant tuberculosis not only  leads to unavoidable deaths  but also causes some degree of social disarray as exemplified by the escape of infected persons from hospitals (as occurred in South Africa and Kenya) with an attendant spread of infections81. While the extent to which silent public health disasters such as ADR-TB exhibit elements of the six Ds may be low in comparison to that of other PHDs, it is not certain that the interaction of the social dynamics and the causal factors will remain unchanged. As such, any change (social, behavioral, and biological) that favors a slight exponential increase in the number of infected patients will foster the transition of the “silent status” of this type of PHD into an “overt status”. Besides the disaster dynamics associated with PHDs, they create scenarios where the multifaceted individual and social interests or good run against one another and will require some measure of balancing. On this note, the general ethical quandaries elicited by PHDs may be elaborated.

1.4  Ethical Dynamics of Public Health Disasters Since public health disasters incorporate elements of disaster bioethics and public health ethics, some of the moral concerns that are at the intersection of these two axes of moral investigation are also elicited by PHDs. Yet, the nature of PHDs (based on any or all of the three possible conceptual interpretations outlined in the  Ezra J Barzilay et al., “Cholera Surveillance During the Haiti Epidemic—the First 2 Years,” New England Journal of Medicine 368, no. 7 (2013). Pp. 599–602. 79  Mei-Ling Xiao et al., “Simulation of Household Evacuation in the 2014 Ludian Earthquake,” Bulletin of Earthquake Engineering 14, no. 6 (2016). 80  Xin Lu, Linus Bengtsson, and Petter Holme, “Predictability of Population Displacement after the 2010 Haiti Earthquake,” Proceedings of the National Academy of Sciences 109, no. 29 (2012). 81  Ross E.G Upshur, “What Does It Mean to ‘Know’ a Disease? The Tragedy of Xdr-Tb,” in Public Health Ethics and Practice, ed. Stephen Peckham and Alison Hann (Policy Press, 2010). P. 55. 78

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previous section) as a distinct type of disaster also generate unique moral dilemmas. The vulnerable nature of human beings, for instance, implies that they are prone to certain negativities just because they belong to the Homo sapiens species. Public health disasters accelerate and accentuate the vulnerability dimensions of human life. They underscore the multifaceted aspects of how humans are susceptible to being hurt and taken advantage of by physical, psychological, social, economic, human and environmental factors.82 In this regard, cultural practices connected to burial rites increase the risk of Ebola viral infection, poor living conditions in overcrowded housing enhance influenza virus transmission, and being born in and living in an earthquake-prone region of the world increases the likelihood of one dying or suffering harm directly from an earthquake, or indirectly from one of its attendant effects such as psychological trauma and cholera infection. Understanding the nature and dimensions of these different kinds of vulnerabilities (social, biological, epistemic, and geographic) will thus enable a better way of engaging the quandaries of PHDs and the attendant pragmatic challenges. The limited human and material resources characteristic of disaster situations creates the need to make difficult moral choices in terms of allocation of these resources including triage decisions. These factors inevitably generate questions of justice, which involves increasing utility in a mutually fair and harmonious atmosphere that is open to contextual values and needs.83 Local justice in the context of PHDs will incorporate the need to prioritize needs and resources amongst local actors and victims of any given disaster. On the other hand, issues of global justice will arise when other nations or international relief agencies become part of the players in disaster situations, or when neoliberal forces constitute some of the background factors that shape the severity of specific disasters. Justice in any of these contexts requires developing and following the fairest and balanced course of action. But the multiple local and global actors involved in disaster situations may complicate the process of achieving justice or agreeing to what constitutes justice in any one given scenario. This is largely because what is fair may vary by context, culture, and experience. Human rights issues also arise within the context of public health disasters. These are context-specific but generally come to the fore as a result of what one individual may do or fail to do to other individuals during disaster situations. For instance, triage decisions by healthcare workers which often come with the exclusion of some disaster victims from receiving medical care may be shown to violate the rights of vulnerable victims of disasters. Such instances cannot be ignored and deserve attention and critical reflection considering the interconnection between health or the right to health and human rights.84 In other words, denial of health  Henk ten Have, Vulnerability: Challenging Bioethics (Routledge, 2016). Pp. 10–11.  Tom L Beauchamp and James F Childress, Principles of Biomedical Ethics (Oxford university press, 2013). Pp. 249–253. 84  Lisa Forman and Stephanix Nixon, “Human Rights Discourse within Global Health Ethics,” in An Introduction to Global Health Ethics, ed. Andrew D Pinto and Ross E.G Upshur (London: Routledge, 2013). Pp. 54–55. 82 83

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needs during public health disaster situations—for whatever potentially justifiable reasons—constitutes a denial of rights. This clearly echoes the thrust of the moral tension that is at the heart of public health ethics. However, even if societies have to painfully sacrifice the rights and needs of a few for the overall interest of her self-­ survival, human rights issues often become nuanced during public health disasters and may be tainted by political and other non-rights considerations. During the 2014 Ebola outbreak, there was a slow pace with which human resources were committed to Ebola-hit regions, especially at the early phase. This contributed to the suspicion that a large-scale situation was being diplomatically incubated to create markets for vaccines so that BigPharma companies may profit off the outbreak. At the same time, there were so-called cases of preferential or “privileged” care and attention/treatment by elite local and international victims of the Ebola outbreak. In some way, this particular observation seems to reflect George Orwell’s idea of “all animals are equal, but some are more equal than others”.85 If this is true, then the traditional moral quandary of human rights elicited during disaster scenarios as well as the selective interpretation or implementation of rights during PHDs deserve critical appraisal. Uncertainty is another significant moral issue that resonates across public health disasters. Specifically, it arises as a result of the absence of certitude or exact knowledge86 to guide the required and necessary courses of public health actions and policies during disaster scenarios. Traditionally, whereas acquiring knowledge is an important means of diminishing uncertainty,87 this hardly applies to contexts of PHDs such as Ebola viral outbreaks, pandemic influenza, atypical drug-resistant tuberculosis, and earthquakes. For instance, the risk factors for Ebola and influenza viral outbreaks are generally well-known. However, the particular way in which the nature-nurture nexus will produce particular disease situations and at what time and place often remain unknown and unpredictable. Similarly, while natural forces beyond the control of humankind contribute to the occurrence of earthquakes88 as well as human activities including the underground detonation of explosives and deep-well injections89; the role of non-anthropological factors (e.g. gods, God, spirits etc.) have been acknowledged but their influences writ large are hard to demonstrate. This is so especially in an increasingly pluralistic and secularized world. These shades of uncertainties sometimes paralyze action, foster complacency but may suggest alternative courses of actions which are barely favored and explored at the public policy level.

 George Orwell, Animal Farm: A Fairy Tale (New American Library, 1946). P. 192.  Hansson. Pp. 1–3. 87  Christof Tannert, Horst-Dietrich Elvers, and Burkhard Jandrig, “The Ethics of Uncertainty,” EMBO Reports 8, no. 10 (2007). Pp. 892–893. 88  Canan Lacin Simsek, “Turkish Children’s Ideas About Earthquakes,” Online Submission 2, no. 1 (2007). Pp. 14–15. 89  Eric K Noji, The Public Health Consequences of Disasters (Oxford University Press, USA, 1997). Pp. 3–8. 85 86

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Vulnerability, local and global justice, human rights and the associated nuances, as well as uncertainty, therefore,  constitute some of the major ethical issues that arise during public health disasters. Each of these ethical quandaries may, however, be shown to arise as a result of context-laden relational dissonances. Such relational dissonances or disharmony occur amidst a complex interplay of human, microbial life and non-anthropological parameters. If this is true, then it would require an ethical framework forged on the foundations of relational principles and values to engage the moral quandaries of public health disasters. Scholars like ten Have, for instance, describe vulnerability as a gradual and relational experience that negatively impact people’s wellbeing.90 Applied to the context of disasters, this suggests the notion that dealing with the different shades of vulnerabilities that PHDs elicit will warrant an approach that takes into consideration the different relational tensions and dimensions that contribute to engendering PHDs ab initio. To be sure, public health disasters bring about several kinds of disruptions in relationships at the personal and social experiential axes. For instance, earthquakes negatively shape personal confidence in nature’s benign nature and engender a sense of fear and helplessness. Earthquakes as a distinct category of PHDs also raise existential and theological questions about how personal or social moral comportment may elicit catastrophic destructions through the forces of nature acting in tandem with a divine hand. Other types of public health disasters including Ebola viral and pandemic influenza outbreaks disrupt individual, familial, and business relationships through the agency of requisite travel restrictions, quarantine, and sometimes a halt in commercial activities. Therefore, engaging these issues will demand an approach that seeks ethically creative ways to prepare moral actors, survivors, and victims of disasters ahead as well as help them to deal with the relational dissonances that public health disasters engender. It is such a task that this book will ultimately address through the global ethical framework it seeks to develop.

1.5  Global Dynamics of Public Health Disasters The increasing realization that contemporary public health has no national boundaries and is inherently global91 underscores the notion that the pragmatic and moral perplexities raised by public health disasters will not be localized but would and should garner a more global kind of reflection, policy response, and pragmatic interventions. The practical import of this is historically illustrated by the case of smallpox which seemed to have begun in Northeastern Africa around 10,000  BC but spread to other regions of the world to wreak untold morbidity.92 Therefore,  ten Have, Vulnerability: Challenging Bioethics. P. 6.  Annas. P. xxiii. 92  Laura H Kahn, Who’s in Charge?: Leadership During Epidemics, Bioterror, Attacks, and Other Public Health Crises (ABC-CLIO, 2009). P. 13. 90 91

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d­ eveloping a global framework for PHDs offers a lens for focusing attention on this global but under-studied issue. The transcontinental nature of the SARS epidemic, for instance, has made some commentators hold the position that there is an urgent need to strengthen the ways the global community deals with emerging infectious diseases, and how novel visions of global solidarity and cooperation will be key in such an endeavor.93 For scholars like Radest, the paucity of an ethical framework that can help deal with the different dimensions of health disasters involving a large number of casualties, deaths, and dislocated societies endanger the global community.94 Other commentators like Schuklenk and Hare emphasize the need for a concerted global response to combat infectious diseases that approach disaster proportions.95 To get better insights into the global dimensions of PHDs, an examination of the social consequences locally, and how these generate global dimensions will be useful. This can be done by pursuing the six-D characteristics of disasters. All public health disasters cause death to different degrees. For example, the 1976 Ebola Sudan outbreak had a mortality rate of 53%, the second outbreak in Zaire also in 1976 had a rate of 89% and the third outbreak in Sudan in 1979 had a mortality rate of 65%.96 These figures translate not only into the deaths of individual human beings including mothers, fathers, children, uncles, and aunties but also engender the social, personal and economic disruption of the lives of the dependents (children and spouses), parents, and associates of the victims. The morbidity wrought by the 2014 Ebola outbreak which killed more than half of infected persons further highlights the mortality of this public health issue and its disastrous consequences. It likewise underscores the importance of a proper pragmatic and ethical approach, especially in terms of the ease with which the disease transcended borders97 and rapidly acquired a global status. With the rise in rapid air-transportation capabilities today which readily moves people including the infected from one region to another (potentially exporting diseases), it is no surprise that there have been suggestions that quantitative analysis of worldwide air-traffic patterns may enable cities and countries around the world to better anticipate the risks of importing global infectious diseases.98 The air transportation restrictions that were instituted during the 2014 Ebola outbreak illustrates this public health preventive approach.  Peter A Singer et al., “Ethics and Sars: Lessons from Toronto,” British Medical Journal 327, no. 7427 (2003). Pp. 1342–1343. 94  Howard B Radest, Bioethics: Catastrophic Events in a Time of Terror (Lexington Books, 2009). Pp. 7–18. 95  Udo Schuklenk and Darragh Hare, “Issues in Global Health,” in Global Bioethics and Human Rights: Contemporary Issues, ed. Wanda Teas, John-Stewart Gordon, and Alison D Renteln (London: Rowman & Littlefield, 2014). Pp. 300–301. 96  Xavier Pourrut et al., “The Natural History of Ebola Virus in Africa,” Microbes and Infection 7, no. 7 (2005). Pp. 1006–1007. 97  Kass. P. 744. 98  K Khan et al., “Spread of a Novel Influenza a (H1n1) Virus Via Global Airline Transportation,” The New England Journal of Medicine 361, no. 2 (2009). Pp. 212–213. 93

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Commercial airlines are a suitable environment for the spread of pathogens carried by passengers or crew; as such, transmission of infectious diseases during commercial air travel is an important public health issue99 locally and globally. In the context of public health disasters, however, the required restriction in the transportation of goods and human cartel will bring about some disruption in social life. Consider, for instance, Mr. G who is a business man living in an area where an outbreak of Ebola has recently taken place. If his primary business involves air-­ travel to buy stock, a travel restriction will negatively affect him. In addition, the local hysteria and fear may keep people away from patronizing his business. Consequently, those directly and indirectly dependent on his economic input will bear some significant pecuniary loss. This is only hypothetical; yet, it illustrates the notion that preparedness efforts need to take into serious consideration the associated complex social dynamics that often surround disaster scenarios. In the hypothetical case, it will be hard to imagine that Mr. G may not seek for alternative travel channels to keep his business alive. It is equally plausible that acts of corruption may create loopholes that will enable Ebola-positive undiagnosed people to circumvent any travel barriers meant to curtail the spread of infection. These pragmatic possibilities again echo the importance of an all-inclusive approach that pays serious attention to all underlying social factors that may shape the actions and inactions of moral agents during PHDs. It also echoes the importance of local solidarity and cooperation as well as well-­coordinated international solidarity during public health disasters. If solidarity, as Featherstone opines, involves creating new ways of relating and interaction,100 then any moral framework developed towards engaging the ethical quandaries that PHDs generate must incorporate creative relational approaches. Although the death, destruction, and social disarray that accompany disease outbreaks such as Ebola viral diseases and pandemic influenza demonstrate the social impacts of public health disasters locally and their global dimensions, the public health consequences of natural disasters such as earthquakes can offer some additional perspectives. To be sure, by 1997 it was estimated that natural disasters such as earthquakes had claimed more than 3 million lives while negatively affecting the lives of other 800 million people as well as causing more than 50 billion USD loss at a global level.101 These figures approach disaster proportions and reflect the death, destruction, and destruction aspects of the six Ds. On the other hand, communicable diseases are also brought to the fore during earthquakes, locally and globally. For instance, dengue fever was imported into the United States during the 2010 Haiti

 Alexandra Mangili and Mark A Gendreau, “Transmission of Infectious Diseases During Commercial Air Travel,” The Lancet 365, no. 9463 (2005). Pp. 989, 994. 100  David Featherstone, Solidarity: Hidden Histories and Geographies of Internationalism (Zed Books, 2012). P. 5. 101  Eric K. Noji, “The Nature of Disasters: General Characteristics and Public Health Effects,” in The Public Health Consequences of Disasters, ed. Eric K.  Noji (New York: Oxford University Press, 1997). Pp. 3–4. 99

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Earthquake.102 Health infrastructures are likewise targets of natural disasters such as earthquakes,103 further hindering and complicating the speed and type of available health responses. In addition, the destruction of houses that accompanies earthquakes expose victims to environmental disease vectors including mosquitoes, lice, and fleas.104 However, it is not only the disease dynamics of earthquakes on a global transmission scale that cause concerns. The enhanced interconnectivity in traditional media and the new social media platforms can rapidly distribute real but disturbing images of the carnage of earthquakes and the associated public health sequelae. These platforms effectively transmit the horrors and realities of earthquakes, the distress of the victims, as well as the overwhelming burdens of the local healthcare system to other parts of the world. But disturbing as this may be, it equally provides an avenue through its capacity to stimulate external acts of solidarity to help lessen the burdens of such public health disasters. As Keim and Noji reported, during the immediate aftermath of the 2010 Haiti earthquake, social media platforms were the source of what people around the world knew. It also served as a new forum for collective intelligence, social convergence, and community activism, and within the first two days of the earthquake led to donations of more than $5 million to the American Red Cross.105 The visceral-type of identification with disaster victims as vulnerable people needing urgent rescue and care which can thereafter elicit acts of solidarity underscores the significance of how burdens of a locality can rapidly become a global burden that demands attention and solutions. At the same time, however, not any kind of international assistance is needed during public health disasters. For instance, Noji argues that a hasty response that is devoid of prior impartial assessment will only complicate the chaos of disasters such as earthquakes. As such, it is better to wait until real needs have been identified.106 Silent public health disasters such as atypical drug-resistant tuberculosis also exert a number of global dimensions. In traditional western societies and in westernized climes, most people value individual freedom and construe it an inviolable “right”. In the American context where the ethos of moralism, meliorism, and individualism hold sway,107 the fate of those carrying an infectious disease is generally not tied to that of the collective society. This is indeed the genesis of the moral tension in public health ethics where the atomization of persons’ interests run contrary to collective interests. Applied to the context of ADR-TB, an autonomy-driven  Tyler M Sharp et al., “A Cluster of Dengue Cases in American Missionaries Returning from Haiti, 2010,” The American Journal of Tropical Medicine and Hygiene 86, no. 1 (2012). P. 16. 103  Noji. Pp. 14–15. 104  Michael J.  Toole, “Communicable Diseases and Disease Control,” in The Public Health Consequences of Disasters, ed. Eric K. Noji (New York: Oxford University Press, 1997). P. 81. 105  Mark E Keim and Eric Noji, “Emergent Use of Social Media: A New Age of Opportunity for Disaster Resilience,” American Journal of Disaster Medicine 6, no. 1 (2010). Pp. 47–50. 106  Noji. P. 17. 107  Albert R Jonsen, The Birth of Bioethics (Oxford University Press, 2000). P. 390. 102

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i­deology naturally runs against compliance to public health directives, especially when they involve bearing burdens that are directly removed from the personal risks and interests of individuals. In the United States, there have been empirical proofs of this tension in relation to tuberculosis. Specifically, this was exemplified by the cases of Robert-Daniels (who refused to comply with directives to wear a mask to prevent disease dissemination in public) and Andrew Speaker (who ignored public health orders and traversed national and international borders).108 The actions of these Americans echo the idea that health policies and programs may be discriminatory and burdensome on human rights; hence, are to be challenged.109 It likewise reflects the Western “me, myself, and I” mantra which prioritizes freedom and self-determination above all other considerations.110 The global risk of spreading infections demands that a global public health engagement of PHDs in general and atypical drug-resistant tuberculosis, in particular, will require an approach that has some departure from a morality forged on individualism. In this regard, a relational-based moral system that reckons with the relationship of people to other people, the infected versus the non-infected and the relationship between microbial life and people offers a useful and remarkable means of addressing this moral quandary and the attendant pragmatic issues.

1.6  Methodology This book draws insights from extant literature from a range of academic arenas including sociology and medical sociology, biomedical sciences, public health, as well as the bioethics literature. This approach reflects what bioethicists like ten Have recently argued for, noting that bioethical discourses increasingly demand multiple voices. If this is true, the voice of reasoned insights from non-bioethics academic disciplines is relevant, especially in areas of shared themes. Four representative types of global problems à la public health disasters across geographic and cultural divides are first selected. This is followed by using an ethical lens that closely mirrors the particular disaster to engage and formulate context-suitable ethical resolutions. For instance, the African moral lens of Ubuntu is applied to Ebola virus outbreaks due to the general origin of such outbreaks from that part of the world. In the case of atypical drug-resistant tuberculosis, a completely new ethical lens is developed based on the specific parameters associated with its dynamics. The relevant transnational nuances and limitations associated with each context-specific ethical lens, the common linkages around each of the PHDs, as well as the  Upshur. Pp. 53–54.  Jonathan M Mann et al., “Health and Human Rights,” Health and Human Rights 1, no. 1 (1994). P. 16. 110  Eric J Cassell, The Nature of Suffering and the Goals of Medicine (Oxford University Press, 2004). Pp. 23, 25–26. 108 109

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overlapping quandaries are then systematically identified and clarified. These are ultimately used to frame a global normative framework for engaging public health disasters as a class of global health problems. Procedurally, the thematic objectives of this book will be realized as follows. From Chaps. 2, 3, 4 and 5, a context-specific ethical framework will be developed for each of the four representative public health disasters. For Ebola viral disease, a Ubuntuan ethical framework will be developed. This will be based on the African notion of Ubuntu which conceives morality as a function of the mutual recognition of personhood in all parties in a relationship,111 affirmed through the maxim: I am because we are. This ethical lens will show that an other-centric cognitive frame of mind is exigent to dealing with the moral quandaries raised by EVDs. Chapter 3 will use two people-centric moral lenses to engage the moral issues embedded in pandemic influenza outbreaks. Specifically, it will employ the communitarian as well as the ethics of care moral framework to point out the strengths of these two and what insights they may offer public health disasters in general. Chapter 4 will develop an anthropo-ecological moral lens for engaging the moral perplexities that arise from atypical drug-resistant tuberculosis. This approach will be framed on the vectorhood and victimhood of humans, the teleological elusiveness of microbes and the evolving nature and capacities of the ecosystem. Chapter 5 will engage the public health consequences elicited by earthquakes as well as the attendant ethical issues. In this regard, it will develop a solidaristic framework that can help address the anthropogenic and non-anthropogenic dimensions of the moral issues. Chapter 6 will systematically examine how the ethical issues elaborated in Chaps. 2, 3, 4 and 5 overlap and the limitations of the moral frameworks that were used to engage the attendant ethical issues which the four respective PHDs bring about. It will then attempt to weave a common logical thread around the range of human and non-human interconnectedness that resonate across Ebola outbreaks, ADR-TB, pandemic influenza, and earthquakes. Using this as a conceptual fulcrum, the chapter will develop a relational-based GEF to address the moral quandaries of public health disasters. It will also offer justificatory polemics as to why such an approach is what best suits the moral quandaries engendered by public health disasters. Finally, Chap. 7 will explore how to translate the relational-based global ethical framework into action guides via relevant local and transnational stakeholders in order to influence on-the-ground realities. The chapter will also examine the GEF vis-a-vis the UDBHR.

 Leonard Tumaini Chuwa, African Indigenous Ethics in Global Bioethics (Springer, 2014). Pp. 36–37.

111

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1.7  Conclusion This introductory chapter has pointed out the conceptual, ethical, trans-national, and global dimensions of public health disasters. It has shown the gaps in the extant bioethics literature. Specifically, it has shown how public health disasters as a notion and an ethical category has not received the needed scholarly attention. It has likewise shown that analyzing the notions of “public health”, “disasters”, “public health ethics”, and “disaster ethics/bioethics” hold the key to untangling what a public health disaster may possibly be. In this vein, PHDs constitute public health ethics-related issues that arise due to disasters such as infectious disease outbreaks of pandemic proportions; public health issues that have disaster dynamics, for instance, the attendant public health impacts of natural or man-made disasters; and “silent” or non-apparent disasters (natural or man-made) that are yet to garner ample public health attention but which may (given the right combination of biological and social conditions) rapidly approach pandemic proportions. This chapter also presented the general ethical quandaries of public health disasters encapsulated by social, existential, biological and geographic vulnerabilities, human dignity and rights-related issues, balancing local and global justice issues, and uncertainty. The local and global dimensions of these quandaries were highlighted as well as the compelling ethical and pragmatic need—illustrated by several shades of the six Ds—to engage them. Finally, the chapter briefly set out the methodological approach that will be used to frame and develop the relational-based GEF for engaging the moral dilemmas generated by PHDs.

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Moodley, Keymanthri. 2014. Ethical Concerns in Disaster Research—a South African Perspective. In Disaster Bioethics: Normative Issues When Nothing Is Normal, 191–204. Dordrecht: Springer. Nie, Hu, Shi-Yuan Tang, Wayne Bond Lau, Jian-Cheng Zhang, Yao-Wen Jiang, Bernard L. Lopez, Xin L. Ma, Yu Cao, and Theodore A. Christopher. 2011. Triage During the Week of the Sichuan Earthquake: A Review of Utilized Patient Triage, Care, and Disposition Procedures. Injury 42 (5): 515–520. Noji, Eric K. 1997a. The Public Health Consequences of Disasters. New York: Oxford University Press. ———. 1997b. The Nature of Disasters: General Characteristics and Public Health Effects. In The Public Health Consequences of Disasters, ed. Eric K.  Noji, 3–19. New  York: Oxford University Press. O’Mathúna, Dónal. 2016. Ideal and Nonideal Moral Theory for Disaster Bioethics. Human Affairs 26 (1): 8–17. O’Mathúna, Dónal P., Bert Gordijn, and Mike Clarke. 2014. Disaster Bioethics: An Introduction. In Disaster Bioethics: Normative Issues When Nothing Is Normal, 3–12. Dordrecht: Springer. Orwell, George. 1946. Animal Farm: A Fairy Tale. New York: New American Library. Peckham, Stephen, and Alison Hann. 2010. Introduction. In Public Health Ethics and Practice, ed. Stephen Peckham and Alison Hann, 1–15. Bristol: Policy Press. Pourrut, Xavier, Brice Kumulungui, Tatiana Wittmann, Ghislain Moussavou, André Délicat, Philippe Yaba, Dieudonné Nkoghe, Jean-Paul Gonzalez, and Eric Maurice Leroy. 2005. The Natural History of Ebola Virus in Africa. Microbes and Infection 7 (7): 1005–1014. Powell, Tia, Kelly C. Christ, and Guthrie S. Birkhead. 2008. Allocation of Ventilators in a Public Health Disaster. Disaster Medicine and Public Health Preparedness 2 (1): 20–26. Radest, Howard B. 2009. Bioethics: Catastrophic Events in a Time of Terror. Lexington Books. Rhodes, Philip. 1976. The Value of Medicine. London: Allen and Unwin. Rios, Claritza L., Michael Redlener, Eric Cioe, Patricia M.  Roblin, Stephan Kohlhoff, Stephan Rinnert, William Lang, Kathleen Powderly, and Bonnie Arquilla. 2015. Addressing the Need, Ethical Decision Making in Disasters, Who Comes First? Journal of US-China Medical Science 12: 20–26. Roberts, Marc J., and Michael R. Reich. 2002. Ethical Analysis in Public Health. The Lancet 359 (9311): 1055–1059. Schuklenk, Udo, and Darragh Hare. 2014. Issues in Global Health. In Global Bioethics and Human Rights: Contemporary Issues, ed. Wanda Teas, John-Stewart Gordon, and Alison D. Renteln, 300–318. London: Rowman & Littlefield. Schwartz, Lisa, Matthew Hunt, Lynda Redwood-Campbell, and Sonya de Laat. 2014. Ethics and Emergency Disaster Response. Normative Approaches and Training Needs for Humanitarian Health Care Providers. In Disaster Bioethics: Normative Issues When Nothing Is Normal, 33–48. Dordrecht: Springer. Šehović, Annamarie Bindenagel. 2017. Coordinating Global Health Policy Responses: From Hiv/ Aids to Ebola and Beyond. Springer. Selgelid, Michael J., P.M.  Kelly, and Adrian Sleigh. 2008. Ethical Challenges in Tb Control in the Era of Xdr-Tb [Unresolved Issues]. The International Journal of Tuberculosis and Lung Disease 12 (3): 231–235. Sharp, Tyler M., Parvathy Pillai, Elizabeth Hunsperger, Gilberto A. Santiago, Teresa Anderson, Trina Vap, Jeremy Collinson, et al. 2012. A Cluster of Dengue Cases in American Missionaries Returning from Haiti, 2010. The American Journal of Tropical Medicine and Hygiene 86 (1): 16–22. Shortridge, Andrew. 2015. Moral Reasoning in Disaster Scenarios. Journal of Medical Ethics 41 (9): 780–781. Shultz, James M., Janice L.  Cooper, Florence Baingana, Maria A.  Oquendo, Zelde Espinel, Benjamin M. Althouse, Louis Herns Marcelin, et al. 2016. The Role of Fear-Related Behaviors in the 2013–2016 West Africa Ebola Virus Disease Outbreak. Current Psychiatry Reports 18 (11): 104.

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Simsek, Canan Lacin. 2007. Turkish Children’s Ideas About Earthquakes. Online Submission 2 (1): 14–19. Singer, Peter A., Solomon R. Benatar, Mark Bernstein, and Abdallah S. Daar. 2003. Ethics and Sars: Lessons from Toronto. British Medical Journal 327 (7427): 1342–1344. Smith, Charles B., Leslie P.  Francis, Margaret Pabst Battin, Jeffrey Botkin, Jay A.  Jacobson, Beverly Hawkins, Emily P. Asplund, and Gretchen J. Domek. 2004. Are There Characteristics of Infectious Diseases That Raise Special Ethical Issues? Developing World Bioethics 4 (1): 1–16. Tannert, Christof, Horst-Dietrich Elvers, and Burkhard Jandrig. 2007. The Ethics of Uncertainty. EMBO Reports 8 (10): 892–896. Taubenberger, Jeffery K., and David M.  Morens. 2006. 1918 Influenza: The Mother of All Pandemics. Review of Biomedicine 17 (1): 69–79. ten Have, Henk. 2014. Macro-Triage in Disaster Planning. In Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Dónal P.  O’Mathúna, Bert Gordijn, and Mike Clarke, 13–32. Dordrecht: Springer. ———. 2016. Vulnerability: Challenging Bioethics. Routledge. Toole, Michael J.  1997. Communicable Diseases and Disease Control. In The Public Health Consequences of Disasters, ed. Eric K. Noji, 79–99. New York: Oxford University Press. Upshur, Ross E.G. 2010. What Does It Mean to ‘Know’ a Disease? The Tragedy of Xdr-Tb. In Public Health Ethics and Practice, ed. Stephen Peckham and Alison Hann, 55–64. Bristol: Policy Press. Verweij, Marcel F., and Angus Dawson. 2009. The Meaning of ‘Public’ in Public Health’. In Ethics, Prevention and Public Health, ed. Marcel F.  Verweij and Angus Dawson, 13–29. Oxford: Clarendon Press. Viboud, Cécile, Lone Simonsen, Rodrigo Fuentes, Jose Flores, Mark A.  Miller, and Gerardo Chowell. 2016. Global Mortality Impact of the 1957–1959 Influenza Pandemic. Journal of Infectious Diseases 213 (5): 738–745. Viens, A.M., and Jasper Littmann. 2015. Is Antimicrobial Resistance a Slowly Emerging Disaster? Public Health Ethics 8 (3): 255–265. Whiley, David M., Namraj Goire, Monica M. Lahra, Basil Donovan, Athena E. Limnios, Michael D. Nissen, and Theo P. Sloots. 2012. The Ticking Time Bomb: Escalating Antibiotic Resistance in Neisseria Gonorrhoeae Is a Public Health Disaster in Waiting. Journal of Antimicrobial Chemotherapy 67 (9): 2059–2061. Wise, Richard, Tony Hart, Otto Cars, Marc Streulens, Reinen Helmuth, Pentti Huovinen, and Marc Sprenger. 1998. Antimicrobial Resistance: Is a Major Threat to Public Health. British Medical Journal 317 (7159): 609. Xiao, Mei-Ling, Yang Chen, Ming-Jiao Yan, Liao-Yuan Ye, and Ben-Yu Liu. 2016. Simulation of Household Evacuation in the 2014 Ludian Earthquake. Bulletin of Earthquake Engineering 14 (6): 1757–1769. Yakubu, Aminu, Morenike Oluwatoyin Folayan, Nasir Sani-Gwarzo, Patrick Nguku, Kristin Peterson, and Brandon Brown. 2016. The Ebola Outbreak in Western Africa: Ethical Obligations for Care. Journal of Medical Ethics 42 (4): 209–210. Zack, Naomi. 2010. Ethics for Disaster. Lanham: Rowman & Littlefield Publishers.

Chapter 2

Ebola Viral Outbreaks: A Ubuntuan Ethical Approach

Abstract  Ebola viral outbreaks are a class of public health disasters that pose significant social burdens across countries and continents. An understanding of its nature, risk, as well as socio-cultural dynamics, locally and globally, can help bring the attendant ethical issues to the fore. Due to its geographical linkage with the African context and the relational issues that are central to the moral dilemmas and trans-national challenges generated during Ebola outbreaks, this chapter develops and applies an ethical approach based on the Ubuntu concept to engage these issues.

2.1  Introduction Ebola viral disease (EVD) outbreaks evince disaster characteristics and pose significant public health burdens. They can, therefore, be categorized as a type of public health disaster since they cause massive shades of disaster-related harms, are sudden, infectious, as well as characterized by the presence of overwhelming needs and insufficient resources.1 These challenges engender moral concerns. This chapter examines the disaster and risk dynamics of Ebola viral disease outbreaks, the socio-­ cultural contexts, as well as the associated ethical issues. It will highlight the different levels of interconnectedness that underlie these dilemmas and examine how a ubuntuan ethical approach may help address them and drive a useful public health policy.

1  Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke, “Disaster Bioethics: An Introduction,” in Disaster Bioethics: Normative Issues When Nothing Is Normal (Springer, 2014). Pp. 3–4.

© Springer International Publishing AG, part of Springer Nature 2018 M. O. Afolabi, Public Health Disasters: A Global Ethical Framework, Advancing Global Bioethics 12, https://doi.org/10.1007/978-3-319-92765-7_2

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2.1.1  Nature & Risk Dynamics of Ebola Viral Disease To properly deal with the practical and ethical issues generated by Ebola outbreaks, it is necessary to provide some conceptual foreground into the nature of the virus and some biomedical insights into the dynamics of the disease. These perspectives will help situate the risk dynamics of EVDs, provide an understanding of the incubation period, symptoms, transmission patterns, and ultimately help frame the disaster dimensions. The Ebola virus belongs to the Filoviridae family and the genus Ebolavirus, which is currently classified into five separate subspecies: Sudan, Zaire, Tai Forest (Ivory Coast), Reston, and Bundibugyo ebolavirus. Wild animals are believed to serve as a reservoir and can transmit the virus to humans.2 Ebolaviruses have been associated with large outbreaks of hemorrhagic fever in human and non-human primates.3 Ebola viral disease is a zoonotic disease transmitted accidentally by direct contact with infected live or dead animals. It was first described in 1976, the first incident being in Sudan.4 There have been more than 14 outbreaks since the 1976 first reported case.5 The natural reservoirs of Ebola virus remain elusive as the only positive results are partial, non-reproducible, and were obtained in doubtful circumstances. Yet, some trails of epidemiological clues suggest bats as the most likely candidates.6 Other kinds of “bushmeat” such as antelopes and monkeys are also thought to serve as foci of infections.7 However, the bushmeat hypothesis has several problems generally because Africans have historically used (and still use) the fruit bat, antelope, and monkeys as culinary delicacies for several years without there having been corresponding Ebola-like disease outbreaks. In Ghana, for instance, Kamins and colleagues reported that about 128,000 bats or E. helvum are sold each year through a commodity chain stretching up to 400 km and involving multiple vendors.8 If fruits bats are indeed natural sources of Ebola virus infections, retrospective logic demands that there would have been more cases in the past as well as more cases in more modern times. This clearly is not the case and casts a cloak of doubt over the bat-Ebola linkage. Callaway recently reported a related line of thought, stating that  Kevin G Donovan, “Ebola, Epidemics, and Ethics – What We Have Learned,” Philosophy, Ethics and Humanities in Medicine 9, no. 15 (2014). Pp. 1–2. 3  Serena A Carroll et al., “Molecular Evolution of Viruses of the Family Filoviridae Based on 97 Whole-Genome Sequences,” Journal of Virology 87, no. 5 (2013). Pp. 2608–2609. 4  Xavier Pourrut et al., “The Natural History of Ebola Virus in Africa,” Microbes and Infection 7, no. 7 (2005). Pp. 1006–1007. 5  J Legrand et al., “Understanding the Dynamics of Ebola Epidemics,” Epidemiology and Infection 135, no. 04 (2007). P. 610. 6  Pourrut et al. P. 1012. 7  Donovan. P. 2. 8  Alexandra O Kamins et al., “Uncovering the Fruit Bat Bushmeat Commodity Chain and the True Extent of Fruit Bat Hunting in Ghana, West Africa,” Biological Conservation 144, no. 12 (2011). Pp. 3000, 3006–3007. 2

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some scientists do not buy the bat story for Ebola virus because bats are much in numbers and too closely connected with humans to elucidate an infection that has emerged just two dozen times over the past four decades.9 The consumption of fruit bats is not restricted to West African nations as this cultural culinary practice occurs even in the largely isolated island of Madagascar.10 Whether or not bats or other kinds of bush meat cause EVD, it is known that the infection results from one of at least 30 RNA viruses capable of causing a viral hemorrhagic fever syndrome, of which the Zaire strain is the most virulent.11 EVD has an incubation period that can last between 3 days to 3 weeks. Transmission does not occur until an infected person gradually becomes sick12 with symptoms such as fever, malaise, myalgia, and headache, followed by pharyngitis, vomiting, diarrhea, and maculopapular rash. Severe and fatal stages are accompanied by hemorrhagic diathesis and multiple-organ dysfunction. Human-to-human transmission of EVD occurs primarily via contact with body fluids.13 Hospitals may, however, serve as facilitators of infections as patients may infect other patients and health workers. Infected healthcare workers then go on to serve as nosocomial foci of infection to other patients and workers in the hospital as well as to their relatives and family  members at home. During the 1995 EVD outbreak in Kinshasa, two hospitals were primary hotbeds of infection transmission.14 Indeed, health facilities and hospitals are one of the primary places where Ebola outbreaks develop, and from where they spread to communities15 through infected hospital employees. Butressing this idea, Verbeek and Mihalache observe that healthcare workers are at a much greater risk of Ebola infection than the general human population.16 Morbidity from EVD has varied from every outbreak. The first outbreak in 1976 had a mortality rate of 53%, the second outbreak in Zaire also in 1976 had a rate of 89%, and the third outbreak in Sudan in 1979 had a mortality rate of 65%. A 1995 Kinshasa outbreak produced a rate of 81%,17 but the 2014 outbreak was the biggest, most volatile, and deadliest Ebola epidemic ever experienced.18 In that outbreak, the mean time to death following hospital admission was 4.2 ± 6.4 days.19  Ewen Callaway, “Ebola Hunters Go after Viral Hideout,” Nature 529, no. 7585 (2016).  Richard KB Jenkins and Paul A Racey, “Bats as Bushmeat in Madagascar,” Madagascar Conservation & Development 3, no. 1 (2008). Pp. 1662–1671. 11  Barry Hewlett and Bonnie Hewlett, Ebola, Culture and Politics: The Anthropology of an Emerging Disease (Cengage Learning, 2007). P. 3. 12  Donovan. P. 1. 13  Abhishek Pandey et al., “Strategies for Containing Ebola in West Africa,” Science 346, no. 6212 (2014). P. 992. 14  Pourrut et al. P. 1007. 15  David L Heymann, “Ebola: Burying the Bodies,” The Lancet 386, no. 10005 (2015). P. 1729. 16  Jos H Verbeek and Raluca Cecilia Mihalache, “More Ppe Protects Better against Ebola,” American Journal of Infection Control 44, no. 6 (2016). P. 731. 17  Pourrut et al. Pp. 1006–1007. 18  Dan Yamin et al., “Effect of Ebola Progression on Transmission and Control in Liberia,” Annals of Internal Medicine 162, no. 1 (2015). Pp. 11–14. 19  WHO Ebola Response Team, “Ebola Virus Disease in West Africa—the First 9 Months of the Epidemic and Forward Projections,” New England Journal of Medicine 2014, no. 371 (2014). Pp. 1481–1490. 9

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These facts about EVD, as well as the associated data, show the personal and social risks that come with the outbreak. The notion of risk implies some measure of undesirability, uncertainty and lack of knowledge.20 In terms of EVD, several shades of risk dynamics come to the fore because people (ordinary citizens as well as experts) hardly know when or where the outbreak might begin, whether the strain will be different from previous ones, and because the  initial symptomatic presentations may mimic those of other viral and bacterial diseases. Although some of the risks associated with EVD are increasingly being speculated such as the association between consumption of bush meats and close proximity to wild animals including monkeys and bats,21 the origin of the epidemic remains unknown in terms of adequate knowledge of reservoirs and natural history of the disease and future prospects for controlling these.22 The greatest risk involves contact with symptomatic patients or those who have died from the disease such as through touching and washing of infected dead bodies.23 Such contacts spell more untoward consequences in the clinical context where health professionals who come in contact with undiagnosed cases in the wards and through blood samples for laboratory staff face the threat of infection, and may potentially serve as a hub of viral transmission. The risk of Ebola infection transmission among health workers is hardly eliminated after diagnosing  an Ebola-positive patient. Although certain recommendations including the use of personal protective equipment (PPE) help limit this, the cumbersome nature of how these are used in practice does not completely remove risks of infection. While PPE is generally effective at decreasing exposure to infected bodily fluids among health care workers, its presence is simply not enough as Ebola is transmissible via direct or indirect contact between bodily fluids from an infected patient and breaks in the skin or exposed mucous membranes of an uninfected person.24 The infection rate recorded amongst health workers during the 2014 outbreak in parts of West Africa supports this notion. Because health workers can only offer supportive care to EVD patients and try to stop the infection from spreading to new victims,25 this often raises the question of ethically acceptable risk to health workers during outbreaks in relation to the boundaries of professional obligations.

 Sven Ove Hansson, The Ethics of Risk: Ethical Analyses in an Uncertain World (Palgrave Macmilan, 2013). Pp. 1–3. 21  Gregg Mitman, “Ebola in a Stew of Fear,” New England Journal of Medicine 371, no. 19 (2014). P. 1764. 22  SI Okware et al., “An Outbreak of Ebola in Uganda,” Tropical Medicine & International Health 7, no. 12 (2002). P. 1074. 23  Pandey et al. P. 992. 24  William A Fischer, Noreen A Hynes, and Trish M Perl, “Protecting Health Care Workers from Ebola: Personal Protective Equipment Is Critical but Is Not Enough,” Annals of Internal Medicine 161, no. 10 (2014). P. 753. 25  Gretchen Vogel, “Are Bats Spreading Ebola across Sub-Saharan Africa?,” Sierra 5, no. 10 (2014). P. 140. 20

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While health workers have a general duty to care for all people, in some circumstances the characteristics of the Ebola outbreaks and the high mortality tends to exceed their general obligation. This argument is often supported by (1) the degree of personal risk required to provide care for EVD patients (2) whether the scenario requiring high-risk care occurs in a context of scarce manpower resource; (3) having no reliable and effective methods to minimize risk; and (4) the lack of effective training or access to effective PPE.26 The 2014 outbreak more than the previous incidents demonstrated the global risk dimensions of the Ebola viral disease. This was demonstrated in part by Patrick Sawyer (who imported the infection from Liberia to Nigeria), Pauline Cafferkey (who imported the infection from Sierra Leone to the United Kingdom), and Thomas Duncan (who imported the disease from Liberia to the United States). Although “only” eight lives were documented to have been lost in Nigeria, one in the USA, none in the UK,27 and one in Germany28; the outcome would have been significantly different if there were multiple streams of importation, which is possible with today’s rapid movement of people through air-travel. Not surprisingly, it has been observed that Ebola viral disease makes up a painful reminder about how an infectious disease outbreak in just a place poses a significant risk everywhere.29 It takes only a bit of imagination to imagine the consequences of a public health disaster such as EVD on a significantly global scale. This realization should spur local and international preparedness efforts but should also garner global solidaristic efforts during PHDs.

2.1.2  Socio–cultural Dynamics of Ebola Viral Disease There has been a very long recognition of the intersection and influences of social and cultural activities on health. In this regards, Benjamin Kogan notes that culture can create and shape health outcomes.30 As an example, male circumcision which is practiced for cultural and/or religious reasons has been consistently shown to cut down the risks of sexually transmitted infections including HIV/AIDS.31 However,  Cynda Hylton Rushton, “Ethical Issues in Caring for Patients with Ebola: Implications for Critical Care Nurses,” AACN Advanced Critical Care 26, no. 1 (2015). P. 66. 27  Robert Johnston, “Statistics on the 2014–2015 West Africa Ebola Outbreak,” http://www.johnstonsarchive.net/policy/westafrica-ebola.html 28  Annamarie Bindenagel Šehović, Coordinating Global Health Policy Responses: From Hiv/Aids to Ebola and Beyond (Springer, 2017). Pp. 76–77. 29   Thomas R Frieden et  al., “Ebola 2014—New Challenges, New Global Response and Responsibility,” New England Journal of Medicine 371, no. 13 (2014). Pp. 1177–1179. 30  Benjamin A Kogan, Health: Man in a Changing Environment (Harcourt Brace Jovanovich, Inc., 1970). 31  Aaron AR Tobian and Ronald H Gray, “The Medical Benefits of Male Circumcision,” Journal of American Medical Association 306, no. 13 (2011). Pp. 1479–1480; Aaron AR Tobian, Ronald H Gray, and Thomas C Quinn, “Male Circumcision for the Prevention of Acquisition and Transmission 26

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culture as socially constructed and/or socially evolved ways of life (at least most of them) probably do not set out to realize health purposes. If this is true, then it would not be surprising to find certain cultures being antithetical to health. Indeed, since technical guidelines for the control of EVD often show the importance of local views vis-à-vis responses to an outbreak32; the possible influences of local factors including culture are germane to a robust discussion on Ebola as well as how socio-­ cultural factors may foster its dissemination. Culture plays some roles in relation to Ebola viral outbreaks; as such, the ethical dynamics associated with understanding and responding to Ebola outbreaks will hardly go away if the role of culture is de-emphasized. Because most primary cases of Ebola outbreaks have occurred in the African continent, it would be useful to employ selected cultures in Africa to illustrate this remark. There is little, if any, lingering doubt about the notion that prior to the African contact with the western model of disease causation, there were indigenous models upon which explanations and interventions were based.33 These generally involve physicalistic and metaphysical levels of causal logic.34 For the Yoruba people, for instance, public health begins at the individual level of imototo, which roughly transliterates as personal cleanliness and proper sanitary behavior.35 Notions of public health and the attendant need to restrict individual actions and movements for the benefit of the collective society were not generally new to traditional Africa societies  either. Waite, for instance, notes that it was standard practice to refrain from conjugal relations and house-tohouse visitations during outbreaks such as smallpox. Incineration of houses following deaths from infectious diseases and village relocation were also common practices.36 However, a novel disease such as EVD does not seem to have elicited a specific cultural response. Culture often furnishes a normative framework for a given people, hence, it is usually prescriptive in terms of specific courses of actions and activities that people may or may not do or participate in, under defined sets of circumstances. In this vein, some West African nations embrace burial practices that are culturally validated. These rites place people near dead bodies, however, contiguity to dead bodies may have negative consequences for infectious diseases like Ebola. For example, 60% of cases in the 2014 incident in Guinea were linked to traditional burials. On this note, it is being championed that an urgent priority vis-à-vis curtailing EVD is of Sexually Transmitted Infections: The Case for Neonatal Circumcision,” Archives of Pediatrics & Adolescent Medicine 164, no. 1 (2010). Pp. 78–83. 32  Barry S Hewlett and Richard P Amola, “Cultural Contexts of Ebola in Northern Uganda,” Emerging Infectious Diseases 9, no. 10 (2003). P. 1242. 33  Michael O.S.  Afolabi, “Entrenched Colonial Influences and the Dislocation of Healthcare in Africa,” Journal of Black and African Arts and Civilization 5, no. 11 (2011). Pp. 231–233. 34  Segun Gbadegesin, African Philosophy (New York: Peter Lang, 1991). 35  Edward C Green, Indigenous Theories of Contagious Disease (Rowman Altamira, 1999). P. 44. 36  Gloria Waite, “Public Health in Precolonial East-Central Africa,” in The Social Basis of Health and Healing in Africa, ed. Steven Feierman; John M.  Janzen (University of California Press, 1992). Pp. 215–215.

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to change long-standing funeral practices that involve close contact with highly infectious corpses.37 The African culturally-inspired way of life which values and cherishes communal lookout for the welfare of others seems to also be a risk factor in relation to the spread of EVD. Brainard and colleagues, for instance, observed that caring for a case in the community especially until death is strongly associated with acquiring the disease, probably due to a high degree of direct physical contact with infected cases.38 These are obvious facts. Yet, calls for sanitary burial of Ebola victims or the suspension of traditional burial rites during Ebola outbreaks seem not to address the issue with ample sensitivity and often address the issue with some tone of rational imperialism. An attestation to how unacceptable such an attitude is interpreted is that a lot of people do not adhere to such instructions, which is again supported by the fact that relatives often hid the dead bodies of victims during the recent Ebola outbreak in Sierra Leone.39 These observations suggest the need for an alternative approach for engaging and breaking the nexus between traditional burial rites and customs and susceptibility to Ebola infections. This is important since public health encompasses distinct but related ideas which singly and collectively aim to foster the optimal health status in given societies. Hence, failure to address this dynamic will not only make it difficult to engage EVD locally but will contribute to its global spread when a local outbreak occurs and transcends local borders. Another socio-cultural dynamic which is often ignored is what model of disease causation people employ for infectious diseases which may or may not be EVD. In other words, beyond the one-size-fits-all approach which largely focuses on case isolation, contact-tracing with quarantine, and sanitary funeral practices as means of reversing the  spread of Ebola outbreaks,40 the peculiar local explanatory models need to be factored, given due consideration and carefully addressed in relation to shaping mass education and public action. This supports the notion that public health programs in developing economies would be more effective if they take existing ethnomedical beliefs into consideration.41 Calls for the interrogation of local context are, in fact, not new. Responding to a paper on the epidemiology of health services in Africa at a 1963 Conference, Thomas Lambo emphasized the need for not merely importing western models of disease causality and cited several instances where such direct importation without contextualization led to failure in public health schemes.42 The 2000–2001 Uganda EVD outbreak further illustrates this point.  Margaret Chan, “Ebola Virus Disease in West Africa—No Early End to the Outbreak,” New England Journal of Medicine 371, no. 13 (2014). Pp. 1183–1185. 38  Julii Brainard et  al., “Risk Factors for Transmission of Ebola or Marburg Virus Disease: A Systematic Review and Meta-Analysis,” International Journal of Epidemiology 45, no. 1 (2015). Pp. 1–3. 39  Anja Wolz, “Face to Face with Ebola—an Emergency Care Center in Sierra Leone,” New England Journal of Medicine 371, no. 12 (2014). Pp. 1081–1082. 40  Pandey et al. P. 991. 41  Green. Pp. 217–218. 42  HBL Russel, “Epidemiology and Provision of Health Services in Africa,” in Man and Africa, ed. Gordon Wolstenholme and Maeve O’Connor (Little, Brown & Company, 1965). P. 167. 37

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During the Ugandan outbreak, many people regarded the symptoms as a regular illness and sought a variety of both biomedical and indigenous cures. By late September of 2000, family heads where several deaths had occurred asked a traditional healer to locate the culprit poisons or yat in the local dialect. While this worked in some instances, in cases where the deaths continued residents began to realize that the outbreak was more than a regular kind of illness and began to classify it as two gemo or an epidemic. This subsumes a metaphysical level of logic. The standard local protocol for this involves the quarantine of victims in a house at least 100 meters from all other houses, with no visitors allowed, the designation of a survivor of the epidemic (who probably would have acquired some immunity) as a caregiver; and if there were no survivors, the designation of an elderly person for the task of caring.43 Therefore, ignoring indigenous systems of response such as this completely and attempting to impose only a western model of causation and spread will both isolate the people, foster ideological tensions for some, and may lead to time wastages that facilitate easy dissemination of infection. Sometimes, prior encounters may count. For instance, during the 1994–1997 outbreak in Gabon, international workers took blood samples without informing people what would be done with them. This led to the belief that the blood was harvested by the Euro-Americans to be taken to Switzerland for sale.44 Besides the ethical issues involved in that incident (for example, concerns about full disclosure and information sharing), a future outbreak in Gabon may lead to distrust of international health experts as well as other aid workers. Such an attitude may foster non-compliance. Another important socio-cultural dynamic is what the notion of public health means for a large swathe of people as opposed to its traditional conception. While public health traditionally refers to the total health status of the society or health interventions to the whole society, or a specific section of it45; there is a unique sense of public health in some parts of the African continent. Peter Ekeh have argued that “public” constitutes an offshoot of the African colonial experience with a unique historical configuration in the postcolonial era46 which has fragmented most African societies into different layers of unconnected publics. This suggests the notion that there is an unknown or uncharted public within the African society which has scanty or no interaction with the public social system. There is, therefore, a kind of public health that is both unknown descriptively and whose needs are hardly ever anchored into public health policy and plans. As such, public health within the African context incorporates the traditional sense of the science and art of promoting health and

 Hewlett and Amola. Pp. 1246–1247.  Hewlett and Hewlett. P. 8. 45  Marcel F Verweij and Angus Dawson, “The Meaning of ‘Public’ in Public Health’,” in Ethics, Prevention and Public Health ed. Marcel F Verweij and Angus Dawson (Oxford: Clarendon Press, 2009). Pp. 18–22. 46  Peter P Ekeh, “Colonialism and the Two Publics in Africa: A Theoretical Statement,” Comparative Studies in Society and History 17, no. 01 (1975). Pp. 91–93. 43 44

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preventing disease47 as well as the state of health of those disconnected from the social system with the attendant need to critically understand this and develop relevant interventions. This unique social dynamic to public health in the African context warrants consideration because the ethos of medicine (and, by implication, the ethos of public health) is governed by the philosophy of the society in which it is practiced.48 As such, interventions to outbreaks such as EVD will not yield optimal results if some of the critical mass of the general populace are left out. This is because public health is socially and culturally embedded and require context sensitivity.49 At the heart of the social context is the source of the ideas that govern and influence stakeholders’ activities. In this vein, it matters that whether the ideas of public health practice reflect local realities and the ideologies of the people concerned. This shows the need to employ a broader contemplation of prevailing social factors in relation to health interventions.50 In other words, there is an urgent need to seek out, catalog, critique, and exchange ideas with hitherto unrecognized “public” views in relation to health generally, and in relation to public health disasters such as EVD. A disquieting social aspect of EVD is that it often mimics other known diseases. With symptoms including fever, diarrhea, fatigue, and abdominal pain which are readily associated with gastrointestinal disturbances, index cases of EVD are hardly ever diagnosed soon enough. At the same time, the “wait period” often means that index cases if treated at home or the hospital will likely spread infection, with new cases further propagating viral transmission within and across communities. For instance, during the Congo outbreak of 1995 patients with bloody diarrhea were initially treated with antibiotics. However, ample protective measures were not adhered to by the health care workers who came in contact with the victims since EVD was not suspected. Following a surgery on an Ebola-infected laboratory staff, several members of the surgical team and other health care workers involved in his treatment became ill, with most of them dying within 1 to 2 weeks.51 Some of the classical six features of a disaster—destruction, death, disease/disorders, displacement, disappearance, and disarray—soon followed as many people fled their homes amidst confusion and the rising death toll. Lastly, there is the problem of trust. Donovan notes that the background crises situations in countries like Sierra Leone and Liberia fostered an atmosphere of a low level of trust of government institutions, including the medical system.52 This would  Adetokunbo O Lucas and Herbert Michael Gilles, Short Textbook of Public Health Medicine for the Tropics (Arnold Publishers, 2003). Pp. 1–6;Verweij and Dawson. Pp. 14–16 48  Philip Rhodes, The Value of Medicine (Allen and Unwin, 1976). Pp. 20–35. 49  Alan Cribb, “Why Ethics? What Kind of Ethics for Public Health,” in Public Health Ethics and Practice, ed. Stephen Peckham and Alison Hann (Polity Press, 2010). Pp. 22–27. 50  Verweij and Dawson. P. 17. 51  Yves Guimard et  al., “Organization of Patient Care During the Ebola Hemorrhagic Fever Epidemic in Kikwit, Democratic Republic of the Congo, 1995,” Journal of Infectious Diseases 179, no. Supplement 1 (1999). Pp. 269–270. 52  Donovan. P. 2. 47

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probably have been reinforced by the colonial history of the medical systems in these places which were created in repressive manners.53 Consequently, it is not surprising that there were people in Ebola-hit regions who would deny that the disease was real, even going so far as to claim that there is no epidemic, but the government, as well as health workers, were killing patients to simulate an epidemic so as to receive Western funding.54 The combination of the untreatable nature of Ebola viral disease, its patterns of human transmission locally and globally, as well as the socio-cultural dimensions surrounding the experience and disaster of an Ebola outbreak, are background factors that require serious reflection. In other words, they can no longer be glossed over.55 These background factors likewise generate a critical mass of ethical issues. These deserve careful examination in some practical way through relevant public health policy interventions that can help address them prior to Ebola outbreaks and during the course of an outbreak. The next section examines these moral quandaries.

2.2  Ethical Issues Embedded in Ebola Outbreaks EVDs foist burdens on people and generate several ethical concerns. This generally occurs due to how people (lay public, health workers, government officials et cetera) act in relation to the disaster burdens of EVD.  This section examines the most important aspects of these moral quandaries.

2.2.1  Vulnerability Vulnerability is founded on the rubric of human nature and human finitude56 and is usually associated with conditions that orient certain categories of humans in states of ready manipulation, coercion, and/or deception that are facilitated by powerless niches or situations.57 As such, it should prompt an instinctual solidaristic response.58  Afolabi. Pp. 234–236.  Donovan. P. 2. 55  Henk ten Have, “Macro-Triage in Disaster Planning,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke (Springer 2014). Pp. 29–30. 56  Maria Patrao Neves, “Respect for Human Vulnerability and Personal Integrity,” in The Unesco Universal Declaration on Bioethics and Human Rights: Background, Principles and Application, ed. Henk ten Have and Michèle Jean (UNESCO, 2009). Pp. 158–162. 57  Michael O.S. Afolabi, “Researching the Vulnerables: Issues of Consent and Ethical Approval,” African Journal Medicine & Medical Science 41 Suppl (2012). P. 9. 58   “A Vulnerability/Solidarity Framework for a Global Ethic: Historical & Contemporary Applications,” Revista Română de Bioetică 13, no. 1 (2015). Pp. 44–46. 53 54

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Being a human being and being located in certain facets of life constitutes possible means of being vulnerable. That is, while we are all vulnerable by belonging to the human community, context-dependent factors shape other categories or the extent of vulnerability. For instance, the elderly, the young, the sick, and pregnant women are often the most vulnerable in times of flooding.59 On a different note, Ruth Macklin argues that natural disasters in developing economies pose greater forms of harms which render the people hit by such disasters more vulnerable.60 This reflects what Barilan and others describe as a kind of double disasters in which extant conditions are chaotic, perilous, and misery-laden;61 thereby, increasing the degree of harm or susceptibility to harm that people in those contexts may suffer.  Ten Have recently remarked that the experience of vulnerability is multifaceted and involve physical, psychological, social, economic, and environmental angles.62 Ebola viral diseases as a type of public health disaster echo these multifaceted dimensions. Human beings reflect the physical dynamic of vulnerability due to their social and relational nature to other human beings. Because victims of infectious public health disasters may visit hospital at the time when the nature of the infection may be unknown, they constitute a serious hub of nosocomial infection63 and leave health workers and other patients that may be at the health facility at the given period of time vulnerable to acquiring infections and potentially spreading these to other patients and/or health workers during their stay, or into the community if Ebola is not diagnosed before they are discharged. Also, people including health workers care for those who are sick without knowing if the sickness is EVD or not and people who recover from EVD share coital intimacy without knowing that EVD may still be in their reproductive organs and the associated fluids,64 thus, making them prone to infecting others. This shows how vulnerability elicits some degree of uncertainty about when and where a PHD such as EVD may occur, what (for instance, a kiss or sexual intimacy) or who (a carrier of the virus) is safe or infectious and experiencing the throes of suffering. On a broader scale, it shows how public health disasters echo the quantum notion of Heisenberg’s uncertainty principle: we can know or predict (sometimes even precisely), that disaster will happen, but we can never know when it will or its exact magnitude. The best response to this uncertainty has been the idea of preparedness,  Sneha Krishnan, “Vulnerability in Disasters,” Opticon1826, no. 14 (2012).  Ruth Macklin, “Studying Vulnerable Populations in the Context of Enhanced Vulnerability,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna (Springer, 2014). P. 159. 61  Michael Y Barilan, Margherita Brusa, and Pinchas Halperin, “Triage in Disaster Medicine: Ethical Strategies in Various Scenarios,” ibid. Pp. 51–52. 62  Henk ten Have, Vulnerability: Challenging Bioethics (Routledge, 2016). P. 11. 63  CJ Peters and JW Peters, “An Introduction to Ebola: The Virus and the Disease,” Journal of Infectious Diseases 179, no. Supplement 1 (1999). P. 10. 64  Karen E Rogstad and Anne Tunbridge, “Ebola Virus as a Sexually Transmitted Infection,” Current Opinion in Infectious Diseases 28, no. 1 (2015). Pp. 83–84. 59 60

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which may come in the form of education, training, the appreciation of preventive ethics, and a right psychological mindset.65 There is, therefore, a psychological dimension to the states of vulnerability elicited by Ebola viral outbreaks. This is illustrated by families and spouses of health professionals and Ebola victims who may suffer higher levels of stress knowing the risks being faced by their relatives and better-halves. The policy of social distancing adopted in Ebola outbreaks illustrates the social vulnerability angle. This is specifically represented by the mandatory closure of schools and prohibition of public gatherings including sporting, shopping, and entertainment-related events.66 Depending on the time period for which it is imposed, social distancing can shape the lives of different categories of people in several negative ways. Owners of small-scale businesses who financially rely on the business proceeds and their dependents will experience loss of income. In a context of economic inequality, this will further widen socioeconomic gaps, and foster social tensions. Also, the social marginalization that comes with the isolation and quarantine process, as well as the un-traditional forms of burial prescribed for victims of Ebola, leaves patients who recover and relatives of victims vulnerable. Social marginalization may also be experienced by those who had been in contact with victims and have been marked out for contact tracing. Lastly, the rapid interconnection of the world and its increasing shrinkage into a little global village leaves everyone—regardless of race and geographical niche— vulnerable to public health disasters. During the last Ebola outbreak, for example, an American man (Patrick Sawyer) infected with Ebola traveled from Liberia to Nigeria and infected some of the medical staff in Lagos and Port Harcourt. While this also led to infection amongst some non-healthcare workers, the threat of exponential growth and subsequent infections of international aid workers in Senegal and Liberia, and transmission in both Spain and the United States ultimately turned Ebola from a newsworthy but exotic disease into an international security threat.67 This observation partly explains Nancy Kass’ remarks about how the last EVD outbreak ignited some of the worst fears in a globalized world, especially in terms of the ease with which it crossed and re-crossed national borders.68 Kass’ observation underscores how the local vulnerability to EVD may gradually transform into global vulnerability concerns, and how neglecting the former will ultimately increase the scale of global vulnerability to Ebola infections.  Fatimah Lateef, “Ethical Issues in Disasters,” Prehospital and Disaster Medicine 26, no. 4 (2011). P. 296. 66  Lawrence O Gostin, Daniel Lucey, and Alexandra Phelan, “The Ebola Epidemic: A Global Health Emergency,” Journal of American Medical Association 312, no. 11 (2014). P. 1095. 67   Annie Wilkinson and Melissa Leach, “Briefing: Ebola–Myths, Realities, and Structural Violence,” African Affairs (2014). P. 3. 68  Nancy Kass, “Ebola, Ethics, and Public Health: What Next?,” Annals of Internal Medicine 161, no. 10 (2014). P. 744. 65

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2.2.2  Human Dignity & Rights Violations The notion and the associated practical correlate of human dignity are tied to the inherent worth of human beings. In other words, it is linked to human nature, as such, humans by belonging to the Homo sapiens species have human dignity, regardless of race as well as educational and social status. Some scholars like Macklin argue that human dignity constitutes a useless bioethics concept that can be relegated to the fringes without any loss of content.69 Such skepticism, however, seems to be born out of the religious origins of human dignity as well as the increasing attempt by contemporary academic scholarship to devalue religious and metaphysical ideas from intellectual discourses, thereby pursuing investigations solely which are more amenable to the post-modernist and materialistic vision. Other bioethicists like ten Have and Welie, however, hold the view that a completely materialistic rhetoric detracts from the dignity and value of human life.70 The idea of human dignity aims at the protection of life: that of (one)self and that of others. For instance, the Yoruba proverb Iku ya ju esin lo (it’s better to die than to endure indignity) enjoins the human person to never allow their dignity to be flouted and trampled upon. This view is reflected in Shaoping’s description of dignity as a moral right to be free from insult. What is considered an insult may be an action that damages the victim’s self or individuality, or it may be a state in which there is a complete loss of control ignited by absolute poverty, family tragedy, the tortures of illness and mental breakdown.71 Examined in this light, Ebola outbreaks may be shown to bring about different sorts of indignities on at least three levels. On the first level, health professionals may be forced to abandon their fiduciary duties to patients during EVD. To be sure, because professionalism and heroism are often confused and conflated during disaster situations,72 the obligation to provide care in the face of these public health emergencies partly makes the philosophy of the duty to provide care inadequate as a normative signpost.73 It has been observed that when healthcare workers exhibit concerns about the risks associated with performing care during infectious disease outbreaks, there is a decline in the quality of

 Ruth Macklin, “Dignity Is a Useless Concept,” British Medical Journal 327, no. 7429 (2003). Pp. 1419–1420. 70  Henk ten Have and Jos Welie, Death and Medical Power: An Ethical Analysis of Dutch Euthanasia Practice: An Ethical Analysis of Dutch Euthanasia Practice (McGraw-Hill International, 2005). P. 168. 71  Shaoping Gan, “Human Dignity as a Right,” Frontiers of Philosophy in China 4, no. 3 (2009). Pp. 370, 380. 72  Joseph J Fins, “Distinguishing Professionalism and Heroism When Disaster Strikes,” Cambridge Quarterly of Healthcare Ethics 24, no. 04 (2015). P. 373. 73  Aminu Yakubu et  al., “The Ebola Outbreak in Western Africa: Ethical Obligations for Care,” Journal of Medical Ethics 42, no. 4 (2016). Pp. 209–210. 69

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care.74 This clearly increases the possibility that EVD patients or those that have been exposed to EVD patients and currently under surveillance may not receive the standard dignifying type of health services. During the outbreak of EVD in Nigeria in 2014, there were some reports about patients and Ebola-exposed individuals being subjected to undignifying experiences at the Infectious Disease Hospital in Lagos.75 This was exemplified by abandonment by medical personnel as well as inadequate supportive therapeutic and emotional interventions. Although health professionals are expected to provide competent medical services with compassion and respect for human dignity76 under “normal” circumstances, it is hard to justify the indignities that patients may be subjected to during EVD. The abandonment of infected health workers by other health professionals77 is also something that is both undignifying and must be deplored. However, such reluctance is partly underscored the high levels of risk they face vis-à-vis EVD. For instance, the incidence of Ebola infection in the 2014 outbreak in Guinea was highest among laboratory technicians and doctors, followed by midwives and nurses.78 Fisher and colleagues reported that in Liberia with a reported total of 51 physicians, 36 healthcare workers died of Ebola and others were struggling with the disease by August 2014.79 Although the undignifying attitude may stem from self-­ preserving commonsensical instincts, ample efforts to enhance the protection that health workers receive during outbreaks will be essential to correcting this ethical challenge. Secondly, ordinary citizens may treat fellow citizens exposed to EVD or those who are infected with condescension and different forms of stigmatizing behaviors.80 During the 2000–2001 EVD outbreak in Uganda, it was found that many survivors experienced intense stigmatization. Specifically, some were not allowed to return home, many had their clothes burned, and some were abandoned by their

 June M McKoy, “Obligation to Provide Services: A Physician-Public Defender Comparison,” Virtual Mentor 8, no. 5 (2006). Pp. 332–333. 75  SaharaReorters, “Ebola Isolation Center Patients in Lagos Neglected, Suffering in Squalor,” http://saharareporters.com/2014/08/14/ebola-isolation-center-patients-lagos-neglected-sufferingsqualor.; FenchurchMedia&BroadcastingNetwork, “Lagos Ebola Patients Neglected, Critically Ill  – Relatives, Colleagues,” http://smooth981.fm/lagos-ebola-patients-neglected-critically-illrelatives-colleagues/ 76  Charles J Dougherty and Ruth Purtilo, “Physicians’ Duty of Compassion,” Cambridge Quarterly of Healthcare Ethics 4, no. 04 (1995). P. 426. 77  Bonnie L Hewlett and Barry S Hewlett, “Providing Care and Facing Death: Nursing During Ebola Outbreaks in Central Africa,” Journal of Transcultural Nursing 16, no. 4 (2005). Pp. 289–290. 78  Margaret Grinnell et  al., “Ebola Virus Disease in Health Care Workers-Guinea, 2014,” MMWR. Morbidity and Mortality Weekly Report 64, no. 38 (2014). Pp. 1083–1085. 79  Fischer, Hynes, and Perl. P. 753. 80  Ann De Roo et al., “Survey among Survivors of the 1995 Ebola Epidemic in Kikwit, Democratic Republic of Congo: Their Feelings and Experiences,” Tropical Medicine & International Health 3, no. 11 (1998). Pp. 883–884. 74

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spouses.81 Lastly, undignifying decisions may be taken by local authorities. During the 2014 Ebola outbreak in Liberia, soldiers often compelled distraught citizens to comply with movement restrictions and curfews. Scare tactics involving displays of guns and firing of shots into the air (which led to at least one death and some injuries) were also employed.82 The incidents referenced in the preceding paragraph provide some general evidence as to the lack of trust between the populace and the government as well as how a mechanistic model is largely used to pursue health agendas in some parts of Africa. Indeed, such undignifying course of action does not go down well with a lot of people as was reflected in the level of social disarray observed via the violent protests which erupted in Monrovia, Liberia during the mandatory travel restrictions. Such social disruptions reflect the idea that public health disasters, if not properly and sensitively managed, may negatively influence social and psychological behavior including overtly anti-social behavior.83 On the other hand, the concept of human rights is embedded within the idea of autonomywhich reflects a person’s capacity for making unencumbered decision, self-regulation, and governance.84 It is likewise related to an inherent capacity for judgment and action85 based on cognitive comprehension of a given state of affairs or a set of options.86 Autonomy also reflects the freedom from undue second party constraint  in the context of making life choices87 and provides veridical accounts of a person’s preferences.88 It can, therefore, be modestly described as the minimal state of being responsible, independent, and possessing the capacity to speak for oneself.89 Several kinds of hindrances to rights and autonomy, however, come to the fore during Ebola viral outbreaks. For victims of Ebola, mandatory quarantining and confinement hinder rights as well as violate and limit the expression of autonomous capacities. When quarantines are implemented in communities, some of these measures may also increase the burdens of people living in such zones. For instance, there were reported cases of extreme daily hardship in the quarantine zones in the last outbreak in Liberia.90  Hewlett and Amola. P. 1246.  Norimitsu Onishi, “Inquiry Faults Liberia Force That Fired on Protesters,” http://www.nytimes. com/2014/11/04/world/africa/soldiers-faulted-in-deadly-crackdown-during-ebola-protests-inliberia.html 83  Stefano Lazzari, “Health Aspects of Disasters,” in The Challenge of African Disasters, ed. WHO (UN. Institute for Training and Research). P. 10. 84   Simon Woods, “Respect for Autonomy and Palliative Care,” in Euthanasia: European Perspectives, ed. Henk ten Have and David Clarke (2005). P. 146. 85  Gerald Dworkin, The Theory and Practice of Autonomy (Cambridge University Press, 1988). Pp. 40–41. 86  David F Kelly, Medical Care at the End of Life: A Catholic Perspective (Georgetown University Press, 2006). P. 29. 87  Tom L Beauchamp and James F Childress, Principles of Biomedical Ethics (Oxford university press, 2013). Pp. 5–15. 88  Woods. P. 150. 89  Neil Levy, “Autonomy and Addiction,” Canadian Journal of Philosophy 36, no. 3 (2006). Pp. 427–435. 90  Chan. P. 1184. 81 82

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Lastly, some healthcare workers’ freedom may be limited in terms of having to work longer hours. There will also be exposure to accelerated levels of risk and possible separation from family while the disaster lasts. Hence, public health disasters such as EVD entail making some degree of adjustment to losing autonomy and freedom of action. For example, travel restrictions are often instituted during outbreaks of EVD to limit human movement and possible inter-community spread of infections.91 Such measures are neccesitated by the moral burden to allow the needs and values of the community trump those of individuals. Different social groups may also be monitored and ordered about by authorities, a situation which hardly exists in routine times.92 Yet, the increasing linkage between the right to health and human rights93 fosters a rights dynamic to Ebola viral outbreaks. In other words, human rights—the ontological rights that one is born with and that are inalienable as long as one belongs to the community of humans, regardless of race, age, and gender—cannot be contextually sacrificed on utilitarian grounds without some measure of moral concerns. This becomes more pressing considering the simultaneous tendency to diminish the dignity of Ebola patients or persons exposed to the virus. Whereas the expediency for the quick mobilization of resources for overall community needs and welfare often takes priority over everyday rights and domains due, in part, to the need to rapidly transport private goods, equipment, personnel, and facilities without due process or normal organizational procedures for the common good94; demanding some sacrifice of rights should engender a reciprocal sensitivity to the burdens being placed on selected segments of society such as individuals, communities and health workers. It should likewise entail a great deal of respect for the dignity of affected persons.

2.2.3  Local & Global Justice Justice and the associated need to pursue justice in nuanced ways remains a recurring decimal in public health.95 It entails enhancing utility in a mutually fair and harmonious atmosphere that is open to contextual values and needs.96 Local and global justice issues come to the fore during outbreaks of EVD. It may, however, not  Gostin, Lucey, and Phelan. P. 1096.  Enrico L Quarantelli, “Catastrophes Are Different from Disasters: Some Implications for Crisis Planning and Managing Drawn from Katrina,” in Understanding Katrina: Perspectives from the Social Sciences (New York: Social Science Research Council, 2005). 93  Lisa Forman and Stephanie Nixon, “A Global Ethical Framework for Bioethics,” in An Introduction to Global Health Ethics, ed. Andrew D Pinto and Ross E.G Upshur (Routledge, 2013). P. 54. 94  Quarantelli. 95  Nancy E Kass, “Public Health Ethics from Foundations and Frameworks to Justice and Global Public Health,” The Journal of Law, Medicine & Ethics 32, no. 2 (2004). Pp. 232–234. 96  Beauchamp and Childress. Pp. 249–253. 91 92

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be so clear-cut achieving agreement as to what constitutes justice when conflicting wants, needs and priorities are at play. Using practical cases where different “needs” for justice are evident in relation to EVD may shed some important insights into the attendant justice-related quandaries. Burial rites are an avenue through which infection to the Ebola virus may occur (assuming the cadaver in question is Ebola-positive). As such, limitng contact with the dead generally can help minimize the risk of infection dissemination.  This appears to be a simple enough preventive measure. Indeed, requiring relatives and family members of the dead to comply with such a directive seems to be a fair demand by the rest of the society, because such a seemingly simple course of action will in the long run help communities to reduce the number of casualties. However, sanitary burial practices involving disinfecting cadavers before enclosure in a body bag97 is socially problematic in an African context where premiums are traditionally placed on the proper burial of the dead. The Yoruba culture, for example, prescribes second burials without which the dead will not return successfully to the afterlife and may be forced to wander about the earth, constituting a menace to the living.98 Such a worldview as this may help explain why some people chose to hide the dead bodies of victims of Marburg virus outbreak in Angola in 200599 as well as during the last Ebola outbreak in Sierra Leone.100 This particular issue shows how social justice (which seeks public health ends) differs from cultural justice (which seeks cosmological consistency), and how ignoring the latter will hardly make the former achievable. The critical nature of this issue is highlighted by the fact that a chain of Ebola transmission can begin due to even a single missed case of infection.101 The capacity to deal with disaster situations are closely tied to the level of a nation’s economic development,102 as such, developing and poorer economies may be ill-equipped to engage the socio-economic demands of PHDs such as Ebola. This will significantly limit the capacities of local authorities to realize logistics-related fairness. This political dimension to local justice also shows up in relation to the capacities of the local authorities to deal with border issues. In this regards, Fauci, observes that the recent Ebola outbreak in Sierra Leone, Liberia, and Guinea are closely linked with extant problems of porous borders as well as existing challenges of the healthcare system including those related to infrastructure and manpower.103  Pandey et al. P. 992.  Babatunde Lawal, “The Living Dead: Art and Immortality among the Yoruba of Nigeria,” Africa 47, no. 01 (1977). P. 54. 99  Nestor Ndayimirije and Mary Kay Kindhauser, “Marburg Hemorrhagic Fever in Angola— Fighting Fear and a Lethal Pathogen,” New England Journal of Medicine 352, no. 21 (2005). P. 2157. 100  Anja Wolz, “Face to Face with Ebola—an Emergency Care Center in Sierra Leone,” ibid.371, no. 12 (2014). Pp. 1081–1082. 101   Thomas R Frieden et  al., “Ebola 2014—New Challenges, New Global Response and Responsibility,” ibid., no. 13. P. 1178. 102  Marion Kelly, “Disaster in the Horn of Africa: The Impact on Public Health,” in Disaster and Development in the Horn of Africa, ed. John Sorenson (St Martin’s Press, 1995). Pp. 241–242. 103  Anthony S Fauci, “Ebola—Underscoring the Global Disparities in Health Care Resources,” New England Journal of Medicine 371, no. 12 (2014). P. 1085. 97 98

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Some scholars hold the idea that the Ebola crisis emerged from the confluence of long-term economic, social, technical, discursive, and political exclusions and injustices which are dramatically unsustainable.104 Hence, how badly a job a government has done in relation to the health needs of her people pior to a disaster will influence the severity of a public health disaster in such a locality. For example, the life expectancy in Sierra Leone was 37 in 2002 and access to sanitary facilities 11% while the same indices for Guinea Bissau were 44 and 47%. Hence, it is not surprising that the last outbreak of EVD wrought more havoc in these countries, compared to Nigeria with 62 and 63% of these same indices.105 Hence, failing to address these underlying social issues creates an atmosphere in which the foundations of any anti-EVD public health action will not be firm, and the efficacy of any public policy built on it will, at best, be partially effective. Since disasters alter extant patterns of health106 and social order, it is equally expedient to address novel issues that may come to the fore during Ebola outbreaks. For instance, travel restrictions will limit the economic power of non-salaried members of society. Failure to reckon with this fact and offer some type of pecuniary stipend in exchange for social compliance may foster non-compliance to public health measures or lead to antisocial activities such as looting and stealing. To be sure, the military-enforced cordon sanitaire on the West Point slum of Monrovia sparked riots and the quarantined areas remained at risk for over-crowding, lack of medical and basic services, and poor sanitation; hence, potentially increasing the spread of disease within those areas.107 Lastly, extant corruption within the healthcare system is another critical factor. In Sierra Leone’s health sector, for example, lack of accountability has been reported to be pervasive at all levels.108 This backdrop introduces novel and “non-technical” dynamics into both the relief and resource allocation aspects of Ebola management, which must be systematically engaged. Failure to have addressed these and other related issues shed some insights into why the last Ebola outbreak turned out to be the most severe acute public health emergency in modern times, killing almost 5000 people and infecting another 13,567.109 Moral issues related to global justice are also elicited by EVDs. Whereas BigPharma acknowledges the idea that the world is now a global village, a rhetoric  Wilkinson and Leach. P. 2.  Adedoyin Soyibo, Health Care Delivery under Conflict: How Prepared Is West Africa? (Ibadan: University Press, 2005). Pp. 23, 35–36, 51; Collins O Airhihenbuwa, “Lessons of Yesterday, Promise of Tomorrow: Framing New Approaches to Health Communications Globally,” Journal of Health Communication 17, no. 6 (2012). P. 629. 106  Lazzari. P. 22. 107  Sherry Towers, Oscar Patterson-Lomba, and Carlos Castillo-Chavez, “Temporal Variations in the Effective Reproduction Number of the 2014 West Africa Ebola Outbreak,” PLoS currents 6 (2014). 108  Pieternella Pieterse and Tom Lodge, “When Free Healthcare Is Not Free. Corruption and Mistrust in Sierra Leone’s Primary Healthcare System Immediately Prior to the Ebola Outbreak,” International Health 7, no. 6 (2015). Pp. 400–403. 109  Wilkinson and Leach. P. 1. 104 105

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which allows them to sell their products overseas as well as conduct standard and non-standard clinical trials in developing economies including African nations; it is not so clear if international pharmaceutical companies are moved by concerns for the plight of people in these regions when the potential for economic incentives are lacking. In this regard, BigPharma companies usually fail to address the desperate need for new drugs when the populations affected are too poor to attract commercially-­driven R&D.110 Rather, they often prioritize the R&D of drugs for chronic conditions that are common among populations in countries with more robust economies.111 On this note and in relation to EVD, it is possible to speculate that if the 1976 first case of the Ebola outbreak had occurred in an affluent Western society, perhaps, Bigpharma would have by now made more therapeutic progress, inspired by the potential monetary returns. To be sure, the renewed interest in vaccine trials during the last outbreak may be tied to the larger number of victims and, perhaps, the potential for monetary gains through international donations to Ebola-­ related clinical research and drug/vaccine trials. While the medical need for new anti-Ebola agents and protective vaccines has been recognized as a priority for many years,112 it was not until 2004 that the first human trial was done. This was, however, an initiative of academic scientists and not driven by BigPharma.113 Seeking global justice as it relates to EVD will, therefore, involve seeing people as ends in themselves and not as monetary resources. Global justice indeed may be seen as self-preserving because not pursuing it may harm the interests of affluent nations if multiple carriers (especially  through ­commercial air transportation) were to export and spread infection in the contemporary era of increased and unavoidable globalization. Another moral issue tied to global justice is linked with the best ethical manner to share the limited amounts of vaccines. If the current state of things persists, then there would be fewer vaccines available to help Ebola-infected people during another outbreak. The question that arises is this: in an event where a choice has to be made between administering limited vaccine supplies such as ZMapp to international health workers and local health workers or infected non-health workers, which is the most ethically appropriate choice? This is problematic but being a practical issue whatever decision that is made will exclude some persons and may potentially lead to their continued suffering and possibly the death of somebody’s husband, wife, friend, father, mother, or uncle. Hence, the outcome of such a choice will hardly appeal to or appease all the parties concerned.  Solomon Nwaka, “Drug Discovery and Beyond: The Role of Public-Private Partnerships in Improving Access to New Malaria Medicines,” Transactions of the Royal Society of Tropical Medicine and Hygiene 99, no. Supplement 1 (2005). Pp. 20–27. 111  Salomeh Keyhani and Joseph S Ross, “The Cost of Pharmaceutical Innovation to Patients,” Expert Opinion on Drug Discovery 2, no. 11 (2007). Pp. 1431–1433. 112  Heinz Feldmann et al., “Ebola Virus: From Discovery to Vaccine,” Nature Reviews Immunology 3, no. 8 (2003). Pp. 677–682. 113  Karen Honey, “Ebola Vaccine Trials,” ibid.4, no. 1 (2004). P. 4. 110

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2.2.4  Rationing Under normal circumstances, the demand for some types of healthcare services and interventions may outweigh supply capacities. This often prompts the need to prioritize competing needs. This description reflects the idea of rationing. The presence of overwhelming needs and insufficient resources constitutes one of the key features of disasters114; as such, issues associated with rationing inevitably arise. In the context of public health, rationing, however, has far-reaching implications if the affected communities have extant social issues such as health inequalities and shortages of professional manpower and drug supplies. Indeed, public health disasters create scenarios in which demand for medical care often exceeds and outstretches available resources, and often necessitate the rationing of care and the expediency to make decisions that enable the best possible use of the limited resources.115 A prominent form of rationing seen in PHD situations including during Ebola viral outbreaks is triage. Triage involves screening patients according to the severity of their need in order to balance available treatment options with the available resources. Examples of triage situations include prehospital, disaster, emergency room, intensive care, and being on the waiting list for lifesaving treatments such as organ transplants, and battlefield situations.116 In traditional healthcare settings or in emergency room contexts of care, triage focusses on seeing the sickest person first and ensuring that they receive all possible life-saving treatments. But in disaster triage, the number of ­victims who present to the emergency room or who are being seen in the field often overwhelms the ability of the attending service to provide medical care for all who need it. Managing multiple victims during disasters, therefore, warrants a system through which treatment needs may be prioritized including and excluding some category of victims. Triage seeks the rapid sorting of victims with the intention of doing the greatest good for the greatest number of people.117 During an Ebola outbreak, the coordination of medical logistics and plans for rational triage of the patients are often key in the latter context.118 In this vein, if 100 infectious Ebola patients are to be treated in an isolation unit, aggressive supportive therapy will be focused on those who are minimally experiencing the pathologic progression of the virus while the most pathologically affected and are, therefore, very unlikely to recover will often receive minimal care. This, however, is morally problematic, as it roughly constitutes “leaving a dying man to hang out to die”.

 Pierre Mallia, “Towards an Ethical Theory in Disaster Situations,” Medicine, Health Care, and Philosophy 18, no. 1 (2015). Pp. 3–4. 115   Sara Kathleen Geale, “The Ethics of Disaster Management,” Disaster Prevention and Management 21, no. 4 (2012). P. 448. 116  Thomas B Repine, Philip Lisagor, and David J Cohen, “The Dynamics and Ethics of Triage: Rationing Care in Hard Times,” Military Medicine 170, no. 6 (2005). Pp. 505–507. 117  Geale. P. 449. 118  Peters and Peters. Pp. 13–14. 114

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2.3  Ubuntu Moral Lens vis-à-vis the Quandaries of EVD The ethical quandaries that have been elaborated above arise, at their core, as a result of what may be described as a relational dissonance. In other words, issues of human rights and dignity violations, local and global justice, vulnerability and rationing occur when someone does something to someone else or fails to do something that they ought to, either before the onset of the EVD or during an outbreak. Scholars like Annas note that a recurring challenge in the era of global public health is embedded in the human rights and equality rhetoric and the difficulty of anchoring the ethical tensions elicited by these in the rubric of commonalities.119 If the ethical quandaries generated by a public health disaster such as EVD occur due to some breakdown in human-human relationships, then an approach that may involve commonalities is one which is based on a relational moral framework. Some scholars argue that there is a need for public health law that focuses on building strong institutional capacities that promote public health and garners public trust towards the system in ordinary circumstances.120 Such a system would have garnered ample trust on the one hand and collective will, on the other hand, to the extent that emergencies such as those pertaining to Ebola may be better handled. A useful approach to building such bridges is looking inwards on the experiential logic with which people act in normal everyday living. Against this background, this section examines how the indigenous African notion of Ubuntu with its relational bearing may help address the moral quandaries elicited by Ebola viral diseases. A brief conceptual elaboration of the concept is however necessary before attempting the ethical application.

2.3.1  The Concept of Ubuntu Ubuntu is an indigenous African moral concept and practice that serves as a normative template through which inter-personal human conduct and relationships are influenced. It encompasses interdependence in social order121 such that the individual and personal “I” exist meaningfully only in a mutually dependent relationship with the societal “we”. As John Mbiti puts it: “I am because we are, since we are therefore I am”.122 In other words, Ubuntu closely ties personal flourishing to social flourishing in an ontological fashion. It underlies much of African culture, traditional

 George J Annas, Worst Case Bioethics: Death, Disaster, and Public Health (Oxford University Press, 2010). Pp. 188–189. 120  Annas, Worst Case Bioethics P. 232. 121  Ronald Nicolson, Persons in Community: African Ethics in a Global Culture (Scottsville: University of Kwa-Zulu Press, 2008). Pp. 4–8. 122  John S Mbiti, African Religions and Philosophy, African Philosophy (London: Longman, 1969). Pp. 204–211. 119

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practices, and institutions,123 and embeds the doing and promotion of common good via cooperation with others in order to foster cosmological balance.124 Whereas Ubuntu is a culturally embedded lens through which most traditional African societies conceive and relate with the world, increased attention now shifts towards this concept due to the otherizing, subordinating impact, and the meager space that globalization grants to the African sphere.125 The latter attitude seems grafted in the logic of “I-am-right-because-I-(once) conquered (you)”,126 and this partly explains why some African scholars reject western-derived global moral frameworks, seeing them as subtle channels at realizing some form of subtle moral hegemony. Within the Ubuntu ethical system is a shared underlying symmetry in terms of the close-knit moral, philosophical, and ontological interdependence of the self upon the other. It thus seeks human flourishing with a view to shaping the moral life and vice versa in an ontologically immanent manner.127 The Ubuntu lens conceives persons as reflections of normative rules which govern the expression or repression of biological capacities.128 The logic works through systematic and progressive social conditioning, from cradle to the grave. For instance, Fulani women keep mute and repress the pangs of childbirth129 not because the pudendal and posterior cutaneous nerves lose their physiolgic function but through socially acquired visceral conditioning. Whereas Ubuntu is a Bantu-derived notion, its application to the African context may be sustained at least on two related grounds. One, the Bantu-speaking people are believed to have migrated from West Africa, which partly explains the similarities between these two groups in terms of attitudes towards God, cosmology, life, and kinship.130 Secondly, the idea of Ubuntu is grafted within a number of African traditional systems. The Yoruba people in Nigeria, for example, have a saying: enia l’aso mi. Transliterated this connotes the notion that people are my garments, as such, my welfare is inseparable from that of other people and vice versa. This signifies the existential state of dependency that people (according to the Yoruba) have towards one another and without which life becomes hollow. While Ubuntu is relational and communal-oriented, that does not mean that it encourages the suppression  Augustine Shutte, “African Ethics in a Globalising World,” in Persons in Community: African Ethics in a Global Culture, ed. Ronald Nicolson (Scottsville: University of Kwa-Zulu Press, 2008). Pp. 26–27. 124  Nhlanhla Mkhize, “Ubuntu and Harmony: An African Approach to Morality and Ethics,” ibid. Pp. 41–42. 125  James T Tsaajor, “African Culture and the Politics of Globalisation,” Journal of Black and African Arts and Civilization 3, no. 1 (2009). Pp. 19–20. 126  J Obi Oguejiofor, “Negritude as Hermeneutics,” American Catholic Philosophical Quarterly 83, no. 1 (2009). p. 84. 127  Shutte. 32–33. 128  Dismas A Masolo, Self and Community in a Changing World (Indiana University Press, 2010). pp. 154–155. 129  Olayiwola Erinosho, Health Sociology (Sam Bookman, 1998). Pp. 27–43; Laura Kaplan Shanley, Unassisted Childbirth (ABC-CLIO, 2012). p. 6. 130  Green. Pp. 24–25. 123

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of the good of the individual as is the case with Marxist collectivism. Rather, it helps the individual pursue his own good via seeking and pursuing the common good.131 Since the ethical notion of Ubuntu emphasizes human interconnectedness and dignity,132 it may offer the template upon which trust may be fostered amongst the different actors before and during public health disasters by facilitating social compliance with public health advice and directives.133 Similarly, because disaster relief is other-centric—like ubuntu—and seeks to ameliorate human suffering with utmost dignity134; engaging public health disasters such as EVD may work through a relational ethical lens such as Ubuntu. On this note, the next part of this section examines how a ubuntuan moral framework may help address the ethical quandaries elicited by Ebola viral outbreaks.

2.3.2  Ubuntu vis-à-vis the Quandaries of EVD Ubuntu incorporates the idea that one first belongs to their cultural group, and secondly to all other human niches. In this vein, the personal “I” exists synergistically within a mutually dependent relationship with the societal “we” and is grounded within a web of cosmological contract. As such, the African notion of individualism inherently subsumes obligations to the community of humans135 and is other-­ oriented. How this moral lens may help address the relational-based quandaries of Ebola viral outbreaks (vulnerability, local and global justice, human rights and dignity violations, and rationing) demands a systematic investigation. If vulnerability constitutes a state of human condition,136 then an ontological obligation of some sorts ought to be directed from one person to other persons such that A who may be contextually non-vulnerable acts towards B who may be currently vulnerable in ways that help ameliorate their current state of discomfort and suffering. This entails the need to respond to the human bodily inclinations and intuitions137 through doing things that facilitate helping one another to mitigate common frailties. Implied in this analysis is the idea of solidarity or the collective

 David W Lutz, “African Ubuntu Philosophy and Global Management,” Journal of Business Ethics 84, no. 3 (2009). P. 313. 132  Yusef Waghid and Paul Smeyers, “Reconsidering Ubuntu: On the Educational Potential of a Particular Ethic of Care,” Educational Philosophy and Theory 44, no. s2 (2012). p. 11 133  Annas, Worst Case Bioethics: Death, Disaster, and Public Health p. 220. 134  Laurel A Spielberg and Lisa V Adams, Africa: A Practical Guide for Global Health Workers (UPNE, 2011). Pp. 1, 3. 135  Masolo. P. 135. 136  Jan Helge Solbakk, “Vulnerability: A Futile or Useful Principle in Healthcare Ethics,” in The Sage Handbook of Healthcare Ethics, ed. Ruth Chadwick, Henk ten Have, and Eric M Meslin (SAGE, 2011). Pp. 228–232. 137  Ruth E Groenhout, Connected Lives: Human Nature and an Ethics of Care (Rowman & Littlefield, 2004). P. 31. 131

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action and unity of a group in terms of seeking cooperative action.138 Also implied in the notion of vulnerability is the idea of a moral extensor muscle upon which morally reprehensible stimuli (or ethical flexors) act to generate corresponding tonus or actions (solidarity) in order to address the morally unsettling incidents or experience of others.139 If vulnerability is a gradual and relational experience that negatively impact people’s wellbeing,140 then the Ubuntu moral outlook with its focus on realizing the common good of others offers an avenue through which multiple non-victims of EVD may help provide the gradual and multifaceted flourishing that the pool of victims as a category of others requires. To be sure, a ubuntuan logic helps creates a flexible ambiance in which the vulnerable states of victims of EVD and the non-­ vulnerable states of unaffected individuals can co-exist in a flux of negotiation and renegotiation. In other words, an “I-we” nexus tied within a web of cosmological contract fosters a social niche in which the sufferings and vulnerabilities of B acts to morally motivate A to give up parts of his personal interests in order to accomplish the greater and common good. Specifically, this may range from accepting risks, sharing sensitive information about having been in contact with Ebola patients or accepting travel restrictions. During Ebola viral outbreaks, one major concern revolves around the potential infecting capacities of loved ones as well as health workers. Another public health concern revolves around how person A might choose to engage in certain courses of actions that significantly endangers person B141 such as refusing to accept quarantine measures. Seen through the lens of the human rights rhetoric, the latter course of action is tacitly encouraged. The case of Kaci Hickox the American nurse who refused quarantine following exposure to Ebola-positive patients in West Africa attests to this. At least generally in the western context, individuals feel entitled to and, indeed, claim rights which the society is enjoined to allow.142 Government capacities’ to enforce rights-restrictive activities even for the collective good are, therefore, often limited by the rights mantra, as such; western governments are often required to respect the rights of people as well as promote, protect and fulfill the exercise of these rights.143 Importing the rhetoric “of rights” (without some qualification) into the African context of PHDs will, however, spell untoward consequences for a number of reasons. According to scholars like Claude Ake, the extent of social atomization in most of Africa is quite limited and many people still dwell within a sense of belonging to  Sister Mechtraud, “Durkheim’s Concept of Solidarity,” Philippine Sociological Review (1955). P. 23. 139  Afolabi, “A Vulnerability/Solidarity Framework for a Global Ethic: Historical & Contemporary Applications.” Pp. 47–48. 140  ten Have, Vulnerability: Challenging Bioethics. P. 6. 141  Michael O.S. Afolabi, “Vaccination,” in Encyclopedia of Global Bioethics, ed. Henk ten Have (Switzerland: Springer International Publishing, 2016). P. 9. 142  Claude Ake, “The African Context of Human Rights,” Africa Today 34, no. 1/2 (1987). P. 5. 143  Annas. Pp. 190–191. 138

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an organic whole. This may be at the level of a family, a clan, a lineage, or an ethnic group.144 This social structure is attuned to a natural moral orientation where pursuing the common good constitutes the norm. Since this default moral state reflects and favors the telos of public health ethics, an overemphasis on human rights in the course of engaging Ebola virus outbreaks may be antithetical to fostering public health agendas. Knowing that people have sometimes abandoned family, relatives, and spouses infected with Ebola during outbreaks, it is possible to speculate that elevating the human right rhetoric will further enhance individualistic behaviors which will ultimately lead to more people shunning the common good and pursuing individual survival. However, muting the rights dynamic cannot be pursued without some form of ethical compensation. This argument reflects Harris and Holms’ idea that a system of compensation is exigent to motivate people to act limit the risks their infectious diseases may pose to other members of the society.145 The Ubuntu rhetoric offers some useful insights on the nuances associated with rights in this context because it allows a continuous process of the negotiation of the rights and responsibilities as well as the means for checking aberrant policy and polity through reciprocal ­cooperation amongst members of the society.146 In this regard, Leonard Chuwa argues that Ubuntu protects the inalienable rights of individuals in the sense that these are subordinate or dependent on the collective rights of the community147 for the sake of communal flourishing. Some scholars argue that the relational approach to ethical issues fits into the informal social contract notion that underlies inter-personal and state-individual relationships.148 If this is true, then one of the most enduring ways of engaging the problematic issues generated by EVD in an African context should involve a relational nexus. This is so because such a relational-based approach coheres with the mental and experiential fabric of the African people for whom the ethical policy is being tailored. One last moral quandary concerning rights is linked with the cultural requirements for burials. It has been shown that lack of sensitivity on this issue often prompts some people to unknowingly (or, perhaps, ignorantly) hide Ebolainfected cadavers. In this vein, David Heymann notes that urban and rural community engagement through local leaders and elders can help facilitate compliance with sanitary disposal methods, and help foster a more rapid containment of

 Ake. P. 9.  John Harris and Soren Holm, “Is There a Moral Obligation Not to Infect Others?,” British Medical Journal 311, no. 7014 (1995). Pp. 1215–1216. 146  Masolo. Pp. 245–246. 147  Leonard Tumaini Chuwa, African Indigenous Ethics in Global Bioethics (Springer, 2014). Pp. 2–3. 148  Robert M Tenery JR, “The Challenge of Universal Access to Health Care with Limited Resources,” in The American Medical Ethics Revolution: How the Ama’s Code of Ethics Has Transformed Physicians’ Relationships to Patients, Professionals, and Society, ed. Robert B Baker, et al. (1999). P. 253. 144 145

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EVD149 through the infected-cadaver nexus. However, appealing to the principles of Ubuntu via public health education efforts and using this as a moral rhetoric to emphasize how pursuing the common societal good ultimately trumps contextual non-­adherence to cultural dictates on the issue of burial will probably achieve better results. Put differently, since an action—through the ubuntuan lens—is considered right if it produces harmony and decreases discord, and morally wrong if it fails to develop community,150 emphasizing how sanitary burials will ultimately foster social harmony (medically and pragmatically) and how hiding possibly infected cadavers will disrupt social harmony can help nudge more people into compliance. The ubuntuan lens is also relevant in engaging the question of ensuring local and global justice. On the question of local justice, the capacity of the ubuntuan analytical lens to naturally facilitate the good of the other would ideally help ensure that resources are shared and rationed in a manner that prioritizes the needs of the more or most vulnerable people and victims. This, however, assumes that all potential actors (government officials, health workers and lay people alike) still subscribe to the ubuntuan moral frame of reference. The issue of corruption which was reported about Sierra Leone’s health sector and the attendant lack of accountability at all levels151 shows that designing an ethical intervention to EVD based on an ubuntuan public policy will suffer shortcomings if a commensurate process of social education does not occur. On the issue of global justice, the ubuntuan logic offers a simple way to help resolve the choice of who gets a vaccine allocation from a limited pool of vaccine supplies. In other words, it may help in resolving the moral tension that  arises when choosing who receives a vaccine between international and local health workers or local health workers and local lay people. The dilemmas that played out in which a choice had to be made between administering doses of ZMapp to two American Ebola-infected health missionaries and local health workers during the 2014 EVD outbreak may be used to illustrate how Ubuntu may help address this issue of global justice. Ubuntu entails a kind of human interconnectedness and dignity that one has towards others, firstly, in the cultural group to which one belongs, and secondly to all other human beings.152 It is thus some form of cosmological contract that begins with the strongest of bonds and increasingly becomes weaker the farther the nexus of blood linkage becomes. In other words, Ubuntu favors moral priorities and preferences based on ontological relatedness. The experimental drug ZMapp was developed partly by the U.S. Army Medical Research Institute of Infectious Diseases and partly by Mapp Biopharmaceutical. As such, it would have benefited from private and public American funds. Applying the Ubuntu rhetoric, it is apparent that the nexus of moral obligations from the drug company begins with the American citizens in question. In other words, the sharing  Heymann. P. 1730.  Thaddeus Metz, “Toward an African Moral Theory,” Journal of Political Philosophy 15, no. 3 (2007). P. 334. 151  Pieterse and Lodge. Pp. 400–402. 152  Waghid and Smeyers. P. 11. 149 150

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of available doses of ZMapp needs to begin with them after which left-over doses may be given out to others. Hence, once the locale of moral relationships become clarified, the ubuntuan logic can help show where the moral meter of fairness should swing. However, if the Americans (Kent Brantly and Nancy Writebo) so wish and decide to forgo the vaccine, then that would be a supererogatory choice that they alone could have made. In this vein, the drugs could then be offered to local health workers as these belong to the same group (health workers) that the missionaries belong, a course of action which ethically adheres to the ubuntuan logic. Lastly, the moral issue of violation of human dignity through triage decisions by healthcare workers and abandonment of relatives and family members which forsake the critically ill and infected also deserve some attention. In this regard, the ubuntuan lens may be used to emphasize the interconnectedness that the non-­ infected as part of the human moral community have towards the infected or Ebola-­ exposed as part of the same community. In other words, the moral synergistic relationship encapsulated by the I-we and we-they nexus can help focus attention away from self-centric interests, shifting it rather towards the common good. However, the ultimate challenge here is that those who have not hitherto reasoned ubuntically can hardly be expected to exhibit a selfless other-centric moral orientation during disaster scenarios such as Ebola viral diseases.

2.4  Conclusion This chapter has argued that Ebola viral outbreaks are a type of public health disasters with local and global dimensions. It has offered a description of the nature of the virus, its virulence and transmission patterns as well as the moral quandaries that come to fore during outbreaks. In that regard, the chapter has shown that some sort of relational dissonance is at the heart of these quandaries and, therefore, necessitate a relational ethical system to engage them. Based on a global problem that has mostly affected the African context, such an ethical system was argued to be the indigenous Ubuntu lens. Tailoring public health policy for engaging the ethical issues elicited by EVD on the mental and experiential fabric of Ubuntu offers a number of benefits. These include its focus on other-centricity and its capacity to help deal with certain local and global nuances associated with the quandaries of EVD (for instance, in the context of rationing and justice). Whereas the ubuntuan moral logic is indigenous to Africa, it does not follow that every potential moral actor that will be involved in disaster situations think in ubuntic terms. This realization, therefore, has the potential to limit the power of the Ubuntuan moral framework in relation to the ethical dilemmas of EVD. However, this problem can be partly addressed via carefully planned pre-disaster social interventions. In this regard, systemic re-education which increasingly makes the ubuntuan logic and praxis part of everyday life during pre-disasters can serve as an important ethical focal point for garnering cooperation during disasters as well as handling specific moral quandaries including issues of vulnerability, rights and

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human dignity, local and global justice, as well as rationing. Since disaster preparedness does not entail one-time planning,153 the specific question is how the Ubuntu idea can be appropriated in the pre-disaster phase. A key ingredient to this is re-formulating the trajectory of educational paradigms. Some commentators have observed that the African reality is often distanced from the western model of educational instructions in schools, from the kindergarten to the university. In other words, little connection exists between indigenous forms of knowledge—which are orally but hardly ever systematically taught—and formal instruction.154 An overhaul of the educational structure to reflect local forms of knowledge is therefore critical. It is within such a social stratum that the notion and praxis of Ubuntu may be systematically and gradually brought back into the African consciousness on a massive scale. As a consequence of such an educational reform, once the key actors in public health disasters—physicians, nurses, other health workers, and the populace—are all pre-armed with the notion of Ubuntu, and practice this as part of the repertoire of everyday life, then the challenges and sacrifices of disaster scenarios may be more readily dealt with. For instance, the designation of an elderly person for the task of caring for victims of PHDs in traditional African societies155 highlight the ubuntu idea of cosmological linkage, and sacrifice. Specifically, it reflects what the Yoruba describe as b’ogede ba’ku aafi omo e ropo (old banana trees die to sustain the lives of the young shoots), signifying that elderly members of the community can relive their lives through ensuring the younger ones live on. In essence, it suggests that elderly members of the community are morally obligated to give up their lives for the sake of the young because in so doing communal existence remains unbroken. An ethical background such as this, therefore, favors the participation of all in the stress and sacrifice of Ebola outbreaks. Compliance with quarantine will likely improve as opposed to its current view as a prison yard, which partly explains why several contacts of Ebola victims often abscond, thereby potentially spreading infection. For health professionals, a grounding in ubuntu moral thinking will facilitate an easier transition into taking on the supererogatory task of accepting the higher than normal levels of risk associated with Ebola outbreaks. This should contribute to dousing some of the tensions traditionally associated with the duty of care and boundaries of acceptable risk during incidents of virulent epidemics.156

 Lazzari. P. 14.  Paulin Hountondji, “Distances,” Ibadan Journal of Humanistic Studies 3 (1983). Pp. 135–140; Michael J Moravcsik and John M Ziman, “Paradisia and Dominatia: Science and the Developing World,” Foreign Affairs 53, no. 4 (1975). Pp. 699–705; Oscar OBrathwaite, “Promoting a PanAfrican Education Agenda by Shifting the Education Paradigm,” in Unite or Perish: 50 Years after the Founding of the Oau, ed. Mammo Muchie, et al. (Africa Institute of South Africa, 2014). Pp. 156–159. 155  Hewlett and Amola. Pp. 1246–1247. 156  Daniel K Sokol, “Virulent Epidemics and Scope of Healthcare Workers’ Duty of Care,” ibid.12, no. 8 (2006). Pp. 1238–1239. 153 154

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Hence, the Ubuntu ethical approach has a short-term and long-term appeal. The former comes to the fore in relation to the disaster phase of EVDs where it can help address the moral quandaries and drive relevant public health policies. The long-­ term benefit of the Ubuntu moral lens rests in its capacity to positively shape the cognitive, social, and educational climate of the African people towards a Ubuntu-­ centric way of life. This has a two-fold importance. One, a ubuntically oriented way of reasoning may influence pre-disaster phase policies and help prepare the local healthcare system to better engage the sudden and profound challenges. Secondly, background issues such as those involving corruption and mismanagement of health funds may be addressed through the ubuntu ethical gaze by using the disservice that accrues to the community as a rallying ground to punish culprits by using such experience as social deterrents to others.

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Harris, John, and Soren Holm. 1995. Is There a Moral Obligation Not to Infect Others? British Medical Journal 311 (7014): 1215–1217. Hewlett, Barry S., and Richard P. Amola. 2003. Cultural Contexts of Ebola in Northern Uganda. Emerging Infectious Diseases 9 (10): 1242. Hewlett, Bonnie L., and Barry S.  Hewlett. 2005. Providing Care and Facing Death: Nursing During Ebola Outbreaks in Central Africa. Journal of Transcultural Nursing 16 (4): 289–297. Hewlett, Barry, and Bonnie Hewlett. 2007. Ebola Culture and Politics: The Anthropology of an Emerging Disease. Belmont: Cengage Learning. Heymann, David L. 2015. Ebola: Burying the Bodies. The Lancet 386 (10005): 1729–1730. Honey, Karen. 2004. Ebola Vaccine Trials. Nature Reviews Immunology 4 (1): 4. Hountondji, Paulin. 1983. Distances. Ibadan Journal of Humanistic Studies 3: 135–146. Jenkins, Richard K.B., and Paul A. Racey. 2008. Bats as Bushmeat in Madagascar. Madagascar Conservation & Development 1: 3. Johnston, Robert. Statistics on the 2014–2015 West Africa Ebola Outbreak. http://www.johnstonsarchive.net/policy/westafrica-ebola.html. Kamins, Alexandra O., Olivier Restif, Yaa Ntiamoa-Baidu, Richard Suu-Ire, David T.S. Hayman, Andrew A. Cunningham, James L.N. Wood, and J. Marcus Rowcliffe. 2011. Uncovering the Fruit Bat Bushmeat Commodity Chain and the True Extent of Fruit Bat Hunting in Ghana, West Africa. Biological Conservation 144 (12): 3000–3008. Kass, Nancy E. 2004. Public Health Ethics from Foundations and Frameworks to Justice and Global Public Health. The Journal of Law, Medicine & Ethics 32 (2): 232–242. Kass, Nancy. 2014. Ebola, Ethics, and Public Health: What Next? Annals of Internal Medicine 161 (10): 744–745. Kelly, Marion. 1995. Disaster in the Horn of Africa: The Impact on Public Health. In Disaster and Development in the Horn of Africa, ed. John Sorenson, 228–248. New York: St Martin’s Press. Kelly, David F. 2006. Medical Care at the End of Life: A Catholic Perspective. Washington, DC: Georgetown University Press. Keyhani, Salomeh, and Joseph S. Ross. 2007. The Cost of Pharmaceutical Innovation to Patients. Expert Opinion on Drug Discovery 2 (11): 1431–1434. Kogan, Benjamin A. 1970. Health: Man in a Changing Environment. New York: Harcourt Brace Jovanovich, Inc. Krishnan, Sneha. 2012. Vulnerability in Disasters. Opticon 1826 14: 49. Lateef, Fatimah. 2011. Ethical Issues in Disasters. Prehospital and Disaster Medicine 26 (4): 289–292. Lawal, Babatunde. 1977. The Living Dead: Art and Immortality among the Yoruba of Nigeria. Africa 47 (01): 50–61. Lazzari, Stefano. Health Aspects of Disasters. In The Challenge of African Disasters, ed. WHO, 9–23. UN: Institute for Training and Research. Legrand, J., R.F.  Grais, P.Y.  Boelle, A.J.  Valleron, and A.  Flahault. 2007. Understanding the Dynamics of Ebola Epidemics. Epidemiology and Infection 135 (04): 610–621. Levy, Neil. 2006. Autonomy and Addiction. Canadian Journal of Philosophy 36 (3): 427–447. Lucas, Adetokunbo O., and Herbert Michael Gilles. 2003. Short Textbook of Public Health Medicine for the Tropics. London: Arnold Publishers. Lutz, David W. 2009. African Ubuntu Philosophy and Global Management. Journal of Business Ethics 84 (3): 313–328. Macklin, Ruth. 2003. Dignity Is a Useless Concept. British Medical Journal 327 (7429): 1419–1420. ———. 2014. Studying Vulnerable Populations in the Context of Enhanced Vulnerability. In Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Aasim Ahmad, Mahmud Syed Mamun, and Dónal P. O’Mathúna, 159–173. Dordrecht: Springer. Mallia, Pierre. 2015. Towards an Ethical Theory in Disaster Situations. Medicine, Health Care, and Philosophy 18 (1): 3–11.

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Masolo, Dismas A. 2010. Self and Community in a Changing World. Bloomington: Indiana University Press. Mbiti, John S. 1969. African Religions and Philosophy, African Philosophy. London: Longman. McKoy, June M. 2006. Obligation to Provide Services: A Physician-Public Defender Comparison. Virtual Mentor 8 (5): 332–334. Mechtraud, Sister. 1955. Durkheim’s Concept of Solidarity. Philippine Sociological Review 3: 23–27. Metz, Thaddeus. 2007. Toward an African Moral Theory. Journal of Political Philosophy 15 (3): 321–341. Mitman, Gregg. 2014. Ebola in a Stew of Fear. New England Journal of Medicine 371 (19): 1763–1765. Mkhize, Nhlanhla. 2008. Ubuntu and Harmony: An African Approach to Morality and Ethics. In Persons in Community : African Ethics in a Global Culture, ed. Ronald Nicolson, 35–44. Scottsville: University of Kwa-Zulu Press. Moravcsik, Michael J., and John M.  Ziman. 1975. Paradisia and Dominatia: Science and the Developing World. Foreign Affairs 53 (4): 699–724. Ndayimirije, Nestor, and Mary Kay Kindhauser. 2005. Marburg Hemorrhagic Fever in Angola— Fighting Fear and a Lethal Pathogen. New England Journal of Medicine 352 (21): 2155–2157. Neves, Maria Patrao. 2009. Respect for Human Vulnerability and Personal Integrity. In The Unesco Universal Declaration on Bioethics and Human Rights: Background, Principles and Application, ed. Henk ten Have and Michèle Jean, 155–164. Paris: UNESCO. Nicolson, Ronald. 2008. Persons in Community: African Ethics in a Global Culture. Scottsville: University of Kwa-Zulu Press. Nwaka, Solomon. 2005. Drug Discovery and Beyond: The Role of Public-Private Partnerships in Improving Access to New Malaria Medicines. Transactions of the Royal Society of Tropical Medicine and Hygiene 99 (Supplement 1): S20–S29. O’Mathúna, Dónal P., Bert Gordijn, and Mike Clarke. 2014. Disaster Bioethics: An Introduction. In Disaster Bioethics: Normative Issues When Nothing Is Normal, 3–12. Dordrecht: Springer. OBrathwaite, Oscar. 2014. Promoting a Pan-African Education Agenda by Shifting the Education Paradigm. In Unite or Perish: 50 Years after the Founding of the Oau, ed. Mammo Muchie, Vusi Gumede, Phindle Lukhele-Olorunju, and Hailemichael T. Demissie, 146–162. Pretoria: Africa Institute of South Africa. Oguejiofor, J. Obi. 2009. Negritude as Hermeneutics. American Catholic Philosophical Quarterly 83 (1): 79–94. Okware, S.I., F.G. Omaswa, S. Zaramba, A. Opio, J.J. Lutwama, J. Kamugisha, E.B. Rwaguma, P.  Kagwa, and M.  Lamunu. 2002. An Outbreak of Ebola in Uganda. Tropical Medicine & International Health 7 (12): 1068–1075. Onishi, Norimitsu. Inquiry Faults Liberia Force That Fired on Protesters. http://www.nytimes. com/2014/11/04/world/africa/soldiers-faulted-in-deadly-crackdown-during-ebola-protests-in-­ liberia.html. Pandey, Abhishek, Katherine E.  Atkins, Jan Medlock, Natasha Wenzel, Jeffrey P.  Townsend, James E. Childs, Tolbert G. Nyenswah, Martial L. Ndeffo-Mbah, and Alison P. Galvani. 2014. Strategies for Containing Ebola in West Africa. Science 346 (6212): 991–995. Peters, C.J., and J.W. Peters. 1999. An Introduction to Ebola: The Virus and the Disease. Journal of Infectious Diseases 179 (Supplement 1): ix–xvi. Pieterse, Pieternella, and Tom Lodge. 2015. When Free Healthcare Is Not Free. Corruption and Mistrust in Sierra Leone’s Primary Healthcare System Immediately Prior to the Ebola Outbreak. International Health 7 (6): 400–404. Pourrut, Xavier, Brice Kumulungui, Tatiana Wittmann, Ghislain Moussavou, André Délicat, Philippe Yaba, Dieudonné Nkoghe, Jean-Paul Gonzalez, and Eric Maurice Leroy. 2005. The Natural History of Ebola Virus in Africa. Microbes and Infection 7 (7): 1005–1014.

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Chapter 3

Pandemic Influenza: A Comparative Ethical Approach

Abstract  Community-networks such as families and schools may foster and propagate some types of public health disasters. For such disasters, a communitarian-­ oriented ethical lens offers useful perspectives into the underlying relational nexus that favors the spread of infection. This chapter compares two traditional bioethical lenses—the communitarian and care ethics framework—vis-à-vis their capacities to engage the moral quandaries elicited by pandemic influenza. It argues that these quandaries preclude the analytical lens of ethical prisms that are individual-oriented but warrant a people-oriented approach. Adopting this dual approach offers both a contrastive and a complementary way of rethinking the underlying socioethical tensions elicited by pandemic influenza in particular and other public health disasters generally.

3.1  Introduction Contemporary healthcare constitutes an instinctual and institutional response to the multifaceted cycles of health, illness, and disease.1 Hence, the problems of diseases including infectious ones affect all and sundry irrespective of current “sick status”. Pandemic influenza is one such incident that afflicts all sectors of the society.2 It also raises questions and issues related to utility and equity, ensuring the protection of vulnerable individuals and groups in society, the need to exercise public health powers with respect for human rights3 as well as the just allocation of human and material resources.4 Attending to these issues, however, juggles many kinds of 1  Michael O.S. Afolabi, “Exploring the Technologies of Laboratory Science for Social Change: An Examination of the Nigerian Healthcare System” (paper presented at the 7th Globelics International Conference, Dakar, Senegal, 2009). Pp. 1–2. 2  Jaro Kotalik, “Preparing for an Influenza Pandemic: Ethical Issues,” Bioethics 19, no. 4 (2005). P. 422. 3  Belinda Bennett and Terry Carney, “Pandemics,” in Encyclopedia of Global Bioethics, ed. Henk ten Have (Dordrecht: Springer Science, 2015). P. 1. 4  Kotalik. P. 422.

© Springer International Publishing AG, part of Springer Nature 2018 M. O. Afolabi, Public Health Disasters: A Global Ethical Framework, Advancing Global Bioethics 12, https://doi.org/10.1007/978-3-319-92765-7_3

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personal, social, political, and professional interests against one another; thus, reflecting the traditional public health dilemma of fine-tuning individual against collective good.5 Since the restrictive approach of individualism-driven moral lenses6 is unsuitable for people-centered quandaries, it seems pertinent to employ a people-centric moral lens to engage them. In this vein, the ethical prism of communitarianism and ethics of care seem apt. By examining and contrasting the core fabric of the communitarian and care ethics frameworks vis-à-vis the attendant dilemmas of pandemic influenza; this chapter attempts to tease out a broader ethical path towards engaging the challenges of pandemic influenza. To properly set the conceptual foreground essential to articulating the ethical features of pandemic influenza, however, it is important to elaborate the associated biological, social, and global dynamics. These parameters, as Macphail recently argues, are exigent in the explication and engagement of pandemic or infectious disease outbreaks.7

3.1.1  Biological Features of Pandemic Influenza Outbreaks There have been some speculations as to the origins of the influenza virus. It has been hypothesized that the virus originated from wild waterfowls and has only slowly evolved through multiple animal species including humans.8 But what is known about the disease caused by the virus—influenza—is that it is a febrile illness of the upper and lower respiratory tract, characterized by a sudden onset of fever, cough, myalgia, and malaise. Pneumonia is a principal serious complication9 and local symptoms include sniffles, nasal discharge, dry cough, and sore throat.10 Pandemic influenza outbreaks describe the rapid spread of influenza infection. Whereas there is some conceptual controversy about the description and definition of pandemics,11 they generally refer to the dissemination of new infective diseases to which immunity has not been developed in a widespread manner across a

 Stephen Holland, Public Health Ethics, 2nd ed. (Polity Press, 2015). Pp. 1–4.  Stephen Peckham and Alison Hann, “Conclusion: Taking Forward the Debate,” in Public Health Ethics and Practice, ed. Stephen Peckham and Alison Hann (Policy Press, 2010). Pp. 215–216. 7  Theresa MacPhail, The Viral Network: A Pathography of the H1n1 Influenza Pandemic (Cornell University Press, 2014). Pp. 7, 21. 8  Sonia Shah, Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond (New York: Sarah Crichton Books, 2016). Pp. 87–88. 9  Robert B. Couch, “Orthomyxoviruses,” in Medical Microbiology. 4th Edition, ed. Samuel Baron (Galveston: University of Texas Medical Branch at Galveston, 1996). 10  Tom Jefferson et al., “Neuraminidase Inhibitors for Preventing and Treating Influenza in Adults and Children,” The Cochrane Database of Systematic Reviews, no. 4 (2014). P. 4. 11  Peter Doshi, “The Elusive Definition of Pandemic Influenza,” Bulletin of the World Health Organization 89, no. 7 (2011). Pp. 532–533. 5 6

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significant part of the world.12 They could break out in nations with a large geographical size (such as China, India, and the United States) or when the number of affected nations are many. The pandemic nature of influenza is historically underscored by the 1918–1919 incident that killed an estimated 20 million to 50 million people.13 Pandemic influenza is generally characterized by an alteration in the viral subtype (due to antigenic shift), higher mortality rates among younger groups, several waves of the particular pandemic, increased capacity of spread, and geographic variation in the impact of the outbreak.14 Specifically, influenza pandemics occur when an influenza virus mutates or when multiple strains combine, or re-assort to produce strains to which there is no current immunity.15 Novel outbreaks of the influenza virus occur either in large nations or across selected nations in close proximity. Contemporary society experiences an increased development of new serotypes of several kinds of respiratory viruses because of the evolutionary potential afforded by the human population explosion and the great global increase in human mobility.16 In a manner of speaking, it seems that PHDs such as pandemic influenza outbreaks have evolved to become recurring features of the human experience. Some insights into the biological features and processes that create pandemic outbreaks support this idea. Influenza viruses belong to the Orthomyxoviruses family. This comprises seven genera including influenza virus A, B, C, and D.17 Although both the genus influenzavirus A and B affect humans and cause pandemics,18 influenza A has been the principal culprit in known outbreaks to the extent that four major pandemics have resulted from it (1918–1919, 1957, 1968, and 2009).19 However, genetic re-­ assortment and exchange of influenza viruses between humans and animals generate antigenic shift, which periodically introduces new viruses to the human population. This, in addition to mutation and selection, produces antigenic drift that accounts for the year-to-year variations in influenza A subtypes.20 Wild ducks, for instance, serve as the primary host for various influenza type A viruses that occasionally spread to other host species and cause outbreaks in such animals as fowl,

 Bennett and Carney. P. 2.  Lawrence O Gostin, “Medical Countermeasures for Pandemic Influenza: Ethics and the Law,” Journal of American Medical Association 295, no. 5 (2006). P. 554. 14  Mark A Miller et al., “The Signature Features of Influenza Pandemics—Implications for Policy,” New England Journal of Medicine 360, no. 25 (2009). P. 2595. 15  HHS, “2009 H1n1 Influenza Improvement Plan,” (Washington DC: U.S. Department of Health and Human Services, 2012). P. 1. 16  Frank Fenner, “Epidemiology and Evolution,” in Medical Microbiology. 4th Edition, ed. Samuel Baron (Galveston: University of Texas Medical Branch at Galveston, 1996). 17  Robert B. Couch, “Orthomyxoviruses,” ibid. 18  Ademola H Fagbami, Medical Virology (Ibadan: Nihinco Prints, 2009). Pp. 67–68, 71. 19  MacPhail. P. 9. 20  Fenner. 12 13

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swine, and horses. Such outbreaks often lead to new human pandemics21 due to novel viruses infecting immunologically naïve people.22 A critical aspect of the emergence of novel virus strains is genetic variation and combination that occur at the hemagglutinin (HA) antigens (of which there are 16) and neuraminidase (NA) enzymes (of which there are nine)23 between and amongst human and animal influenza viruses. The subtypes of the HA and NA surface proteins forms the basis for the classification of outbreaks.24 For example, the 1918 through 1919 virus was H1N1, the 1957 through 1963 virus was H2N2, the 1968 through 1970 outbreak was caused by H3N2,25 the 1996 virus was H5N1,26 and the 2009 outbreak was caused by H1N1;27 while the most recent virus seen in Eastern China in 2013 was H7N9.28 All of these traditional and new influenza viruses cause pandemics of differing proportions but more are projected to occur.29 This projection is well supported by the scientific community. However, it is not known when any will occur or whether it will be caused by the H5N1 avian-derived influenza virus, newer subtypes like H7N9, or completely novel subtypes. Virologists like Webster and Govorkova argue that given the number of cases of H5N1 influenza that have occurred in humans (more than 251) with a mortality or death rate of more than 50%, it would be prudent to develop robust plans for dealing with such pandemic influenza and its (expected) new variations.30 Such plans, however, necessarily demand attention to the associated ethical dynamics. Regardless of the specific subtype of human or animal-derived influenza outbreaks, the public health challenges and the moral quandaries are essentially the same. A critical biological feature of influenza lies in its mode and pattern of transmission. This revolves around its capacity to evolve and become airborne-transmissible between and amongst human beings.31 The influenza  virus transmits from person to person primarily in droplets released by sneezing and coughing. Some of the inhaled virus lands in the lower respiratory tract, the primary site of disease  Marion Russier et al., “Molecular Requirements for a Pandemic Influenza Virus: An Acid-Stable Hemagglutinin Protein,” Proceedings of the National Academy of Sciences 113, no. 6 (2016). Pp. 1636–1639. 22  Anna V Cauldwell et  al., “Viral Determinants of Influenza a Virus Host Range,” Journal of General Virology 95, no. 6 (2014). Pp. 1193–1195. 23  Couch. P.; Shah. P. 94. 24  Cauldwell et al. P. 1193. 25  Miller et al. Pp. 2595–2597. 26  Shah. P. 89. 27  Rebekah H Borse et al., “Effects of Vaccine Program against Pandemic Influenza a (H1n1) Virus, United States, 2009–2010,” Emerging Infectious Diseases 19, no. 3 (2013). Pp. 439–441. 28  Cauldwell et al. P. 1204. 29  MacPhail. P. 9. 30  Robert G Webster and Elena A Govorkova, “H5n1 Influenza—Continuing Evolution and Spread,” New England Journal of Medicine 355, no. 21 (2006). Pp. 2174–2175. 31  Russier et al. Pp. 1636–1637. 21

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being the tracheobronchial tree, and sometimes the nasopharynx.32 Largely because breathing is an essential biological need of human beings and partly because human-human associations are an inevitable part of reality, this biological feature of influenza viruses makes everyone vulnerable and susceptible to infection. Specifically, crowds of people facilitate viral transmission by enabling sharp upticks in the rate of transmission. The virus also circulates for longer periods in infected persons.33 The biological features of influenza and its mode of transmission elicit some observations. One, pandemic influenza is not a single disease for which a single and specific therapeutic intervention that will be effective all the time can be developed. In other words, while there is a general approach to engaging this public health disaster, specific interventions will usually vary by each outbreak. This gives an existential and evolutionary advantage to the influenza virus over human communities. It also engenders a disaster dynamic in the sense that every outbreak becomes “sudden” and potentially associated with large human casualties. Secondly, it shows the common vulnerability to which the local and global human community are subject vis-à-vis the ease of spread of the viral infection. Thirdly, the biological features of pandemic influenza demonstrate how a collective response (human material, scientific etc.) is key to engaging its social and other attendant consequences. The importance of this last remark will become clearer against the backdrop of the social and global features of pandemic influenza outbreaks, a. theme addressed in the next section of this chapter.

3.1.2  S  ocial and Global Features of Pandemic Influenza Outbreaks An influenza pandemic has the potential to cause more deaths and illnesses than any other public health threat.34 Influenza pandemics are characterized by a widely varying number of deaths,35 and each outbreak has always underscored this notion. Seasonal influenza, for instance, kills up to half a million people every year. The 1918 pandemic, on the other hand, caused at least 40 million global deaths.36 For the period up to August 2010, 18,500 deaths associated with laboratory-confirmed 2009

 Couch.  Shah. Pp. 85–86. 34  HHS, “Hhs Pandemic Influenza Plan,” (Washington DC: U.S. Department of Health and Human Services 2005). P. B4. 35  Eric J Kasowski, Rebecca J Garten, and Carolyn B Bridges, “Influenza Pandemic Epidemiologic and Virologic Diversity: Reminding Ourselves of the Possibilities,” Clinical Infectious Diseases 52, no. suppl 1 (2011). Pp. 44–46. 36  Shah. Pp. 90, 96. 32 33

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pandemic influenza A H1N1 were reported.37 Also, the H5N1 outbreak recorded a death rate of 59%,38 and the recent H7N9 outbreak caused 251 human infections and 67 deaths.39 In the United States, the estimated potential threat of pandemic influenza is 1.9 million deaths, 90 million sick people, and nearly 10 million hospitalizations, with almost 1.5 million requiring intensive-care units.40 Global estimates are higher. For instance, the 1918 “Spanish flu” caused an estimated 20–50  million global deaths.41 It has been projected that a recurrence of the 1918 influenza strain would probably result in the death of 51–81 million individuals.42 These data show that substantial numbers of deaths are an inevitable consequence and feature of pandemic influenza. However, death itself often brings about certain social consequence including the death of some of the most gifted members of the society. Sir William Osler, one of the pioneers of scientific medicine, died of complications arising from influenza in 1919. Influenza was cited by the German war general, Erich von Ludendorff, as a significant reason for why the initial gains of their last offensive faltered and ultimately failed during World War 1.43 From a biological perspective, influenza exploits naïve immune systems which tend to over-respond to the influenza virus. As such, young and promising adults constitute a large part of vulnerable victims. In this regard, potential contributions to societies are nipped in the bud, young widows and widowers emerge as well as a lot of orphans. For instance, 21,000 children were orphaned due to the 1918 outbreak in New York City.44 Influenza also spread within households soon before or after the onset of symptoms in primary infected patients.45 Hence, it is little surprising that businesses become crippled, distribution of essential goods and services disrupted and halted during outbreaks.46  Fatimah S Dawood et al., “Estimated Global Mortality Associated with the First 12 Months of 2009 Pandemic Influenza a H1n1 Virus Circulation: A Modelling Study,” The Lancet: Infectious Diseases 12, no. 9 (2012). Pp. 687–689. 38  Shah. P. 89. 39  Cauldwell et al. P. 1204. 40  Ezekiel J Emanuel and Alan Wertheimer, “Who Should Get Influenza Vaccine When Not All Can?,” Science 312, no. 5775 (2006). P. 854. 41  Tokiko Watanabe and Yoshihiro Kawaoka, “Pathogenesis of the 1918 Pandemic Influenza Virus,” PLoS Pathogens 7, no. 1 (2011). P. e1001218. 42  Christopher JL Murray et al., “Estimation of Potential Global Pandemic Influenza Mortality on the Basis of Vital Registry Data from the 1918–20 Pandemic: A Quantitative Analysis,” The Lancet 368, no. 9554 (2007). P. 2215. 43  John M Barry, The Great Influenza: The Story of the Deadliest Pandemic in History (Penguin, 2005). Pp. 299–300, 171. 44  Dorothy E Vawter, Karen G Gervais, and J Eline Garrett, “Allocating Pandemic Influenza Vaccines in Minnesota: Recommendations of the Pandemic Influenza Ethics Work Group,” Vaccine 25, no. 35 (2007). P. 6522. 45  Simon Cauchemez et al., “Household Transmission of 2009 Pandemic Influenza a (H1n1) Virus in the United States,” New England Journal of Medicine 361 (2009). P. 2619. 46  Alfred W Crosby, America’s Forgotten Pandemic: The Influenza of 1918 (Cambridge University Press, 2003). Pp. 81–100. 37

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Another associated social feature of pandemic influenza is the closure of schools with an attendant truncation of learning and educational opportunities, depending on the length of the outbreak. While some of these social features are local and exert localized effects, human beings as social animals with the aid of the increased means of locomotion transmit some of the local features into a global experience. The 1957 pandemic of influenza which occurred during a time of much less globalization spread to the United States within 4–5 months of its detection in China while the 1968 pandemic spread to the U.S. from Hong Kong within 2–3 months.47 It is estimated that the burden of the next influenza pandemic will be overwhelmingly focused in the developing world.48 However, the epidemiological notion well-known to public health experts that infectious diseases can predicate outbreaks in neighboring places and nations49 implies that even so-called developed societies cannot be spared as long as the current interpenetration of people across the globe remains. The 2009 influenza outbreak, for instance, spread to 85 countries and caused a total of 39, 620 cases of infection.50 In short, in a globalized world, infectious diseases travel in nodes of human, material, and animal networks.51 Data from sporadic studies suggest that influenza may be fairly prevalent in Africa, albeit sub-clinically. It may, therefore, have a considerable impact on morbidity and mortality on the continent52 should a combination of factors create a virus that is viable enough to cause a pandemic. This will have far-reaching consequences for the continent due to the material and human resource constraints, lack of preparedness plans as well as the very limited bio-therapeutic capacities that are currently available to produce vaccines. It may likewise create the dispersal of a virus novel to other continents that have experienced typical outbreaks. Geographical location plays a major role in public health,53 and disasters including health disasters are unique in that each affected region of the world has different social, economic, and health backgrounds.54 As such, while there is a global spread, the nature of each local context and how it responds shapes pandemic influenza in some key ways. First, the nature of the “disseminating” nation influences how infection spreads elsewhere. For example, China’s slow reaction to the 2003 SARS outbreak as well as its limiting of access to patients and other relevant  information

 HHS, “Hhs Pandemic Influenza Plan.” P. B6.  Murray et al. P. 2216. 49  MacPhail. P. 89. 50  Simon Cauchemez et  al., “Closure of Schools During an Influenza Pandemic,” The Lancet: Infectious Diseases 9, no. 8 (2009). P. 473. 51  MacPhail. P. 95. 52  Maria Yazdanbakhsh and Peter G Kremsner, “Influenza in Africa,” PLoS Med 6, no. 12 (2009). P. e1000182. 53  James N Logue, “Disasters, the Environment, and Public Health: Improving Our Response,” American Journal of Public Health 86, no. 9 (1996). P. 1208 54  Eric K Noji, “Public Health Issues in Disasters,” Critical Care Medicine 33, no. 1 (2005). P. S29. 47 48

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seemed to have deepened the global intensity of that crisis.55 In other words, how a local public health disaster is handled shapes the local severity and how it spreads elsewhere. On the other hand, well-handled local health crises positively influence the possible impacts on contiguous nations. In this vein, Radest notes that Canada’s rapid and coordinated response to the SARS outbreak significantly limited its spread and impact in the United States.56 The above examples echo the interconnectivity of the modern world and show how a course of action in one place, however passive, may significantly influence the course of events in another for good or bad. It supports the idea that contemporary health in the twenty-first century is now inevitably and inherently global with respect to infectious diseases.57 At the heart of these remarks, however, is the possibility of utilizing different networks of human interconnectivity to actively foster the global good. In other words, learning about how people connect and relate at different levels (individually, communally, institutionally et cetera) and learning about the chief actors and players in such a relationship nexus may provide a powerful tool for driving global public health agenda. Yet, integral to such a process is how responses to pandemic influenza are framed and implemented locally as well as their attendant limitations. This theme is addressed in the next section.

3.2  Responses to Pandemic Influenza Outbreaks The human instinct for self-preservation has, at the social plane, always resulted in some institutional responses to diseases, whether rudimentary, barely adequate, or sophisticated. In the context of PHDs, responses are shaped by the nature of the specific disaster, where it is taking place, and what human, material, pecuniary and technological resources are available to deal with  the given emergency situation. For instance, the United States prioritizes building a system that ensures stable and economically viable vaccines to engage influenza outbreaks.58 Countries that lack the same kind of resource will clearly prioritize other approaches. However, the general approaches to pandemic influenza are therapeutic and non-therapeutic in nature. This section briefly examines them.

 MacPhail. P. 91.  Howard B Radest, Bioethics: Catastrophic Events in a Time of Terror (Lexington Books, 2009). P. 86. 57  Alison K Thompson et al., ““With Human Health It’sa Global Thing”: Canadian Perspectives on Ethics in the Global Governance of an Influenza Pandemic,” Journal of Bioethical Inquiry 12, no. 1 (2015). P. 115. 58  Gostin. P. 554. 55 56

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3.2.1  Therapeutic Responses Pandemic influenza outbreaks, like most diseases, have elicited some bio-­ pharmaceutical responses geared towards mitigating its disastrous effects. Due to the changing biological and social dynamics associated with the outbreak, social as well as scientific responses are always evolving to keep up. Nevertheless, the therapeutic measures fashioned to combat pandemic influenza fall into two groups. These are preventive measures involving the use of anti-viral drugs as well as vaccination. In the past, drugs like rimantadine and amantadine were used as prophylaxis against influenza A.59 But drug resistance has increasingly been observed to these M2-ion channel-blocking agents.60 Today, drugs of choice are mainly Tamiflu (oseltamivir) and Relenza (zanamivir). Black et al. noted that early anti-viral intervention during the 2009 pandemic helped reduce the doubling time in the early stages of the outbreak.61 The linkage between antiviral use and reduction in clinical severity and influenza infectiousness is generally supported in the extant literature.62 Hence, treatment of clinical cases with anti-viral agents constitutes the first-line of engagement for pandemic influenza and these drugs are employed to control or contain pandemic outbreaks long enough for vaccines to be made.63 Yet, drugs like oseltamivir and zanamivir, usually neuraminidase inhibitors, can only help reduce transmission if given within a day of the onset of symptoms.64 On the contrary, delay in symptoms diagnosis, as well as intervention, favors infection dissemination. Nevertheless, antiviral agents for influenza offer some protection to families and households once infection has been detected. In clinical trials, antiviral treatments have been shown to be efficacious in preventing infection, hence, slowing down transmission as well as limiting the severity of the disease.65 But the effectiveness of neuraminidase such as oral oseltamivir and inhaled zanamivir at reducing mortality is uncertain.66 In addition, there is some evidence of side-effects. For instance, in adults as in children, oseltamivir increases the risk of nausea and vomiting. Also,  Raphael Dolin et al., “A Controlled Trial of Amantadine and Rimantadine in the Prophylaxis of Influenza a Infection,” New England Journal of Medicine 307, no. 10 (1982). Pp. 580–582. 60  Jianfang Zhou et al., “Biological Features of Novel Avian Influenza a (H7n9) Virus,” Nature 499, no. 7459 (2013). P. 502. 61   Andrew J Black et  al., “Epidemiological Consequences of Household-Based Antiviral Prophylaxis for Pandemic Influenza,” Journal of The Royal Society Interface 10, no. 81 (2013). P. 7. 62  Neil M Ferguson et al., “Strategies for Mitigating an Influenza Pandemic,” Nature 442 (2006). P. 449. 63  Black et al. P. 1. 64  Ferguson et al. P. 448. 65  Black et al. P. 1. 66  Stella G Muthuri et  al., “Effectiveness of Neuraminidase Inhibitors in Reducing Mortality in Patients Admitted to Hospital with Influenza a H1n1pdm09 Virus Infection: A Meta-Analysis of Individual Participant Data,” The Lancet: Respiratory Medicine 2, no. 5 (2014). Pp. 395–401. 59

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treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced.67 Resistance to these anti-viral drugs has also been reported, even in people who have never been previously treated with them.68 Ultimately, the success of antiviral p­ rophylaxis critically depends on the identification of index cases in households, pre-­schools, schools, and other institutional settings.69 This clearly highlights the importance of personal, social, and institutional cooperation in relation to dealing with the associated challenges. On the other hand, vaccination as one of the most effective and cost-saving strategies for ameliorating infectious diseases70 offers a protective approach to limiting and/or curtailing the social and economic consequences of pandemic influenza. Two types of vaccines are generally used. Trivalent inactivated vaccine and live attenuated influenza virus vaccine, both of which contain the predicted antigenic variants of influenza A(H3N2), A(H1N1), and B viruses.71 Borse et al. estimated that 2009 vaccination program against influenza prevented 700,000–1,500,000 clinical cases, 4000–10,000 hospitalizations, and 200–500 deaths. They also reported that the national health effects of vaccination were greatly influenced by the timing of vaccine administration and the effectiveness of the vaccine.72 Similarly, Ferguson et al. estimated that during a global outbreak, vaccination at the rate of 1% of the population per day would need to begin within 2 months of the initial outbreak. But this is not feasible under current vaccine technologies.73 This pragmatic challenge would, however, create a biological and social climate in which infection may flourish in a logarithmic manner. The recurring antigenic variation in influenza viruses which leads to the frequent emergence of new infectious strains74 increases the likelihood of continuous outbreaks. This and the capacity of the influenza virus to acquire amino acid changes in its viral proteins75 implies that each outbreak will demand novel vaccines. This often delays the possible response time, again creating a window where infection can readily spread, locally and globally. For instance, it will take at least 4 months from identification of a candidate vaccine strain until production of the very first

 Jefferson et al. Pp. 3–4.  Mélanie Samson et  al., “Influenza Virus Resistance to Neuraminidase Inhibitors,” Antiviral Research 98, no. 2 (2013). Pp. 178–180. 69  Ira M Longini et al., “Containing Pandemic Influenza with Antiviral Agents,” American Journal of Epidemiology 159, no. 7 (2004). Pp. 630–631. 70  Michael O.S. Afolabi and Ikeolu O. Afolabi, “Vaccine-Preventable Diseases: An Examination of Measles and Polio in Nigeria,” The IAFOR Journal of the Social Sciences 1, no. 1 (2013). Pp. 33–34. 71  Kristin L Nichol and John J Treanor, “Vaccines for Seasonal and Pandemic Influenza,” Journal of Infectious Diseases 194, no. Supplement 2 (2006). P. 112. 72  Borse et al. Pp. 439–441. 73  Ferguson et al. P. 451. 74  Janis Kuby, “Immunology, 1997,” (WH Freeman and Company, New York, 1997). P. 392. 75  Watanabe and Kawaoka. P. e1001218. 67 68

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vaccine76 during an outbreak. This biological fact makes it difficult to stockpile influenza vaccines ahead of outbreaks and, by consequence, limits the preparedness efforts geared towards confronting the public health challenges and moral quandaries. It is important to note that vaccines have some limitations. For instance, they are not entirely safe public health interventions, especially when specifics are ­examined.77 This fact has increasingly come to light in relation to vaccines against pandemic influenza. Besides sore arm and redness at the injection site as well as red eyes which have been reported in earlier vaccine trials,78 there has been some association between increased incidence of narcolepsy in children and the use of the ASO3-adjuvanted vaccine for pandemic H1N1 influenza in Scandinavian countries.79 In addition, anecdotal reports of fetal deaths occurring shortly after vaccination emerged in 2009 and raised public health concerns about vaccine safety.80 Another shortcoming associated with vaccination generally is vaccine failure,81 which often creates a false sense of protection in recipients while allowing the continued spread of infection.82 In relation to pandemic influenza specifically, vaccine failure was recently reported by Manjusa et al. in people of 65 years and above as well as those who have been vaccinated against seasonal influenza.83 This is quite troubling partly because vaccine failure vis-à-vis pandemic influenza vaccines has been little studied, and partly because there are countries like the United States where seasonal flu vaccine shots are almost the norm. Another dimension to vaccine failure relates to the variation of influenza virus clades. Nelson et al. recently reported that Nigeria, Côte d’Ivoire, and Cameroon exhibit more variable patterns of influenza virus seasonality, hence, there is a possibility of variants evolving locally within West Africa. This, they further argue, undermines the assumption that a vaccine matched to globally dominant lineages will necessarily protect against these local lineages.84 This notion further raises the question of whether the immune system of populations living in tropical African  HHS, “Hhs Pandemic Influenza Plan.” P. B12.  Michael O.S. Afolabi, “Vaccination,” in Encyclopedia of Global Bioethics, ed. Henk ten Have (Switzerland: Springer International Publishing, 2016). P. 2913. 78  Anthony E.  Fiore, Carolyn B.  Bridges, and Nancy J.  Cox, “Seasonal Influenza Vaccines,” in Vaccines for Pandemic Influenza, ed. Richard W.  Compans and Walter A.  Orenstein (Berlin: Springer, 2009). P. 56. 79  Yves Dauvilliers et al., “Increased Risk of Narcolepsy in Children and Adults after Pandemic H1n1 Vaccination in France,” Brain 136, no. 8 (2013). Pp. 2486–2490. 80  Siri E Håberg et al., “Risk of Fetal Death after Pandemic Influenza Virus Infection or Vaccination,” New England Journal of Medicine 368, no. 4 (2013). P. 333. 81  Afolabi and Afolabi. Pp. 42–43. 82  Afolabi, “Vaccination.” P. 2913. 83  Manjusha Gaglani et al., “Risk Factors of Influenza Vaccine Failure in 2012–13, 2013–14 and 2014–15 at Baylor Scott & White Health (Bswh) in Central Texas,” Open Forum Infectious Diseases 3, no. 1 (2016). P. 636. 84  Martha I Nelson et al., “Multiyear Persistence of 2 Pandemic a/H1n1 Influenza Virus Lineages in West Africa,” Journal of Infectious Diseases 210, no. 1 (2014). Pp. 121–123. 76 77

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environments would react similarly to a vaccine developed mainly for populations restricted to certain geographical areas of the world.85 On this note, in the possible event that someone originally from any of these nations were present in a pandemic influenza scenario outside African shore, the likelihood of their benefiting from vaccination seems slim. Hence, a significant offshoot of vaccine failure in relation to pandemic influenza (especially if newer studies show more negative results) will be the reluctance of people to receive vaccines for seasonal flu and those developed for pandemic influenza outbreaks. These have unsettling public health and moral consequences. One way of engaging the limits of influenza vaccines involve creating a vaccine type that is capable of eliciting cross-protective peptides/epitopes that would be effective against different variants. But this is very difficult.86 Besides the scientific technicalities, producing vaccines for pandemic influenza is not a cheap venture. For example, Meltzer, Cox, and Fukuda estimated in 1999 that it would cost the United States about $166.5 billion to contain pandemic influenza.87 Whereas the economic burden of influenza in lower- and middle-income countries involves direct costs to the health service and households and indirect costs due to a loss in human productivity,88 these countries also have limited financial capacities to pursue pandemic influenza vaccination as a public health tool. The impacts of the ensuing disease burden from such a constraint will not be locally confined, as it will ultimately seep into the trans-national and global terrains. In summary, the major and, perhaps, insurmountable constraint to vaccination as a tool for engaging pandemic influenza lies in the logistic challenge of producing a pandemic vaccine from scratch, conducting pre-clinical testing as well as generating billions of doses within a very short time for global distribution,89 which may, however, not work across all nations. But considering the limitations associated with antiviral drugs as well as vaccines in relation to combating pandemic influenza, some form of non-therapeutic approach is necessary, at least as some adjunct to mitigate the overall impact of pandemic influenza on the local and global human community. The next section addresses this theme.

 Yazdanbakhsh and Kremsner. P. e1000182.  Nichol and Treanor. P. 116. 87  Martin I Meltzer, Nancy J Cox, and Keiji Fukuda, “The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention,” Emerging Infectious Diseases 5, no. 5 (1999). P. 664. 88  Natasha de Francisco et  al., “A Systematic Review of the Social and Economic Burden of Influenza in Low-and Middle-Income Countries,” Vaccine 33, no. 48 (2015). P. 6537. 89  Lauren J.  DiMenna and Hildegund C.J.  Ertl, “Pandemic Influenza Vaccines,” in Vaccines for Pandemic Influenza, ed. Richard W. Compans and Walter A. Orenstein (Berlin: Springer, 2009). P. 292. 85 86

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3.2.2  Non-therapeutic Responses The non-pharmaceutical and non-therapeutic approaches to pandemic influenza revolve around measures such as case isolation, school or workplace closure, restrictions on travel,90 quarantine as well as contact tracing. For instance, school closure is a non-pharmaceutical intervention often suggested for mitigating influenza pandemics. The logic behind this lies in the notion that children are important vectors of transmission, more infectious, and susceptible to most influenza strains than adults. It is also tied to the idea that high a contact rate in schools fosters transmission of infection. This approach, according to Cauchemez and colleagues, may bring about an estimated 40% reduction in peak attack rates. However, this reduction will be hindered if children are not adequately isolated or if the policy is not well implemented.91 Whereas school closure may only bring about a small reduction in cumulative attack rates, it can foster a substantial reduction in peak attack rates.92 Closure of schools may, however, increase anxiety and create a crisis, as was observed in France during the 1957 outbreak.93 Closure of workplaces is another non-pharmaceutical intervention for pandemic influenza. It may be warranted by the degree of the outbreak in which businesses shut down at their own discretion, and for their own safety, as was seen during the 1918–1919 outbreak.94 However, it may also be warranted by government policy. Either way, business closure incurs huge economic costs, pecuniary, and other consequences for the different people tied to  and/or  dependent on the affected businesses or their services and goods. Different forms of quarantine measures are also used to mitigate the spread of infection during an influenza pandemic. For instance, isolation and quarantine of infected patients allow some containment of infection which consequently slows down viral transmission.95 Ultimately, quarantine contributes towards reducing the overall costs and impact of an outbreak. Some medical experts see household quarantine as the most effective social distance measure, provided the level of compliance is good.96 Yet, quarantine—at least on a general note—does not always work. For example, maritime quarantine was one of the measures employed in West Africa to engage the 1918 influenza outbreak as well as interning the ill. However, historians like Heaton and Falola note that these approaches yielded meager success in relation to quelling the spread and virulence of the pandemic.97 Indeed, while other

 Ferguson et al. P. 448.  Cauchemez et al. Pp. 473, 478. 92  Ferguson et al. P. 450. 93  Cauchemez et al. “Closure of schools during an influenza pandemic.” P. 475. 94  Crosby. Pp. 81–100. 95  Cauchemez et al. P. 2627. 96  Ferguson et al. P. 451. 97  Matthew Heaton and Toyin Falola, “Global Explanations Versus Local Interpretations: The Historiography of the Influenza Pandemic of 1918–19  in Africa,” History in Africa 33 (2006). P. 207. 90 91

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measures such as cancellation of non-essential public gatherings and restrictions on long-distance travel might help to decrease influenza transmission rates as well as overall morbidity, their effectiveness has not been quantified.98 The nature of pandemic influenza, the therapeutic and non-therapeutic approaches, and the associated limitations generate some moral concerns. The next section discusses this.

3.3  E  thical Issues Embedded in Pandemic Influenza Outbreaks Ethical issues arise during outbreaks of pandemic influenza. Some of these are directly tied to the nature of the virus, some in relation to human responses, some to the social responses, and others to how different human beings respond differently to the several challenges elicited by the pandemic. Bioethicists have underscored the critical need to reflect on the ethical issues raised by the specter of pandemic influenza outbreaks.99 However, what may and what may not be feasible to do will never be clear enough if these ethical quandaries are not clearly explicated. Hence, this section seeks to clarify the moral quandaries elicited by pandemic influenza and show the core connecting strands that resonate amongst them.

3.3.1  Uncertainty Generally, contexts of uncertainty are tied to the evolving nature of knowledge. Tannert et al. opine that uncertainty occurs because the more the human community gains insights into the mysteries of nature, the more they realize the limits of their knowledge about how things are. These limitations, they note, make it impossible to foresee all the associated future effects and implications of situations and decisions with certitude.100 In relation to medicine, Jean Daly notes that the art of medicine seeks to abolish uncertainty.101 Regardless of the good intentions and telos of medicine, the stark reality is that this task has hardly been achieved. Hence, different facets of uncertainty remain in medicine generally as well as in different biomedical

 Julia E Aledort et al., “Non-Pharmaceutical Public Health Interventions for Pandemic Influenza: An Evaluation of the Evidence Base,” BMC Public Health 7, no. 208 (2007). P. 6. 99  Alison K Thompson et al., “Pandemic Influenza Preparedness: An Ethical Framework to Guide Decision-Making,” BMC Medical Ethics 7, no. 12 (2006). P. 11. 100  Christof Tannert, Horst-Dietrich Elvers, and Burkhard Jandrig, “The Ethics of Uncertainty,” EMBO Reports 8, no. 10 (2007). P. 892. 101  Jeanne Daly, Evidence-Based Medicine and the Search for a Science of Clinical Care (University of California Press, 2005). P. 10. 98

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contexts. James Marcum contends that uncertainty is largely a part of medicine because of the variability of the underlying biology.102 Uncertainty is not new in the realm of science.103 However, in the context of public health disasters uncertainty has a strong pragmatic dimension which can influence courses of actions and decisions in multiple unfavorable ways. For example, it occurs during pandemic influenza outbreaks and generates many concerns. In this vein, Borse et al. note that the public health community cannot accurately predict the arrival of a pandemic.104 Indeed, a great deal of uncertainty occurs in relation to estimating the potential impact of a pandemic such as influenza.105 This scenario stifles preparedness efforts, especially in resource-constrained countries where there are often competing social needs to be met with limited budgets. However, the two main uncertainty issues embedded in pandemic influenza involve the nature of the virus and the types of responses available to engage outbreaks. On the one hand, the influenza virus undergoes constant variation in its antigens, creating new infectious strains.106 The virus also acquires amino acid changes in its proteins. These scenarios increase the likelihood of pandemic outbreaks. However, the question of when, where, and of what magnitude the outbreak will be is never clear-cut. Worst-case scenario analysis based on the 1918–20 pandemic provides no insight into the probability of an influenza pandemic in the next 1, 5, or 10 years107 and how serious such an outbreak might be. This scientific uncertainty or paucity of precise knowledge ignites some social uncertainty and may prompt moral inertia in relation to the level of preparedness and the ability to mitigate the various possible ramifications of an outbreak, when it does occur. This backdrop of uncertainty creates at least three possibilities: over-­preparedness, ample preparedness, and under-preparedness. Assuming the level of risks remains constant, over-preparing for a pandemic will undoubtedly involve the committing and expenditure of more human and material resources to an outbreak. This will create a sense of waste (to decision and policy makers) after the incident and may affect the resources that will be committed to future outbreaks. The right amount of preparation will help curtail an outbreak while under-preparedness will barely help curtail an outbreak. However, if the level of risk increases, over-preparing may help curtail a pandemic whereas what was hitherto ample preparedness as well as what was hitherto not enough will enable the full range of the effects of a pandemic outbreak to be felt.  James A Marcum, An Introductory Philosophy of Medicine: Humanizing Modern Medicine, vol. 99 (Springer Science & Business Media, 2008). P. 157. 103  Theresa MacPhail, “A Predictable Unpredictability: The 2009 H1n1 Pandemic and the Concept of Strategic Uncertainty within Global Public Health,” Behemoth: A Journal on Civilisation 3, no. 3 (2010). P. 57. 104  Borse et al. P.443. 105  Martin I Meltzer, Nancy J Cox, and Keiji Fukuda, “The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention,” ibid.5, no. 5 (1999). P. 669. 106  Kuby. P. 392. 107  Murray et al. Pp. 221–2215. 102

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In other words, the changing nature of the virus demands a constant readjustment of the level of preparedness without a reliable frame of reference with the attendant possibility of some inevitable social harm. Not surprisingly, scholars like Peter Doshi argue that there is a need for evidence-based ways to address hypothetical scenarios of non-zero probability such as the notion that novel influenza pathogens acquire increased virulence during successive “waves” of infection.108 The scientific uncertainty associated with health disasters such as pandemic influenza may, however, tempt government officials to attempt some form of a cover-up, hence, raising trust issues. For instance, during the 1911 cholera outbreak in Naples, Italian officials paid newspapers and reporters not to report the outbreak. Chinese officials tried to keep the 2003 SARS outbreak a secret. Saudi officials, likewise, tried to silence the virologist who discovered the coronavirus in 2012 and ultimately forced him to resign from his position.109 Incidents like these have the tendency to dissuade social cooperation during public health emergencies like influenza and have the potential to weaken the overall success of public health interventions. On the other hand, there is a lot of uncertainty surrounding the therapeutic and non-therapeutic approaches adopted vis-à-vis pandemic influenza. It is uncertain, for example, if neuraminidase antiviral drugs really cut down mortality when implemented as the first line of defense.110 This may create some sense of hesitation in relation to using them. Secondly, it is uncertain who and who will not develop some of the associated side-effects. These factors, at a pragmatic level and for less rich nations, may dis-incentivize prioritization of funds for antiviral drugs. Uncertainty likewise plays out in the context of influenza vaccines. For instance, only a small amount of any vaccine can be stockpiled111 because the scientific and public health community can hardly be sure of the efficacy of any given vaccine prior to an outbreak. This is due to possible vaccine failure which will make a new outbreak not amenable to the biological effects of hitherto effective vaccines. Hence, vaccines are generally not produced until the new virus strain causing a pandemic is isolated.112 Also, there is uncertainty over who will be at highest risk of infection and complications.113 This creates a dilemma of some sorts with the potential that a class of the people who need vaccines may not get enough, while another class of people who will benefit less from vaccination gets too much. Another kind of uncertainty is linked with possible side-effects of vaccines. While some incidence of narcolepsy was reported in children after the use of ASO3-adjuvanted H1N1 influenza vaccine in Scandinavian countries,114 and there have been anecdotal reports of fetal deaths

 Doshi. P. 535.  Shah. Pp. 108–111. 110  Muthuri et al. Pp. 395–401. 111  HHS, “Hhs Pandemic Influenza Plan.” P. S5–6. 112  Kotalik. P. 427. 113  Emanuel and Wertheimer. P. 854. 114  Dauvilliers et al. Pp. 2486–2490. 108 109

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occurring shortly after the 2009 vaccination115; it is not clear if these safety issues are one-off events or may recur for other pandemic vaccines. Responding to influenza vaccine safety signals during a pandemic constitutes a scientific and public health policy issue since decision-makers must balance the immediate consequences of disease against uncertain risks.116 One of the consequences of the therapeutic uncertainties associated with pandemic influenza is the validity of administering potentially ineffective antiviral drugs with side-effects or vaccines that may cause harm to people. Another is the validity of withholding such drugs and vaccines because it may not be useful for some class of people, or because some people may experience certain degrees of side-effects. These issues raise concerns about human rights and whether or not they may be violated through these courses of actions, or by any other course of action associated with handling a pandemic influenza outbreak.

3.3.2  Human Rights The 1948 Universal Declaration of Human Rights and the 1966 International Covenant on Economic, Social and Cultural Rights documents enunciate the rights of “everyone to the enjoyment of the highest attainable standard of physical and mental health”.117 Hence, it is perhaps more than ever taken for granted that there are rights-related obligations that society, as well as healthcare providers, owe patients118 as well as those that may potentially fall sick. Since everybody is theoretically a potential victim of ill-health depending on time, placek and  social or physiological circumstances, individuals can appeal to a rights-based rhetoric to garner positive action from government and healthcare professionals in relation their health. The morality of such a claim stems partly from governments’ moral obligation to their citizens and partly from the fiduciary obligations that health professionals have towards fostering the health of patients (and potential patients) in a fashion that preserves their rights as human beings. Many moral concerns related to human rights come to the fore in the context of pandemic influenza outbreaks. The first is related to the limited number of vaccines that can be available for each outbreak (due to reasons outlined in the preceding section) and the best sharing formula to use. Whatever adopted formula in a given place or situation, some people who may benefit could be excluded. For instance,  Håberg et al. P. 333.  JC Maro et al., “Responding to Vaccine Safety Signals During Pandemic Influenza: A Modeling Study,” PLoS ONE 9, no. 12 (2014). Pp. 1–2. 117  Tracy Slagle et al., “Lessons from Africa: Developing a Global Human Rights Framework for Tuberculosis Control and Prevention,” BMC International Health and Human Rights 14, no. 34 (2014). P. 2. 118  Jonathan M Mann, “Medicine and Public Health, Ethics and Human Rights,” Hastings Center Report 27, no. 3 (1997). Pp. 6–9. 115 116

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pandemic influenza often generates a high number of sick people over a large geographic area who will need care at the same time. While this “need” begins at the local plane, it may evolve to be regional and/or global depending on the extent and severity of an outbreak. Hence, the human and material resources of healthcare will be rapidly depleted and overwhelmed.119 Since the needs of everyone cannot be met under such a scenario, there is usually some need to ration available resources. In fact, vaccines are hardly enough during pandemics, and rationing is generally considered as the ethical option.120 Yet, the contemporary interconnection between health, the right to health and human rights121 implies that withholding vaccines from some people who might be potential victims of a pandemic outbreak may be a human rights violation. On the other hand, administering antiviral drugs to non-vaccinated at-risk people helps reduce the severity of illness.122 During disaster scenarios, the goal remains saving lives but a pandemic scenario in which 25–50% of the population can fall sick within a very short time123 often demands some type of prioritization of resources. This is partly because keeping some sets of people alive, especially health workers will ultimately help society keep more people alive during a public health disaster. For instance, the traditional view is that prioritizing the vaccination of front-line healthcare workers can help reduce staff absenteeism as well as help prevent them from becoming vectors of viral infection. This is often justified by the logic that a PHD situation such as pandemic influenza often makes health professionals work outside their normal scope of practice, put in extra hours, cover for ill workers, accept great risks124 as well as incur other situational unexpected responsibilities and supererogatory duties. Although adults aged 65 years or older, pregnant women, and people of any age with underlying medical conditions are at high risk of pandemic influenza and its associated complications, the notion that death is more tragic in children and young adults as opposed to elderly persons, perhaps, because younger persons have not had the chance to live and develop through all stages of life and accomplish their dreams has made some ethicists argue for the prioritization of vaccines to younger people.125 Yet, if persons are inherently born with human rights and do not have to earn rights, such an idea tends to revamp the rights to health of some class of people at the expense of others. Indeed, notions such as this echo the idea that mainstream bioethical issues tend to be far-flung from the values of ordinary people and often  Kotalik. P. 424.  Vawter, Gervais, and Garrett. P. 6535. 121  Lisa Forman and Stephanix Nixon, “Human Rights Discourse within Global Health Ethics,” in An Introduction to Global Health Ethics, ed. Andrew D Pinto and Ross E.G Upshur (London: Routledge, 2013). P. 54. 122  Kotalik. P. 428. 123  David M Morens and Anthony S Fauci, “The 1918 Influenza Pandemic: Insights for the twentyfirst Century,” Journal of Infectious Diseases 195, no. 7 (2007). P. 1026. 124  Kotalik. P. 429. 125  Emanuel and Wertheimer. P. 855. 119 120

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irrelevant to the decisions they experience in their encounter with healthcare.126 In other words, an empirical approach which takes into consideration what people would want when faced with this thorny dilemma rather than an armchair speculation ought to influence the criteria for rationing vaccines. One of the non-therapeutic responses to pandemic influenza is the isolation and quarantine of infected patients.127 Whereas a visibly infected and sick person may have just a little objection to quarantine (after all, such a state mirrors the ambulatory limitations that most disease states naturally impose on people), it is often problematic for other categories of people. In this vein, isolation and quarantine raise concerns about the acceptability of confining people and preventing them from engaging in some of the social activities they otherwise would have loved. Whereas restriction of movement is ethically problematic,128 it is equally problematic to allow person A who may be infectious to roam free, thereby potentially infecting other persons who may also (without the imposition of some restriction) further spread infection. It is clear from the foregoing that pandemic influenza challenges and raises some moral concerns regarding the rights of people,129 preempting the need to balance them against what is the optimal good of the society. But embedded in these reservations is the demand for autonomous living, broadly conceived. Whereas this has been associated with western contexts, concerns about rights violations in relation to quarantine measures are not confined to the West. Sambala and Manderson recently commented about how Ghanaians and Malawians perceive public health interventions including quarantine as being intrusive.130 But this perception seems to run contrary to the cultural norm of most African people. In relation to this strand of thought, Shah notes that during epidemics, the traditional attitude of the Acholi people of Uganda involves working together to isolate the sick, mark homes of the sick with long elephant grass, warn outsiders not to visit affected villages, and refraining from potentially infection-transmitting practices including sexual intercourse.131 This suggests at least two things. One, in traditional African societies there may be some fairly general consensus about the need to adopt mutual and social cooperation for the overall benefits of the society in engaging collective threats. Secondly, it shows how the global village has increasingly penetrated and fragmented societies that were once non-individualized in orientation. But it seems that societies have been affected differently by the globalizing current of individualistic logic. For instance, Macphail remarks that  Larry R Churchill, “Are We Professionals? A Critical Look at the Social Role of Bioethicists,” Daedalus 128, no. 4 (1999). Pp. 253–257. 127  Cauchemez et al. P. 2627. 128  Aledort et al. P. 6. 129  Adrienne Torda, “Ethical Issues in Pandemic Planning,” Medical Journal of Australia 185, no. 10 (2006). P. S73. 130  Evanson Z Sambala and Lenore Manderson, “Ethical Problems in Planning for and Responses to Pandemic Influenza in Ghana and Malawi,” Ethics & Behavior just-accepted (2016). https://doi. org/10.1080/10508422.2016.1274993 131  Shah. P. 98. 126

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whereas Europeans and Americans generally view quarantine during influenza as almost worthless, Asians such as Hong Kongers, expect it as the norm during health disasters, and demand it.132 This probably shows how strong an influence the communal-­oriented Confucian idea still exerts in that country. In the context of pandemic influenza outbreaks, over-emphasizing individualism and the attendant call for autonomy (even when such does not cohere with social interests) overlooks communal values and the relational nature of social interactions.133 It likewise ignores the complex nature of pandemic influenza and how it plays out in an equally complex web of this global age and how people more or less are susceptible to the harms of public health disasters regardless of their proximity. It has also contributed, as Lachman argues, to a reduction in the fear of infectious diseases by increasing the emphasis on patients’ rights, giving rise to a dangerous complacency that may do great damage to the goals of public health.134 One of the ways to address the attendant dangers inherent in this almost pervasive trend is recognizing the vulnerabilities even to far-flung harm that is fast becoming an integral aspect of contemporary life.

3.3.3  Vulnerability Vulnerability—in different forms and facets—plays out in pandemic influenza, as in other public health disasters. Traditionally, belonging to the human community or occupying specific facets of life constitutes sources of vulnerability. But the state of being susceptible to harm by the actions and activities of other people or by parts of nature such as viral organisms is also a potential source. In addition, the state of vulnerability may ensue from a range of social, economic, and political conditions.135 In the context of pandemic influenza, the naturalistic, socioeconomic, epistemic, political, and biological dimensions of vulnerability arise. On the one hand, humans located in pandemic-prone cities or countries and other human beings linked to the global community by technological means of transportation (such as air travel) or non-technological ones (such as migrating birds) are generally vulnerable to influenza outbreaks. The likelihood of a novel strain of influenza outbreak occurring in a country such as China (for instance, Jiangcun in Guangzhou) where large numbers of people, birds, and swine mingle freely in certain markets is very high136; hence, making the local population and consequently the people of such a nation more vulnerable.  MacPhail, The Viral Network: A Pathography of the H1n1 Influenza Pandemic. Pp. 95–95.  Bennett and Carney. P. 7. 134  Peter J Lachmann, “Public Health and Bioethics,” The Journal of Medicine and Philosophy 23, no. 3 (1998). P. 298. 135  Henk ten Have, “Vulnerability as the Antidote to Neoliberalism in Bioethics,” Revista Redbioética/UNESCO 1, no. 9 (2014). P. 88. 136  Shah. Pp. 87–94. 132 133

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On the other hand, the strength of health systems reflected by availability of experts, economic and technical resources will vary the extent of pandemic-related vulnerability which different societies will experience. In addition, it is widely believed within the scientific community that influenza pandemics can hardly be halted, but they can be delayed.137 Therefore, the “ignorance gap” that occurs during pandemic influenza outbreaks creates a context in which some of the preparatory strategies will inevitably fail (due to no fault of anyone), thereby leaving some people less protected. In relation to the socioeconomic dynamics, it is estimated that most influenza pandemic-associated deaths occur in poor countries or in societies with scarce health resources which are already stretched by extant health priorities and challenges.138 Farmer and Campos underscore the need for bioethics to engage the growing problem posed by the gap between rich and poor nations, and how such a course of action reflects social justice.139 Politically, communist nations such as China present unique dimensions to the vulnerabilities of pandemic flu as they may control critical information traffic and access to patients, thereby deepening the crisis situation,140 or misrepresenting it, and thereby subjecting the rest of the connected world to avoidable risks. The biological make-up of human beings both make them vulnerable to becoming infected with influenza virus as well as make them good vectors of dissemination. For instance, the virus has a surface molecule that enables it to attach firmly to cells in the  mucous membranes of the respiratory tract, preventing it from being swept out by the ciliated epithelial cells.141 But breathing is a normal aspect of human existence, and the oxygenation of the human blood and other oxygen-­ dependent biochemical processes of the human body rely on it. Yet, the combination of these factors facilitates the ready transfer and exchange of the influenza viruses amongst people, especially when they are in close proximity.142 The foregoing shows how susceptibility and vulnerability to infection during pandemic influenza reflect a combination of factors.143 How these combine in specific localities and regions will, therefore, determine the extent of an outbreak. It is also clear that some amount of control can be exerted on minimizing some of these factors. For instance, the use of face mask (to limit infection acquisition and spread), transparency (to combat political bottlenecks), and monetary aid (to help poor nations) will exert some preventive effects on infection transmission, hence, limiting the overall burdens and severity of an outbreak. Since everyone may not receive the same level of healthcare for various reasons during a public health disaster (depending on time, place, and category of persons such as adults, the aged, or children), questions about justice and what is just in the context of a pandemic outbreak arise.  MacPhail, The Viral Network: A Pathography of the H1n1 Influenza Pandemic. Pp. 23–24.  Murray et al. P. 2211. 139  Paul Farmer and Nicole Gastineau Campos, “Rethinking Medical Ethics: A View from Below,” Developing World Bioethics 4, no. 1 (2004). P. 40. 140  MacPhail, The Viral Network: A Pathography of the H1n1 Influenza Pandemic. Pp. 91–93. 141  Kuby. P. 6. 142  Shah. P.86. 143  Cauchemez et al. P. 2625. 137 138

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3.3.4  Local and Global Justice Pandemic outbreaks exacerbate extant inequalities to the extent that certain groups of people face disproportionate risks and impacts of disease.144 This obviously seems unfair, especially if pre-pandemic actions that would have ameliorated the situation were not done. For instance, school closure in certain districts may interrupt educational opportunities or growth of some children, and business closures will lead to financial losses. Since such restrictions may not apply to every region of the nation, these measures may seem unfair to those affected, knowing that other children continue to have access to education, and other people continue to run their businesses. If this characterizes the feelings of some of the people affected by these restrictions, then it is reasonable that some form of compensation may be required to foster optimal compliance to the public health measures that are to implemented. Indeed, bioethicists like Michael Selgelid and Søren Holm make explicit arguments for some form of compensation to people who suffer financial and other losses due to compliance with public health directives issued during influenza outbreaks.145 Although compensation may not be a problem in more affluent nations where other educational stimulus and business tax breaks may help alleviate any temporary pandemic-­associated losses, poorer countries will find it hard to compensate people for any such losses. Rationing also raises issues about justice in terms of how vaccines (if available) will be shared during an influenza pandemic. Given the limited amount of supply available globally, and locally in a developed economy like the US, distributing the limited supply will require determining priority groups.146 For people not to feel a sense of being left out during local vaccine administration, it is better to have debated and developed a preparedness plan with the consensus of the local populace. Resolving vaccine distribution on a global scale will, however, involve very complex sets of factors. For instance, will countries who supply most of the technical and financial resources to develop such an influenza vaccine demand that the needs of her people be prioritized as opposed to the needs of nations that have ­contributed little or not at all? Even if such a question were not explicitly raised, will it be fair to distribute vaccines equally if every country or affected region has not made significantly even contributions? These are unsettling questions that are bereft of simple answers. Some ideas stand out when all the ethical issues generated by pandemic influenza are closely examined. Four of these ideas demand attention. The first is the need to help people. Secondly, the nexus of relationship that exists between people  Henk ten Have, Vulnerability: Challenging Bioethics (Routledge, 2016). Pp. 70–71.  Michael J Selgelid, “Promoting Justice, Trust, Compliance, and Health: The Case for Compensation,” The American Journal of Bioethics 9, no. 11 (2009). Pp. 22–23; T Ly, MJ Selgelid, and I Kerridge, “Pandemic and Public Health Controls: Toward an Equitable Compensation System,” Journal of Law and Medicine 15, no. 2 (2007). Pp. 296–300; Søren Holm, “Should Persons Detained During Public Health Crises Receive Compensation?,” Journal of Bioethical Inquiry 6, no. 2 (2009). Pp. 197–201. 146  Emanuel and Wertheimer. P. 854. 144 145

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and the influenza virus and the changing nature of what is known as well as what can be done to help people under such constraints will limit the help some people may ultimately get during an outbreak. Thirdly, the threat of an outbreak presents different risks which vary by context, time, and place. Lastly, regardless of the different situational dynamics that pandemic influenza presents locally, regionally, and globally; its threat will affect everyone to varying degrees. Since nations theoretically care about their people, it is only reasonable that a people-centered approach offers a useful way to engage the moral quandaries elicited by pandemic influenza outbreaks.

3.4  A  People-Centric Approach to Pandemic Influenza Outbreaks The subject matter of diseases is human populations.147 In fact, the preoccupation of medicine remains the amelioration of the distress of people technically referred to as patients. If a people-centric approach constitutes a viable way of engaging the ethical issues embedded in pandemic influenza scenarios, one way to glean a sufficiently nuanced angle on such an approach will involve turning to ethical lenses that are, in principle, people-oriented. Two principal examples of such ethical prisms are communitarianism and ethics of care. This section briefly explains each of these moral lenses, and how each may help engage the ethical issues generated by pandemic influenza.

3.4.1  Communitarianism: Conceptual Elaboration The communitarian moral lens adopts a people or community-centric perspective to moral issues. Applied to public health, it offers a population-centered approach which best reflects the philosophy of public health in terms of its commitment to doing the most for the greatest number of people in a society or within a social context. Bioethicists like Stephen Holland regard the communitarian lens as useful since it aims at realizing collective interests. This same idea offers a strong justificatory argument for adopting it in relation to public health interventions.148 Communitarianism pays attention to the social sphere, institutions, and inter-­ relationships in relation to moral judgments that will inform public health policy and practice. Its ethos provides an alternative to the dominant atomistic lens of individualism which operates via the logic of self-protection149 and the unbridled

 MacPhail, The Viral Network: A Pathography of the H1n1 Influenza Pandemic. P. 196.  Stephen Holland, Public Health Ethics (Polity Press, 2007). Pp. 51–55. 149  Michael Yudell, “Public Health Ethics: An Update on an Emerging Field,” in The Penn Center Guide to Bioethics, ed. V. Ravitsk, A. Fiester, and Arthur L. Caplan (New York: Springer, 2009). P. 563. 147 148

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pursuance of self-interests. It holds that the social nature of life and institutional and social relationships should inform moral thinking, and by implication, the process of determining appropriate courses of actions should lie within the social space.150 To be sure, the communitarian notion appeals to the historical traditions of communities or people who share customs, ideals, and values151; and thus prioritizes common threads of thought and practices within specific communities as a strong moral basis for justifying decisions that pit different individual and social interests against one another. There is an important phenomenological aspect of communitarianism. For people raised within the traditional family structure—father, mother, children, and relatives—the family unit constitutes a micro-community which generally socializes the child into a community-oriented way of reasoning. While the strength of such an orientation is expressed in different measures by different individuals, it also provides the cognitive platform for balancing and pursuing personal interests in a feedback loop with the collective interests of other family members. Yet, the ultimate measure of what level of community-oriented reasoning an individual retains in adult life will depend on their education, social experiences, whatever meanings they draw from these, and how these parameters are brought to bear in the context of specific decisions and choices. This reality partly explains the multiple versions and interpretations of communitarianism, which tends to mar its conceptual and theoretical coherence.152 It also partly explains why community values are not generally shared by all.153 Communitarians advance three different types of claims: descriptive claims which stress the social nature of people; normative claims which celebrate the value of community and solidarity, and a meta-ethical claim which emphasizes the idea that political principles should mirror “shared understandings’.154 Two of these dynamics—the normative as well as the metaethical—are important in relation to engaging the ethical issues elicited by pandemic influenza. The significance of the meta-ethical dimension of communitarianism is its capacity to help drive and ground public health policies. This is especially so considering the reality that community and living together in today’s fragmented and individualistic world is generally seen ever less as a necessity and assumes the dimensions of a choice  as the default state.155 Hence, these two facets will be examined in relation to their possible  Holland, Public Health Ethics. Pp. 42–43.  Ronald Bayer et  al., Public Health Ethics: Theory, Policy and Practice (Oxford: Oxford University Press, 2007). Pp. 18–19. 152  Holland, Public Health Ethics. Pp. 44–50. 153  Will Kymlicka, “Liberalism and Communitarianism,” Canadian Journal of Philosophy 18, no. 2 (1988). P. 200. 154  Simon Caney, “Liberalism and Communitarianism: A Misconceived Debate,” Political Studies 40, no. 2 (1992). Pp. 273–274. 155  Alberto Pirni, “Rethinking Community in the Aftermath of Communitarianism: Outlines of a Phenomenological Path,” Ethic: an International Journal for Moral Philosophy 12, no. 1 (2013). P. 12. 150 151

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insights and pragmatic importance vis-à-vis engaging the quandaries associated with influenza outbreaks. 3.4.1.1  Communitarianism vis-à-vis the Quandaries of Pandemic Influenza Healthcare focuses on helping sick people regain optimal health and healthy people maintain good health. Pellegrino and Thomasma remark that medicine seeks to foster social flourishing as well as the medical good of society.156 If this is true, and if the end of the communitarian moral lens is to ensure the survival of the society by promoting the interests of people over the selfish interests of individuals, then how can this approach help engage issues of uncertainty, vulnerability, human rights and justice? This can come through appropriate educational policies and approaches carried out prior to and during influenza outbreaks. It is not known when and in whom influenza therapeutic interventions such as antiviral drugs and vaccines may cause side-effects. It is also not known when an outbreak will occur or the attendant magnitude. Since public health disasters are classless in terms of who will and who may not be affected, the scenario of uncertainty affects every segment of people in the local communities and nation. Hence, health workers, government officials, the rich, the poor, the educated and illiterates and other possible stratification of society are potential victims. A communitarian ethos is useful in at least two ways in relation to dealing with the uncertainties associated with pandemic influenza. Generally, it can—with the right pre-disaster public education—help ensure that people understand the unavoidable scientific and knowledge-related gaps in preparedness policies and specific plans put together to engage a specific outbreak. This will help avoid or minimize blame, since scapegoating during disease outbreaks causes different shades of disruption and target important actors including health workers.157 In fact, the better educated the public is about the challenges of stockpiling vaccines, the more cooperative they will likely be to the vaccine-supply challenges that arise during an outbreak. A communitarian ethos may also help engage the real and possible harms that may ensue due to the therapeutic uncertainties associated with pandemic influenza. These harms arise from the uncertain nature of what is knowable about a pandemic virus before it strikes as well as the biological limits of the therapeutic arsenals often produced within a very narrow time window. This is also generally tied to the reality that new health interventions including drugs and vaccines come with the possibility of some adverse events, which may be linked to the chemical/biological/physical components of the product, to genetic susceptibilities in certain individuals, or to

 Edmund D Pellegrino; David C. Thomasma, “The Good of Patients and the Good of Society: Striking a Moral Balance,” in Public Health Policy and Ethics, ed. Michael Boylan (Springer, 2006). Pp. 17–25. 157  Shah. P. 125. 156

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environmental triggers.158 Keeping the public aware of this fact before and during an outbreak as well as emphasizing that accepting these risks (though uncomfortable at the individual plane) will serve to ensure the society overcome a pandemic should help garner some level of support critical to ensure proper compliance. Since people are born with inherent human rights and do not have to earn them, it is hard to justify trumping the rights of some for the sake of public health. This is especially so if the people whose rights may be inhibited or violated do not consent to the process. To avert this, a discursive approach  involving inclusive  deliberations is essential. In this vein, the communitarian lens can help foster dialogue as well as call for the need to reward people for the sacrifices they may or will bear on behalf of the community and the society. For instance, guaranteeing that some compensation will be paid for financial losses incurred through workplace closure as well as apt public education about the nature, purposes, and conditions of quarantine facilities will help convince people that such temporary rights-related inconveniences are for the benefits of the overall society. In relation to vulnerability and justice, the communitarian lens can help clarify the different kinds of social, biological, and natural vulnerabilities that face different people in different contexts. For example, it can offer a way of making the important distinction between general vulnerability that people will experience as human beings, vulnerability based on age, and occupational vulnerability seen in health professionals. Based on these distinctions, it can help underscore how context-­specific cooperation will help ensure the overall success of the countermeasures adopted to engage a given pandemic. Critical to this, however, is the moral currency of trust. Trust shapes how the public evaluates risks and benefits. It also influences the acceptance of prescribed public measures to mitigate present or perceived risks.159 Effective risk and crisis communication depend on public trust in the government during a pandemic. As such, a higher level of trust will influence a more positive level of social compliance. van der Weerd and colleagues corroborated this in their empirical study of the 2009 pandemic in the Netherlands.160 In addition to trust, transparency in terms of how priorities will be made in terms of the allocation of vaccines as well as antiviral agents, and decisions pertaining to school and/or workplace closures is important. Even in western climes, public health experts have sometimes pointed out the paucity of transparency in ethical reasoning and the scanty explicit ethical justification for pandemic-related policies.161 Obviously, an atmosphere of trust and transparency will be conducive to  S Sohail Ahmed et al., “Narcolepsy, 2009 a (H1n1) Pandemic Influenza, and Pandemic Influenza Vaccinations: What Is Known and Unknown About the Neurological Disorder, the Role for Autoimmunity, and Vaccine Adjuvants,” Journal of Autoimmunity 50 (2014). P. 2. 159  Michael Siegrist, Timothy C Earle, and Heinz Gutscher, “Test of a Trust and Confidence Model in the Applied Context of Electromagnetic Field (Emf) Risks,” Risk Analysis 23, no. 4 (2003). Pp. 705–708. 160  Willemien van der Weerd et al., “Monitoring the Level of Government Trust, Risk Perception and Intention of the General Public to Adopt Protective Measures During the Influenza a (H1n1) Pandemic in the Netherlands,” BMC Public Health 11, no. 1 (2011). Pp. 575–579. 161  JC Thomas, N Dasgupta, and A Martinot, “Ethics in a Pandemic: A Survey of the State Pandemic Influenza Plans,” American Journal of Public Health 97, no. S1 (2007). P. S29. 158

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discussing and addressing issues related to local justice. This is especially relevant in relation to less wealthy nations or countries with weak institutions. For instance, it will be hard to garner cooperation in hitherto abandoned communities by appealing to communitarian ethos without addressing extant disparities in the social fabric as well as the healthcare system. If human beings are located in particular communities but are willy-nilly part of a global community,162 how well the vulnerability and justice-related issues are locally addressed will influence the extent of their regional and global dynamics. This echoes the notion that badly managed local issues associated with pandemic influenza will pose more challenges and burdens at the regional and global levels. Since every nation lacks an equal capacity to deal with the local burdens of pandemic influenza, it is necessary for wealthier nations to rally around poorer ones. Indeed, the transcontinental nature of health disasters including pandemic influenza and SARS underscores the urgent need to strengthen how the global community deals with emerging infectious diseases, and how novel visions of global solidarity and cooperation will be key in such an endeavor.163 This constitutes a preventive stance and falls well within the traditional agenda of public health. This approach is also a reasonable economic and health security choice as it will statistically cut down the possibility of global and transnational infection dissemination. While the communitarian ethos as argued above offers some insights into how to flexibly engage the moral dilemmas generated by influenza outbreaks, its application in non-community-oriented contexts potentially raises some difficulty at the institutional and individual planes. Such possible difficulties, however, call for a global but locally nuanced moral framework. That theme, however, will be addressed in Chap. 6. For now, the rest of this chapter will explore another people-centric moral lens, care ethics, in relation to resolving the quandaries of pandemic influenza.

3.4.2  Ethics of Care: Conceptual Elaboration In addition to the communitarian lens, the ethics of care perspective (EOC) constitutes a people-centric method of attempting to resolve ethical issues. Whereas it sometimes arrives at the same conclusions reached by traditional bioethical approaches,164 employing it as a complimentary approach to the moral quandaries generated by pandemic influenza should yield additional nuances and insights vis-­ à-­vis resolving the  associated moral concerns. Care ethics emphasizes varying degrees of care within relational contexts ranging from the personal sphere to the realm of moral strangers. Hence, it is an other and people-centric moral lens. It has  Henk ten Have, Global Bioethics: An Introduction (Routledge, 2016). P. 113.  Peter A Singer et al., “Ethics and Sars: Lessons from Toronto,” British Medical Journal 327, no. 7427 (2003). Pp. 1342–1343. 164  Edwards, “Is there a Distinctive Care Ethics?” P. 185. 162 163

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been applied to diverse relational contexts including everyday lives, professional practices, social and public policies, as well as international relations.165 For scholars like Steven Edwards, ethics of care uses a distinct ontological commitment to realize its outcomes as well as justify its stance.166 It is an attempt to re-conceptualize and renegotiate the moral landscape in order to give room for a plurality of values.167 Some have argued that the removal of friendship with its altruistic emotional sequelae and the subversion of virtue ethics from the sphere of morality were some key factors that warranted the moral change which birthed the ethics of care framework.168 While EOC is also linked with gender-based morality which undergirded campaigns for equal employment opportunities between the sexes, legal rights, reforms of family life and sexual standards, and better education169; scholars like Noddings have pointed out that it is broader and deeper than feminist ethics.170 To be sure, one of its major impetus is the call for the expression of higher capabilities.171 Care ethics also encapsulates a spectrum of ideas. For Kittay, care constitutes an “achievement term” such that caring occurs only when specific acts of care have been carried out.172 In this vein, intentionality would not qualify as part of the baggage of care rhetoric. This obviously has some pragmatic appeal. Most people, for instance, would only appreciate care if it helps contribute towards relieving their current distress. Yet, caring may also constitute a general attitude and an orientation which may provide appropriate background conditions for shaping responses to others’ needs and states of distresses. Also, one may care but situational constraints may limit how a caring impulse may translate into pragmatic ends. Therefore, that someone simply “lacked opportunity” to show care as Apostle Paul writes in his epistle to the Philippians does not necessarily indicate the absence of care.173 Hence, caring cannot be reduced only to materialistic terms. One way to distinguish the general caring orientation from specific acts of care is to refer to each as “caring about” and “caring for” respectively.174

 Marian Barnes et  al., eds., Ethics of Care: Critical Advances in International Perspective (Bristol: Policy Press, 2015). P. 4. 166  Edwards, “Is there a Distinctive Care Ethics?” P. 190. 167  Virginia Held, The Ethics of Care: Personal, Political, and Global (Oxford University Press, 2006). Pp. 1, 23–25 168  Peter Ikechukwu Osuji, African Traditional Medicine: Autonomy and Informed Consent (Springer, 2014). Pp. 55–58. 169  Marlene LeGates, In Their Time: A History of Feminism in Western Society (Routledge, 2012). P. 237. 170  Nel Noddings, “Care Ethics and “Caring” Organizations,” in Care Ethics and Political Theory, ed. Maurice Hamington and Dan Engster (Oxford: Oxford University Press, 2015). P. 72. 171  Tronto, Moral Boundaries Pp. 61–63. 172  Steven D Edwards, “Is There a Distinctive Care Ethics?,” Nursing Ethics 18, no. 2 (2011). P. 190. 173  Holy Bible, King James Bible (Project Gutenberg, 1996). Philippians 1:10. 174  Noddings. P. 74. 165

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Care ethics locates morality within the ambiance of family, friends, and colleagues, and ultimately towards the public sphere.175 It rejects the independent and atomistic notion of the self and champions an inter-dependent and inter-related view.176 This approach grants EOC a psychological gestalt to which people brought up in caring relationships, at least in the early phases of their lives, can readily identify with. It thus partly appeals to Kohlberg’s theory of moral development. Here, the emphasis is put on the foundational roles of trust and its place in fostering a deepened sense of reciprocity within a social context of inequality.177 Not surprisingly, some ethicists describe caring as the primary virtue which offers a general account of right versus wrong actions as well as political justice.178 Whereas the informal social contract idea underlies inter-personal and state-­ individual relationships,179 the care ethical lens may be applied to the personal sphere as well as social institutions180 due to its multiple ways of situating relationality.181 Indeed, EOC focuses on attentiveness and sensitivity to the needs of others182 and offers a moral compass for teasing out delicate boundaries between obligation-based ethics and responsibility-based ethics. As such, it seeks to transcend the depersonalized realm of asking “what obligations do I have to Mr. X” to the humane realm of asking “how can I help Mr. X” in scenarios of moral crises.183 Since caring embodies an activity, a set of activities or a labor of care from one person to the other, it presupposes that the capacity for receiving care184 will be present in the recipient(s) of care. Public health disasters including pandemic influenza with their myriad of ethical and pragmatic challenges create a spectrum of needs and contextual dependencies which some people will have to meet, directly and indirectly. It thus creates different types of carer versus cared-for relationships between and amongst victims, at-­ risk people, health workers, and government officials. Since it is a foundational nexus like these that underlie the caring ethic, it will be insightful to examine how the ethics of care moral lens may help resolve the moral dilemmas elicited during pandemic influenza outbreaks.  Osuji. P. 58.  Edwards. P. 187 177  Joan C Tronto, Moral Boundaries: A Political Argument for an Ethic of Care (Routledge, 1993). Pp. 63–72. 178  Held. P. 19. 179  Robert M Tenery JR, “The Challenge of Universal Access to Health Care with Limited Resources,” in The American Medical Ethics Revolution: How the Ama’s Code of Ethics Has Transformed Physicians’ Relationships to Patients, Professionals, and Society, ed. Robert B Baker, et al. (1999). P. 253. 180  Held. Pp. 10, 15, 17. 181  Marian Barnes, “Beyond the Dyad: Exploring the Multidimensionality of Care,” in Ethics of Care: Critical Advances in International Perspective, ed. Marian Barnes, et  al. (Bristol: Polity Press, 2015). Pp. 31–32. 182  Held, Ethics of Care 37–39 183  Edwards. P. 188 184  Osuji. P. 59. 175 176

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3.4.2.1  Ethics of Care vis-à-vis the Quandaries of Pandemic Influenza Outbreaks Whereas Tirima recently argued that ethics of care is irrelevant to addressing the moral imperatives in disaster scenarios because it only builds off on relationships and, therefore, requires some proximity between the caring moral agent and the cared-for victim,185 such a stance is flawed for at least three important reasons. Firstly, care ethics can, through relevant public policy,186 positively influence how victims of disasters are cared for. Secondly, contexts of duty exist between some of the players and victims of disasters which form the basis of a relationship of caring. For instance, healthcare professionals incur fiduciary duties to at-risk people, victims of a public health disaster as well as the general populace that may potentially be infected and infect others. Thirdly, if the care ethical prism emphasizes how individuals may offer help “in scenarios of moral crises,187 then it should be relevant in health scenarios where different kinds of conflicting moral emergencies occur. The application of care ethics to specific disaster contexts such as influenza outbreaks, however, requires elaboration. Specifically, this needs some explication with reference to issues of uncertainty, vulnerability, human rights and justice. Whereas the dilemma of uncertainty that arises during pandemic influenza affects everyone, it will affect different sets of people differently. For instance, the biological uncertainties associated with an influenza outbreak are not known to the same extent by public health experts, health workers, the literate, and illiterate members of the society. Caring about the potential practical consequences that may result from the attendant “ignorance” gap should, therefore, involve sharing as much useful information as possible between and amongst the different rungs of people. The relational context, in this regard, may be situated and realized through professional associations, institutional contexts, public announcements through media outlets and patient-­ health professional interactions. Kunin et al. recently reported on how primary care physicians helped pass on important pandemic-related information to out-patients during the 2009 pandemic in Israel. This, they concluded, helped enhance the success of the national pre-pandemic preparedness plans.188 Indeed, during public health disasters, the speed at which information is needed by policymakers may be faster than is usually possible through traditional mechanisms of research

 Humphrey G Tirima, “Unprecedented Lead Poisoning Outbreak in Zamfara, Nigeria: A Multidisciplinary Humanitarian Response to an Environmental Public Health Disaster in a Resource Scarce Setting” (University of Idaho, 2014). Pp. 110–111. 186  Helena Olofsdotter Stensöta, “Public Ethics of Care—a General Public Ethics,” Ethics and Social Welfare 9, no. 2 (2015). Pp. 183–185. 187  Edwards. P. 188 188  Marina Kunin et  al., “Challenges of the Pandemic Response in Primary Care During PreVaccination Period: A Qualitative Study,” Israel Journal of Health Policy Research 4, no. 32 (2015). Pp. 1–5. 185

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dissemination. This scenario makes information sharing a norm; even possibly those provided by preliminary research findings.189 Humans instinctively show care to other humans in need. While this caring instinct has been socially modified and conditioned in some parts of the world where individualistic tendencies run rife, some communal-oriented cultures give room for a freer expression of the instinct of care. The instinct of care may, however, be counterproductive in the context of PHDs. For instance, during pandemic influenza, sick and dying patients remain active carriers of infection,190 as such, will infect susceptible friends and relations who feel obligated to show care in relation to helping them. In other words, “unbridled” caring may increase the vulnerabilities elicited during pandemic influenza. Yet, the care ethics moral lens may help modify and re-direct the caring impulse in a more socially useful way during a pandemic. The other-centric nature of the EOC lens implies that people should care not only about themselves but about others, perhaps, even moral strangers. How person A will care during a public health disaster will, however, differ from how B will choose to act in a manner that reflects care, depending on their levels of knowledge, resources available to them as well as their social and spatial location. In other words, how a healthcare worker will care professionally in the hospital context and supererogatorily in the non-hospital context will differ from how a lay member of the society can show care in a pandemic situation. However, appealing to the EOC may help facilitate the selflessness needed. If someone cares that their society survives an influenza outbreak, then they should be willing to play roles that will help bring about that goal. This will facilitate compliance with therapeutic measures such as vaccines and antiviral drugs as well as non-pharmaceutical measures such as contact tracing, quarantine, and workplace closure. Collective adherence to these measures will help cut down the susceptibility and vulnerability of individuals, groups of people, and the society to the impact of influenza outbreaks. By enabling the willingness of people to subject themselves to the public health restrictions required to contain pandemic influenza and accept the potential risks and side-effects associated with vaccines and antiviral agents, the EOC approach may indirectly eliminate or downplay the human rights-related quandaries engendered by pandemic influenza. Noddings has argued that attentiveness and responsiveness are exigent to rights, flowing from one person to the other.191 If this is true, then the EOC may help individuals adjust the emphasis they place on articulating their rights contextually during an influenza pandemic for the sake of the collective good. Finally, an appeal to the care ethical lens may help address the moral quandaries associated with local justice. Although some versions of care ethics hold the posi-

 NS Crowcroft, LC Rosella, and BN Pakes, “The Ethics of Sharing Preliminary Research Findings During Public Health Emergencies: A Case Study from the 2009 Influenza Pandemic,” Eurosurveillance 19, no. 24 (2014). Pp. 1–3. 190  Shah. P. 87. 191  Noddings. P. 72. 189

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tion that it is not possible to integrate and apply justice to care,192 such a limitation hardly applies to the context of a public health disaster such as pandemic influenza. For instance, the different conflicting priorities that arise during influenza outbreaks such as rationing of limited resources will be easier if some people are at least willing to forgo their interests for others. In non-familial carer and cared-for relationships involving at-risk government representatives and at-risk members of the society and familial relationships involving parents and children living in the same house, an appeal to a care ethical lens may help drive the moral sensitivity to the needs of others, enabling some vaccine-eligible persons (under the standard rationing criteria) to forgo their ration, preferring rather that other at-risk  people (for example, ordinary people and younger family members) have them. This kind of selflessness approximates some form of humanitarian act in that person A decides to overlook their interests for others “without expecting rewards”.193 However, because human beings naturally seek their own personal interests, there may be some difficulty in achieving this other-centric goal in as many people as possible in a public health disaster situation. This implies that the care ethical lens may have some limitations in relation to sufficiently engaging the ethical dilemmas raised by pandemic influenza in particular and other types of public health disasters, in general. That theme will, however, be addressed in Chap. 6.

3.5  Conclusion During disasters, there is the utilitarian goal of doing the most good for as many people as possible with minimal harm.194 A people-oriented moral lens, this chapter argues, may be apt in  accomplishing such an agenda. The chapter explored the strengths of the communitarian and care ethics moral lenses in relation to engaging the moral quandaries elicited during pandemic influenza outbreaks. Because it is difficult to engage pandemic outbreaks with little prior preparation,195 these moral lenses become important since they can help people develop an other-centric orientation and sensitivity to the needs of others. To systematically drive the importance of a people-centered approach to pandemic influenza, this chapter explicated the biological make-up of the influenza virus as well as the social and global features of the associated pandemic. This helped underscore the local, regional, and global seriousness of pandemic influenza as a distinct type of public health disaster. The chapter went on to show how an  Barnes et al. P. 5.  Laurel A Spielberg and Lisa V Adams, Africa: A Practical Guide for Global Health Workers (UPNE, 2011). Pp. 1–2. 194  Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna, “Evidence and Healthcare Needs During Disasters,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke (Netherlands: Springer, 2014). Pp. 100–101. 195  Vawter, Gervais, and Garrett. P. 6535. 192 193

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understanding of the social and biological dynamics of influenza has shaped the therapeutic and non-therapeutic approaches to engaging outbreaks. It also articulated some of the attendant limitations of pandemic influenza countermeasures including vaccines and anti-viral drugs. This chapter has also highlighted the ethical quandaries generated by influenza outbreaks. These are issues related to epistemic and social uncertainty, biological, social, geographical and political vulnerabilities, potential violations of human rights through some of the therapeutic and non-therapeutic countermeasures, as well as issues of local and global justice. Against this conceptual background, the chapter pointed out how helping people is a central concern in pandemic influenza, and how the thorny ethical issues constitute difficulties encountered in accomplishing this goal. On that note, it showed how people-centered lenses such as communitarianism and ethics of care may be useful in engaging the associated practical and moral challenges. To clarify the importance of each of these approaches, the chapter elaborated each of these ethical lenses, and showed how each may help orient different players in the context of a pandemic influenza towards acquiring a sense of community and an other-centric sensitivity which will be essential to resolving the moral dilemmas as well as realizing the critical public health objective central to such a public health disaster. However, partly because there are limited grounds for deciding what the limits of practical reasoning will be ab initio,196 and partly because of the complexities and nuances that are associated with the global dimensions of the issues at stake in pandemic influenza situations, these ethical lenses may suffer some limitations. Whereas this chapter has examined none of such limits, they will be engaged in Chap. 6 where the relational-ased global ethical framework will be formulated.

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Thompson, Alison K., Karen Faith, Jennifer L. Gibson, and Ross E.G. Upshur. 2006. Pandemic Influenza Preparedness: An Ethical Framework to Guide Decision-Making. BMC Medical Ethics 7 (12): 1–11. Thompson, Alison K., Maxwell J.  Smith, Christopher W.  McDougall, Cécile Bensimon, and Daniel Felipe Perez. 2015. “With Human Health It’sa Global Thing”: Canadian Perspectives on Ethics in the Global Governance of an Influenza Pandemic. Journal of Bioethical Inquiry 12 (1): 115–127. Tirima, Humphrey G. 2014. Unprecedented Lead Poisoning Outbreak in Zamfara, Nigeria: A Multidisciplinary Humanitarian Response to an Environmental Public Health Disaster in a Resource Scarce Setting. Moscow: University of Idaho. Torda, Adrienne. 2006. Ethical Issues in Pandemic Planning. Medical Journal of Australia 185 (10): S73–S76. Tronto, Joan C. 1993. Moral Boundaries: A Political Argument for an Ethic of Care. New York: Routledge. van der Weerd, Willemien, Daniëlle R.M.  Timmermans, Desirée J.M.A.  Beaujean, Jurriaan Oudhoff, and Jim E. van Steenbergen. 2011. Monitoring the Level of Government Trust, Risk Perception and Intention of the General Public to Adopt Protective Measures During the Influenza a (H1n1) Pandemic in the Netherlands. BMC Public Health 11 (1): 575–586. Vawter, Dorothy E., Karen G. Gervais, and J. Eline Garrett. 2007. Allocating Pandemic Influenza Vaccines in Minnesota: Recommendations of the Pandemic Influenza Ethics Work Group. Vaccine 25 (35): 6522–6536. Watanabe, Tokiko, and Yoshihiro Kawaoka. 2011. Pathogenesis of the 1918 Pandemic Influenza Virus. PLoS Pathogens 7 (1): e1001218. Webster, Robert G., and Elena A. Govorkova. 2006. H5n1 Influenza—Continuing Evolution and Spread. New England Journal of Medicine 355 (21): 2174–2177. Yazdanbakhsh, Maria, and Peter G. Kremsner. 2009. Influenza in Africa. PLoS Medicine 6 (12): e1000182. Yudell, Michael. 2009. Public Health Ethics: An Update on an Emerging Field. In The Penn Center Guide to Bioethics, ed. V.  Ravitsk, A.  Fiester, and Arthur L.  Caplan, 559–569. New  York: Springer. Zhou, Jianfang, Dayan Wang, Rongbao Gao, Baihui Zhao, Jingdong Song, Xian Qi, Yanjun Zhang, et al. 2013. Biological Features of Novel Avian Influenza a (H7n9) Virus. Nature 499 (7459): 500–503.

Chapter 4

Silent Public Health Disasters: An Anthropo-­ecological Approach

Abstract  Some public health disasters may be ongoing, spreading but remain largely “silent”. This chapter clarifies the notion of silent public health disasters and applies this to the context of atypical drug-resistant tuberculosis (ADR-TB). It examines the nature of antimicrobial drug-resistance generally and ADR-TB in particular with the attendant public health implications. In addition, the chapter examines the attendant ethical quandaries and develops an anthropo-ecological moral approach in relation to engaging these moral perplexities.

4.1  Introduction Tuberculosis remains the second leading cause of preventable infectious diseases.1 This may, however, change considering the recent emergence of atypical drug-­ resistant forms exemplified by extensively drug-resistant and extremely drug-­ resistant strains with their high index of untreatability. Drug-resistant TB is considered one of the most profound ethical challenges facing global health.2 If this is true, then ADR-TB should be of more concern due to its untreatable and subtle nature. This biological subtlety with the attendant social and public health implications largely show how ADR-TB constitutes a silent public health disaster. Atypical drug-resistant tuberculosis, as used in this chapter and throughout this book, encompasses drug-resistant forms of tuberculosis outside the traditional multi-drug-resistant genre. Specifically, it refers to both extensively resistant and excessively resistant strains of tuberculosis which are resistant to first-line and at least three of the six classes of second-line anti-mycobacterium drugs (such as aminoglycosides, polypeptides, thioamides, fluoroquinolones, cycloserine and para-­

1  Michael J Selgelid, PM Kelly, and Adrian Sleigh, “Ethical Challenges in Tb Control in the Era of Xdr-Tb [Unresolved Issues],” The International Journal of Tuberculosis and Lung Disease 12, no. 3 (2008). P. 231. 2  Ross E.G Upshur, “What Does It Mean to ‘Know’ a Disease? The Tragedy of Xdr-Tb,” in Public Health Ethics and Practice, ed. Stephen Peckham and Alison Hann (Policy Press, 2010). P. 53.

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aminosalicylic acid).3 Since variance between these types of resistance is one of contextual magnitude with little clinically significant differences, they usually elicit the same attendant social and ethical issues. This justifies the conceptual description, “atypical”, employed to tie these two forms of resistance to anti-TB drugs. Atypical drug-resistant tuberculosis also reflects a form of a silent public health disaster. This is due to its non-apparent but harmful and infectious nature which can have disaster-like consequences locally, trans-nationally, and globally. Whereas ADR-TB does not overtly exhibit all of the traditional six Ds of disasters, its “silent” nature mirrors silent genetic mutations which hardly alter phenotypic parameters,4 but may sometimes bring about subtle harms5; for instance, through alteration in substrate specificity and altered cellular functions.6 Based on this analogy, while the disaster nature of ADR-TB may not be as obvious compared to other public health disasters, the unpredictable nature of when the associated harm may manifest and in what magnitude are a cause for social and ethical concern. Scholars like Fauci and Morens note that infections have been compelling actors in the drama of human history due to their unpredictability and potential for explosive effect.7 Perhaps, humankind should not, therefore, expect them to completely go away, at least in this earthly life. Indeed, one-third of the global population is infected with latent forms of tuberculosis, and between 5% and 10% of the infected populace are at risk of developing active disease.8 Besides the fact that tuberculosis kills about 3500 people every day, extant biomedical literature show that an active untreated case of TB will infect an average of 10–15 people annually.9 These bits of data, the report that ADR-TB has been identified in at least 1 person in 50 countries10; and its untreatability indicate that the estimated percentage of those that will develop atypical forms of resistance will be many. This scenario is unsettling and lends further credence to the silent disaster nature of atypical drug-resistant tuberculosis.

3  Karen R Jacobson et al., “Treatment Outcomes among Patients with Extensively Drug-Resistant Tuberculosis: Systematic Review and Meta-Analysis,” Clinical Infectious Diseases 51, no. 1 (2010). PP. 6–11. 4  Jack J Pasternak, An Introduction to Human Molecular Genetics: Mechanisms of Inherited Diseases (John Wiley & Sons, 2005). P. 96. 5  Tom Strachan and Andrew P. Read, Human Genetics 3 (Garland Publishing, 2004). P. 334. 6  Chava Kimchi-Sarfaty et  al., “A” Silent” Polymorphism in the Mdr1 Gene Changes Substrate Specificity,” Science 315, no. 5811 (2007). Pp. 526–527. 7  Anthony S Fauci and David M Morens, “The Perpetual Challenge of Infectious Diseases,” New England Journal of Medicine 366, no. 5 (2012). P. 454. 8  Michael J Selgelid, “Ethics, Tuberculosis and Globalization,” Public Health Ethics 1, no. 1 (2008). P. 11. 9  Tracy Slagle et al., “Lessons from Africa: Developing a Global Human Rights Framework for Tuberculosis Control and Prevention,” BMC International Health and Human Rights 14, no. 34 (2014). p. 1. 10  Christopher Dye, “Doomsday Postponed? Preventing and Reversing Epidemics of DrugResistant Tuberculosis,” Nature Reviews Microbiology 7, no. 1 (2009). P. 81.

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Social contexts also shape ADR-TB. Since drug availability and affordability are a cardinal aspect of the process of ameliorating diseases,11 weak drug systems or absence of effective drugs for ADR-TB leads to continued circulation of infections. This negates the telos of public health—fostering positive health outcomes—12 and engenders increased morbidity and mortality. Not addressing the problems posed by drug-resistant tuberculosis in general and atypical drug-resistant TB  specifically, therefore, constitutes allowing one of the core drivers of mortality and morbidity to run amok in local communities, and for the consequences of such neglect to ultimately creep into and shape the global human community. An elaboration of the nature and causes of traditional antimicrobial drug resistance will, however, provide the conceptual background to better ground the discourse and analyses on ADR-TB.

4.1.1  Nature & Causes of Antimicrobial Drug-Resistance To fully comprehend the significance of atypical drug-resistant tuberculosis, some background into the nature and causes of antimicrobial drug-resistance will be useful. This section will offer some insights in this vein. Antimicrobial drug resistance embeds the failure of hitherto effective natural or synthetic antibiotics to elicit bactericidal and bacteriostatic potency in relation to specific disease-causing bacteria.13 In the past, a lot of antimicrobial drugs proved remarkably effective for the control of bacterial infections including pneumonia and sepsis. During the golden age of the discovery of antibiotics, millions of lives were saved14; however, some bacterial pathogens have developed and others are increasingly developing resistance to many first-line drugs. Such resistance also occurs to new classes of drugs, to the extent that concerns have been expressed about the capacity of new antimicrobial drugs to keep pace with the development of resistance.15 This emergence of populations of antimicrobial-resistant pathogenic bacteria constitutes a major global health concern.16 Consequently, diseases and disease agents that were once thought to be controlled by antibiotics are no longer amenable to antibiotic therapy and are returning  Michael O.S. Afolabi, “A Disruptive Innovation Model for Indigenous Medicine Research: A Nigerian Perspective,” African Journal of Science, Technology, Innovation and Development 5, no. 6 (2013). P. 446. 12  Adetokunbo O Lucas and Herbert Michael Gilles, Short Textbook of Public Health Medicine for the Tropics (Arnold Publishers, 2003). Pp. 1–10. 13  Paul Singleton, Bacteria in Biology, Biotechnology and Medicine, 4th ed. (Chichester: John Wiley & Sons, 1997). Pp. 324–325. 14  Jean Carlet et al., “Ready for a World without Antibiotics? The Pensières Antibiotic Resistance Call to Action,” Antimicrobial Resistance and Infection Control 1, no. 11 (2012). P. 1. 15  Howard S Gold and Robert C Moellering Jr., “Antimicrobial-Drug Resistance,” New England Journal of Medicine 335, no. 19 (1996). Pp. 1445–1450. 16  L Cantas et al., “A Brief Multi-Disciplinary Review on Antimicrobial Resistance in Medicine and Its Linkage to the Global Environmental Microbiota,” Frontiers in Microbiology 4, no. 96 (2013). P. 1. 11

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in new leagues,17 impervious to previously effective therapies. Thus, antimicrobial resistance creates a biological lacuna through which infections may progress in many people, thereby festering different levels of mortality and morbidity.18 But the high prevalence of potentially fatal infectious diseases of bacterial origin due to the ability of micro-organisms to rapidly mutate and acquire resistance19 echoes the teleological tension amongst and between species in terms of the instinctual need for survival. To be sure, at the heart of this “biological rebellion” is the inattention that has generally been paid to the idea that microbial organisms also seek survival in our shared ecosystem, and may evolve several ways to evade humankind’s constant barrage of magic bullets as a “coping mechanism” in an environment increasingly being made hostile to them by the activities (that is, antibiotic use) of humankind. Understanding the causes of antimicrobial drug-resistance offers more insights into the nature of the phenomenon as well as some finer and important distinctions into its human-influenced origins. Natural causes of antimicrobial drug-resistance result from the innate capacity of some bacteria species to “withstand” and “resist” bactericidal and bacteriostatic processes marshaled against them. Such bacteria may employ enzymes to render antimicrobial drugs ineffective, have impermeable cell walls or lack suitable receptors.20 Some may undergo mutation or develop resistance plasmids and transposons, thereby evading or countermanding the potency of hitherto effective antibiotics,21 while others utilize innate resistance mechanisms such as efflux pumps.22 Natural antibiotic resistance may, therefore, be described as an inherently biological process of self-preservation geared towards thriving amidst other (actively or passively) competing organisms in the ecosystem. It likewise reflects some evolutionary advantage of microbes over their human host.23 In the context of resistance to anti-TB drugs, resistance arises due to the selection of naturally occurring mutants with innate resistance to individual agents in the face of exposure to drugs producing incomplete suppression of growth.24 This further suggests the presence of a teleological response within bacterial organisms in relation to thwarting human efforts at eliminating them.  Stuart B Levy and Bonnie Marshall, “Antibacterial Resistance Worldwide: Causes, Challenges and Responses,” Nature Medicine 10 (2004). P. S122. 18  Thomas F O’Brien, “The Global Epidemic Nature of Antimicrobial Resistance and the Need to Monitor and Manage It Locally,” Clinical Infectious Diseases 24, no. Supplement 1 (1997). P. S2 19  Charles B Smith et  al., “Are There Characteristics of Infectious Diseases That Raise Special Ethical Issues?,” Developing World Bioethics 4, no. 1 (2004). P. 4. 20  John Ochei and Arundhati Kolhatkar, Medical Laboratory Science: Theory and Practice (McGraw Hill, 2003). Pp.795–798. 21  Singleton. Pp. 331–332. 22  Stewart T Cole, “Who Will Develop New Antibacterial Agents?,” Philosophical Transactions of the Royal Society B 369 (2014). P. 2. 23  Fauci and Morens. P. 455. 24  Susan E Dorman and Richard E Chaisson, “From Magic Bullets Back to the Magic Mountain: The Rise of Extensively Drug-Resistant Tuberculosis,” Nature Medicine 13, no. 3 (2007). P. 295. 17

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Acquired causes of resistance largely reflect human agency.25 One of such is the increased speed and extent of travel around the world26 which not only facilitates the rapid transportation of microbes to vulnerable hosts but has created, sustained, and somehow normalized the prophylactic use of antibiotics during travel. Equating feeling well with being well,27 or equating subjective feelings of recuperation with biological cure is another human-influenced cause of drug resistance. In this vein, some individuals previously experiencing the discomfort of bacterial diseases come to believe that optimal health set in at the point of symptomatic alleviation, thereby discontinuing their drug regimen. At the biological plane, this misconception enables genetic recombination amongst surviving strains through mutation and the  development of resistance factors through genetic transfer between strains of bacteria.28 Acquired resistance to antibiotics also ensues from self-medication when antimicrobial drugs are used to treat self-diagnosed symptoms or disorders ascribed to bacterial etiology. This results specifically when antibiotics are used to treat recurrent or chronic bacterial-mediated diseases29 such as sinusitis, otitis media, and pneumonia. While the problem of antibiotic drug resistance is often associated with economically less developed nations, people who live in  developed economies may also face this public health challenge due to a breakdown in extant public health measures.30 Poor adherence to therapeutic regimen, improper prescription, and drug interactions or malabsorption are additional factors that facilitate the onset of antimicrobial drug resistance31 in developed economies. This shows the global nature of the problem of antibiotic drug resistance, which has clearly increased dramatically to the extent that future patients are in real danger, even as pathogenic commensal microorganisms such as Escherichia coli and Klebsiella pneumoniae are increasingly becoming resistant to third-generation cephalosporins.32 Although how human agency shapes the onset of antimicrobial-drug resistance varies by social context locally and globally, this subsequently influences the causal variance in the humanrelated factors that foster resistance. The biological, clinical, and public health implications are invariably much the same, differing only in numerical terms.

 Upshur.P. 52.  Peter J Lachmann, “Public Health and Bioethics,” The Journal of Medicine and Philosophy 23, no. 3 (1998). P. 299. 27  Patricia A. Kaufert, “Screening the Body: The Pap Smear and the Mammogram,” in New Medical Technologies, ed. Margaret Lock, Allan Young, and Alberto Cambrosio (Cambridge University Press, 2000). Pp. 170, 176. 28  Ochei and Kolhatkar. P. 794. 29  C.O. Omolase et al., “Self-Medication Amongst out-Patients in a Nigerian Community Hospital,” Annals of Ibadan Postgraduate Medicine 5, no. 2 (2007). P. 55. 30  Stephen S Morse, “Factors in the Emergence of Infectious Diseases,” Emerging Infectious Diseases 1, no. 1 (1995). P. 10. 31  Dorman and Chaisson. p. 295. 32  Carlet et al. P. 1. 25 26

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Atypical drug-resistant tuberculosis is not an individualized problem alone. Like most public health issues with infectious dynamics, it echoes the traditional moral conundrum of weighing and balancing individual needs and interests against those of others with whom one lives locally, and increasingly globally. Yet, infectious disease patients are both victims or persons-in-need as well as vectors or persons-­ as-­threats.33 As such, advancing social interests at the expense of individuals and/or protecting individual rights to the detriment of community interests34 may not be adequate in engaging the associated ethical quandaries. The limits of personal choices vis-à-vis the acquisition of ADR-TB and the huge causal role that structural factors such as poverty and weak health infrastructures play in increasing the risk of infection suggests the need for some innovative reasoning, ethically and practically. A socio-medical perspective affirms the social construction levels of health.35 This also plays out and exerts some significant influences vis-à-vis the phenomenon of atypical drug-resistant TB. On this note, recognizing a social dimension is exigent into a viable normative approach framed to engage the ADR-TB. If one agrees with Upshur who describes traditional or typical drug-resistant TB as one of the most profound ethical challenges facing global health,36 then the ethical issues that ADR-TB generates seem weightier. However, an explication of some of the public health implications of atypical drug-resistance will help place these issues in proper perspective.

4.1.2  P  ublic Health Implications of Atypical Drug-Resistant Tuberculosis The phenomenon of atypical drug-resistant tuberculosis exhibits certain features that have significant public health consequences. Strains of Mycobacterium tuberculosis that cause ADR-TB are refractory to isoniazid and rifampicin (first line anti­TB drugs) and to one or more fluoroquinolones and one or more injectables.37 These second-line drugs are not only less safe but are also costly. Since second line anti-­ mycobacterium drugs are more toxic and less potent compared to first-line drugs,38 the phenomenon of ADR-TB foists at least three levels of risk on the human society at the individual, local and global boundaries. Firstly, the biochemical and/or phar Margaret P. Battin et al., “The Patient as Victim and Vector: Challenges of Infectious Diseases,” in Blackwell Guide to Medical Ethics, ed. Rosamond Rhodes, Leslie P. Francis, and Anita Silvers (Blackwell Publishers, 2007). P. 272. 34  Stephen Holland, Public Health Ethics, 2nd ed. (Polity Press, 2015). P. 34. 35  Daniela Cojocaru and Cristina Gavrilovici, “The Intricate Meanings of Health and Illness,” Revista Romana de Bioetica 13, no. 1 (2015). Pp. 3–4. 36  Upshur. P. 53. 37  Dye. P. 81. 38  Selgelid. P. 12. 33

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macological toxicity of second-line drugs implies certain direct and indirect harms to patients already struggling with an uncomfortable disease experience. In this regard, it has been reported that the use of second-line drugs for TB requires prolonged therapy with toxic, poorly tolerated medications.39 For instance, there is some linkage between the incidence of hypothyroidism and treatment with second-­ line anti-TB drugs.40 Therefore, there is an exponential increase in the financial, biological, and psychological costs of ADR-TB. The second level of risk characteristic of second-line TB drugs involves the direct and indirect harms that infected persons pose to the rest of the local society. For example, in some countries with a fledgling economy, national diagnostic or treatment algorithms for drug-resistant TB are absent, facilitating increased transmission of resistant strains in families, communities, and hospital wards.41 This  creates a viable sphere for the unmitigated spread of ADR-TB transmission. It may also put individual health interests at loggerheads with social interests. For example, people who develop overt symptoms of infection may receive some form of deportation and/or stigmatization42 as a means of protecting the health interests of the rest of the society. Consequently, people may respond to such unpleasant social measures or even clinical strategies including quarantine by hiding. For instance, in South Africa ADR-TB patients have been known to resist mandatory detention and abscond from the hospital/treatment centers to take refuge in the community, though infectious.43 Although people may have some moral obligation to act in ways that limit their transmission of infectious diseases,44 it is obvious that when society chooses to enforce such obligations without offering commensurate and caring responses to the plight of the infected, the moral meter shifts towards the self-­centered zone. Even where some individuals would have chosen to be other-centric, latent cases of TB defeats the realization of such a moral agenda while a lack of diagnostic facilities defeats the societal agenda to achieve early detection as a preventive strategy. The global community also faces risks of harm when people traverse geographic borders through land, sea, or air transportation. As part of the socio-economic repertoire of contemporary life, people traverse borders rapidly today more than ever. However, they may bring diseases with them in the process, innocently. However, some people may also travel knowing full well of their ADR-TB status primarily to  Timothy Sullivan and Yanis Ben Amor, “Global Introduction of New Multidrug-Resistant Tuberculosis Drugs—Balancing Regulation with Urgent Patient Needs,” Emerging Infectious Diseases 22, no. 3 (2016). P. e1. 40  R Bares et  al., “Hypothyroidism During Second-Line Treatment of Multidrug-Resistant Tuberculosis: A Prospective Study,” The International Journal of Tuberculosis and Lung Disease 20, no. 7 (2016). Pp. 876–880. 41  Sabine Bélard et al., “Limited Access to Drugs for Resistant Tuberculosis: A Call to Action,” Journal of Public Health 37, no. 4 (2015). P. 693. 42  Philip LoBue, Christine Sizemore, and Kenneth G Castro, “Plan to Combat Extensively DrugResistant Tuberculosis: Recommendations of the Federal Tuberculosis Task Force,” MMWR Recommendations and Reports 58, no. 3 (2009). Pp. 21–27. 43  Upshur. P. 55. 44  John Harris and Soren Holm, “Is There a Moral Obligation Not to Infect Others?,” British Medical Journal 311, no. 7014 (1995). Pp. 1215–1216. 39

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evade health officials. This played out in the case of Andrew Speaker, an American attorney who contracted tuberculosis and attempted to leave the United States to evade reporting to public health authorities.45 This state of affairs, according to Keshavjee and Farmer, underscores the need for equity plans that reckon with the biosocial complexity of tuberculosis, a lethal airborne infection that has stalked humankind for centuries.46 Beyond limiting the effectiveness of combination drug regimens,47 ADR-TB enables the further dispersal of resistance within and amongst communities and between economic and geographic divides,48 exhibiting an unsettling ripple effect. In other words, tuberculosis which used to predominantly be a disease of the poor has rapidly evolved into a classless infectious disease largely due to the inevitable force of social and global inter-penetration. Since the onset of infectious diseases such as TB is often abrupt49; the dispersal of M. tuberculosis through aerosols50 greatly enhances the spread of infection in an age accelerated by the currents of globalization. Specifically, the public health impact of ADR-TB significantly increases in contexts that encourage close inter-mingling of people. Genetic analysis of drug-resistant strains has shown that airborne transmission of undetected and untreated strains of TB as well as ADR-TB is an important mechanism through which resistance is created and dispersed.51This makes rural communities in developing economies and high-population density settings such as day-care centers or prisons in industrialized nations more susceptible,52 hence, vulnerable. The public health implication of ADR-TB can also be explored through the lens of therapeutic failure that occurs to previously effective anti-TB drugs. This comes with scientific, social, and ethical complexities.53 The phenomenon of ADR-TB, therefore, poses significant threats to TB control and elimination schemes,54 threatens not only individual lives but that of whole communities, and potentially that of the global village. In addition, ADR-TB is largely irreversible.55 For this reason, it  Upshur. Pp. 55–56.  Salmaan Keshavjee and Paul E Farmer, “Tuberculosis, Drug Resistance, and the History of Modern Medicine,” New England Journal of Medicine 367, no. 10 (2012). Pp. 934–935. 47   Giovanni Battista Migliori et  al., “Drug Resistance Beyond Extensively Drug-Resistant Tuberculosis: Individual Patient Data Meta-Analysis,” European Respiratory Journal 42, no. 1 (2013). P. 170. 48  Richard Wise et  al., “Antimicrobial Resistance: Is a Major Threat to Public Health,” British Medical Journal 317, no. 7159 (1998). P. 810. 49  Fauci and Morens. P. 454. 50  Council on Bioethics Nuffield, Public Health: Ethical Issues (Cambridge Publishers Ltd., 2007). P. 52. 51  Keshavjee and Farmer. Pp. 931–933. 52  Morse. P. 11. 53  Selgelid. p. 12. 54  Alberto Matteelli et al., “Multidrug-Resistant and Extensively Drug-Resistant Mycobacterium Tuberculosis: Epidemiology and Control,” Expert Review of Anti-infective Therapy 5, no. 5 (2007). Pp. 857–859. 55  Lachmann. P. 298. 45 46

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has been argued that failure to act rapidly, develop tools and strategies for diagnosis and treatment may transform hitherto magic bullets of anti-TB drugs into blanks.56 The practical implications of this idea are quite shocking. There is also a “silent” public health issue embedded within the phenomenon of atypical drug-resistant tuberculosis. Cases of ADR-TB have been identified in at least 1 person in 50 different countries.57 If this is true and if diagnostic capacities for ADR-TB are generally poor across the globe, one can estimate that many people across the globe will develop atypical forms of drug-resistance. Against this background, the currently latent or low prevalence rate for ADR-TB when combined with its potential to rapidly acquire pandemic capacities reflects its public health disaster feature, albeit in a silent tone. This notion is partly supported by the observation that substantial numbers of patients in some countries with ADR-TB who have failed treatment and have positive sputum cultures are being discharged (since they cannot be held indefinitely) from the hospital and are likely to transmit disease into the wider community.58 Specifically, this poses about 5–10% risk of possible transmission to household contacts via airborne transmission.59 However, undiagnosed cases of ADR-TB in countries that do not have the relevant diagnostic and containment capacities means that there is a poorly understood route for nosocomial transmission of infection. Based on the South African scenario, Delft and others recently reported that healthcare professionals and students are increasingly becoming infected with multi-drug and extensively drug-resistant TB as a form of occupational hazard.60 It is well documented that undetected TB is a major outlet through which the airborne infection spreads, amplifies and transcends borders.61 Since infectious diseases including tuberculosis have been sources of enormous fear and social distress historically,62 the high index of worse clinical outcome for ADR-TB63 and its general untreatability further lends credence to its characterization as a silent public health disaster which may soon evolve into a full-blown global health disaster if not tackled on time.

 Dorman and Chaisson. P. 295.  Dye. P. 81. 58  Elize Pietersen et  al., “Long-Term Outcomes of Patients with Extensively Drug-Resistant Tuberculosis in South Africa: A Cohort Study,” The Lancet 383, no. 9924 (2014). Pp. 1230, 1237. 59  Keertan Dheda et  al., “Global Control of Tuberculosis: From Extensively Drug-Resistant to Untreatable Tuberculosis,” The Lancet: Respiratory Medicine 2, no. 4 (2014). P. 333. 60  Arne von Delft et al., “Exposed, but Not Protected: More Is Needed to Prevent Drug-Resistant Tuberculosis in Healthcare Workers and Students,” Clinical Infectious Diseases 62, no. suppl 3 (2016). Pp. 275–278. 61  Slagle et al. P.8. 62  Smith et al. P.1. 63  N Sarita Shah et  al., “Worldwide Emergence of Extensively Drug-Resistant Tuberculosis,” Emerging Infectious Diseases 13, no. 3 (2007). P. 386. 56 57

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Another public health implication of ADR-TB is tied to traditional countermeasures including isolation,64 self-reporting, state notification, expanding high-quality directly observed therapy or DOT programs, addressing HIV-associated tuberculosis and drug resistance, strengthening healthcare systems and primary care services, and the use of good clinical practices.65 These are largely ineffective in the context of atypical drug-resistant tuberculosis and are bedeviled with drawbacks. For instance, patients infected with active TB or multi-resistant strains may be isolated until they are no more contagious, usually for a period of 2 weeks or more following the start of antibiotic therapy.66 The high index of untreatability of ADR-TB, or the high cost of it (100 times more than the cost of treating typical TB) where available however raises the need to perpetually isolate and/or quarantine some categories of patients (raising attendant human rights issues) and release some into the community to propagate infection transmission (unwittingly) as ADR-TB is functionally untreatable.67 Finally, the situation also implies that some people will remain untreated due to the unavailability of treatment options. In relation to the notion of the right to health which is grounded in the human rights language,68 the latter observation entails an abandonment of parts of the moral responsibilities that governments have towards her people as primary providers of health services, directly or indirectly. Even where treatment is available, it takes more than 2 years to achieve an effective cure.69 At the same time, countries where treatment options for ADR-TB are absent, or where present are non-accessible to the socio-economically poor, may be expected to continue to “allow” resistance to incubate and spread locally, across regions and, ultimately, globally. The preceding sets of analyses suggest that the issues tied to ADR-TB are hardly clear-cut and embed different shades of grey areas. In other words, there are several nuanced dimensions to ADR-TB. This notion deserves clearer elaboration and the next section seeks to untangle the nuances associated with ADR-TB.

 JD Kraemer et al., “Public Health Measures to Control Tuberculosis in Low-Income Countries: Ethics and Human Rights Considerations,” The International Journal of Tuberculosis and Lung Disease 15, no. Supplement 2 (2011). Pp. S19–S21. 65  Mario C Raviglione and Ian M Smith, “Xdr Tuberculosis—Implications for Global Public Health,” New England Journal of Medicine 356, no. 7 (2007). Pp. 658–659. 66  CDC, Tuberculosis Control Laws and Policies: A Handbook for Public Health and Legal Practitioners (The Centers for Law and the Public’s Health, 2009). P. 10. 67  Dheda et al. Pp.333–334. 68  Lisa Forman and Stephanix Nixon, “Human Rights Discourse within Global Health Ethics,” in An Introduction to Global Health Ethics, ed. Andrew D Pinto and Ross E.G Upshur (London: Routledge, 2013). Pp. 54–55. 69  Selgelid, “Ethics, Tuberculosis and Globalization. P. 12. 64

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4.1.3  The Nuances of Atypical Drug-Resistant Tuberculosis Some biological and social nuances pervade the phenomenon of atypical drug-­ resistant tuberculosis. The biological nuances are associated with the nature of the M. tuberculosis bacteria, how it counteracts anti-mycobacterium drugs, and how different strains interact to create ADR-TB. For instance, exogenous reinfection of a TB patient constitutes an important mechanism for the development of ADR-­ TB.70 Hence, not all patients with tuberculosis will develop atypical drug-resistant tuberculosis. Some categories of TB patients develop ADR-TB during TB treatment regimen when wild-type pan-susceptible strains are genetically converted to drug-­ resistant strains. Others are, however, directly infected through active cases,71 which might have been diagnosed or not. In other words, the biological evolution of ADR-TB is not always halted by the institutional interventions of the healthcare system. This is quite upsetting as it suggests that ADR-TB is slowly but freely being transmitted within and across communities with little or no social confrontation. This echoes a recent submission by Gehre and colleagues who sounded an alarm that on-going transmission of ADR-TB is currently insufficiently controlled.72 Because patients with ADR-TB may need to be placed in airborne infectious isolation units during the monitoring of initial treatment response in order to prevent disease transmission to others,73 and because such isolation units are unavailable in most countries of the South and in only some of the nations in the North, it is clear that there is also a significant nosocomial and/or an iatrogenic  avenue through which infection is currently spreading. These sets of remarks again reflect the silent nature of the public health disaster dimensions of atypical drug-resistant tuberculosis in relation to local and global contexts. Another biological nuance characteristic of ADR-TB relates to untreated tuberculosis. In this vein, drugs including fluoroquinolones and other anti-TB drugs routinely used in the treatment of bacterial infections in undiagnosed TB patients may convert conventional TB to ADR-TB as they promote the multiplication and spread of resistant strains of tuberculosis.74 The evolving tendency of resistance with the possible transmission of resistant strains of TB to hitherto non-resistant

 Jason R Andrews et  al., “Exogenous Reinfection as a Cause of Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis in Rural South Africa,” Journal of Infectious Diseases 198, no. 11 (2008). P. 1582. 71  Sanjeev Kumar Narang, “Extensively Drug Resistant Tuberculosis (Xdr-Tb),” J Med 359 (2008). 72  Florian Gehre et al., “The Emerging Threat of Pre-Extensively Drug-Resistant Tuberculosis in West Africa: Preparing for Large-Scale Tuberculosis Research and Drug Resistance Surveillance,” BMC Medicine 14, no. 160 (2016). Pp.10–11. 73  LoBue, Sizemore, and Castro. Pp. 5–9. 74  Dye. P. 81 70

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ones75 and the presence of immunosuppression exemplified by diseases such as HIV/AIDS76 are other biological nuances associated with ADR-TB. Since there are well-­documented connections between poor nutrition and immunosuppression,77 it follows that social contexts ravaged by poverty and other socio-economic challenges that ultimately have negative impacts on nutritional status are fertile grounds for the evolution and dissemination of ADR-TB. The intersection of poverty and disease situations often ensue as a by-product of economic and policy processes such as the 10/90 gap.78 One important notion that comes out of this is that while ADR-TB is a biological threat that faces humankind, underlying or background social factors will influence how the threat plays out in different societal locales. In short, there are social nuances embedded within the phenomenon of ADR-TB. These social nuances are tied to socio-cultural contexts, and how variant differences in these contexts facilitate the onset of ADR-TB in different ways. Where anti-TB drugs are not free or are costly with respect to the social milieu, weak economic power will negatively influence the capacity to buy these drugs. This may, however, encourage the evolvement of ADR-TB due to therapeutic non-compliance. For instance, out-patient cost of DOT for TB averages $US130 in some parts of sub-­ Saharan Africa.79 Since impoverished people who can barely meet basic life needs would equally be financially incapacitated to meet their health needs,80 balancing personal and family needs with the cost of seeking anti-TB intervention may nudge infected, poor patients towards partial compliance or non-compliance with treatment. Such practical wisdom, however, does not remove the public health implications that are foisted on the individual as well as their immediate family members and by implication the larger society. Hence, biological lacunas created due to socio-economic factors influence the development of ADR-TB and their further dispersal within and across communities. Beyond pharmacological and public health interventions, social dynamics occupy a key place in the epidemiology of tuberculosis.81 Although available ­statistic shows that the rate of ADR-TB is notably high in Eastern Europe and Asia, there is a paucity of data on its prevalence in sub-Saharan Africa.82 Gehre and colleagues recently reported that West African patterns of ADR-TB prevalence raise a  Dorman and Chaisson. P. 296.  Upshur. P. 55. 77  Archith Boloor, Amina Asfiya M Iqbal, and Jagadish Padubidri Rao, “Malnutrition: The Underestimated Link in the Pathogenesis of Pulmonary Tuberculosis-a Preliminary Study,” Journal of Pharmaceutical and Biomedical Sciences 4, no. 05 (2014). Pp. 473–478; Devan Jaganath and Ezekiel Mupere, “Childhood Tuberculosis and Malnutrition,” Journal of Infectious Diseases 206, no. 12 (2012). Pp. 1809–1813. 78  Henk Ten Have, Global Bioethics: An Introduction (Routledge, 2016). P. 62. 79  Nisser Ali Umar et al., “The Provider Cost of Treating Tuberculosis in Bauchi State, Nigeria,” Journal of Public Health in Africa 2, no. 2 (2011). P. 78. 80  Afolabi. p. 447. 81  Selgelid. P. 11. 82  Mandeep Jassal and William R Bishai, “Extensively Drug-Resistant Tuberculosis,” The Lancet Infectious Diseases 9, no. 1 (2009). P. 20. 75 76

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previously underestimated, yet serious public health threat.83 To be sure, because the African region bears 13% of the global burden of disease with only 24% of the world’s population,84 the incidence of ADR-TB, as well as the attendant public health consequences, is probably elevated due to extant disease burdens which generally favor susceptibility to ADR-TB. According to Michael Selgelid, ethical reasoning in healthcare requires identifying ethically important empirical questions critical to sound policy.85 If one agrees with this perspective, then there is some degree of urgency in the African as well as in the global context to engage in epidemiological studies in order to generate data which may be used to reliably ground and drive ADR-TB-related policy and interventions. Another social dynamic of ADR-TB comes to the fore when one considers the general idea that infectious diseases including TB often spread to and from people with close, physical contact including family members, spouses, friends, co-­ workers, sexual partners,  and so forth.86 Consequently, while some communities such as those with problems of overcrowding may be more susceptible, humans as social beings who form and maintain varying degrees of inter-personal relationships are generally prone to it. This echoes the limits of the medical model of disease which typically focuses its gaze on the pathogenesis and pathophysiology of the disease and ignores the anthropological question of “why here and now?”.87 In relation to ADR-TB, this observation partly underscores the need for an anthropological angle beyond biological explanatory models as well as incorporating such a perspective vis-à-vis the attendant moral challenges. For instance, the medical model assumes that knowing the harms of self-medication will orient more and more persons into choosing to shun the practice. Hence, it assumes that human persons are like automatons that respond only to the button of reasoning and logic and ignores the inexorable social matrix within which decision making occur as well as the emotional context of decision making. For instance, if confronted with the choice of continuing a costly anti-TB medication when self-perception has indicated “recovery”, and feeding self and family, someone living in a non-welfare nation will hardly choose the former. After all, someone needs to be alive to be able to determine the quality of life s/he prefers. This analysis partly reflects the idea expressed by Margaret Battin and others that the ideal of the thoughtful chooser runs counter and contrary to the embedded nature of human agency.88 In industrialized nations, there seems to be an entrenched assumption which links ADR-TB almost exclusively with those whose lives lack meaningful order  Gehre et al. Pp. 1–2.  Jennifer G. Cooke, Public Health in Africa: A Report of the Csis Global Health Policy Center (Washington: Center for Strategic and International Studies, 2009). P. 11. 85  Michael J. Selgelid, “Pandethics,” Public Health 123, no. 3 (2009). P. 258. 86  Battin et al. Pp. 281, 286. 87  Henk ten Have, “The Anthropological Tradition in the Philosophy of Medicine,” Theoretical Medicine 16, no. 1 (1995). P. 10. 88  Battin et al. P. 277. 83 84

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such as the homeless, the destitute, and the drug addict.89 However, the case of Andrew Speaker challenges this narrative. Speaker was a well-educated American attorney of high socioeconomic status who contracted TB and attempted to leave the United States to avoid reporting to health authorities.90 This hints at the idea that ADR-TB is not always a class-bound disease but is increasingly transforming into a classless silent public health disaster due to a complex interplay of local, global, social, drug-related, and microbial-based factors. Besides being less effective and costlier than first-line agents, the toxic nature of second-line anti-mycobacterial drugs91 and the inconvenient side effects which can interfere with work and/or social functioning may make certain categories of patients not to adhere properly to treatment schedules. These possibilities will prolong disease duration as well as creates a window that facilitates the spread of infection. Finally, since it is possible to be biologically sick without subjectively knowing, it is equally plausible to be infectious without realizing it. As such, the situation where infective persons subjectively feel alright also fosters the dissemination of atypical drug-resistant TB. A close examination of the biological and social nuances surrounding atypical drug-resistant tuberculosis highlights a number of issues. At the core of these, however, is some form of relational dissonance. In other words, an understanding of the derangement in the harmonious balance in the relationship nexus between human beings and other humans and what one set of people may do or fail to do for or to other people as well as the relationship nexus between humans and microbial life constitutes a viable locus for examining the causes, subtleties, and extent of the challenges that ADR-TB elicits. For instance, the instinctual survivalist proclivities that are found in almost all living forms of life is reflected in the teleological response within bacterial organisms including M. tuberculosis in relation to thwarting human efforts (via antibiotics) to eliminate them. If the teleological elusiveness of microbes is an inevitable and irreversible dynamic of the ecosystem where human beings also live, then one real-world import of this notion is that humankind need to rely less on the “magic” of magic bullets or drugs and focus more on exploring alternative modes of understanding and relating to microbial life vis-à-vis infectious diseases. On the other hand, how humans have created social systems in which they live generally determines and influences the social nuances pervading ADR-TB. For instance, poor health systems, as well as poverty, are largely consequences of a combination of human ineptitude, greed, corruption, and mismanagement. As was shown in preceding paragraphs, these background factors and the extent to which they are present in specific societies play a role in influencing the ADR-TB dissemination and the attendant congeries of harms. Lastly, at the core of absconding from hospitals when infected and the unwillingness to report to health authorities when an active carrier of disease is the “trust relationship” that individuals have in the society gener Selgelid. P. 11.  Upshur. Pp. 55–56. 91  Jacobson et al. 89 90

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ally or in a particular societal segment such as the healthcare system or the community where they live. Addressing these issues will, therefore, demand that the underlying relational disharmonies are identified, clarified, and engaged. The biological and social nuances embedded within the phenomenon of atypical drug-resistant tuberculosis and the relational dissonances these raise create an array of moral quandaries that grate one set of choices against others as well as create opposing priorities, especially in terms of the problematic nature of how to make the most of the limited countermeasures to ADR-TB. These ethical issues demand some explication since their examination offer further insights not only into the dynamics of the relational issues embedded in ADR-TB but also offer some insights into potential ways to engage the moral issues. The next section of this chapter addresses this theme.

4.2  E  thical Issues Embedded in Atypical Drug-Resistant Tuberculosis Atypical drug-resistant tuberculosis engenders many ethical issues. Some of these are largely confined to the local space, but the contemporary global village which has created an unprecedented interconnection and interpenetration of people converts some of these issues into trans-national and global moral concerns. This section seeks to explicate these moral quandaries.

4.2.1  Uncertainty & Vulnerability One of the principal moral elements embedded in atypical drug-resistant TB is the idea of uncertainty, which itself raises several issues about the vulnerable nature of humankind as living species, how they interact with one another locally and globally, as well as their relationship with microbial life forms. Whereas public health is generally buoyed by the statistical morality of utilitarian politics,92 the dynamics of uncertainty embedded within ADR-TB implies the inadequacy of a purely utilitarian approach. There are at least three dimensions to this uncertainty all of which are mired in the qualitative distinctions between the uncertainty of possible infectious disease, that of the present moment and the immediate future.93 The first type of uncertainty relates to scenarios that may or may not facilitate the evolution of typical tuberculosis to ADR-TB. In this vein, while it is known that conditions of overcrowding, poor clinical management of TB or poor health infrastructures for diagnosing or curtailing ADR-TB help the transmission of infection,  Edmund D Pellegrino, “Guarding the Integrity of Medical Ethics: Some Lessons from Soviet Russia,” Journal of American Medical Association 273, no. 20 (1995). P. 1623. 93  Theresa MacPhail, The Viral Network: A Pathography of the H1n1 Influenza Pandemic (Cornell University Press, 2014). Pp. 134–135. 92

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how transmission may occur for one specific person in the family, community or in a nosocomial context is never completely known. Hence, some people may be exposed to known risks but remain uninfected. This uncertain correlation between exposure and definite development of infection may, however, trivialize the severity of ADR-TB as well as the urgency with which it needs to be engaged. Tha, it tends to relegate the associated risk to the sphere of the abstract. The second uncertainty is grounded in what to do about active cases of ADR-TB. In this vein, many patients who have failed treatment and have positive sputum cultures are being discharged (since they cannot be held nor quarantined perpetually as that would be a violation of their human rights) from hospitals, as such, creating the likelihood of disease transmission into the wider community.94 The last type is how the combination of the first two kinds of uncertainty will shape the public health impact of ADR-TB, especially in terms of what needs to drive public health action. These three types of uncertainty partly reinforce the nuances of ADR-TB and partly underscore the difficulty inherent in designing and implementing the best course of action. Whereas acquiring knowledge is an important means of diminishing uncertainty,95 this hardly applies to the context of ADR-TB because the associated uncertainty derives directly from the current limited state of knowledge and understanding. In specific terms, the uncertainty becomes undesirable due to the lack of certitude or exact knowledge96 to guide specific courses of public health actions and policies. This may partly explain the poor level of coordination which Codecasa et al. recently reported about the clinical management of ADR-TB vis-à-vis those in preventive medicine/public health and those in clinical practice.97 Another aspect of the uncertainty inherent in ADR-TB is the minimal amount of behavioral control that people as moral agents can exert, at least at the very first point of contact with the “infectious  disaster agent”. Therefore, while those who enact and implement public health schemes and individual members of society for whom such are meant are linked by a common denominator, behavior,98 ADR-TB like traditional disasters may set in suddenly.99 This should be no surprise at all, considering that there are multiple channels (as elaborated in the previous section) through which infection may be silently but gradually spreading. ADR-TB also mirrors the non-preventable nature of traditional disasters,100 significantly enhanced under the associated climate of uncertainty.  Pietersen et al. P. 1230.  Christof Tannert, Horst-Dietrich Elvers, and Burkhard Jandrig, “The Ethics of Uncertainty,” EMBO Reports 8, no. 10 (2007). Pp. 892–893. 96  Sven Ove Hansson, The Ethics of Risk: Ethical Analyses in an Uncertain World (Palgrave Macmilan, 2013). Pp. 1–3. 97  Luigi R Codecasa et al., “Managing an Extensively Drug-Resistant Tuberculosis Outbreak: The Public Health Face of the Medal,” European Respiratory Journal 45, no. 1 (2015). Pp. 292–293. 98  Holland. Pp. 24–25. 99  Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke, “Disaster Bioethics: An Introduction,” in Disaster Bioethics: Normative Issues When Nothing Is Normal (Springer, 2014). P. 3. 100  Henk ten Have, “Macro-Triage in Disaster Planning,” ibid., ed. Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke (Springer). Pp. 16, 18. 94 95

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The uncertainty associated with ADR-TB is further compounded by the fact that while it is known that traditional tuberculosis may evolve into it, the absence of a single biological factor responsible for the process shortchanges preventive strategies. This form of uncertainty is considered as ontological, being caused by stochastic features involving complex technical, biological, and/or social systems; and characterized by nonlinear behavior.101 The nature and levels of uncertainty that characterize atypical drug-resistant TB echoes the vulnerable status of humans as human beings, as members of related and non-related human communities as well as their humanity in relation to the ecosystem in which they live. The experience of human nature and human finitude102 underpins vulnerability and entails conditions that favor the ready manipulation, coercion and/or deception of humans who may be powerless.103 Bioethicists like ten Have argue that vulnerability means that human beings are open to the world, have relationships with other persons and can interact with the world.104 This capacity, nevertheless, opens the human species to harm from other people and from elements of the world including disease-causing bacteria such as M. tuberculosis. The evolution of typical TB into ADR-TB, for instance, shows some of the limited powers that human beings have and can exert on microbial life as co-inhabitants of the ecosystem. This echoes the idea that belonging to the human community is a possible source of vulnerability. A range of social, economic, and political conditions,105 however, often influences how vulnerability plays out in different scenarios. In other words, two individuals may face the same biological threat but the social context in which each of them lives may amplify or dampen the extent of harm that is ultimately experienced. Specifically, a number of vulnerabilities lie within the experience of atypical drug-resistant tuberculosis. Patients with immunosuppressive conditions such as HIV/AIDS106 are, for instance, prone to developing ADR-TB. Thus, people who live in HIV/AIDS-dominated countries such as South Africa107 are more susceptible to the possibility of becoming infected, unlike those who live where HIV/AIDS prevalence is low. The incidence of ADR-TB may also be fueled by prevalent ineffective TB treatment. This is closely linked with the challenge of limited resources common to developing economies which often lack proper diagnostic testing and have poor

 Tannert, Elvers, and Jandrig. Pp. 894–895.  Maria Patrao Neves, “Respect for Human Vulnerability and Personal Integrity,” in The Unesco Universal Declaration on Bioethics and Human Rights: Background, Principles and Application, ed. Henk ten Have and Michèle Jean (UNESCO, 2009). Pp. 158–162. 103  Michael O.S. Afolabi, “Researching the Vulnerables: Issues of Consent and Ethical Approval,” African Journal Medicine & Medical Science 41 Suppl (2012). P. 9 104  Henk ten Have, “Vulnerability as the Antidote to Neoliberalism in Bioethics,” Revista Redbioética/UNESCO 1, no. 9 (2014). Pp. 89–90. 105  Ibid. P. 88. 106  Upshur. P. 55. 107  Andrews et al. Pp. 1582–1583. 101 102

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infection control practices.108 People living where health systems have been historically weak are also more vulnerable to ADR-TB.109 Health institutions within and across countries hardly have the same functional capacities in terms of diagnostic facilities, disease monitoring and surveillance, drugs availability et cetera. Although people in the context of infectious disease are never fully in control of their status as either victims or vectors,110 the extent of control or lack of it vary significantly when geographic divides are examined (for instance, Euro-American versus Afro-Asian contexts) and economic (North versus South contexts). The level of control that people in developing economies have by way of access to requisite drugs is also limited partly because BigPharma companies hardly address the drug needs of less industrialized nations who are too poor to pay out of pockets for drugs and can hardly attract commercially-driven research and development. As such, BigPharma prioritizes drugs for medical conditions that are common among populations in industrialized countries.111 Hence, the possibility that concerted efforts will be made to develop effective drugs against ADR-TB—a pathology of mostly poor people—seems bleak. From 1975 to 2004, only 1.3% of the 1556 new chemical entities registered were meant for use for tropical diseases and tuberculosis,112 with which countries of the South are hardest hit. The trifling level of pharmaceutical development in most poor nations, therefore, makes their citizens doubly vulnerable to ADR-TB. This analysis again shows that while infectious diseases remind us of our vulnerability to assaults from outside the person,113 the extent and significance of vulnerability associated with ADR-TB vary by geographic, social, and economic contexts. Nevertheless, the forces of globalization are rapidly shrinking the geographic boundaries of vulnerability embedded in ADR-TB. In other words, beyond structural causes of vulnerability in countries of the South, the common human frailties and susceptibility to harm shared by people across geographic and social lines are avenues through which ADR-TB vulnerabilities may transit one point to the next, aided by modern means of transportation. Refugees and asylum seekers from tuberculosis-­ravaged regions present a potential nexus through which infection may be exported. Some novel demands or access that are increasingly open to people  Jassal and Bishai. P. 21.  Dorman and Chaisson. P. 295. 110  Battin et al. P. 275. 111  Afolabi, “A Disruptive Innovation Model for Indigenous Medicine Research: A Nigerian Perspective.” p. 448; Solomon Nwaka, “Drug Discovery and Beyond: The Role of Public-Private Partnerships in Improving Access to New Malaria Medicines,” Transactions of the Royal Society of Tropical Medicine and Hygiene 99, no. Supplement 1 (2005). Pp. 20–26; Salomeh Keyhani and Joseph S Ross, “The Cost of Pharmaceutical Innovation to Patients,” Expert Opinion on Drug Discovery 2, no. 11 (2007). Pp.1431–1433. 112  M Berger et  al., “Strengthening Pharmaceutical Innovation in Africa,” in Council on Health Research for Development (COHRED) New Partnership for Africa’s Development (NEPAD). ISBN (2010). P.16. 113  Leslie P Francis et al., “How Infectious Diseases Got Left out–and What This Omission Might Have Meant for Bioethics,” Bioethics 19, no. 4 (2005). P. 312. 108 109

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through globalization may serve also as infection routes. For example, an increase in the number of tourists seeking ‘sex tourism’ in developing economies has been identified as a possible route for the spread of ADR-TB.114 While this may merely reflect a sensual adventure, it is nevertheless known that globalization allows personal relationships to be formed including marriages.115 The notional downside, however, is the possibility that some international partners (regardless of gender) may be harboring latent forms of TB which may evolve to ADR-TB. If infection lacks regard for geographic boundaries,116 then the possibility of ADR-TB spreading through transnational/international marriages and other sexual relationships suggests the idea that the process of getting an infection seems to have no respect for the sacred space of human affection and intimacy. The report of Nuzzo et al. sheds another global dimension to the vulnerability associated with ADR-TB.  They found that the rate of treatment completion for latent tuberculosis infection in the Baltimore area of the United States was significantly higher among refugees than other referral groups.117 If refugees (from foreign local context) do pose risks but do better at adherence to therapeutic regimen (compared to local residents), then it means that partially treated and untreated residents are a potential source of infection transmission and amplification. This suggests the importance of individual decision making and choice in stemming or accelerating the spread of ADR-TB (in contexts where some measure of treatment options are available), and how this ultimately influences the susceptibility of others. It also raises questions about how the autonomy of one person may affect the health of those around them as well as what human rights are guaranteed when some conflation of interests or needs occurs, and what rights are fluid and negotiable.

4.2.2  Autonomy & Human Rights Autonomy embeds the idea that people as individuals are separate from the rest of the society or community where they live. It recognizes individual variances as well as the freedom to make choices unhindered. In bioethics discourses, the notion of autonomy is generally regarded to be grounded within the Euro-American tradition and subsumes the presence of the capacity for self-regulation,118 judgment, and  Jalal-Eddeen Abubakar Saleh and PH Haruna Ismaila Adamu, “Globalization and the Spread of Multi-Drug Resistant Tuberculosis,” Globalization 18 (2015). P. 21. 115  Katharine Charsley, Transnational Marriage: New Perspectives from Europe and Beyond (Routledge, 2013). Pp. 19–21. 116  Solomon R Benatar, Abdallah S Daar, and Peter A Singer, “Global Health Ethics: The Rationale for Mutual Caring,” International Affairs 79, no. 1 (2003). Pp. 111–112. 117  Jennifer B Nuzzo et al., “Analysis of Latent Tuberculosis Infection Treatment Adherence among Refugees and Other Patient Groups Referred to the Baltimore City Health Department Tb Clinic, February 2009–March 2011,” Journal of Immigrant and Minority Health 17, no. 1 (2015). Pp. 56–64. 118  Simon Woods, “Respect for Autonomy and Palliative Care,” in Euthanasia: European Perspectives, ed. Henk ten Have and David Clarke (2005). P. 146. 114

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action.119 Yet, this does not mean that other societies are bereft of the idea of the “separatehood” or separateness of individuals from others. Rather, the degree of emphasis on the interaction of individuals with the society as well as the corresponding responsibilities are some of the core features that make the construction of autonomy different in non-Euro-American niches. Inherent in the notion of autonomy is the idea of competence or the choice of acceptance or refusal on the basis of cognitive comprehension120 as well as freedom from undue second party interference of choice and/action.121 Although considered as a reflection of veridical accounts of persons’ preferences,122 autonomy is not simply about the choices of separate and separable agents who interact with one another only in a contingent manner.123 For Francis et al., autonomy is reasoned choice by a competent individual.124 However, this hides a number of assumptions. One, it implies the presence of some consensus or a clear frame of reference as regards what is considered a reasonable as opposed to an unreasonable choice within and across cultures and contexts. Secondly, it glosses over the thorny issues embedded around the notion of competence. Lastly, not all reasonable and competent humans who inhabit the world think from an individualistic conceptual enclave. It is even hard to insist that rural communities in a Western nation like the United States are completely couched in individualism without significant fringes of communal tendencies and moral inclinations. Applied to the context of atypical drug-resistant tuberculosis, the conception of autonomy will shape the stridency of the attendant quandaries. Prevailing ontologies which govern everyday lives will influence what will be considered ethical as well as what will be discountenanced across geographic and socio-cultural domains. Autonomy is also a strong feature of the increasing interconnection between health, the right to health, and human rights.125 To be sure, both the 1948 Universal Declaration of Human Rights and the 1966 International Covenant on Economic, Social and Cultural Rights documents enunciate the rights of “everyone to the enjoyment of the highest attainable standard of physical and mental health”.126 It is, therefore, expected that the affirmation of rights-related responsibilities from healthcare providers and the society to patients127 in relation to the conception of autonomy will shape how rights-related issues play out in the health context and in pulic health disaster scenarios.  Gerald Dworkin, The Theory and Practice of Autonomy (Cambridge University Press, 1988). pp. 40–41. 120  David F Kelly, Medical Care at the End of Life: A Catholic Perspective (Georgetown University Press, 2006). P. 29. 121  Tom L Beauchamp and James F Childress, Principles of Biomedical Ethics (Oxford university press, 2013). Pp. 5–15. 122  Woods. P. 150. 123  Battin et al. P. 279. 124  Francis et al. P. 318. 125  Forman and Nixon. P. 54. 126  Slagle et al. P. 2. 127  Jonathan M Mann, “Medicine and Public Health, Ethics and Human Rights,” Hastings Center Report 27, no. 3 (1997). Pp. 6–9. 119

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Yet, this analysis partly implies that the idea of human right and its linkage to the sphere of health stems from at least two morally contractual foundations. The first arises from the society, may be championed by government activities as well as the activities of Civl organizations and other non-governmental organizations that directly or indirectly have some bearing on the health of individuals and people. The second foundation stems from the fiduciary obligations that health professionals have towards fostering the health of patients and potential patients in a fashion that preserves their rights as human beings. Also implicit in this notion is the two-way nature of the rights rhetoric. That is, the rights of all ought to be guaranteed generally and as it applies to the health context. In traditional Western societies and in Westernized climes, most people value individual freedom and construe it as an inviolable “right”. In the American context where the ethos of moralism, meliorism, and individualism generally prevail,128 the fate of those carrying an infectious disease is generally not tied to that of the collective society. This reflects the moral tension in public health ethics where the atomization of persons’ interests run contrary to collective community interests. Applied to ADR-TB, an autonomy-driven ideology will shape the pace of compliance to public health injunctions. In the United States, there has been some empirical evidence of this in relation to TB exemplified by the cases of Robert Daniels (who refused to comply with directives to wear a mask to prevent disease dissemination in public) and Andrew Speaker (who ignored public health orders and traversed national and international borders).129 The actions of these Americans echo the idea that health policies and programs are discriminatory and burdensome on the grounds of human rights; hence, are to be challenged.130 It likewise reflects the  largely Western self-centric “me, myself, and I” mantra which prioritizes freedom and self-­ determination above all other considerations.131 But this raises at least two different moral dilemmas. One, it assumes that infected people should take moral responsibility for a disaster in which they themselves are merely victims. Secondly, individuals are hardly responsible for the sociological and economic (and sometimes human) factors that combine to create inept health systems in which infectious diseases such as TB readily run amok. As such, restricting the rights of people infected with ADR-TB through actions such as quarantine or imprisonment (as occurred in Kenya in 2010) approximates punishing them for the inadequacy of failed health systems132 in which they have largely played no part to create (except where they have participated in electing weak or incompetent political office-holders and leaders).

 Albert R Jonsen, The Birth of Bioethics (Oxford University Press, 2000). P. 390.  Upshur. Pp. 53–54. 130  Jonathan M Mann et al., “Health and Human Rights,” Health and Human Rights 1, no. 1 (1994). P. 16. 131  Eric J Cassell, The Nature of Suffering and the Goals of Medicine (Oxford University Press, 2004). Pp. 23, 25–26. 132  Slagle et al. P. 2. 128 129

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Drug resistance as it concerns certain diseases including tuberculosis poses substantial infringements on individual freedom and liberties. This becomes thorny considering the caveat of refraining from harming others which is embedded within the language of rights.133 In other words, resolving the conflicts between the interests of a known individual (with an infectious disease such as ADR-TB) against those of a real but unidentifiable person by default goes in favor of the infected, when the right rhetoric is invoked. However, this becomes reversed in a context of isolation which seeks to place some restrictions on the activities of a known infected person, typically at a treatment center where they can receive appropriate medical care to prevent or limit the transmission of disease to other members of the society.134 Under such circumstances, refusal to be isolated will clearly wreak public health havoc on the populace if the infected person is in the active phase of ADR-TB. However well-intentioned the human right rhetoric is, it seems to embed some form of self-centeredness. In the name of rights, the HIV/AIDS advocacy for access to experimental drugs in the 80s135 underscored the willingness of infected people to accept some risk to their lives in the expectation of profiting from ongoing clinical trials. In the Western context, the rights language  is sometimes used as a tool of convenience by individuals to attempt to draw personal benefits without considering the possible repercussion on the fate of others. These benefits may range from privacy to freedom of movement (illustrated by Speaker and Daniels’ cases). Although the atomistic model of autonomy is inadequate and at best is an abbreviation of the normative scheme of things in relation to infectiousness136; it has hitherto shaped some public health policies on infectious diseases. For example, consistent with the rights ideology, an exceptionalist perspective emerged as a right in relation to the moral dilemmas of HIV/AIDS which relied on education for mass behavioral change rather than restrictive public health measures.137 Yet, the minimal amount of behavioral control involved in the spread of ADR-TB precludes a similar approach. Non-Western contexts hardly rely heavily on the atomistic model of autonomy. Emphasis is rather focused on inter-relationships. As such, the stridency of autonomy is often muted in the African context where the Ubuntu (exemplified by the I-am-because-we-are logic) precept or variations of it generally holds sway138 or the Asian context where Confucianism (which elevates family and society above self) is rife.139 Because non-Western moral outlooks are obligation-based, the assertion  Lachmann. P. 301.  Nuffield. P. 72. 135  John Y Jr. Killen, “Hiv Research,” in The Oxford Textbook of Clinical Research Ethics, ed. Ezekiel J Emanuel, et al. (Oxford: Oxford University Press, 2008). Pp. 97–105. 136  Battin et al. P. 275. 137  Ronald Bayer and Amy L Fairchild, “The Genesis of Public Health Ethics,” Bioethics 18, no. 6 (2004). P. 478. 138  Yusef Waghid and Paul Smeyers, “Reconsidering Ubuntu: On the Educational Potential of a Particular Ethic of Care,” Educational Philosophy and Theory 44, no. s2 (2012). P. 11. 139  Neil A Englehart, “Rights and Culture in the Asian Values Argument: The Rise and Fall of Confucian Ethics in Singapore,” Human Rights Quarterly 22, no. 2 (2000). Pp. 561–566. 133 134

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and use of human rights rhetoric generally and in the specific context of health has not been at par with the way it is employed in the Euro-American context, though it is held that being human confers some rights or dignity to persons. In the African healthcare context, the endogenous cultural and cognitive values have been largely discountenanced while Western theoretical currents with her biomedical conception of health and disease operate and drive the system. This has created an entrenched systemic dislocation140 where faithfulness to the Western model is hardly ever pursued adequately as most of the rhetoric employed generally alienate the people (except the elite and professionals).141 Within such a climate, the Western notion of right as well as its attendant praxis operates weakly or inconsistently. Another reason why the notion of rights has  a minimal foothold in the non-Euro-American context relates to the lack of concretized and visible dimensions to rights as people daily grapple with socio-political constraints.142 In this vein, bioethicists like Churchill argue that mainstream bioethical issues tend to be far-flung from the values of ordinary people and often irrelevant to the decisions they experience in their encounter with healthcare.143 What seems obvious, however, is that the affirmation of autonomy in the face of the risk of infection will put the uninfected and the larger society at risk, thus, negating the telos of public health. Hence, preserving autonomy and rights in the dawn of a silent public health disaster like ADR-TB is very problematic, morally and practically. Perhaps, placing more emphasis on mutual responsibilities rather than pursuing the human rights approach may offer a better and more flexible way to engage the autonomy and rights-related quandaries that are at the heart of atypical drug-­ resistant tuberculosis. In relation to the moral challenges of ADR-TB, socio-political issues and the obligations owed between contextual actors such as patients, community or healthcare providers should occupy a central position. For instance, in South Africa some ADR-TB patients have been known to resist mandatory detention and abscond from the hospital/ treatment centers to take refuge in the community while still being infectious.144 Such a scenario where a community would willingly shield and harbor an infectious person clearly illustrates the depth of the obligation-based praxis in the African context. In another manner, it probably also reflects how the poor state of government-run health insurance schemes145 (which leaves healthcare  Michael O.S.  Afolabi, “Entrenched Colonial Influences and the Dislocation of Healthcare in Africa,” Journal of Black and African Arts and Civilization 5, no. 11 (2011). Pp. 229–230. 141  Afolabi “Re-Writing Realities through the Language of Healing; a Critical Examination” (paper presented at the Ibadan International Conference on African Literature Ibadan: Nigeria, July 3–6 2008). Pp. 5–15. 142  Claude Ake, “The African Context of Human Rights,” Africa Today 34, no. 1/2 (1987). Pp. 10–11. 143  Larry R Churchill, “Are We Professionals? A Critical Look at the Social Role of Bioethicists,” Daedalus 128, no. 4 (1999). Pp. 253–257. 144  Upshur. P. 55. 145  Afolabi, “A Disruptive Innovation Model for Indigenous Medicine Research: A Nigerian Perspective.” P. 445. 140

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cost almost exclusively on individual purchasing power) may elevate economic considerations over those related to health. For instance, confronted with the choice of meeting family-related obligations and paying for preventive medical services, many people will choose the former. This idea echoes the notion that medicine cannot serve humankind without attending to both personal and communal needs.146 It also shows how personal and micro-communal obligations may foist some forms of harm to collective well-being. It will be, therefore, illuminating to elaborate harm as well as the related issue of social justice vis-à-vis how the clash of obligations and the attendant harm come to the fore.

4.2.3  Harm & Social Justice Harm embeds the process of circumventing the interest of a person or persons. In ethical discourse, harm is often associated with human agency such that while Mr. A could harm Mr. B or a group of persons X, Y, and Z; such capability is not generally ascribed to non-human agents. It is generally believed that there exists a moral duty to behave responsibly and not knowingly put other people at risk. This duty is especially affirmed and applied to people with communicable diseases.147 Therefore, harming a second party constitutes a moral infraction. This idea has a strong tangible and appealing dimension because contracting an infectious disease such as ADR-TB entails the possibility of death to the self, transmitting it and the possibility of killing148 an other or some others. Generally, ADR-TB imposes devastating human suffering and isolation upon patients, their communities as well as those called upon to help them.149 Hence, it is a source of medical and social harm. Specifically, there are at least three kinds of harm embedded in atypical drug-resistant TB. The first relates to the consequences of health interventions, another is inherent and tied to infected persons while the third is tied to the uncertain and nuanced nature of its biological and social dissemination. These harms may either translate into personal harm (at the individual level where disease progression may or may not lead to death) or social harm (at the communal or global plane where the individual harm logarithmically transmits infection within and across geographic borders). That ADR-TB causes both personal and social harms suggests the inadequacy of the traditional public health approach of seeking to weigh and balance personal interests against societal interests vis-à-vis making public health decisions.

 Edmund D Pellegrino, Humanism and the Physician (University of Tennessee Press, 1979). P. 103 147  Harris and Holm. P. 1217. 148  Battin et al. P. 276. 149  von Delft et al. P. 275. 146

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Although public health responsibilities are implemented through policies and programs promulgated by, or with support from, the state.150 Specific government programs that seek to foster collective wellbeing via the restriction of individual liberties such as isolation and mandatory treatment may be interpreted as a form of harm in the Western libertarian tradition. However, within the same ideological niche it is held by many that the avoidance of significant harm from person A to others who are at risk from a serious communicable disease such as tuberculosis outweighs consideration of personal privacy or confidentiality; though overriding this right must be to the minimum extent possible to achieve the desired aim.151 In non-Western obligation-based traditions, such measures may be interpreted as embodying two related kinds of obligation between the sick and healthy members of the society. To those with infectious diseases such as ADR-TB, the State—by adopting such public health interventions—is simply carrying out its health-related obligation to preserve and improve the lives of her citizens, regardless of their status of sickness. Conversely, sick people are expected to place communal interests above personal considerations, as such, will be obligated not only to report infection but to follow through with the requisite course of health interventions that the country provides. Failure on the part of sick infectious people to do this will thus be regarded as some breach of moral obligation and may be punished to deter other members of the society from following a similar course of action when under the same circumstances. This scenario partly explains (but does not justify) why two non-adherent TB patients were considered a source of a public health threat in Kenya and imprisoned in 2010 for several months,152 an action that was in alignment with Kenya’s Public Health Act.153 This partly echoes the importance of engaging bioethicists and bioethical insights in designing public health policies. There is a global dimension to harm that warrants mentioning. The rapid transit of people today means that a Westerner infected with ADR-TB may be visiting another part of the globe where communal interests are prioritized (generally or contextually) when a diagnosis is made. The use of the local policies to enforce compliance with requisite interventions including quarantine measures for such a person may be deemed harmful due to the exclusive rights-based rhetoric to which s/he is accustomed. This partly echoes the nuances embedded in what may or may not count as harmful as well as how the idea of harm and its ethical overtones lack a coherent, consensual meaning  across different sociocultural contexts. Consequently, if harm constitutes an unsavory process or action, then there is a corresponding duty to reduce or eliminate it.

 Jonathan M Mann et al., “Health and Ruman Rights,” Health and Human Rights 1, no. 1 (1994). P.13. 151  Nuffield. P. 66. 152  Slagle et al. P. 2. 153  JD Brian Citro et al., “Developing a Human Rights-Based Approach to Tuberculosis,” Health and Human Rights 18, no. 1 (2016). P. 3. 150

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Although the harm reduction rhetoric has featured in ethical debates about illegal drug use, adolescence health and behavior, mental health, and end of life154; it has hardly been applied to disaster contexts. Since ADR-TB constitutes a form of silent public health disaster, it may be insightful to engage and see how the principle of harm reduction may be applicable. Although the notion of harm reduction is fraught with conceptual ambiguities, it has become an integral aspect of public health activities.155 Its ethical thrust lies in the distinction between justifying it per se and justifying specific kinds of harm reduction policies and programs. In other words, harm reduction focuses on the ethical legitimacy of specific interventions,156 and employs this as a moral gauge for determining the best course of action. Stephen Holland echoes and affirms this line of reasoning by showing some of the moral stand-offs that ensue when different ethical theories including utilitarianism, Kantianism, and communitarianism are employed to justify harm reduction broadly. He concludes that it is better to focus on specific harm reduction strategies rather than seeking broad theoretical justifications.157 Hence, reducing the three kinds of harm associated with ADR-TB entails paying attention to the individual dynamics of each. For instance, engaging the socio-­ political domain which expedites the onset of ADR-TB (such as high cost of TB drugs, the high prevalence of HIV/AIDS, weak health systems and networks et cetera) is a critical and non-negotiable step. Developing a framework that creatively reckons with the dynamics of the attendant uncertainty is equally important. The problematic nature of harm and the ways through which it may be reduced, at least in the context of infectious diseases, is that it lumps diverse interests together, thereby, creating a potential avenue for wrongfully shortchanging the interests of some of the parties concerned. This leads to the question of social justice. If social justice is conceived as impartiality158 and reflects the internal arrangements and structures within a society; then the myriads of social, economic, and health-related variations within individual societies imply that internal injustice, however limited, exists in most societies. This sheds some light on the negotiated nature of justice. For Beauchamp and Childress, justice entails increasing utility in a mutually fair and harmonious atmosphere that is open to contextual values and needs, and in a manner that presents the least burdens to all parties concerned.159 However, since what is termed burdensome often has individual and situational variations as well as the attached significance, deciding what is really “less burdensome” is hardly straightforward. Applied to the context of ADR-TB, social justice at the local and global planes constitutes a thorny issue. In the local plane, social inequalities are known to favor and facilitate the emergence of disease.160 It is,  Holland, Pp. 174–184.  Holland. Pp. 161–164. 156  John Kleinig, “The Ethics of Harm Reduction,” Substance Use & Misuse 43, no. 1 (2008). P. 8. 157  Holland. P. 167. 158  Brian M Barry, Justice as Impartiality (Oxford University Press, 1995). Pp. 1–15. 159  Beauchamp and Childress. Pp. 250–258. 160  Paul Farmer, “Social Inequalities and Emerging Infectious Diseases,” Emerging Infectious Diseases 2, no. 4 (1996). P. 267. 154 155

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therefore, doubtful how a least burdensome approach may come to fore vis-a-vis resolving the interests of the sick (such as retaining the latitude to move about and mingle freely and the refusal of public health interventions) and those of the society or community (such as avoiding the risk of infection from infected members). In the global context, extant factors such as the 10/90 gap, disparities in political power structures, stark variation in technological capabilities and the historical differences of colonialism and slavery (present in the South and absent in the North) show that discussing the idea of free and equal human beings161 is more of a myth in terms of global justice. In relation to ADR-TB, the lack of scientific and pharmaceutical resources, the entrenched problem of HIV/AIDS as well as the economic situation which generally make countries in the South more vulnerable, hence, more susceptible specifically highlight how the current scheme of things hardly foster global justice. Without addressing all or most of these background factors, it will be difficult to engage the global justice issues embedded in atypical drug-resistant tuberculosis.

4.3  A  n Anthropo-ecological Approach to Atypical Drug-­Resistant Tuberculosis Although Hernández-Marrero et  al. recently observed that the development of a bioethical framework for antibiotherapy requires a careful analysis of the ethical issues “behind the scenes”,162 this has not been developed. At the heart of the moral quandaries associated with atypical drug-resistant tuberculosis is a two-dimensional relational dissonance. One relates to what humans may do (e.g. quarantine) or fail to do (e.g. social justice) to others and how these specific courses of actions impact on the lives of others (e.g. harm). The second dimension embodies the nexus of the relationship between humans and microbial life and how this passively (e.g. existential vulnerability) or actively affect the welfare of people (e.g. harm from non-­ adherence to treatment regimen) and how bacterial species such as M. tuberculosis respond by evolving drug-resistant mechanisms (e.g. biological vulnerability). Examining this analysis closely, it is possible to argue that a multi-faceted approach is needed to address the concerns of ADR-TB. Scholars like Peckham and Hann note that a motley of forces shape public health actions163; and by implication

 David R Buchanan, “Autonomy, Paternalism, and Justice: Ethical Priorities in Public Health,” American Journal of Public Health 98, no. 1 (2008). P. 17. 162   Pablo Hernández-Marrero et  al., “Toward a Bioethical Framework for Antibiotic Use, Antimicrobial Resistance and for Empirically Designing Ethically Robust Strategies to Protect Human Health: A Research Protocol,” Journal of International Medical Research 45, no. 6 (2017). Pp. 1787–1789. 163  Stephen Peckham and Alison Hann, “Conclusion: Taking Forward the Debate,” in Public Health Ethics and Practice, ed. Stephen Peckham and Alison Hann (Policy Press, 2010). P. 215. 161

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its attendant ethics. If this is true, and if a silent public health disaster such as ADR-TB embeds public health concerns as well as disaster elements, a multi-­ faceted approach seems most germane. This must necessarily involve the social, microbial, and environmental dynamics in which human life is enmeshed. Specifically, an approach that acknowledges that infectious patients are both persons-­in-need as well as vectors or persons-as-threats164 while factoring in the teleological elusiveness of microbes as well as a re-understanding of the nature of the individual agent in terms of infectious disease165 will help connect these issues. It will likewise furnish some of the relevant conceptual building blocks upon which an ethical approach may be developed in relation to addressing the moral and practical aspects of ADR-TB.  Against this conceptual backdrop, this section seeks to frame an anthropo-ecological approach to the moral quandaries that ADR-TB elicits.

4.3.1  Clarifying an Anthropo-ecological Ethic This segment clarifies and fleshes out the parameters of the anthropo-ecological ethic that is proposed to help engage the moral quandaries that atypical drug-­ resistant tuberculosis elicits. Simply put, this involves an approach that combines human factors (anthropo) with the dynamics of the ecosystem (eco) in order to frame a normative approach to the dilemmas of ADR-TB. This partly echoes Van Rensselaer Potter’s idea about the significance of the ecosystem in relation to ethical reflections.166 Since human beings are both biological and social beings, exploring humanity’s biological and social nature and how each of these fosters the phenomenon of ADR-TB will provide the insights exigent to formulating the anthropo-ecological ethical approach. If values derive partly from a normative understanding of human nature and from a transcendental or secular perspective on life and the world,167 exploring and ­examining the role of microbial life in the context of an ethical model is a significant option for ethical analyses. Today, humankind—represented largely by the learned and scientific community—may be said to be driven by the hubris of technological achievements to the extent that nothing is seen to be impossible. This hubris partly explains why humankind is increasingly trapped in the web of his technological triumph,168 and it is partly evident in the context of infectious diseases. Writing  Battin et al. P. 272.  Francis et al. P. 321. 166  Van Rensselaer Potter, “Bioethics, Science of Survival,” Perspectives in Biology and Medicine 14, no. 1 (1970). Pp. 134, 151–152. 167  H Tristram Engelhardt Jr., “Consensus: How Much Can We Hope For?,” in The Concept of Moral Consensus, ed. Kurt Bayertz (Springer, 1994). P. 23. 168  Benjamin A Kogan, Health: Man in a Changing Environment (Harcourt Brace Jovanovich, Inc., 1970). P. ix. 164 165

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along these lines of thought, Sonia Shah notes that people generally see themselves as victors fighting a winnable war against pathogens. But such a simplistic enemy-­ victor dichotomy does not capture the complexity of the matter.169 Chiarelli echoes this idea in stating that in the pursuit to dominate the natural world, humanity has generally lost sight of the need to balance their interaction with the natural world and with all other forms of life.170 If the world is emergent and warrants ongoing explanatory approximations of its state of affairs,171 then humans as a critical part of the organisms that inhabit the world need to be fluid and open in engaging the data and challenges of living in the world. However, humans hardly live alone but live rather in local and global communities which are a part of a larger ecosystem where microbial life-forms also live. In addition to the human-human inter-relationship which inevitably forms the fabric of life, biological organisms are legitimate tenants of the earth. This analysis underscores the idea that a human-human and a human-microbial relationship constitute a phenomenological reality. Therefore, paying attention to the nature and nuances of these relationships may provide a leeway for examining the moral quandaries of infectious diseases (such as atypical drug-resistant tuberculosis) which are by-­ products of derangements or disharmonies in these same relationships. In the context of infectious diseases, this biological inter-connection has hitherto been neglected, though the limits of the biomedical model of health abound.172 Indeed, bioethicists like Benatar, Daar, and Singer have voiced the idea that the re-­emergence of tuberculosis in multi-drug resistant variations show that the hope of a complete victory over infectious diseases might be a mirage, and illustrate the limits of a narrow scientific approach.173 In other words, without an understanding of the complex relationship patterns between human-human relatedness and human-bacterial life relatedness, a harmonious truce may never be reached in relation to ADR-TB. The need for a relational approach reflected by an anthropo-ecological ethics was recently echoed by Citro and others. For them, in an era of globalization tuberculosis can no longer be fought exclusively through biomedical and public health-based perspectives.174 Humans live in an environment filled with microbes whose means of subsistence often involves moving from one individual human person to the other.175 Infectious diseases have an evolutionary advantage over human hosts partly because of their  Sonia Shah, Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond (New York: Sarah Crichton Books, 2016). Pp. 208–209. 170  Brunetto Chiarelli, “The Bioecological Bases of Global Bioethics,” Global Bioethics 25, no. 1 (2014). Pp. 19–20. 171  Karl R Popper, The Open Universe: An Argument for Indeterminism, ed. W.W. Bartley (London: Routledge, 1982). Pp. 46, 130. 172  Mark Tausig et al., “Taking Sociology Seriously: A New Approach to the Bioethical Problems of Infectious Disease,” Sociology of Health & Illness 28, no. 6 (2006). P. 842. 173  Benatar, Daar, and Singer. P. 111. 174  Brian Citro et al. P. 6. 175  Battin et al. P. 280. 169

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replicative and mutational capacities that render them highly adaptable, and partly because they rely closely on the nature and complexity of human behavior to thrive.176 Despite the fact that medical science has recorded tremendous strides in stemming the tide of infectious diseases in the twentieth century,177 the evolutionary capacity of infectious pathogens such as Mycobacterium tuberculosis to adapt to new ecologic niches as well as to pressures directed at their elimination will always foment new or re-emerging infectious threats. Hence, the perpetual challenge of infectious diseases such as TB demands perpetual responses.178 From an anthropological perspective, atypical drug-resistant tuberculosis as a type of infection poses continuous cycles of victories and defeats against ever-­ changing biological foes.179 This challenges the long-held notion of Paul Erlich’s magic bullet with the capacity to eradicate infections and achieve a perfect cure. It also sounds a bleak expectation for the capacity of public health to have a once-for-­ all win in the war on infectious diseases and affirms the idea that all human communities are vulnerable to biological organismic activities. Common vulnerability should, however, engender common and coordinated social responses. Battin et al. argue that this common susceptibility should spur the need to include biological vulnerabilities into the normative account of human moral agency.180 The human condition is such that life and death, illness and health are unavoidable experiential expectations.181 Infectious agents with whom humans share the world contribute to this cycle in different ways. In addition, other humans—also legitimate fellow earth-dwellers—may infect and be infected by others in a manner beyond their personal choices.182 This again echoes the notion that humans are all vulnerable to the potential infections that other humans may spread. It likewise ­highlights the need to consider the circumstances and dynamics of potentially transmitting vectors183 between and amongst humans. Antimicrobial drug resistance tends to reflect the teleological inter-species war in which the fittest alone often survives and thrives. From an anthropological perspective, microbes such as M. tuberculosis are merely parasites that require endless elimination through modern arsenals of antibiotics. This is often supported by the idea that humankind will soon or late discover the right drug for every infectious disease.184 From a teleologic standpoint, however, some bacteriologists believe that it is not in the best interest of pathogens to kill their hosts because the death of the  Fauci and Morens. P. 455.  Neil M Ampel, “Plagues—What’s Past Is Present: Thoughts on the Origin and History of New Infectious Diseases,” Review of Infectious Diseases 13, no. 4 (1991). P.658. 178  Fauci and Morens. P.460. 179  Ampel. P. 664. 180  Battin et al. Pp. 276–277. 181  Henk AMJ ten Have, “Medicine and the Cartesian Image of Man,” Theoretical Medicine 8, no. 2 (1987). P. 244. 182  Francis et al. P. 320. 183  Ibid. P. 322. 184  Lachmann. PP. 297–301. 176 177

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host often translates into the death of the pathogen.185 On this basis, humans and microorganisms may be partners in nature,186 each usually looking out to his and its interests through a relationship that may inadvertently and even sometimes directly harm the other. Perhaps, this state of affairs ought to give room for some kind of existential compromise between humankind and microbial life, reflecting the stance of Lepora and Goodin on the need for an ethical compromise in relation to dealing with disasters.187 If this is true, then there is an increasing need to realize that antibacterial drug resistance in general and related phenomena such as ADR-TB are here to stay. This is especially so considering the observation made by scholars like Stewart Cole that there will hardly be another golden age of antimicrobial drug development.188 Every living organism in the ecosystem confronts a constant threat by other organisms; as a result, each species has an elaborate adaptive learning system to protect its interests.189 With reference to this idea, drug-resistance may be described as a flexible protective system that enables bacteria species such as M. tuberculosis to thrive in a hostile world of antibiotics. Therefore, in addition to being a teleological response to ensure species survival vis-à-vis humankind’s constant barrage of magic bullets, antimicrobial drug resistance such as ADR-TB seems to reflect a form of biological solidarity. Visick and Fuqua, for instance, note that microbial life forms including bacteria talk to one another, though biologists are yet to understand what they are saying; or what wavelength to tune-in to listen.190 But it is known that complex microbial populations exist in nature under conditions of b­ iological solidarity and interdependence connected by a web of chemical signals, using many types of molecules.191 Against this background, antimicrobial drug-­resistance seems to represent some type of coping mechanism in an increasingly hostile environment. Years ago, sociologists like Baldwin described biological solidarity as a natural instinct that seeks to ensure the survival of biological organisms.192 If one subscribes

 Johnny W.  Peterson, “Bacterial Pathogenesis.,” in Medical Microbiology. 4th Edition, ed. Samuel Baron (Galveston: University of Texas Medical Branch at Galveston, 1996). 186  Howard B Radest, Bioethics: Catastrophic Events in a Time of Terror (Lexington Books, 2009). P. ix. 187  Chiara Lepora and Robert E Goodin, On Complicity and Compromise (OUP Oxford, 2013). Pp. 14–17. 188  Cole. P. 1. 189  Dipankar Dasgupta, “Immunity-Based Intrusion Detection System: A General Framework” (paper presented at the Proceedings of the 22nd National Information Systems Security Conference, 1999). Pp.1–2. 190  Karen L Visick and Clay Fuqua, “Decoding Microbial Chatter: Cell-Cell Communication in Bacteria,” Journal of Bacteriology 187, no. 16 (2005). Pp. 5507–5514. 191  Julian Davies, “Are Antibiotics Naturally Antibiotics?,” Journal of Industrial Microbiology and Biotechnology 33, no. 7 (2006). P. 498. 192  J Mark Baldwin, “The Basis of Social Solidarity,” The American Journal of Sociology 15, no. 6 (1910). Pp. 823–824. 185

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to this notion, then the use of innate resistance mechanisms such as efflux pumps193 to render antibiotics such as first and second line anti-TB drugs therapeutically ineffective reflect the notion that disease-causing bacteria are teleologically equipped to face the shifting tide of humanity’s antibiotic war. Bacteriologists like Gold and Moellering have sounded some warning about the rise of resistance to new classes of drugs, to the extent that the capacity of new antimicrobial drugs to keep pace with the development of resistance is barely feasible.194 On this note, the medical model of disease which typically focuses its gaze on the pathogenesis and pathophysiology of diseases while ignoring relevant anthropological questions including “why here and now?”195 needs supplementation from anthropological insights with a renewed understanding of the teleology of microbes. That antimicrobial drug resistance including ADR-TB entails some evolutionary advantage of microbes over their human host196 is an indicator of a pressing need to combine anthropological insights with knowledge of the role of infection-causing bacteria in the ecosystem to develop an approach that can help engage the practical as well as the moral aspects of the phenomenon. Concerning the challenges of ADR-TB, thinking outside the box seems not to currently preoccupy scientists as a very recent review touted improvement in the detection of active ADR-TB cases and the development of new drugs and molecular diagnostic tools as the panacea.197 Public health disasters—as elaborated in Chap. 1—echoes the increasing intersection of traditional public health ethics and disaster bioethics. Addressing the quandaries of public health disasters would at least require some combination of public health and disaster-related interventions. Public health seeks to foster disease prevention, community health protection, as well as relevant behavioral modification198 and needs an annexation of the social context to realize such goals.199 On the other hand, disasters create situations where there is a rapid transition from the individual focus to crowd focus200 in order to ameliorate human suffering201; which subsequently often demands collective sympathy, solidarity, generosity, and action.202 If these premises are true, then an anthropo-ecological perspective offers

 Cole. P. 2.  Gold and Moellering Jr. Pp. 1447–1451. 195  ten Have, “The Anthropological Tradition in the Philosophy of Medicine.” Pp. 9–10. 196  Fauci and Morens. P. 455. 197  Keertan Dheda et al., “Recent Controversies About Mdr and Xdr-Tb: Global Implementation of the Who Shorter Mdr-Tb Regimen and Bedaquiline for All with Mdr-Tb?,” Respirology 23, no. 1 (2018). Pp. 39–42. 198  Lucas and Gilles. Pp. 1–9. 199  Peckham and Hann, “Introduction.” Pp. 2–5. 200  Pierre Mallia, “Towards an Ethical Theory in Disaster Situations,” Medicine, Health Care, and Philosophy 18, no. 1 (2015). P. 3. 201  Laurel A Spielberg and Lisa V Adams, Africa: A Practical Guide for Global Health Workers (UPNE, 2011). Pp. 1, 3. 202  ten Have, “Macro-Triage in Disaster Planning.” Pp. 16, 18. 193 194

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a broader approach for a silent public health disaster such as ADR-TB. But what might be some of the specific parameters of an anthropo-ecological ethic? An anthropo-ecological ethic constitutes a combination of the anthropological dimensions of human experiences and capacities with an understanding of microbial life forms vis-à-vis framing a normative moral lens. Hence, it is an ethical approach that involves identifying the vagaries of social, biological, and existential vulnerabilities that inevitably plague humankind. It also entails the realization that antimicrobial drug resistance may hardly be eliminated and recognizes the importance of paying attention to and enhancing some of the naturally-occurring antimicrobial tools inherent in the human physiology. Whereas the human body is laden with some inherent and contextual vulnerabilities it has some mechanical and chemical means to fight off infections, or limit their influences.203 Hence, humanity is not completely at the mercy of the onslaught of bacteria, regardless of their resistance or non-resistance capacities. In other words, drug resistance does not abolish the human body’s natural capacity to mount a flexible immune response to pathogens including M. tuberculosis.204 For example, most people—regardless of geographic origins—mount a CD4+ T-cell–mediated immune response to M. tuberculosis and employs this biological protective mechanism to control infection and garner protection against reinfection.205 Hence, while there is a biological, teleological and social vulnerability to ADR-TB, the complex web of inter-relationships between humans and other human beings and humans and bacterial life forms may furnish the conceptual fodder which can help fuel a normative approach. In more specific terms, an anthropo-­ ecological approach to a silent public health disaster such as ADR-TB embeds at least three critical dimensions. Firstly, a notion of common vulnerability between human and microbial life-forms. Since bacterial species use some type of biological solidarity to evade humanity’s biological bullets, human beings need to deepen existing nexus of solidarity amongst one another locally and globally to face the common threat posed by ADR-TB. To be sure, if healthcare embodies an instinctual and institutional response to the dilemma of health and disease206 and partly reflects an unconscious reflex to help in response to the plight of infirm people207; traditional  Kogan. Pp. 156–158.  Michael C Abt et  al., “Tlr-7 Activation Enhances Il-22–Mediated Colonization Resistance against Vancomycin-Resistant Enterococcus,” Science: Translational Medicine 8, no. 327 (2016).; Greg J Fox et  al., “Preventing the Spread of Multidrug-Resistant Tuberculosis and Protecting Contacts of Infectious Cases,” Clinical Microbiology and Infection In Press (2016). Anne O’Garra et  al., “The Immune Response in Tuberculosis,” Annual Review of Immunology 31 (2013). Pp. 475–501; 205   Janis Kuby, “Immunology, 1997,” (WH Freeman and Company, New  York, 1997). Pp. 400–401. 206  Michael O.S. Afolabi, “Exploring the Technologies of Laboratory Science for Social Change: An Examination of the Nigerian Healthcare System” (paper presented at the 7th Globelics International Conference, Dakar, Senegal, 2009). Pp. 1–2. 207  ten Have, “The Anthropological Tradition in the Philosophy of Medicine.” P. 8. 203 204

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and new ways of fostering “collective action, companionship and realization of mutual interests”208 will be important to solving the challenges posed by a silent PHD like ADR-TB. At the social plane, this will help garner sympathy for the plight of the infected and foster social cooperation through public health policies and health programs. At the public health level, solidarity will increasingly motivate context-specific and humane interventions and responsibilities from both victims of ADR-TB, those that care about them, those that formulate public health policies, and the uninfected but infectable members of the society. A second dimension echoes the need to see as obligatory the solidarity and other social demands that infectious disease may foist on us as creatures united by a common humanity and facing the same microbial and human-mediated foe. This also involves uniting locally and globally to engage the complex background factors such as poverty and weak health institutions that make certain regions or certain people more vulnerable. Since an anthropo-ecological ethic like the immune mechanism seeks to help humankind overcome the challenges posed by antimicrobial drug resistance including ADR-TB, the third dimension involves adaptive learning. Specifically, this entails constant reviews of the successes and failures observed through the first two dimensions to identify and fill possible gaps and limitations. Against this conceptual template, it is necessary to examine how this anthropo-­ ecological perspective may specifically engage the moral quandaries raised by ADR-TB.

4.3.2  An Anthropo-ecological Ethic vis-a-vis the Quandaries of ADR-TB This section seeks to show how an anthropo-ecological ethic may help engage the ethical issues inherent in the phenomenon of ADR-TB. Whereas public health is inherently utilitarian,209 attempting to promote and salvage the welfare of the uninfected many against those of the few infected precludes a utilitarian lens. This is partly due to the silent and insidious nature of ADR-TB which blurs a clear-cut distinction between the uninfected and the sick by placing even those that are not yet diagnosed or infected in the category of the potentially infectable. Although differing contexts present different degrees of risks and susceptibility, this introduces an uncertainty dynamic which affects all. In this vein, an anthropo-­ ecological ethic conceives the plight of the infected and the potentially infected as a collective societal local problem, and by implication a global problem. This may provide the sort of social environment which may help prioritize tuberculosis control and research efforts, energized by the appearance of highly resistant strains such  Sister Mechtraud, “Durkheim’s Concept of Solidarity,” Philippine Sociological Review (1955). Pp. 23, 27. 209  Battin et al. P. 271. 208

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as ADR-TB that may not be halted unless immediate investments match the associated challenges.210 To this end, an anthropo-ecological perspective must necessarily deal with the moral quandaries and related challenges embedded in the phenomenon of ADR-TB. Hence, an elaboration of how specific issues such as uncertainty, vulnerability, harm, social justice, autonomy and human rights may be ethically examined and engaged through the lens of an anthropo-ecological ethic is necessary. 4.3.2.1  A  n Anthropo-ecological Ethic vis-a-vis Uncertainty & Vulnerability As elaborated in Sect. 4.2.1, there are three levels of uncertainty associated with ADR-TB. These reflect the possible risk of infection, what may or may not happen at a given moment and future-related risks. In each of these instances, an anthropo-­ ecological perspective may furnish some important insights. Possible risk of infection may be engaged by learning about the role of all the actors involved in ADR-TB, specifically, the kinds of human relationships and behavior that favor ADR-TB and gaining more biological insights into the evolution of typical Mycobacterium species into atypical strains. These sets of knowledge will demand some behavioral modification at the institutional and individual planes. At the institutional plane, social factors that enable the persistence of weak health infrastructures need to be carefully identified and fixed as well as factors such as unemployment and poverty which create ADR-TB-­ promoting conditions such as malnutrition. The institutional changes with the attendant societal overhaul will ultimately create conditions that will enhance individual choices (for example, anti-TB drug purchasing power and adherence to TB treatment schedules) which can slow down or prevent ADR-TB. However, due to the 10/90 gap, wealthier nations who also face the global and common threat of ADR-TB need to show some  degree of financial  solidarity towards less wealthy nations in their efforts to build and augment their health infrastructures. A justification for this sort of solidarity lies in the notion that someone from a nation financially constrained to provide diagnositic and relevant anti-TB drugs might end up disseminating ADR-TB in a wealthier nation. Hence, rendering pecuniary assistance in the context of ADR-TB ultimately consitutes an indirect means of preventing or slowing down the local, trans-national, and global sread of infection. An anthropo-ecological ethic will help in responding to the second type of uncertainty by placing an emphasis on infected people as human beings first to foster an approach that is both humane and compassion-laden. This will influence how quarantine measures, for instance, are implemented and will help avoid extreme measures such as imprisonment that was observed in Kenya. Since the future is largely a by-product of the present, engaging the possible and immediate risks posed by

210

 Raviglione and Smith. Pp. 658–659.

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ADR-TB through an anthropo-ecological ethic translates into reducing the future impact of its local and global spread. Levels of vulnerabilities are evident in ADR-TB such as the presence of existing diseases such as HIV/AIDS, the capacity of some strains of TB to develop atypical drug-resistance, modern realities such as sex tourism, transnational/international relationships and marriages, and an increase in global migration. These socio-­ biological vulnerabilities may be engaged by an anthropo-ecological ethic through an emphasis on the need to identify and build up weak health systems, sourcing local and global resources and actors to accomplish the task as well as the need to develop and implement routine TB testing for latent and resistance forms across the globe. In this regard, local networks, government, and non-governmental organizations, as well as international partners and collaboration will be crucial to developing and shaping the specifics of realizing this ethical agenda. 4.3.2.2  An Anthro-ecological Ethic vis-a-vis Autonomy & Human Rights Some of the ethical issues generated by atypical drug-resistant tuberculosis are linked with autonomy and human rights. Using an anthropo-ecological moral lens, the threat presented by ADR-TB may be seen as a part of the cycle of life where everyone faces the risk of possible infection through multiple and unavoidable pathways. This consequently places the infected and yet-to-be-infected in the same category of infectables. Affirming this “collective predicament” may help to contextually erode entrenched boundaries of autonomy and human rights by enabling all concerned parties to see one another as confronting a similar existential threat, belonging to the same human community and facing the same challenges posed by infectious diseases in general and a silent public health disaster like ADR-TB in particular. Since humans possess physical and social locatedness,211 stressing the obligations owed to one another may help set aside the self-centered rights rhetoric to enable collective dialogue and reciprocation212 over a collective societal problem as well as facilitating willing participation in public health intervention programs, however inconvenient. Although community values in traditional communities are not shared by all members,213 this limitation should barely apply to the context of ADR-TB because of the inherent harm that may occur to everyone, at least theoretically. As such, if no one would want to be infected or would wish that if they ever got an infection that society should offer the best of care to their plight, then traversing the boundaries of individual and community interests should be conceived as a flexible process. Some bioethicists have voiced a similar idea that rights and duties are linked and that the capacity to enjoy rights should go pari passu with the willingness to accept responsibilities.214  Battin et al. P. 283.  Upshur. P. 58. 213  Will Kymlicka, “Liberalism and Communitarianism,” Canadian Journal of Philosophy 18, no. 2 (1988). P. 200. 214  Benatar, Daar, and Singer. P. 210. 211 212

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4.3.2.3  An Anthro-ecological Ethic vis-a-vis Harm & Social Justice There are two types of harm associated with ADR-TB: human and microbial harm. Human-based harm associated with ADR-TB may occur intentionally or otherwise but are generally related to a given public health policy or the absence of one. Intentional harm such as escaping from the hospital while harboring an infection often echoes deep-seated personal fears, or a lack of trust in the health system’s capacity to care for the infected individual. An anthropo-ecological lens would demand that societies develop trust in her citizens (prior to the onset of a public health disaster such as ADR-TB) to the extent that when faced with balancing their personal interests and those of the community they would willingly follow an other-­ centric path. In other words, societies need to serve her citizens prior to expecting the same people to be selfless patrons in a time of public health disaster. Non-intentional harm resulting from ADR-TB such as passively spreading  an infection when a diagnosis has not been made may be solved by the implementation of periodic testing for TB and its various drug-resistant forms including ADR-TB. This will ensure early detection and intervention (provided hitherto weak health systems have been strengthened). In other words, the design and implementation of relevant policies based on an anthropo-ecological analysis of the dynamics of ADR-TB can help engage its moral and practical challenges. Another non-­ intentional harm relates to non-compliance and/or partial compliance with anti-TB drug regimens. This, as have been pointed out, has the potential to help typical TB bacteria species evolve into atypical forms. However, rational drug use is one useful strategy that may help tailor specific infections and strains of disease-causing bacteria to specific antibiotics to limit the potential evolution of resistant strains including Mycobacterium. Harms caused by ADR-TB, however, reflect the teleological tension between the survival of two species, humankind and bacterial life forms. If humans and microorganisms are partners in nature,215 and ADR-TB may hardly go away; one option open to human beings vis-à-vis achieving a relational balance is the pursuit of innovative non-antibiotic-based treatment options such as immunotherapies. Developing drugs that can target the crucial mechanisms through which Mycobacterium species evade the innate and acquired immune responses of their human host is another viable approach. In relation to the development of novel therapeutic approaches to TB, MDR-TB, and ADR-TB, some microbiologists have pointed out that a combination of antibiotics and immunomodulators could be the key to reduce drug-­ resistant bacteria as well as the possibility of reinfection and reactivation.216 Lastly, an anthropo-ecological ethic may also help address some of the facets of the social justice issues embedded in ADR-TB. For Stephen Holland, ethical theories often attempt to resolve public health dilemmas by promoting only one part rather than facilitating a rich sense of the nature of the dilemma. This leaves little room for striking an ethical balance between extreme pro-community and pro-­  Radest. P. ix.  Debapriya Bhattacharya, Ved Prakash Dwivedi, and Gobardhan Das., “Revisiting Immunotherapy in Tuberculosis,” Journal of Mycobacterial Diseases 4, no. 1 (2013). P.2.

215 216

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individual positions.217 Bioethics scholars like ten Have argue that employing the coherence and interrelationships of persons constitute a critical lens for examining the living being.218 Applied to the context of ADR-TB, addressing the underlying social factors including poverty, inadequate health infrastructure, and health financing that facilitate the occurrence of ADR-TB in countries of the South as well as the 10–90 gap will go a long way in creating a social atmosphere where the public policy-related elements of the anthropo-ecological idea may take root.

4.4  Conclusion This chapter has shown how atypical drug-resistant tuberculosis reflects a form of a silent public health disaster. By examining the biological foundations and nature of antimicrobial drug resistance, it showed how ADR-TB constitutes a survival mechanism that bacteria employ to ensure species survival. An examination of the public health implications of ADR-TB in terms of local and global contexts, however, shows the urgency with which it needs to be addressed. This is further supported by the associated biological and social nuances which give the phenomenon a subtle form and lend some conceptual credence to its silent disaster description. Atypical drug-resistant tuberculosis elicits many moral quandaries such as uncertainty, vulnerability, autonomy, human rights, harm and social justice. These issues are largely a result of some derangement in the harmonious balance in the relationship nexus between human beings and other humans and what one set of people may do or fail to do for other sets of people, all belonging to different categories of infected and potentially infectable victims and vectors, as well as the relationship nexus between humans and microbial life. An understanding and clarification of these different sets of relatedness constitutes a viable locus for examining the causes, subtleties, and the extent of the challenges that ADR-TB brings about. In this vein, the chapter developed an anthropo-ecological ethical prism. Specifically, an anthropo-ecological ethic constitutes a combination of the anthropological dimensions of human experiences and capacities with an understanding of microbial life forms vis-à-vis framing a normative moral lens. It involves identifying the social, biological, and existential vulnerabilities that inevitably plague humankind. It likewise entails the realization that it is almost impossible to eliminate antimicrobial drug resistance, paying attention to and enhancing some of the naturally-occurring antimicrobial tools inherent in the human physiology. Other anthropo-ecological considerations include passive and active forms of pecuniary and non-pecuniary solidarity and adaptive learning. The Chapter argues that an anthropo-ecological moral lens can help address the moral quandaries generated by atypical drug-resistant tuberculosis in several ways. These include helping to 217 218

 Holland. Pp. 33, 35.  ten Have, “The Anthropological Tradition in the Philosophy of Medicine.” P.10.

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garner the local and global solidarity from relevant moral actors in relation to engaging the common threat of ADR-TB, drawing attention to the relevant socio-­economic and institutional dimensions, as well as helping to blur the distinctions between human rights, autonomy, and social responsibilities by placing everyone in the category of infectables. Finally, an anthropo-ecological prism involves focusing attention on the victimhood and vectorhood of humans while emphasizing the value of prior social trust in shaping cooperation with health instructions during PHDs.

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Kelly, David F. 2006. Medical Care at the End of Life: A Catholic Perspective. Washington, DC: Georgetown University Press. Keshavjee, Salmaan, and Paul E. Farmer. 2012. Tuberculosis, Drug Resistance, and the History of Modern Medicine. New England Journal of Medicine 367 (10): 931–936. Keyhani, Salomeh, and Joseph S. Ross. 2007. The Cost of Pharmaceutical Innovation to Patients. Expert Opinion on Drug Discovery 2 (11): 1431–1434. Killen, John Y., Jr. 2008. HIV Research. In The Oxford Textbook of Clinical Research Ethics, ed. Ezekiel J. Emanuel, Christine Grady, Robert A. Crouch, Reidar K. Lie, Franklin G. Miller, and David Wendler, 97–109. Oxford: Oxford University Press. Kimchi-Sarfaty, Chava, Jung Mi Oh, In-Wha Kim, Zuben E. Sauna, Anna Maria Calcagno, Suresh V. Ambudkar, and Michael M. Gottesman. 2007. A “Silent” Polymorphism in the Mdr1 Gene Changes Substrate Specificity. Science 315 (5811): 525–528. Kleinig, John. 2008. The Ethics of Harm Reduction. Substance Use & Misuse 43 (1): 1–16. Kogan, Benjamin A. 1970. Health: Man in a Changing Environment. New York: Harcourt Brace Jovanovich, Inc. Kraemer, J.D., Oscar A. Cabrera, J.A. Singh, Timothy B. Depp, and Lawrence O. Gostin. 2011. Public Health Measures to Control Tuberculosis in Low-Income Countries: Ethics and Human Rights Considerations. The International Journal of Tuberculosis and Lung Disease 15 (Supplement 2): S19–S24. Kuby, Janis. 1997. Immunology, 1997. New York: WH Freeman and Company. Kymlicka, Will. 1988. Liberalism and Communitarianism. Canadian Journal of Philosophy 18 (2): 181–203. Lachmann, Peter J. 1998. Public Health and Bioethics. The Journal of Medicine and Philosophy 23 (3): 297–302. Lepora, Chiara, and Robert E. Goodin. 2013. On Complicity and Compromise. Oxford: OUP. Levy, Stuart B., and Bonnie Marshall. 2004. Antibacterial Resistance Worldwide: Causes, Challenges and Responses. Nature Medicine 10: S122–SS29. LoBue, Philip, Christine Sizemore, and Kenneth G.  Castro. 2009. Plan to Combat Extensively Drug-Resistant Tuberculosis: Recommendations of the Federal Tuberculosis Task Force. MMWR Recommendations and Reports 58 (3): 1–43. Lucas, Adetokunbo O., and Herbert Michael Gilles. 2003. Short Textbook of Public Health Medicine for the Tropics. London: Arnold Publishers. MacPhail, Theresa. 2014. The Viral Network: A Pathography of the H1n1 Influenza Pandemic. Ithaca: Cornell University Press. Mallia, Pierre. 2015. Towards an Ethical Theory in Disaster Situations. Medicine, Health Care, and Philosophy 18 (1): 3–11. Mann, Jonathan M. 1997. Medicine and Public Health, Ethics and Human Rights. Hastings Center Report 27 (3): 6–13. Mann, Jonathan M., Lawrence Gostin, Sofia Gruskin, Troyen Brennan, Zita Lazzarini, and Harvey V. Fineberg. 1994. Health and Human Rights. Health and Human Rights 1 (1): 6–23. Matteelli, Alberto, Giovanni Battista Migliori, Daniela Cirillo, Rosella Centis, Enrico Girard, and Mario Raviglione. 2007. Multidrug-Resistant and Extensively Drug-Resistant Mycobacterium Tuberculosis: Epidemiology and Control. Expert Review of Anti-infective Therapy 5 (5): 857–871. Mechtraud, Sister. 1955. Durkheim’s Concept of Solidarity. Philippine Sociological Review 3: 23–27. Migliori, Giovanni Battista, Giovanni Sotgiu, Neel R. Gandhi, Dennis Falzon, Kathryn DeRiemer, Rosella Centis, Maria-Graciela Hollm-Delgado, et  al. 2013. Drug Resistance Beyond Extensively Drug-Resistant Tuberculosis: Individual Patient Data Meta-Analysis. European Respiratory Journal 42 (1): 169–179. Morse, Stephen S. 1995. Factors in the Emergence of Infectious Diseases. Emerging Infectious Diseases 1 (1): 7–15.

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Chapter 5

Public Health Disasters During Earthquakes: A Solidaristic Approach

Abstract  Natural and human-made disasters belong to the class of public health disasters largely because their disaster-related dynamics elicit different types of health consequences at the individual, social, trans-national, and global planes. This chapter examines and articulates the public health disaster dynamics of earthquakes and underscores how natural disasters may engender serious public health consequences. It also teases out the attendant moral quandaries and develops a solidaristic ethical lens in relation to resolving them.

5.1  Introduction Whereas the public health disasters that have been described in Chaps. 2, 3, and 4 arise as a consequence of viral and bacterial life forms and their complex interplay with the biological and social nature of humankind, Gaillard and Texier note that other types of disasters occur from the spatial and temporal conjunction between natural hazards and the fragile human community.1 Earthquakes belong to this category. They are part of the fundamental problems that face some regions of the world.2 Yet, the interconnection of the contemporary world means that people far-­ flung from those regions may have family, friends, and colleagues living in those regions  (temporarily or permanently) and who may become victims. Indeed, the trauma and gory tales transmitted via print, electronic, and social media foster a sense of connection with victims of earthquakes. However, this sense of virtual-­ driven connection may spur people removed from the location of such disasters into doing something to help ameliorate the various distresses of victims. Earthquakes also raise some public health issues, some of which may be exported from the affected country.

1  Jean-Christophe Gaillard and Pauline Texier, “Religions, Natural Hazards, and Disasters: An Introduction,” Religion 40, no. 2 (2010). P. 81. 2  Canan Lacin Simsek, “Turkish Children’s Ideas About Earthquakes,” Online Submission 2, no. 1 (2007). P. 14.

© Springer International Publishing AG, part of Springer Nature 2018 M. O. Afolabi, Public Health Disasters: A Global Ethical Framework, Advancing Global Bioethics 12, https://doi.org/10.1007/978-3-319-92765-7_5

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Earthquakes by their very nature, consequences, the social responses, as well as the attendant public health issues generate some moral concerns. Inattention or inadequacy of focus on these ethical issues creates roadblocks to engaging the practical challenges associated with earthquakes. Such moral issues deserve critical reflection and a viable moral lens to help resolve them. Against this conceptual backdrop, this chapter seeks to tease out the anthropogenic and non-anthropogenic concerns embedded in earthquakes. It develops a solidaristic moral approach vis-à-­ vis addressing the ethical issues that the public health challenges of earthquakes elicit.

5.1.1  The Nature of Earthquakes Earthquakes constitute sudden vibrations of specific parts of the earth with the attendant collapse of buildings, infrastructures, the inclosure of people, traumatization, and loss of lives. Landesman describes them as sudden slippages in portions of the earth’s crust with associated vibrations and regards them as the most destructive and frightening of all the forces of nature.3 This is largely because of the vast amounts of energy contained within the surface of the earth.4 Earthquakes are not new in the experiential repertoire of humankind. They have occurred in the past and occur in the contemporary world. They can shake the ground into several feet high of standing waves, rip tree trunks, spill rivers and lakes over their banks, turn highways into strips of broken rubble, and cut open fissures in the earth more than a hundred miles.5 The Richter scale and the modified Mercalli scale are common parametric tools for evaluating earthquakes. The Richter scale gives a logarithmic assessment of earthquakes based on their intensity on a scale of 1 and 8. The 2010 earthquake in Haiti, for instance, was 7.0 in magnitude6 while Japan’s 2011 incident had a magnitude of 9.0.7 The modified Mercalli scale assesses earthquakes on a scale of I (lowest) through XII (highest).8 Earthquakes have been associated with naturalistic, supernatural and, more recently, human-associated causes. Scientific understanding about earthquakes has 3  Linda Young Landesman, Public Health Management of Disasters: The Practice Guide (American Public Health Association, 2005). P. 10. 4  Bruce W Clements and Julie Casani, Disasters and Public Health: Planning and Response (New York: Butterworth-Heinemann, 2016). P. 224. 5   James W Stratton, “Earthquakes “in The Public Health Consequences of Disasters ed. U.S. Department of Health and Human Services (Atlanta: Georgia.: Center for Disease Control 1989). P. 13. 6  Giuseppe Raviola et  al., “The 2010 Haiti Earthquake Response,” Psychiatric Clinics of North America 36, no. 3 (2013). P. 436. 7  Tetsuji Aoyagi et al., “Characteristics of Infectious Diseases in Hospitalized Patients During the Early Phase after the 2011 Great East Japan Earthquake,” Chest 143, no. 2 (2013). P. 349. 8  Clements and Casani. Pp. 224–225.

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evolved over time. It was once held, for instance, in the 1700s that a combination of coal, sulfur, niter, and other flammable elements beneath the earth caused them.9 Today, it is known that certain parts of the world are tectonically active and have zones of deformation. Within such zones, elastic strain energy accumulates which when rapidly released causes portions of the earth to vibrate and “quake” or slit open.10 In the United States, for example, natural geographic factors such as the collision between the Pacific and North American Plates give rise to most of the Seismic disturbances along the Pacific West Coast and Alaska, especially the San Andreas Fault in California with other parts of the country facing smaller and ranging levels of seismic activities.11 Besides California, Utah, and Idaho, six major American cities with a population greater than 100, 000 are located within the New Madrid Fault.12 Although some countries such as Turkey, Mexico, El Salvador, Philippines, Ecuador, India, and Pakistan are more seismically active regions, and therefore experience more frequencies; earthquakes have occurred in countries without these traditional features. Also, the degree of earthquakes does not necessarily determine their impact. For instance, the January 2010 incident in Haiti was 7.0 on the Richter scale and produced more than 220, 000 deaths while the February 2010 incident in Chile was 8.8 magnitude but produced less than 800 deaths.13 As such, it is difficult to relate both the causes and impacts of earthquakes exclusively with naturally-­ occurring seismic activities. Not surprisingly, some historical and contemporary schools of thought have regarded earthquakes as acts of God.14 The Puritans, for instance, both acknowledged a natural and a morally-driven supernatural cause to earthquakes. For them, the moral deficit in collective human behavior could engender earthquakes as a form of divine retribution.15 Supernatural explanations for earthquakes sometimes co-exist with scientific ideas. For instance, the English Clergyman and scientist, Stephen Hales, held that earthquakes often occur naturally but could be deplored by God to achieve some specific intent such as the repentance of humankind.16 Even today, supernatural explanations persist. For instance, a study in Turkey reported that 30% of school children believe that earthquakes result from the bad moral conduct of people.17 In a postmodern world where religious notions are increasingly derided, an ethical concern arises. This relates to the possibility of a correlation between the 9  Agustin Udias, “Earthquakes as God’s Punishment in 17th-and 18th-Century Spain,” Geology and Religion: A History of Harmony and Hostility 310, no. 1 (2009). P. 41. 10  William L Ellsworth, “Injection-Induced Earthquakes,” Science 341, no. 142 (2013). P. 7. 11  Stratton. Pp. 13–14. 12  Landesman. Pp. 10–11. 13  Naomi Zack, Ethics for Disaster (Rowman & Littlefield Publishers, 2010). Pp. xx–xxi. 14  Gaillard and Texier. P. 81. 15  Maxine Van De Wetering, “Moralizing in Puritan Natural Science: Mysteriousness in Earthquake Sermons,” Journal of the History of Ideas (1982). Pp. 420–421. 16  Stephen Hales, “Some Considerations on the Causes of Earthquakes,” Philosophical Transactions 46, no. 46 (1749). Pp. 669–671. 17  Simsek. P. 17.

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decrease in the personal and social conformity to God-related moral laws and the rise in the frequency of earthquakes. However, this concern— at the level of social public policy— will be hard to resolve since religious and God-related questions are generally outside the purview of scientific illumination and because not everyone believes in the notion of a “God”. There is also no secular and even religious consensus about what constitutes “God” or what objective  parameters  are needed to determine what “God”, a “God”, or the “gods” want or consider as morally appropriate human conduct. Anthropogenic causes of earthquakes have also been increasingly identified and clarified. In this vein, Stratton notes that human activities including the underground detonation of nuclear explosives and deep-well injections influence the occurrence of earthquakes.18 For instance, the injection of water under high pressure into impermeable basement rocks in Basel in 2006 triggered an earthquake,19 and the extraction of natural gas from shallow pits in the Northern part of Netherlands has been known to induce earthquakes.20 Of all three types of earthquakes, this anthropogenic kind is, however, the least severe. Yet, it is often difficult with the current seismological methods to always distinguish man-made from natural tectonic earthquakes.21 But regardless of their causes, some socio-geographical factors influence the severity of earthquakes, potential victims, and the attendant social consequences.

5.1.2  Socio-geographical Dynamics of Earthquakes There are socio-geographical dynamics to earthquakes because geographical territories and social factors influence the risk of earthquakes and the attendant consequences. This is important because while natural forces beyond the control of humankind22 shape earthquakes, the idea that certain human activities such as morality or technological incursion made into the earth’s surface may initiate them suggest that the interaction of the geographical and natural parameters with the social dynamics of human behavior ultimately influence the tone, place, and significance of an earthquake. For instance, living in certain parts of countries like India, Turkey, Mexico, El Salvador, Japan, Philippines, Ecuador, and Pakistan constitutes a geographic risk for earthquakes. This risk may, however, be heightened through how people ­construct their houses in such locations. In this vein, the availability of relevant building codes and their implementation can influence whether or not houses have  Stratton. P. 15.  Nicholas Deichmann and Domenico Giardini, “Earthquakes Induced by the Stimulation of an Enhanced Geothermal System Below Basel (Switzerland),” Seismological Research Letters 80, no. 5 (2009). Pp. 784–788. 20  Torild Van Eck et  al., “Seismic Hazard Due to Small-Magnitude, Shallow-Source, Induced Earthquakes in the Netherlands,” Engineering Geology 87, no. 1 (2006). Pp. 105–116. 21  Ellsworth. P. 3. 22  Simsek. Pp. 14–15. 18 19

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been constructed on vulnerable sites.23 Bilham shares this perspective in reporting that the construction of several buildings on vulnerable sites with brittle steel, coarse non-­angular aggregate, and cement mixed with dirty or salty sand greatly contributed to the severity of the January 2010 earthquake in Haiti.24 In addition, earthquakes and other natural disasters such as floods and hurricanes afflict Western nations such as the United States largely because houses, industries, and communities have increasingly been built along sites prone to these.25 Sometimes, the overcrowded nature of an area and/or its proneness to seismic activities trigger earthquakes. For instance, the 2008 8.0 magnitude earthquake that struck Wenchuan County in the Sichuan Chinese Province and claimed the lives of more than 69,000 victims while causing 400,000 injuries26 was partly due to overcrowding. Yet, earthquakes have occurred suddenly in areas not previously associated with one. For instance, the 1923 earthquake in Tokyo.27 The moral relationship that has been associated with earthquakes implies that certain people in certain places living a certain way of “immoral life” will be more susceptible to earthquakes. This has been played out in a number of previous earthquakes. For example, the misfortune experienced by the people of Natchez, a town along River Mississippi with a “distasteful and immoral reputation”, during the New Madrid earthquake of 1811–1812 was attributed to the consequence of their way of life.28 More recently, this same notion has been used to explain earthquakes in Haiti. In this regard, some people have employed the Judeo-Christian ethical lens to note that the historical and contemporary practice of idolatry in that country compels God to use these earthquakes as a form of divine punishment.29 If this perspective is true, then people living in places where “immoral behavior” runs rife and those who may be visiting temporarily face significant risks from earthquakes.  However, even this perspective becomes problematic at the social plane because what is considered moral and immoral vary across cultures, religions, and secular worldviews. Some of the by-products of modern life and the technological incursion into nature may also exacerbate the severity of earthquakes or trigger them. For instance, the 1906 San Francisco post-earthquakes fires were started by stored chemicals.30  Patrick Bellegarde-Smith, “A Man-Made Disaster: The Earthquake of January 12, 2010—a Haitian Perspective,” Journal of Black Studies 42, no. 2 (2011). Pp. 265–266. 24  Roger Bilham, “Lessons from the Haiti Earthquake,” Nature 463, no. 7283 (2010). P. 878. 25  Linda Young Landesman, Public Health Management of Disasters: A Practical Guide (Washington DC: American Public health Association, 2001). P. 1. 26  Hu Nie et al., “Triage During the Week of the Sichuan Earthquake: A Review of Utilized Patient Triage, Care, and Disposition Procedures,” Injury 42, no. 5 (2011). P. 515. 27  Bilham P. 879. 28  Tom Kanon, “Scared from Their Sins for a Season: The Religious Ramifications of the New Madrid Earthquakes, 1811–1812,” Ohio Valley History 5, no. 2 (2005). P. 25. 29  Felix Germain, “The Earthquake, the Missionaries, and the Future of Vodou,” Journal of Black Studies 42, no. 2 (2011). Pp. 247–250. 30  Stratton. P. 15. 23

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Also, man-made activities such as the injection of water under high pressure into impermeable basement rocks,31 and the extraction of natural gas from shallow pits32 have been known to trigger earthquakes. These sets of factors show the significance of human agency, at least in some way, in the occurrence of some earthquakes. They also highlight the idea that there is some preventive window to earthquakes through modification of human activities. On the other hand, earthquakes —like traditional disasters— cause destruction, death, diseases/disorders, displacement, disappearance, and disarray.33 Some of these features also raise health concerns such as mental health, infectious diseases, and trauma-related issues. The next section examines these public health issues.

5.1.3  Public Health Dynamics of Earthquakes The public health dynamics of earthquakes and their extent are generally influenced by the intensity of seismic activities.34 They involve mass trauma, infectious diseases, and mental health issues in an accelerated manner. The physical and violent trauma of earthquakes cause deaths and various degrees of harms. For instance, the 2010 Haitian 7.0 magnitude earthquake killed at least 220,000 people and displaced about 1.5 million people,35 In 1556, a 1556 8.0 magnitude earthquake in Shaanxi province in China killed an estimated 830,000 people in the worst earthquake recorded in human history.36 Apart from deaths, crush injuries which may lead to renal and cardiac failure are features of earthquakes.37 Severe body injuries also often occur that may lead to amputation of limbs. For instance, the 2005 earthquake of Pakistan and Kashmir which led to 73,338 deaths left over 125,000 severely injured, 60% of which were limb-related injuries.38 During the 2010 Haiti earthquake an estimated 4, 000 people had amputations.39 These are physically and emotionally traumatizing experiences  Deichmann and Giardini. Pp. 784–788.  Van Eck et al. Pp. 105–116. 33  Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna, “Evidence and Healthcare Needs During Disasters,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke (Netherlands: Springer, 2014). P. 96. 34  Eric K Noji, “Earthquakes,” in The Public Health Consequences of Disasters, ed. Eric K Noji (New York: Oxford University Press, 1997). P. 142. 35  Raviola et al. P. 436. 36  EY Chan, Y Gao, and SM Griffiths, “Literature Review of Health Impact Post-Earthquakes in China 1906–2007,” Journal of Public Health 32, no. 1 (2009). Pp. 55.58. 37  Bruce Clements, Disasters and Public Health: Planning and Response (Butterworth-Heinemann, 2009). P. 134. 38  Syed Muhammad Awais, Usman Zafar Dar, and Ayesha Saeed, “Amputations of Limbs During the 2005 Earthquake in Pakistan: A Firsthand Experience of the Author,” International Orthopaedics 36, no. 11 (2012). Pp. 2323, 2326 39  Henk Ten Have, Global Bioethics: An Introduction (Routledge, 2016). P. 5. 31 32

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for the victims. The public health dynamics of this, however, relates to the need for triage that often arises. Triage is a military-derived system that involves screening of patients according to the degrees of their need in order to balance available treatment options with the available  and often limited resources.40 In public health disaster settings, triage involves two opposing loyalties. One occurs in infectious disease contexts such as epidemics while the other occurs due to how professionals must balance their fiduciary obligations to patients or victims of disaster and their duty to their immediate family members.41 Both of these may, however, come to the fore during earthquakes because of the potential for infectious disease outbreak (such as cholera) as well as the traditional challenges engendered by the disastrous effects of the seismic havoc. To be sure, after earthquakes the number of victims who will need medical help often overwhelms the capacity of the local healthcare system. This often warrants the need for triage, involving the rapid sorting of victims with the intention of doing the greatest good for the greatest number of people.42 Put differently, it means doing the least harm to the fewest possible people, and it is clearly problematic since it adopts an almost instrumentalist and materialist notion of the human person. On the other hand, observing dead bodies and mangled body parts can be a significant cause of post-traumatic stress disorder to victims as well as bystanders following an earthquake.43 The elevated extent of mental health issues such as depression observed after the 2010 Haiti earthquake underscore this notion.44 This is of particular importance because mental health issues engendered by natural disasters are known to foster suicidal thoughts, substance abuse, derailed relationships, and cause phobias as well as anxieties.45 The nexus between natural disasters and mental-related issues such as post-traumatic stress disorders and depression is well-documented and transcends geographic borders. For example, it was observed during the 1989 Loma Prieta, California earthquake.46 It was also reported in v­ ictims

 Thomas B Repine, Philip Lisagor, and David J Cohen, “The Dynamics and Ethics of Triage: Rationing Care in Hard Times,” Military Medicine 170, no. 6 (2005). Pp. 505–507. 41  Michael Y Barilan, Margherita Brusa, and Pinchas Halperin, “Triage in Disaster Medicine: Ethical Strategies in Various Scenarios,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna (Springer, 2014). P. 50. 42   Sara Kathleen Geale, “The Ethics of Disaster Management,” Disaster Prevention and Management 21, no. 4 (2012). P. 449. 43  Ümit Tural et al., “Psychological Consequences of the 1999 Earthquake in Turkey,” Journal of Traumatic Stress 17, no. 6 (2004). Pp. 451–453. 44  Giuseppe Raviola et  al., “Mental Health Response in Haiti in the Aftermath of the 2010 Earthquake: A Case Study for Building Long-Term Solutions,” Harvard Review of Psychiatry 20, no. 1 (2012). Pp. 74–75. 45  Landesman, Public Health Management of Disasters: A Practical Guide. P. 106. 46   Susan Nolen-Hoeksema and Jannay Morrow, “A Prospective Study of Depression and Posttraumatic Stress Symptoms after a Natural Disaster: The 1989 Loma Prieta Earthquake,” Journal of Personality and Social Psychology 61, no. 1 (1991).Pp. 115–210. 40

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and survivors47 as well as health workers after the 2005 earthquake in Pakistan.48 The pragmatic public health importance of this nexus may be better understood if one considers the myriads of possible consequences of a mental health condition afflicting the head of a household in a resource-poor nation like Haiti. Earthquakes shake the foundations of the earth. Indeed, seismic activities often cause structures to collapse, may start fires, and bring about other kinds of hazards49 such as the nuclear threat due to the Fukushima Nuclear Plant after Japan’s 2011 earthquake.50 Hence, buildings, regardless of their social functions, will be affected indiscriminately. The public health consequences when buildings like hospitals and prisons collapse are, however, dire. For instance, while earthquakes may cause the loss of lives of patients and staff within hospitals and healthcare facilities, the attendant destruction of equipment and drugs and other medical gadgets will leave surviving professionals ill-equipped to deal with the congeries of the health-related aftermath. Earthquakes may also set in-patients free. But some of these may include mental health patients and patients undergoing treatment for behavioral-related conditions such as addiction, thereby potentially posing a health threat to contiguous communities. This happened at the Los Angeles County-Olive View Medical Center during the 1971 earthquake in California.51 Earthquakes likewise worsen existing medical conditions. In relation to this idea, Bartels and VanRooyen note that chronic medical disorders such as diabetes, heart disease, and asthma often worsen after earthquakes.52 In addition, seismic activities create an environment that accelerates the spread of infectious diseases. For instance, damages to septic tanks will pollute underground water and destruction of water pipes will deprive people of clean drinking water. As such, diseases such as cholera constitute common post-earthquake events.53 Plague, an infection caused by Yersinia pestis and transmitted by rats, broke out in California in 1907 a year after the earthquake.54 Among hospitalized patients, infectious diseases were significantly

 Adriana Feder et al., “Coping and Ptsd Symptoms in Pakistani Earthquake Survivors: Purpose in Life, Religious Coping and Social Support,” Journal of Affective Disorders 147, no. 1 (2013). Pp. 156–170. 48  Thomas Ehring, Saiqa Razik, and Paul MG Emmelkamp, “Prevalence and Predictors of Posttraumatic Stress Disorder, Anxiety, Depression, and Burnout in Pakistani Earthquake Recovery Workers,” Psychiatry Research 185, no. 1 (2011). Pp. 161–163. 49  Clements. P. 133. 50  Kazuya Nakayachi, Hiromi M Yokoyama, and Satoko Oki, “Public Anxiety after the 2011 Tohoku Earthquake: Fluctuations in Hazard Perception after Catastrophe,” Journal of Risk Research 18, no. 2 (2015). Pp. 156–158. 51  Ronald R Koegler and Shelby M Hicks, “The Destruction of a Medical Center by Earthquake. Initial Effects on Patients and Staff,” California Medicine 116, no. 2 (1972). Pp. 63–66. 52   Susan A Bartels and Michael J VanRooyen, “Medical Complications Associated with Earthquakes,” The Lancet 379, no. 9817 (2012). Pp. 748–750. 53  Ezra J Barzilay et al., “Cholera Surveillance During the Haiti Epidemic—the First 2 Years,” New England Journal of Medicine 368, no. 7 (2013). Pp. 599–605. 54  Clements. P. 125. 47

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increased following the 2011 earthquake in Japan.55 Medical conditions such as acute upper respiratory tract infection, acute enteritis, and hemorrhagic enteritis were specifically reported during the 2008 Sichuan earthquake in China.56 Infectious diseases, however, do not only spread locally during earthquakes, but  may be exported out of the affected region. To be sure, scholars like Karkee contend that the significance of globalization and its effect on global health becomes profound usually during disasters, as in the case of a large-scale earthquake.57 Not surprisingly, dengue fever was “exported” to the United States from Haiti during the 2010 Earthquake.58 Other kinds of infectious diseases or unique local strains of infectious agents may be picked up by some of the humanitarian and health workers called in to assist to ameliorate the impact of earthquakes. On the other hand, novel diseases may also be “imported” to disaster locations. As an example, United Nations peacekeepers from Nepal brought a virulent strain of cholera to Haiti in 2010.59 This hints at the notion that external help, though well-intentioned, may sometimes bring about some types of harm to victims  and survivors of natural disasters. The above analyses echo how earthquakes as an example of a public health disaster generate significant physical, psychological, social, and environmental harm.60 Responding to these issues, however, elicit certain ethical concerns beyond those intrinsic to earthquakes. These concerns deserve some reflection and are systematically engaged in the next section.

5.2  Ethical Issues Elicited by Earthquakes A number of moral quandaries arise from earthquakes. Some of these relate to the individual, socio-cultural, theological, and scientific understanding of their causes while some relate to the social and institutional responses. But these fall into two broad categories: anthropogenic and non-anthropogenic  ethical  dilemmas  or quandaries.

 Aoyagi et al. Pp. 349–355.  Lulu Zhang et  al., “Rescue Efforts Management and Characteristics of Casualties of the Wenchuan Earthquake in China,” Emergency Medicine Journal 28, no. 7 (2011). P. 619. 57  Rajendra Karkee, “Globalization, Global Health, and Disaster,” Frontiers in Public Health 3, no. 262 (2015). P. 1. 58  Tyler M Sharp et  al., “A Cluster of Dengue Cases in American Missionaries Returning from Haiti, 2010,” The American Journal of Tropical Medicine and Hygiene 86, no. 1 (2012). Pp. 16–18. 59  Ten Have. P. 5. 60  Keymanthri Moodley, “Ethical Concerns in Disaster Research—a South African Perspective,” in Disaster Bioethics: Normative Issues When Nothing Is Normal (Springer, 2014). P. 192. 55 56

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5.2.1  Anthropogenic Quandaries The anthropogenic moral quandaries are human-related and include homelessness, security concerns (spurred by the potential decimation of law enforcement officers such as police and the “release” of criminals from collapsed prisons), extant vulnerabilities, resource allocation amidst constraints, the use and implementation of triage (which raise attendant issues of autonomy and human rights), whether or not some clinical research may be permissible and humanitarian aid issues. Homelessness entails some form of disaggregation and severance from the social order.61 Whereas the homeless are usually assumed to be mentally unstable, of bad character, dangerous, substance abusers, a public nuisance, lazy, and free riders, and consequently, must be kept off the streets62; this common notion hardly holds true in the context of disasters. Earthquakes often “produce” thousands of homeless people. The 2010 Haitian earthquakes, for instance, led to the displacement and homelessness of about 1.5 million people63 while the 2011 earthquake in Japan led to about 470,000 displaced persons.64 However, the linkage between crime and disease with the state of homelessness65 means that many victims and survivors will face heightened levels of biological and social harm following a seismic disaster. The possibility that jail-houses and prisons could be affected by earthquakes thereby setting loose inmates, as happened during the Kashmir incident in 2005 when about 4, 000 criminals gained unbridled access to the society,66 underscores the multifaceted dimension of the direct and indirect harms that face both victims and survivors of earthquakes. Such scenarios show some of the unique types of vulnerable situations that may occur post-earthquakes. For instance, the release of criminals increases the vulnerability of women and children to rape and sexual assaults. This was reported following the 2010 Haiti earthquake.67 The fact that more than 380,000 Haitian children were rendered homeless following that earthquake68 is also a serious cause for concern. Although earthquakes may be non-preventable, at least when seen through the scientific and naturalistic lens, social conditions prior to earthquakes significantly shape the extent of the possible harms that people will face and experience during and after an incident. In other words, the vulnerability issues that earthquakes 61  David Wagner, Checkerboard Square: Culture and Resistance in a Homeless Community (Westview: Boulder, 1993). P. 176. 62  Andrew F Smith, “In Defense of Homelessness,” Journal of Value Inquiry 48, no. 1 (2014). P. 35. 63  Raviola et al. P. 436. 64  Takashi Takahashi et  al., “Infectious Diseases after the 2011 Great East Japan Earthquake,” Journal of Experimental & Clinical Medicine 4, no. 1 (2012). P. 20. 65  Henk ten Have, Vulnerability: Challenging Bioethics (Routledge, 2016). P. 6. 66  Bilham. P. 879. 67  Lisa Davis, “Still Trembling: State Obligation under International Law to End Post-Earthquake Rape in Haiti,” University of Miami Law Review 65 (2011). Pp. 868–869 68  Patrice K. Nicholas et al., “Orphans and at-Risk Children in Haiti: Vulnerabilities and Human Rights Issues Postearthquake,” Advances in Nursing Science 35, no. 2 (2012). Pp. 182–183.

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engender are closely tied to local and social contexts. For instance, whereas the 2011 earthquake in Japan was a magnitude of 9.0 on the Richter scale only about 20, 000 deaths occurred69 largely because houses are built to be seismically resilient and adaptive.70 The 2010 Haiti earthquake, on the other hand, caused more than 20,000 deaths because most of the buildings lacked such capacity. Bilham notes that this was facilitated by decades of unsupervised construction allowed by a government indifferent to the plate-boundary location of the country.71 Even if the Haitian officials had genuine care, the economic challenges faced by the nation constitutes a potential disincentive to engaging the problem, especially when seen against the backdrop of conflicting social priorities. Human behavioral responses during earthquakes are known to influence the degree of harm suffered.72 Positive responses to earthquake emergencies are often realized through evacuation drills involving emergency medical techniques, search and rescue, fire suppression, and other relevant skills.73 Hence, it is hardly surprising that a nation like Japan where routine evacuation drills are held often experience low fatality cases compared to a nation like Haiti where none occurs. This difference again echoes the socioeconomic divide between both nations and how this may shape preparedness as well as the effects of earthquakes. However, being a poor nation does not automatically translate into poor and porous preparedness. For instance, Auerbach notes that despite the poor state of Nepal the level of preparedness that was locally put together in conjunction with some external help enabled the nation to well prepare and minimize the overall human and material losses.74 In other words, while limited human and material resources are constant features of disaster situations75;,76 human failure in terms of poor decisional choices even amidst limited resources contributes to the ultimate negative outcomes of seismic havocs. That scarce medical resources during natural disasters challenge the existing protocols for medical intervention77 creates a context where ethically difficult

 Michael S Niederman, “Preparing for the Unexpected: Lessons Learned About Respiratory Infection from the Japanese Tsunami of 2011,” CHEST Journal 143, no. 2 (2013). Pp. 287–288. 70  Aoyagi et al. P. 349–350. 71  Bilham. P. 878. 72  Clements. P. 130. 73  David M Simpson, “Earthquake Drills and Simulations in Community-Based Training and Preparedness Programmes,” Disasters 26, no. 1 (2002). Pp. 55–59. 74  Paul S.  Auerbach, “Preparedness Explains Some Differences between Haiti and Nepal’s Response to Earthquake,” British Medical Journal 350, no. 3059 (2015). Pp. 1–2. 75  Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke, “Disaster Bioethics: An Introduction,” in Disaster Bioethics: Normative Issues When Nothing Is Normal (Springer, 2014). Pp. 3–4. 76  Claritza L Rios et al., “Addressing the Need, Ethical Decision Making in Disasters, Who Comes First?,” Journal of US-China Medical Science 12 (2015). Pp. 20–23. 77  Annekathryn Goodman and Lynn Black, “The Challenge of Allocating Scarce Medical Resources During a Disaster in a Low Income Country: A Case Study from the 2010 Haitian Earthquake,” in International Disaster Health Care: Preparedness, Response, Resource Management, and Education, ed. Girish B Kapur and Amado A Baez (Oakvile: Apple Academic Press, 2016). P. 123. 69

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d­ ecisions have to be made, some of which inevitably involve ethical compromise.78 Triage, for instance, alters standards of care and is often at odds with the Hippocratic traditions.79 The questions that usually arise in the context of triage include: how urgent is this patient’s condition? Do we have adequate resources to meet this patient’s needs? And assuming we admit this patient and provide the level of care required, can the patient’s life be saved?80 Answering these questions is important but the practical implication for people not included is worrisome, especially against the background of the traditional pro-life nature of medicine. Indeed, triage roughly constitutes “leaving some dying persons to hang out to die” amidst difficulty. One way that ethicists have attempted to get around the moral problem of triage is to focus on the manner of its implementation, especially in terms of fairness.81,82 Some stress the need for community involvement prior to catastrophic events.83 However, a major limitation of the latter approach is that disasters including earthquakes happen suddenly, and are known to have occurred even in “non-susceptible” regions. Scholars like da Costa argue that recognizing the human rights of people involved in disaster contexts help enhance individuals’ resilience to face the accompanying challenges.84 However, rights-related issues are difficult to skirt in the context of triage since triage itself seems to advance the right to life of some people at the expense of that of others. Even people who are not educated can perceive these ethical tensions as recently reported by Durocher et al.85 Whereas it is agreed that prior triage decisions are better compared to arbitrary ones made during earthquake scenarios,86 this does nothing to ameliorate the associated moral dilemma. The extent of the material and human resource losses that accompany seismic havocs weaken the local capacity to respond to and engage the aftermaths. Hence, that 25% of the Haitian populace within the civil service died during the 2010

 Chiara Lepora and Robert E Goodin, On Complicity and Compromise (OUP Oxford, 2013). On complicity and compromise Pp. 18–30. 79  Rios et al. P. 20. 80  Ofer Merin et  al., “The Israeli Field Hospital in Haiti—Ethical Dilemmas in Early Disaster Response,” New England Journal of Medicine 362, no. 11 (2010). P. e382. 81  Henk ten Have, “Macro-Triage in Disaster Planning,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke (Springer 2014). Pp. 13–16. 82  Michael Y Barilan, Margherita Brusa, and Pinchas Halperin, “Triage in Disaster Medicine: Ethical Strategies in Various Scenarios,” ibid., ed. Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna (Springer). Pp. 49–52. 83  Rios et al. P. 26. 84  Karen da Costa, “Can the Observance of Human Rights of Individuals Enhance Their Resilience to Cope with Natural Disasters?,” Procedia Economics and Finance 18 (2014). Pp 62–68. 85  Evelyne Durocher et  al., “Ethical Questions Identified in a Study of Local and Expatriate Responders’ Perspectives of Vulnerability in the 2010 Haiti Earthquake,” Journal of Medical Ethics (2017). doi: 10.1136/medethics-2015-102896 86  Nie et al. Pp. 515–517. 78

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e­ arthquake87 suggests the level of disruption that would have occurred in key institutional settings such as healthcare and other public services. This partly explains why disasters often prompt some request for assistance outside the impacted areas.88 It likewise underscores the notion that social context not only influences the consequences of earthquakes but also determines the nature and type of external assistance. While disaster relief is a form of humanitarianism which focuses on human welfare without expecting rewards89 with the utilitarian goal of doing the maximal good for as many people as possible with minimal harm90; this standard rhetoric often fails to address the underlying socio-economic dynamics in pre-disaster situations. Engaging such underlying issues offers some preventive approach to limiting the amount of resources that will be needed to deal with the consequences of disasters. Scholars like Paul Farmer support an approach like this. For him, inattention to underlying socioeconomic factors and nuances highlights the inadequacy of facile claims of causality, particularly those that scant the pathogenic roles of social inequalities. It also underscores the need to evolve models which can incorporate change and complexity and are alive to local variation91 and contexts. During natural disasters including earthquakes, the tendency for public authorities to monitor and order people about increases.92 This can both be undignifying as well as violate some of the autonomous decisions and actions of the vulnerable victims and distraught survivors. In other words, victims and survivors of disasters may face the additional burden of having limited self-regulation, and governance93 as well as the free expression of judgment and action.94 For instance, survivors and victims of earthquakes may have to live in makeshift homes, eat food below their personal and accustomed standards, sleep under suboptimal conditions, and so forth. Above these, they can exercise very little choice and control. This can lead to personal distress and exacerbate the mental health consequences of the disaster. It also increases the overall vulnerability of those caught in the web

 Raviola et al. P. 437. Pp. 515–517.  Fatimah Lateef, “Ethical Issues in Disasters,” Prehospital and Disaster Medicine 26, no. 4 (2011). P. 289. 89  Laurel A Spielberg and Lisa V Adams, Africa: A Practical Guide for Global Health Workers (UPNE, 2011). Pp. 1–2. 90  Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna, “Evidence and Healthcare Needs During Disasters”, Pp. 100–101. 91  Paul Farmer, “Social Inequalities and Emerging Infectious Diseases,” Emerging Infectious Diseases 2, no. 4 (1996). P. 259. 92  Enrico L Quarantelli, “Catastrophes Are Different from Disasters: Some Implications for Crisis Planning and Managing Drawn from Katrina,” in Understanding Katrina: Perspectives from the Social Sciences (New York: Social Science Research Council, 2005). 93   Simon Woods, “Respect for Autonomy and Palliative Care,” in Euthanasia: European Perspectives, ed. Henk ten Have and David Clarke (2005). P. 146. 94  Gerald Dworkin, The Theory and Practice of Autonomy (Cambridge University Press, 1988). pp. 40–41. 87 88

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of seismic ­disasters. The combination of these factors qualifies earthquakes as examples of double disasters.95 The above remark makes it doubly problematic to enlist disaster victims for any research purpose during their misfortunes. Indeed, scholars like Bohannon observe that disaster scenarios are very chaotic, stressful, constitute dangerous environments, and are therefore far from suitable for conducting scientific activities such as clinical  research.96 Arguing along similar lines of thought, Shuster states that research on disaster victims largely constitute a luxury.97 The idea that disaster-time clinical research may benefit future victims of similar misfortune often sounds like a useful polemic for highlighting its potential benefits and rendering some moral justification. However, asking people already burdened with severe emotional, physical, and other kinds of stress and whose autonomous capacity has been somewhat compromised not only entails demanding too much from fragile people but seems a violation of their dignity. Another moral issue engendered by earthquakes relates to what obligations, if any, that people outside the region of the disaster (from an intra-national, trans-­ national, and global perspective) may have towards those affected. In other words, are Haitians living outside Port-au-Prince, for instance, the only people obligated to rally round to catering to the needs of the 2010 earthquake? Or are people of the same continent and even those from the farthest continent of the world obligated to show some material and financial support? Who are the actors and other stakeholders that ought to show solidarity towards the plight of disaster victims? Are some of such moral actors obligated to do more compared to others? If these rhetorical questions are taken for granted, should there be some “punishment” for actors that fail to act in relation to helping reduce the myriads of suffering that victims and survivors of natural disasters such as earthquakes face? These questions will, however, be left at the rhetorical level for now and will be revisited in the context of formulating the solidaristic moral framework which this chapter seeks to develop in relation to resolving the ethical perplexities that earthquakes bring about. But it is clear from the foregoing that human actions and activities in terms of what they may do or fail to do during and after a seismic havoc generate ethical tensions. Other tensions, however, come to the fore that are not solely linked to human actions but may be tied to human inactions as well as non-­ materialistic elements of the universe. The next section examines these issues.

 Barilan, Brusa, and Halperin. Pp. 51–52.  John Bohannon, “War as a Laboratory for Trauma Research,” Science 331, no. 6022 (2011). Pp. 1621–1622. 97  Evelyne Shuster, “Interests Divided: Risks to Disaster Research Subjects Vs. Benefits to Future Disaster Victims,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Donal P. O’Mathúna, Bert Gordijn, and Mike Clarke (Springer, 2014). P. 110. 95 96

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5.2.2  Non-anthropogenic Quandaries The non-anthropological quandaries associated with earthquakes are partly tied to human activity (moral deficiency), human inaction (indifference to God-related issues), and elements of the divine (the will of God, what pleases or does not please God). Invariably, they echo whether or not the causal factors are natural or embed some elements of the divine acting through the forces of nature. For instance, the increasing relegation of religious and metaphysical concerns and notions vis-à-vis the explanation of real-world events raises the question of whether or not the decreasing attention to theological “business” at the personal and social levels may partly drive the rising frequencies of earthquakes. This is particularly relevant since ignorance of the “divine will” will likely lead to non-conformity and disobedience which may ultimately bring about divine retribution. Amidst the strident noise of postmodernism and the heightened sense of secularism that characterize modern life, supernatural interpretations of natural disasters tend to be perceived as symbols of superstition or cognitive backwardness.98 Nevertheless, the moral lens of religious logic has not completely gone away. For instance, natural explanation coexists with supernatural notions about the cause and purpose of earthquakes in a country such as Philippine. Such a view is not confined to the uneducated populace, or amongst only the religious.99 Similar attitude occurs in well-educated communities in Sicily.100 There may be other communities in other countries and people different other countries who hold a theological or moral view of the cause of earthquakes whose views have not been surveyed, hence, not reported in the extant literature. Indeed, the nexus between earthquakes and the supernatural is not confined to the Christian faith. In Islam, for instance, scholars like Akasoy remark that Allah may utilize forces of nature including those originating from the skies such as thunderstorms and those originating from below such as earthquakes to serve both as a punishment as well as reorient people towards repentance, especially as they portend the ultimate day of Judgment of the whole world.101 Hence, only hypocrites and unbelievers, in the Islamic tradition, are believed to be largely affected by the direct and indirect consequences of earthquakes.102 The Islamic attitude to natural disasters

 David K Chester, “Theology and Disaster Studies: The Need for Dialogue,” Journal of Volcanology and Geothermal Research 146, no. 4 (2005). P. 320. 99  Greg Bankoff, “In the Eye of the Storm: The Social Construction of the Forces of Nature and the Climatic and Seismic Construction of God in the Philippines,” Journal of Southeast Asian Studies 35, no. 1 (2004). Pp. 93–94. 100  Chester. P. 321. 101  Anna Akasoy, “Islamic Attitudes to Disasters in the Middle Ages: A Comparison of Earthquakes and Plagues,” The Medieval History Journal 10, no. 1–2 (2007). Pp. 392–394. 102  Thomas R Paradise, “Perception of Earthquake Risk in Agadir, Morocco: A Case Study from a Muslim Community,” Global Environmental Change Part B: Environmental Hazards 6, no. 3 (2005). Pp. 167–171. 98

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including earthquakes is fatalistic. But such a frame of mind helps give meaning in scenarios where believers in the faith are part of victims.103 It is known that following earthquakes a lot of people undergo some psychological changes which lead to a broadened view of life and an increase in the sense of meaning and purpose for existence.104 This is important in several ways. Firstly, it creates an aura for sober reflection that enables people to think and attend to issues of religious conversion in some autonomous fashion. In other words, if matter is not the only reality, and if there is some “God” of the universe whose will is to reconcile humankind to himself, then it means that public health disasters such as earthquakes — regardless of their negative consequences—may stimulate the quest for seeking answers to the existential and teleological purpose of life. The Apostle Paul hints at this notion in his Corinthian Epistle: godly sorrow worketh repentance to salvation not to be repented of.105 Secondly, if this first notion is true, then it provides a preventive axis in relation to future earthquakes. For instance, the New Madrid earthquake shaped the religious climate in such a way that there was a surge in pietistic passion.106 To be sure, if some supernatural causal agent or agents are at play in the occurrence of some natural disasters such as earthquakes, then some supernatural-related kind of intervention should be able to ameliorate or prevent them. Selected instances seem to validate this notion. The use of religious relics at the Mount Etna region of Sicily have been largely effective in preventing volcanic eruptions to the extent that defy purely scientific and secular models of disaster response.107 In the Philippines, a nation very prone to natural disasters, prayer forms part of the normal repertoire of the coping mechanisms as well as response.108 Thirdly, if the nexus between aberration in the moral life of a people and the occurrence of earthquakes is true, then some form of specific ethical behavioral modification becomes exigent and constitutes a more significant means of limiting or preventing such disasters. For instance, the Islamic idea about earthquakes partly involves the reversals in society such as occur when men begin to behave like women and vice versa with the attendant decline in the moral state of society.109 This idea is likewise reflected in the Christian tradition where the erosion of godliness and the relegation of God in the affairs of humankind to the fringes is believed to engender natural calamities including earthquakes as well as signal the nearness of the “end” of the world.110 These assertions are obviously serious and show how decrying the  Hoda Baytiyeh and Mohamad K.  Naja, “Can Education Reduce Middle Eastern Fatalistic Attitude Regarding Earthquake Disasters?,” Disaster Prevention and Management 23, no. 4 (2014). Pp. 343–346. 104  Kari A O’Grady et al., “Earthquake in Haiti: Relationship with the Sacred in Times of Trauma,” Journal of Psychology and Theology 40, no. 4 (2012). Pp. 289–296 105  Holy Bible, King James Bible (Project Gutenberg, 1996). 2 Corinthians 7:10. 106  Kanon. Pp. 22, 27. 107  Chester. P. 320. 108  Bankoff. Pp. 94–103. 109  Akasoy. P. 395. 110  Bible. Matthew 24:7, 12. 103

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relevance and efficacy of divine elements in relation to natural disasters, and describing them as aimless111 constitute a means of further endangering the lives of people, though not in a tangible and materialistic manner. This is important because mainstream science, as well as the social pervasive postmodernist paradigm, is couched within the Darwinian lens which adopts an earth-centric telos for humankind.112 An offshoot of the Darwinian idea is the relegation of existential questions and experiences to the sphere of unimportance, at least at the social sphere. The religious notion which conceives humankind as a God-created being, however, ascribes ownership to God and, as such, makes humanity morally bound and accountable to divine dictates. Despite the knowledge-driven character of contemporary society as well as the sophistication of modern science, the God question remains open. It is one area where science ultimately encounters an inevitable limitation since one-time events and metaphysical realities are outside the purview of scientific investigations. A theme that emerges from the anthropogenic and non-anthropogenic quandaries raised by earthquakes is the finitude of human life. This connotes certain things such as the relatedness of human experiences across geographic planes, the inter-­ dependency of human beings, locally and globally, necessitated by the situational and contextual frailties and vulnerabilities of the human species. On this note, the next section develops a solidaristic moral lens vis-à-vis engaging the ethical issues that earthquakes bring about.

5.3  A Solidaristic Approach to Earthquakes It is possible to describe the range of social and medical responses to earthquakes as rallying grounds for ameliorating the attendant vulnerabilities of the people affected. This constitutes an act of moral solidarity. If this is true, then one may develop a solidaristic ethical lens in relation to engaging the moral quandaries embedded in PHDs such as earthquakes. This section seeks to realize this conceptual and ethical agenda. However, some understanding of the notion of solidarity is necessary.

5.3.1  The Concept of Solidarity Solidarity is a derivative term from French legal history. It connotes different ideas including activist responses to political injustice as well as other kinds of sympathetic responses and reactions to tragedy.113 In more specific terms, it entails collec Jean Tayag et al., “People’s Response to Eruption Warning: The Pinatubo Experience, 1991– 1992,” in Fire and Mud. Eruptions and Lahars of Mount Pinatubo, Philippines, ed. C.G. Newhall and R.S. Punongbayan (Seatle: University of Washington Press). Pp. 94–95. 112  Allen E Buchanan, Beyond Humanity?: The Ethics of Biomedical Enhancement (Oxford University Press, 2011). Pp. 4–6, 115–116. 113  Sally J Scholz, “Seeking Solidarity,” Philosophy Compass 10, no. 10 (2015). P. 725. 111

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tive action and unity vis-à-vis realizing cooperative action,114 and reflects the willingness to help others with whom one has some similarity in some relevant respects.115 For scholars like Scholz, solidarity involves the willingness to acknowledge social bonds with others and to act on behalf of the needs or interests of those others, whether or not those needs and interests are shared.116 In other words, it may be described as a manifestation of an instinctual other-centric identification with the vulnerable in order to help address some of the underlying causes of their vulnerability, by elimination or palliation.117 Some scholars advance the notion that solidarity seeks to bear the financial, social, and emotional “costs” of assisting others.118 In the context of disasters, however, this will hardly be the norm. A Yoruba normative principle, for instance, notes that ti ina ba njo eni, ti o njo omo eni, ti ara eni ni aa ko gbon (in an inferno, one is obligated to promptly seek some escape and comfort, however minimal, before helping others). This echoes the charge given out prior to commercial flights during which flight attendants implore passengers to fix their gas mask first, in the event of an emergency, before helping their child(ren).119 On this note, solidarity during natural disasters will involve internal and external empathy which will thereafter shape actions directed at self as well as others. Elements of the solidaristic impulse echo in today’s increasingly globalized world, where a considerable degree of human interaction and interconnectedness occurs through shared experiences, overlapping interests, and pursuits. Indeed, human health increasingly constitutes a globally shared responsibility that echoes common risks and vulnerabilities.120 This suggests that some close linkage exists between vulnerability and solidarity, an observation which has been advanced in the bioethics literature.121 Solidarity entails a naturalistic and teleological impulse which joins one human to another to foster companionship and societal interests.122 If this is true, then it does not necessarily have to involve group or subgroup actions all the time. In other words, the solidaristic impulse may be embedded in the human  Sister Mechtraud, “Durkheim’s Concept of Solidarity,” Philippine Sociological Review (1955). Pp. 23, 27 115  Barbara Prainsack and Alena Buyx, Solidarity: Reflections on an Emerging Concept in Bioethics (Nuffield Council on Bioethics, 2011). P. 34; “Solidarity in Contemporary Bioethics–Towards a New Approach,” Bioethics 26, no. 7 (2012). P. 346. 116  Sally Scholz, “Solidarity,” in Encyclopedia of Global Bioethics, ed. Henk ten Have (Switzerland: Springer International Publishing, 2016). Pp. 2653–2655. 117  Michael O.S. Afolabi, “A Vulnerability/Solidarity Framework for a Global Ethic: Historical & Contemporary Applications,” Revista Română de Bioetică 13, no. 1 (2015). Pp. 45–46. 118  Peter GN West-Oram and Alena Buyx, “Global Health Solidarity,” Public Health Ethics 1, no. phw021 (2016). Pp. 2–3. 119  Ayo Faleti, Yoruba Proverbs and Their Contexts: A Simplification (Lulu, 2011). P. 55. 120  Lawrence O Gostin and Ames Dhai, “Global Health Justice,” in Global Bioethics and Human Rights: Contemporary Issues, ed. Wanda Teays, John-Stewart Gordon, and Alison D.  Renteln (New York: Rowman & Littlefield, 2014). Pp. 320–321. 121  Afolabi. Pp. 44–56; Ten Have. Global Bioethics P. 218. 122  Mechtraud. Pp. 23–24, 27. 114

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person and should be extended to other human beings, regardless of local, cultural, spatial, and other group-associated considerations. Scholars like Wilde describe solidarity as a moral feeling of indignation against various forms of disrespect which engenders specific actions. In this vein, it may generate a rallying point for members of movements in a struggle.123 It may also constitute a feeling of sympathy shared by people within and across groups which impels supportive action.124 Given that solidarity is a social construct or social fact, the presence of different groups within society implies the idea and possibility that solidarity may manifest in specific societal contexts or segments. On the other hand, if it is a natural and inherent feature of the human person, its manifestation should not be limited by location, time, place and culture.125 Scholz shares this interpretation. For her, solidarity may extend to all humanity in which case it is not particularistic but universal and extends the nexus of obligations to all humanity.126 Consequently, it is possible to garner local and trans-local solidarity in relation to engaging the moral perplexities that confront fellow human beings, regardless of who, what, and where they may be. Against this conceptual backdrop, this section will attempt to explore how anthropogenic and non-anthropogenic types of solidaristic impulses and actions may be systematically used to engage the moral quandaries that earthquakes cause.

5.3.2  Anthropogenic Solidarity vis-à-vis the Quandaries of Earthquakes Scholars like ten Have argue that the coherence and inter-relationships of human persons constitute a critical lens for examining the living being.127 Human beings during their life, however, suffer many experiences fraught with some failure in their inter-relationship to one another and to nature. Earthquakes constitute one of such unwieldy experiences. But since they affect everyone, though with a differing degree, uniting or coming together to engage the attendant challenges and quandaries is a useful and viable approach. The significance of the solidaristic impulse during disasters is echoed in Oliver-­ Smith’s anthropological observation. He notes that during crisis scenarios such as after a natural disaster, a spontaneous kind of solidarity usually arises that enables people to set aside self-interests and seek cooperation.128 Commenting on the 2011  Lawrence Wilde, “The Concept of Solidarity: Emerging from the Theoretical Shadows?,” The British Journal of Politics & International Relations 9, no. 1 (2007). P. 176. 124  Lawrence E. Wilde, Global Solidarity (Edinburgh University Press, 2013). Pp. 1–2. 125  Afolabi. P. 46. 126  Scholz. “Seeking solidarity”, P. 2623. 127  Henk ten Have, “The Anthropological Tradition in the Philosophy of Medicine,” Theoretical Medicine 16, no. 1 (1995). Pp. 3–7. 128  Anthony Oliver-Smith, “The Brotherhood of Pain: Theoretical and Applied Perspectives on Post-Disaster Solidarity,” in The Angry Earth: Disaster in Anthropological Perspective, ed. Anthony Oliver-Smith and Susannah M. Hoffman (Psychology Press, 1999). Pp. 157–163. 123

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earthquake in Japan, James Dwyer noted that the scenario required responsiveness, solidarity, social responsibility, and the need to effect change.129 In relation to earthquakes generally, this remark implies at least two levels of solidarity vis-à-vis engaging the associated public health disasters. One involves primary actors (such as local government officials and health workers, the unaffected local populace, search and rescue teams, firemen, and international human and material aid) while the other type of solidaristic intervention involves the potential victims or local populace. The basic type of solidarity that can effectively help mitigate the ethical and pragmatic challenges of earthquakes is preventive and lies in the purview of local government officials. In this regard, policies that deter the building of houses in earthquake-prone regions, those that specify and enforce strict building codes in such locations and those that support periodic mock evacuation plans will help minimize casualties. The extensive casualty rate that was recorded during the 2010 earthquake in Haiti, for instance, was partly due to the weak government policies in relation to housing codes.130 The minimal loss of lives seen in the 2011 9.0 magnitude earthquake in Japan131 underscores the relevance of this preventive approach. In other words, one of the best possible ways to show solidarity to potential victims of earthquakes, and consequently, reduce the different forms of vulnerabilities brought about during earthquakes is doing all that is within the human purview that can limit the impact of seismic havocs on human as well as enhance the rapid and systematic removal of people from disaster locations when they occur. Policies may also help address the issues of resource allocation. Poor nations in earthquake-prone regions need to invest in warning systems by acting locally and by enlisting the help of donor agencies and nations. The relevance of early warning systems is underscored by the fact that they can provide a warning to the tune of tens of seconds about an impending disaster, hence, enabling the initiation of first rapid-­ response steps.132 In one sense, this is a cost-saving approach that ultimately reduces the amount of resources that will be expended to deal with the public health disaster dynamics of earthquakes. In another way, it also contributes towards reducing the vulnerability of people living in seismically active regions. Whereas disasters such as earthquakes may inspire some degree of selflessness,133 different people based on their previous experiences and training will respond differently. For instance, health workers normally committed to the moral activity of healthcare are more likely to perceive the moral needs of disaster situations. This set of professionals may specifically demonstrate solidarity through taking on supererogatory responsibilities including working for longer hours and suspending some  James Dwyer, Kenzo Hamano, and Hsuan Hui Wei, “The Disasters of March 11th,” Hastings Center Report 42, no. 4 (2012). P. 11. 130  Bilham. P. 878. 131  Niederman. Pp. 287–288. 132  Jacek Stankiewicz et al., “The Use of Spectral Content to Improve Earthquake Early Warning Systems in Central Asia: Case Study of Bishkek, Kyrgyzstan,” Bulletin of the Seismological Society of America 105, no. 5 (2015). Pp. 2764–2765. 133  Oliver-Smith. Pp. 157–158. 129

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of their personal affairs for the sake of attending to the needs of the victims and survivors. Yet, some pre-disaster training will go a long way in facilitating such selflessness. Along this line of thought, Joan Bold argues that ethical education can help enhance the decision-making process for professionals involved in disaster situations, and ultimately foster a higher quality of care for victims of disasters.134 In disaster-prone regions, the solidaristic lens offers a threefold insight in relation to the issues of human rights and constraints of autonomy that arise largely due to triage-related issues as well as concerns related to rape and sexual assaults. Firstly, engaging the local populace in activities that foster solidarity or concern for others in pre-disaster situations can help enhance sensitivity to the plight of others. Secondly, engaging would-be principal actors (such as healthcare workers, firemen, law enforcement officers and search and rescue teams) in disaster situations in discussions and deliberations about the ethical issues, and generating specific action plans out of the reflections will facilitate prompt action and minimize restraint when such issues arise during their responses to the challenges of an earthquake. Since the goal of solidarity in public health involves communal well-being,135 a third consequence of a solidaristic approach is that the consensus reached for formulating specific action plans will look beyond individual interests and shift the focus on the interests of the public, thereby side-stepping one of the greatest challenges in public health emergencies. It is to be expected that some of the local populace will feel very empathetic towards the victims and survivors of an earthquake and will spontaneously desire to get involved in rendering some type of assistance. Such a response reflects their moral nature and echoes the solidaristic impulse. Yet, it is not in their personal interest and little good may result from rushing to the disaster area as it could be excessively dangerous and possibly harmful.136 As such, prior social education in disaster-prone regions that emphasizes the role and importance of coordinated responses is critical to nudging people towards responding in ways that are conducive to engaging the challenges thrown up, rather than complicating the response. Empathizing with disaster victims as vulnerable people needing urgent rescue and care which can thereafter elicit acts of transnational solidarity underscores the significance of how burdens of a locality may rapidly become a global burden that demands attention and solutions. At the same time, however, not any kind of international assistance is needed during public health disasters. In this vein, Eric Noji notes that a hasty response that is devoid of prior impartial assessment often complicates the chaos of disasters. It is, therefore, better to wait until real needs are determined.137 This echoes the notion: having too many cooks prepare a dish, spoils  Joan A Bold, “Ethics, Confidence, and Training as Predictors of Decision-Making by Nurses During Disasters” (Walden University, 2012). Pp. 1–10. 135  Scholz. P. 2655. 136  Dwyer, Hamano, and Hui Wei. P. 13. 137  Eric K. Noji, “The Nature of Disasters: General Characteristics and Public Health Effects,” in The Public Health Consequences of Disasters, ed. Eric K.  Noji (New York: Oxford University Press, 1997). p. 17. 134

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the broth. Hence, to get the best form of solidarity, international assistance needs proper coordination and viable partnerships with competent local principal actors. This is especially important considering the confusion that usually arises including who should command and coordinate relief plans amongst government institutions as well as whether or not international non-governmental organizations should be allowed to work independently.138 Merin’s description of how their local hospital in Haiti only utilized the United Nations and other relief organizations to facilitate the post-discharge management of care of patients and victims shows the significance of properly delineating roles and minimizing logistics and managerial confusion after an earthquake.139 On the other hand, it is not only the disease dynamics of earthquakes that cause concerns and thereafter generate actions of solidarity on a global scale. The enhanced interconnectivity in traditional media and the new social media platforms, for instance, can rapidly distribute real but disturbing images of the carnage of earthquakes and the associated public health sequelae. These platforms effectively transmit the horrors and realities of earthquakes, the distress of the victims as well as the overwhelming burdens of the local healthcare system to other parts of the world. But disturbing as this may be, it equally provides an avenue that can inspire and motivate external rallying around that may engender specific acts of solidarity. These will contribute to lessening the burdens of people affected by such public health disasters. Keim and Noji reported that during the immediate aftermath of the 2010 Haiti earthquake, social media platforms were the source of what people around the world knew. They served as a new forum for collective intelligence, social convergence, and community activism, which within the first 2 days following the earthquake led to donations of more than $5 million to the American Red Cross via mobile phone texting.140 Hence, while international mobilization of people to locations of earthquake disasters may be delayed in order to ensure proper orderliness and avoid unnecessary physical and material presence141; acts of solidarity may be redirected towards mobilization of funds. These can be more fruitfully spent following the identification of pertinent needs. Lastly, an anthropogenic form of solidarity involves the scientific community. In relation to this, it is important to enact laws that prohibit activities such as deep-­ water injection that induces earthquakes. Since some of these activities are potentially beneficial, their impact and complex causal relationships with the earth’s crust need to be studied with a view to developing clear-cut guidelines on where and when to pursue such earth-meddling activities without the attendant triggering of seismic waves.

 Karkee. P. 2.  Merin et al. P. e583. 140  Mark E Keim and Eric Noji, “Emergent Use of Social Media: A New Age of Opportunity for Disaster Resilience,” American Journal of Disaster Medicine 6, no. 1 (2010). Pp. 47–50. 141  Noji. Pp. 17–18 138 139

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5.3.3  Non-anthropogenic Solidarity vis-à-vis the Quandaries of Earthquakes Natural disasters such as earthquakes constitute a breakdown in the ways humans relate to their environment.142 From a theological perspective, the human environment extends beyond the sphere of material reality. Hence, a viable approach to the moral quandaries and practical challenges raised by earthquakes need to take into consideration not only the nature of relationships that exist between humans but the inter-relationships of humans and their non-human environment. In this vein, Gaillard and Texier note that during and after natural disasters, religion can serve as a resource rather than constitute a hindrance.143 The instinct of solidarity is a phenomenological human capacity. Therefore, it is no surprise that several religious lenses give some voice to it. Scholz, for instance, notes that the Judeo-Christian faith, as well as Islam, espouses a tradition of solidarity between believers and the divine, and between believers and non-believers.144 Natural disasters often create a context where a belief in God and a belief in an ultimate and deeply powerful “nature” emerge and run against one another.145 Indeed, while the materialistic conception of the human person and human experiences146 attempts to denounce elements of the divine; natural disasters such as earthquakes often bring back existential questions amongst victims, survivors, and bystanders. Yet, this nexus has often drawn some criticisms. For example, that the 1755 earthquake could strike Lisbon despite the city’s religious inclination (as attested to by the presence of about 90 monasteries and 40 churches) is sometimes seen as a reason to dislodge the divine nexus and accept earthquakes and other natural disasters as inescapable fates of humankind.147 That logic, however, suffers at least two limitations. The first involves the idea that the wrong God could have been the deity being worshipped at those religious institutions. Secondly, even if the right God were being worshipped at those religious places in Lisbon, worshipping the right God in a wrong way and with an unacceptable standard still constitutes an act of disobedience. If this is true, then it would not be a surprise if natural disasters such as earthquakes occur in such a climate as some form of retribution and a signpost to spur people to repentance.

 S William A Gunn, Dictionary of Disaster Medicine and Humanitarian Relief, 2nd ed. (Switzerland: Springer Science & Business Media, 2012). P. 48. 143  Gaillard and Texier. P. 83. 144  Scholz. P. 726. 145  Richard Bohannon, “Acts of God and Acts of Nature,” Forum Lectures 36 (2011). 146  James A Marcum, “Reflections on Humanizing Biomedicine,” Perspectives in Biology and Medicine 51, no. 3 (2008). Pp. 393–396. 147  Jochen Zschau and Andreas N Küppers, Early Warning Systems for Natural Disaster Reduction (Springer Science & Business Media, 2013). P. 4. 142

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Disasters have prompted people to seek God or to re-examine the moral states of their lives.148 Also, an appeal to the divine nexus has sometimes been effective in ways that defy purely scientific and secular explanations.149 Consequently, if the human person is not at all alone in the world, and if some “God” or cosmic force or being exerts control over the affairs of humankind and employ disasters such as earthquakes partly due to disobedience to his will, the erosion of godliness or the relegation of God in the affairs of humankind150; then the inputs of this non-­ anthropogenic element become all the more important. The purpose of a non-anthropogenic solidarity may be examined in terms of the local, global and individual contexts. Locally, prayer is useful for guidance and strength.151 Specifically, religious people may reflect as groups, reexamine their faiths and faithfulness to their faiths in the wake of natural disasters, and pray for victims and survivors. Globally, in addition to sending human and material resources, when such a need has been clearly identified, people of religious convictions may support the victims of such disasters with their prayers that they find the strength to weather the storm as well as experience the will of God (be it for salvation or repentance) in the face of such challenges. In other words, while religious groups often have a legacy of delivering services and offering physical and social resources to victims and survivors of disasters,152 they may also motivate people into giving some thought to key existential questions. At the individual plane, the sudden challenges caused by natural disasters present a sober avenue for reflection over the existential purpose(s) of life, if any. It is known that disasters force difficult existential issues onto the consciousness of human beings. These involve the moral and ethical core of their belief system and include a deep delving into concepts of both social and cosmic justice, sin and retribution, causality, the relationship of the secular to the sacred, and the existence and nature of the divine.153 Indeed, disasters raise issues about death and what and what does not happen thereafter. However, death or the possibility of it often fosters despair154 and raises questions linked to the human condition.155

 David K Chester and Angus M Duncan, “Responding to Disasters within the Christian Tradition, with Reference to Volcanic Eruptions and Earthquakes,” Religion 40, no. 2 (2010). Pp. 85–91. 149  Chester. P. 320. 150  Bible. Matthew 24:12. 151  Jerry T Mitchell, “The Hazards of One’s Faith: Hazard Perceptions of South Carolina Christian Clergy,” Global Environmental Change Part B: Environmental Hazards 2, no. 1 (2000). P. 38. 152  Pathik Pathak and Derek McGhee, “‘I Thought This Was a Christian Thing?‘Exploring Virtuous and Exclusionary Cycles in Faith-Based Social Action,”.Community Development Journal 50, no. 1 (2015). Pp. 40–41. 153  Anthony Oliver-Smith, “Anthropological Research on Hazards and Disasters,” Annual Review of Anthropology 25, no. 1 (1996). P. 308. 154  Marcella Colbert, “The Medicalization of Death & Dying,” Life and Learning 6, no. XIV (2011).P. 230. 155  Philippe Ariès, Western Attitudes toward Death: From the Middle Ages to the Present (JHU Press, 1975).P. 28. 148

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As such, faced with the uncertainty of what lies in the afterlife as well as the absence of scientific certitude on the matter, individuals may dither between anxiety and agony, or come to cherish life significantly more than earlier.156 A non-­ anthropogenic solidarity involves personal reflection of the place of oneself in the scheme of the moral order of the universe as well as helping others pursue a similar quest.

5.4  S  elected Implications of the Solidaristic Approach to Earthquakes If the solidaristic approach described above offers some handle vis-à-vis engaging the anthropogenic and non-anthropogenic issues that earthquakes generate, then there should be some nexus where the associated insights may be systematically and practically used to engage such realities. In other words, what implications a solidaristic approach have for shaping public policy demands some attention. Scholars like Prainsack and Buyx note that there are three tiers of solidarity: interpersonal, group, and contractual.157 However, if solidarity during emergency situations such as natural disasters entails some level of self-reflection and proper self-positioning to better help others, there is a fourth intra-personal dimension to solidarity. In this vein, moral actors and stakeholders who intend to act in ways that help bring succor to victims and survivors of disasters need to evaluate their capacity and efficiency at rendering specific types of assistance to ensure meaningful responses. At the same time, acting should be done in consultation with local stakeholders and officials to prevent unnecessary aid and causing preventable chaotic scenarios. Specifying the roles that will be played by different actors during a disaster prior to their occurrence has been identified as another possible way to show solidarity because it allows the evolution of supererogatory actions into moral obligations. This may be implicit in people’s roles as neighbors, teachers, and physicians.158 A solidaristic lens offers some ways of crystallizing or transforming these roles into some sort of contractual obligations. Because values and principles solidify not only into social norms but manifest themselves in contractual or other legal norms, the third level of solidarity may serve as a formal channel to institutionalize specific acts of solidarity.159 This is particularly important because of the multiplicity of meanings and diverse voices that characterize disaster scenarios.160  Li Yiting et  al., “End-of-Life Care in China: A View from Beijing,” in End-of-Life Decision Making—a Cross-National Study, ed. Robert H.  Blank and Janna C.  Merrick (The MIT Press, 2005). P. 54. 157  Prainsack and Buyx, “Solidarity in Contemporary Bioethics–Towards a New Approach.” Pp. 346–347. 158  Dwyer, Hamano, and Hui Wei. P. 13. 159  Prainsack and Buyx, “Solidarity in Contemporary Bioethics–Towards a New Approach.” P. 347. 160  Oliver-Smith, “Anthropological Research on Hazards and Disasters.” P. 309. 156

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Formalization of the anthropogenic dimension of the solidaristic lens at the local and national level will involve deliberation amongst key actors (health professionals, ethicists, officials at non-governmental organizations, religious leaders, law enforcement officers, as well as ordinary citizens). Such deliberations will both include the key concerns at play during natural disasters and how each of these groups thinks that such issues may be addressed. Such a forum will also require the presence and active participation of ethicists who can articulate the insights and normative obligations from a solidaristic perspective. The formal consensus reached through such a forum may, therefore, form the basis and action plan for the training and retraining of the those that will be involved in handling future seismic disasters. On a global note, the same document will serve as the basis for deliberation with international bodies such as World Health Organization, Médecins Sans Frontières, and other key international NGOs. Because such a formal document will be country-­ specific, the roles and responsibilities that will be played by global health organizations and other humanitarian bodies will consequently vary from one country to another. This will preserve the sovereignty of a nation to respond to natural disasters without foreign imposition and dictatorship. This analysis reinforces the idea that local culture is critical in relation to mounting successful responses to disasters such as earthquakes.161 It also echoes Farmer’s emphasis on the need to ensure local and contextual variation162 in engaging disasters generally.

5.5  Conclusion This chapter has argued that earthquakes constitute another type of public health disaster. It presented a conceptual picture of the nature of earthquakes, the social and geographic dynamics and the ethical issues that arise when they occur. It showed that such ethical issues arise largely out of the public health dimensions of earthquakes which revolve around issues of triage, mental health issues, infectious diseases, and trauma-related issues. The moral quandaries that are embedded in earthquakes are broadly anthropogenic or completely human-related and non-anthropogenic. Whereas appropriate behavioral modifications may help address the anthropogenic issues, the non-­ anthropogenic issues may not be adequately addressed without some human reach out to the spiritual or metaphysical sphere. But at the heart of the needs created by earthquakes is the motivation of non-vulnerable local and international members of the human community to try and render different kinds of useful material and non-­ material assistance. These local and transnational moral actors become instinctually and morally moved to offset the financial, social, material, and other costs of the disaster. On this note, the chapter explored a solidaristic approach to how relevant 161 162

 Chester. P. 325.  Farmer. P. 259.

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moral actors may help engage the ethical issues and other challenges that earthquakes elicit. Specifically, the chapter examined and explored how an anthropogenic type of solidarity may help address the human-related challenges and quandaries via modifying the behavioral patterns of principal actors, the geoscientific community, and the local populace. It also examined how a non-anthropogenic type of solidarity may help address the theological issues at the heart of earthquakes through fostering an atmosphere that encourages giving attention to existential questions at the personal and social spheres. The chapter likewise presented how the third axis of solidarity (in terms of generating formal instruments through dialogue and consensus of stakeholders) constitutes the means through which the solidaristic normative insights may be used to shape the local context and create a flexible means of enlisting global actors that act in ways that will help address some of the quandaries and challenges engendered by public health disasters such as earthquakes.

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Vulnerabilities and Human Rights Issues Postearthquake. Advances in Nursing Science 35 (2): 182–189. Nie, Hu, Shi-Yuan Tang, Wayne Bond Lau, Jian-Cheng Zhang, Yao-Wen Jiang, Bernard L. Lopez, Xin L. Ma, Yu Cao, and Theodore A. Christopher. 2011. Triage During the Week of the Sichuan Earthquake: A Review of Utilized Patient Triage, Care, and Disposition Procedures. Injury 42 (5): 515–520. Niederman, Michael S. 2013. Preparing for the Unexpected: Lessons Learned About Respiratory Infection from the Japanese Tsunami of 2011. Chest Journal 143 (2): 287–289. Noji, Eric K. 1997a. Earthquakes. In The Public Health Consequences of Disasters, ed. Eric K. Noji, 135–172. New York: Oxford University Press. ———. 1997b. The Nature of Disasters: General Characteristics and Public Health Effects. In The Public Health Consequences of Disasters, ed. Eric K.  Noji, 3–19. New  York: Oxford University Press. Nolen-Hoeksema, Susan, and Jannay Morrow. 1991. A Prospective Study of Depression and Posttraumatic Stress Symptoms after a Natural Disaster: The 1989 Loma Prieta Earthquake. Journal of Personality and Social Psychology 61 (1): 115–121. O’Grady, Kari A., Deborah G.  Rollison, Timothy S.  Hanna, Heidi Schreiber-Pan, and Manuel A. Ruiz. 2012. Earthquake in Haiti: Relationship with the Sacred in Times of Trauma. Journal of Psychology and Theology 40 (4): 289–301. O’Mathúna, Dónal P., Bert Gordijn, and Mike Clarke. 2014. Disaster Bioethics: An Introduction. In Disaster Bioethics: Normative Issues When Nothing Is Normal, 3–12. Dordrecht: Springer. Oliver-Smith, Anthony. 1996. Anthropological Research on Hazards and Disasters. Annual Review of Anthropology 25 (1): 303–328. ———. 1999. The Brotherhood of Pain: Theoretical and Applied Perspectives on Post-Disaster Solidarity. In The Angry Earth: Disaster in Anthropological Perspective, ed. Anthony Oliver-­ Smith and Susannah M. Hoffman, 156–172. Psychology Press. Paradise, Thomas R. 2005. Perception of Earthquake Risk in Agadir, Morocco: A Case Study from a Muslim Community. Global Environmental Change Part B: Environmental Hazards 6 (3): 167–180. Pathak, Pathik, and Derek McGhee. 2015. ‘I Thought This Was a Christian Thing? ‘Exploring Virtuous and Exclusionary Cycles in Faith-Based Social Action. Community Development Journal 50 (1): 40–54. Prainsack, Barbara, and Alena Buyx. 2011. Solidarity: Reflections on an Emerging Concept in Bioethics. London: Nuffield Council on Bioethics. ———. 2012. Solidarity in Contemporary Bioethics–Towards a New Approach. Bioethics 26 (7): 343–350. Quarantelli, Enrico L. 2005. Catastrophes Are Different from Disasters: Some Implications for Crisis Planning and Managing Drawn from Katrina. In Understanding Katrina: Perspectives from the Social Sciences. New York: Social Science Research Council. Raviola, Giuseppe, Eddy Eustache, Catherine Oswald, and Gary S. Belkin. 2012. Mental Health Response in Haiti in the Aftermath of the 2010 Earthquake: A Case Study for Building Long-­ Term Solutions. Harvard Review of Psychiatry 20 (1): 68–77. Raviola, Giuseppe, Jennifer Severe, Tatiana Therosme, Cate Oswald, Gary Belkin, and Father Eddy Eustache. 2013. The 2010 Haiti Earthquake Response. Psychiatric Clinics of North America 36 (3): 431–450. Repine, Thomas B., Philip Lisagor, and David J. Cohen. 2005. The Dynamics and Ethics of Triage: Rationing Care in Hard Times. Military Medicine 170 (6): 505–509. Rios, Claritza L., Michael Redlener, Eric Cioe, Patricia M.  Roblin, Stephan Kohlhoff, Stephan Rinnert, William Lang, Kathleen Powderly, and Bonnie Arquilla. 2015. Addressing the Need, Ethical Decision Making in Disasters, Who Comes First? Journal of US-China Medical Science 12: 20–26. Scholz, Sally J. 2015. Seeking Solidarity. Philosophy Compass 10 (10): 725–735.

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Chapter 6

A Global Ethical Framework for Public Health Disasters

Abstract  Public health disasters reflect a class of global problems that generate moral quandaries and challenges. As such, they demand a global bioethical response involving an approach that is sufficiently nuanced at the local, trans-national, and global domains. Using the overlapping ethical issues engendered by Ebola and pandemic influenza outbreaks, atypical drug-resistant tuberculosis, and earthquakes, this chapter develops a global ethical framework for engaging PHDs. This framework exhibits sufficient responsiveness to local, global, microbial, and metaphysical realities as well as scientific concerns.

6.1  Introduction Public health disasters reflect the conceptual, ethical, and practical intersection between the concerns of traditional public health ethics and the emerging academic discourse on disaster bioethics. They refer to three distinct phenomena, namely: public health issues of serious proportions such as infectious disease outbreaks, the attendant public health impacts of natural or man-made disasters, and currently latent or low prevalence public health issues with the potential to rapidly acquire pandemic capacities. Ebola and pandemic influenza outbreaks, atypical drug-­ resistant tuberculosis and earthquakes reflect this conceptual interpretation in various shades. Consequently, the moral quandaries at the heart of PHDs reflect the ethical concerns that overlap across individual disasters such as Ebola outbreaks, atypical drug-resistant tuberculosis, earthquakes, and pandemic influenza. These issues may be outlined specifically as different forms of vulnerability, human dignity as well as rights-related issues, uncertainty, and justice, from local and global perspectives. On a closer examination, these overlapping issues show the presence and complicated interaction of human agents, human actions and inactions, biological organisms such as bacteria and viruses, and the possible agency of a divine non-human “God”. As such, addressing these moral issues can only come through a clear under-

© Springer International Publishing AG, part of Springer Nature 2018 M. O. Afolabi, Public Health Disasters: A Global Ethical Framework, Advancing Global Bioethics 12, https://doi.org/10.1007/978-3-319-92765-7_6

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standing of the interactions of these human and non-human actors/factors. This idea has at least two conceptual implications. Firstly, it suggests the inadequacy of the context-specific frameworks developed for each of the representative disasters in relation to properly engaging the ethical quandaries of PHDs as a class of global problem. Secondly, it suggests the need to develop a broader and more encompassing moral compass for engaging public health disasters  as a specific class of global health problems. Developing such a broad moral framework will, however, require an approach beyond extant ethical lenses. In other words, the conceptual building blocks of a global ethical framework will reflect some transnational moral diversity as well as incorporate multi-­disciplinary perspectives. Scholars like ten Have favors the latter approach in stating that ethics, as it increasingly becomes global and broader, should be a language of several voices.1 Global bioethics pursues global problems, that is, issues that will cause significant harm in the absence of cross-border and trans-national cooperation.2 Without a doubt, public health disasters are a class of global problems as they or their impacts can originate from any region of the world as well as disseminate to other parts of the globe. They, therefore, often rapidly transform local issues into global ones. As such, the attendant ethical quandaries demand a global bioethical solution. Against this conceptual foreground, this chapter seeks to articulate the relational bases of the ethical issues elicited by public health disasters, examine the limits of the four different moral approaches to specific public health disasters that were developed in Chaps. 2 through 5, as well as use some of the associated relational insights to frame a global ethical framework that may help engage the moral issues embedded in PHDs as a category of global health problems.

6.1.1  T  he Relational Basis of Ethical Issues in Public Health Disasters The overlapping ethical issues that resonate amongst those elaborated from Chaps. 2 to 5 constitute the moral quandaries elicited by public health disasters, writ large. These quandaries fall into two distinct categories. The first reflects human dynamics, and issues in this class include socioeconomic vulnerabilities, human rights and human dignity, harm, rationing/triage and local and global justice. Central to them is what a single individual or a group of individuals within or outside the location of a disaster may do  or fail to do in response to the challenges and needs of other human beings during a public health disaster. On the other hand, the second category of quandaries arises due to the interaction or non-interaction of human, biological, and non-human dynamics. Issues in this cat1  Henk Ten Have, Global Bioethics: An Introduction (Routledge, 2016). Global Bioethics Pp.19, 171. 2  Jay Drydyk, “Foundational Issues: How Must Global Ethics Be Global?,” Journal of Global Ethics 10, no. 1 (2014). Pp. 116–18.

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egory include biological and epistemic uncertainties, biological and geographic vulnerabilities, and whether there is a non-human “being” or “God” who responds to the moral inadequacies of humankind. Hence, these issues partially reflect what humans are yet to know about the non-human dynamics of earthly existence and how this epistemic gap and the associated moral shortcomings (if any) may elicit disasters. The next section examines the disaster dynamics of the human and non-human-­ generated quandaries at the individual, institutional, national, and global levels of interplay.

6.1.2  R  elational Basis of the Human Quandaries of Public Health Disasters Some of the moral concerns at the heart of public health disasters echo through the actions or inactions of humans as individuals, groups, professionals, and policymakers. They involve a range of choices made prior to, during, and after disasters that enhance or curtail the flourishing of self and that of other members of society and/or the global village. These can, however, be analyzed through a relational lens involving two human agents, or groups of these. Individual members of a society afflicted with a given PHD may be physicians, nurses, civil servants, hunters, morticians, policymakers, or university professors. For public health disasters with biological agents  such as a bacteria (e.g. Mycobacterium tuberculosis) or a virus (e.g. influenza A virus), the way any of these moral entities encounter the agent and the subsequent way they relate with other members of the society (such as friends, children, colleagues, patients, clients, and strangers) will influence whether a disaster ensues. In the context of Ebola viral disease, an innocent surgery on an undiagnosed patient will start a concentric ring of infection cycle from the health workers to the community.3 This often contributes to the cycle of diseases, deaths, and displacement. The “susceptibility factor” or vulnerability nexus in this context lies in human-human relationships that may be economic, health-related, professional, filial or social. On the other hand, weak institutions and inept institutional policies create an unfavorable backdrop to PHDs. This mostly applies to developing economies. In the African context, this is particularly significant because most health and social institutions were established without genuine local interests in mind and with goals alien to the local logic and interests.4 As such, policies tainted by this background or other 3  Yves Guimard et  al., “Organization of Patient Care During the Ebola Hemorrhagic Fever Epidemic in Kikwit, Democratic Republic of the Congo, 1995,” Journal of Infectious Diseases 179, no. Supplement 1 (1999). Pp. 269–270. 4  Michael O.S.  Afolabi, “Entrenched Colonial Influences and the Dislocation of Healthcare in Africa,” Journal of Black and African Arts and Civilization 5, no. 11 (2011). Pp. 235–241; Paulin Hountondji, “Distances,” Ibadan Journal of Humanistic Studies 3 (1983). Pp. 135–138; Adetokunbo O Lucas, Health Research in Nigeria: Is It Worth It? (Ibadan: Bassir-Thomas Biomedical Foundation, 2003). Pp. 2–5.

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kinds of policies, poor or good, or badly implemented ones, will shape social realities by influencing the actions and inactions of different sets of people. O’Hare recently observed that the minimal expenditure on health historically contributed to the crippling of the Sierra Leonean healthcare system. He noted that the country (where 53% of the population live below the poverty line) spends $25 million on health and $244 million to give tax incentives to foreign companies and organizations.5 In other words, a more rational and need-based spending would have enhanced the capacity of health institutions to mount a better response to the Ebola incident. Addressing this issue will require local and global types of justice. The nexus between weak infrastructure and negative social outcomes from the Ebola outbreak was not confined to Sierra Leone, as it has also been ascribed to the severity of the outbreak in Liberia and Guinea.6 However, external policies through external international bodies may sometimes be culpable in contributing to the weakness of local health institutions. In this vein, Kentikelenis et al. argue that the International Monetary Fund (IMF) contributed to the circumstances that enabled the crisis to arise and/or worsen in the west African region through their prior policies that had partly weakened the health systems in countries like Guinea, Liberia, and Sierra Leone,7 Specifically, the conditionalities of the IMF which mandated recipient governments to adopt policies that prioritize short-term economic objectives over investment in healthcare and education8 may be fingered because Guinea, Liberia, and Sierra Leone have received IMF support since 1990.9 This clearly suggests that the vulnerability of people to health disasters such as Ebola in these regions and the attendant trans-border health risks posed to nearby nations and the global village may begin prior to any specific incident. The practical and negative outcomes of weak institutions and bad policies often shape local trust in unfavorable ways. For instance, a lot of people in Liberia and Guinea denied the threat of Ebola and thought it was fake to the extent of claiming that the government and health workers were killing patients to simulate an epidemic in order to receive funds from Western governments and organizations.10 Applying and modifying the language of Battin et al., one may state that how people and nations become victims or persons-in-need or nations-in-need and

5  Bernadette O’Hare, “Weak Health Systems and Ebola,” The Lancet: Global Health 3, no. 2 (2015). Pp. e71–72. 6  Anthony S Fauci, “Ebola—Underscoring the Global Disparities in Health Care Resources,” New England Journal of Medicine 371, no. 12 (2014). P. 1085. 7  Alexander Kentikelenis et al., “The International Monetary Fund and the Ebola Outbreak,” The Lancet: Global Health 3, no. 2 (2015). P. 69. 8  David Stuckler and Sanjay Basu, “The International Monetary Fund’s Effects on Global Health: Before and after the 2008 Financial Crisis,” International Journal of Health Services 39, no. 4 (2009). Pp. 771–774. 9  Kentikelenis et al. P. 69. 10  Kevin G Donovan, “Ebola, Epidemics, and Ethics - What We Have Learned,” Philosophy, Ethics and Humanities in Medicine 9, no. 15 (2014). P.2.

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p­ ersons-as-­threats or nations-as-threats11 reflect (at the institutional level) disparities in institutional relationships in terms of disclosure of intentions, distinguishing real from pseudo-interests, exploitation of trust, as well as short-sightedness (on the part of local leaders and policymakers). The IMF and other agencies such as the World Bank are not the only avenues where local pseudo-interests have been pursued at the expense of real ones. For instance, the Structural Adjustment Program in most African countries was instrumental to rising ill-health and decreasing access to healthcare in the two-thirds of the population.12 These are important underlying factors that need to be engaged, understood, and prevented from reoccurring. Some policy deficits which may facilitate PHDs, are however, found in several nations, hence, are global in nature. Whereas cases of atypical drug-resistant TB have been identified in fifty different countries,13 diagnostic capacities are generally poor across the globe. Lack of policy in this direction is worrisome because drug-resistant TB is one of the most profound challenges facing global health.14 The global dynamics of public health disasters also echo through the movement of people as was exemplified by the case of Patrick Sawyer (Liberia-Nigeria nexus), Pauline Cafferkey (Sierra Leone-UK nexus), and Thomas Duncan (Liberia-USA nexus). These cases underscored how an infectious disease outbreak in just a place poses a significant risk everywhere15 and the capacity of trans-national infectious diseases to get out of control if not handled properly. This notion was exemplified in China’s slow reaction to the 2003 SARS outbreak and how the country restricted international access to patients and information which is believed to have contributed to the global intensity of that crisis.16 In other words, how a local public health disaster is handled determines and influences local severity, and how it spreads elsewhere. On the other hand, well-handled local health crises positively shape the possible impacts on contiguous nations as was demonstrated by Canada’s rapid and coordinated response to the SARS outbreak which limited its spread and impact in the United States.17 Against this background, the relational basis of the human quandaries elicited by PHDs may be examined. Socioeconomic vulnerabilities, for instance, facilitate poor health and biological vulnerability to diseases such as pandemic influenza, tubercu Margaret P. Battin et al., “The Patient as Victim and Vector: Challenges of Infectious Diseases,” in Blackwell Guide to Medical Ethics, ed. Rosamond Rhodes, Leslie P. Francis, and Anita Silvers (Blackwell Publishers, 2007). P. 272. 12  Rene Loewenson, “Structural Adjustment and Health Policy in Africa,” International Journal of Health Services 23, no. 4 (1993). Pp. 717–718. 13  Christopher Dye, “Doomsday Postponed? Preventing and Reversing Epidemics of DrugResistant,” Nature Reviews Microbiology 7, no. 1 (2009). P. 81. 14  Ross E.G Upshur, “What Does It Mean to ‘Know’ a Disease? The Tragedy of Xdr-Tb,” in Public Health Ethics and Practice, ed. Stephen Peckham and Alison Hann (Policy Press, 2010). P. 53. 15   Thomas R Frieden et  al., “Ebola 2014—New Challenges, New Global Response and Responsibility,” New England Journal of Medicine 371, no. 13 (2014). Pp. 1177–1179. 16  Theresa MacPhail, The Viral Network: A Pathography of the H1n1 Influenza Pandemic (Cornell University Press, 2014). P. 91. 17  Howard B Radest, Bioethics: Catastrophic Events in a Time of Terror (Lexington Books, 2009). P. 86. 11

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losis, and Ebola infections, and is often borne out of the absence of state-financed subsidizing of health for the indigent. People who have never cared for the rights of others can hardly be counted upon to respect the rights of victims of disasters. Indeed, victims of disasters who have been brought up in contexts bereft of an understanding of rights will hardly know when their rights are violated by public health measures such as forced quarantine. In addition, those who associate some rights violation with quarantine measures and whose input has not been sought prior to the implementation of such measures will likely resist or not comply. This played out significantly during the Ebola outbreak in West Africa.18 Such contextual social resistance may inadvertently bring about positive outcomes. For instance, protests at the location of Ebola quarantine center in a crowded hospital in Abuja, Nigeria compelled the government to relocate it to a safer place, thus, potentially preventing infection transmission. However, they may also bring about negative outcomes. For example, public outcry and social resistance led to the suspension of an Ebola trial in 2015.19 In addition, lack of knowledge about the limits of influenza therapeutic measures and their possible side-effects as well as the failure of health authorities to disclose these bits of information will make people at risk accept the associated potential harms without asking the right questions and making duly informed decisions. To be sure, by trying to prevent personal harms through wearing protective suits during Ebola outbreaks, some patients may feel alienated and refrain from giving full information necessary for clinical diagnosis20 Also, prior experience with the ethically challenging practice of triage and rationing during disasters will influence how compliance will be achieved. Lastly, the previously stated issues in conjunction with existing local and transnational policies will influence matters of justice. Against this background, it seems that providing the right education and training (for health workers and other emergency first-responders), information (to the general populace), and enacting the right policies in an inclusive manner that is ideologically suitable and socially sensitive will go a long way in providing the right background as well as orienting all the moral actors involved in a PHD context to relate and act better. Before commenting further on this, the relational basis of the non-human quandaries generated by PHDs needs to be examined. The next section focuses on this.

 Adia Benton and Kim Yi Dionne, “International Political Economy and the 2014 West African Ebola Outbreak,” African Studies Review 58, no. 1 (2015). P. 228. 19  Godfrey Tangwa, Katharine Browne, and Doris Schroeder, “Ebola Vaccine Trials,” in Ethics Dumping: Case Studies from North-South Collaborations, ed. Doris Schroeder, et al. (Switzerland: Springer, 2018). Pp. 49–52. 20  David von Drehle, “The Ebola Fighters,” Time Magazine 2014. P. 10. 18

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6.1.3  R  elational Basis of the Non-Human Quandaries of Public Health Disasters The nonhuman or non-anthropogenic quandaries generated by public health disasters centers around the notion of whether human activities (reflected by moral deficiencies), human inaction (reflected by indifference to God-related issues) and elements of the divine (reflected by the will of God) may causally influence natural events such as earthquakes. Integral to these is the increasing relegation of religious and metaphysical concerns vis-à-vis the explanation of real-world events. At the individual level, the Western intellectual tradition generally conceives the human person as a moral agent who is ultimately accountable to himself. This logic locates the destiny of the individual person and consequently that of the whole universe in the conceptual conclave of human agency. Thus, it celebrates the individualistic mantra of me, myself and I,21 while advocating free social contact and contract between people as the basis for situating social laws and accountability. This view has its core biological foundations in Darwinism, has generally fostered atheistic and agnostic attitudes, and has adopted science as its religious priest.22 It has likewise given rise to secular strands of morality with their own sets of “ises” or descriptive ethical lens and oughts or normative ethical prisms. These parameters not only shape individual and social life, but their influences extend to the sphere of institutional goals, activities, pursuits, and global interactions. However, the liberal, social and democratic secular approach to morality which also resounds in the bioethical enterprise23 has not completely turned the mind of Western people (its origins) and non-Western people (its destination of globalization) from forsaking the religious quest nor its attendant morality. The religious lens conceives the human person as a creation rather than an evolutionary accident that has emerged ex nihilo through speculatory and non-repeatable processes such as the Big Bang. Amidst the plurality of gods, the religious moral lens locates the nexus of primary obligation to the dictates of the creator to whom all of humanity is ultimately accountable. It asserts that the moral capacities inherent in human nature are insufficient to enable them to act ethically always, thereby, underscoring the need for some connection with the divine. There are at least three logical possibilities implied in the preceding analyses in relation to natural disasters like earthquakes. First, it raises the idea that human-­ generated morality or moral systems may only suffice in selected and situational

 Albert R Jonsen, The Birth of Bioethics (Oxford University Press, 2003). Pp. 390–393.  John Dupré, Human Nature and the Limits of Science (Taylor & Francis, 2003). Pp. 4–5. 23  H Tristram Engelhardt, “The Search for a Global Morality: Bioethics, the Culture Wars and Moral Diversity,” in Global Bioethics: The Collapse of Consensus, ed. H Tristram Engelhardt (Salem: M & M Scrivener Press, 2006). Pp. 18–19. 21 22

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contexts. That is, only PHDs whose origins are completely natural are amenable to human manipulation through relevant social measures. It also suggests the possibility that responses to the quandaries  and challenges associated with such natural disasters may not be adequately engaged through human-based ethical reasoning and responses alone. Thirdly, it implies that ignorance of the “divine will” or disobedience to it will exert tangible effects on personal and social life in the form of divine retribution. If these three ideas are true, then any ethical approach geared towards engaging public health disasters such as earthquakes need to embrace the religious perspective because the moral capacities of all the moral actors cannot be exclusively enhanced by human-created ethical frames of reference. Public health disasters including earthquakes and volcanic eruptions have been partly ascribed to a religious dynamic, though such a causal nexus is often seen as representing a symptom of superstition or cognitive backwardness.24 Yet, such a charge remains baseless at least for some reasons. One-time events and metaphysical realities are outside the purview of scientific investigations because they are non-replicable. Secondly, there are several transcultural accounts of how the supernatural has causally influenced human behavior and experiences, as well as the course of natural events. For instance, there are verifiable miracles that have occurred within the Christian tradition that defy scientific explanations.25 Divine interventions have also been recorded in several traditional religions across the globe.26 Similarly, religious relics have been used in Sicily to thwart earthquakes.27 Hence, an open approach or what scholars like Dupre calls a combination of insights from a variety of perspectives not limited to the scientific arena28 may hold the key to an adequate account of human nature and behavior. Such a combinational approach seems apt for addressing PHDs such as earthquakes that may have some  metaphysical undertones. Beyond offering a descriptive account, such an approach should also provide some normative template that bears a relationship to the scientific as well as the religious. Without a doubt, public health disasters foster suffering. But they also create the atmosphere for sober reflection which may facilitate personal ratiocination vis-à-vis the individual relationship (if any) to the divine. Therefore, they may serve as a critical avenue for seeking answers to the existential and teleological purposes of life or the affirmation of agnostic and atheistic stance. It is one thing to affirm the importance of the religious outlook. However, the pluralistic nature of modern life as well as the entrenched notion of multiculturalism—which assumes equal credence and validity to all religions—seems to be a source of potential conflict in deciding which specific perspective to use during a  David K Chester, “Theology and Disaster Studies: The Need for Dialogue,” Journal of Volcanology and Geothermal Research 146, no. 4 (2005). P. 320. 25  Craig S Keener, Miracles: The Credibility of the New Testament Accounts (Baker Books, 2011). Pp. 309–253. 26  Edith LB Turner, Among the Healers: Stories of Spiritual and Ritual Healing around the World (New York: Praeger 2006). Pp. 65–74, 105–107. 27  Chester. P. 320. 28  Dupré. Pp. 3–6. 24

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health disaster that may have a metaphysical undertone. Nevertheless, the conundrum may be solved by what can be described as the Mariner’s pluralistic solution. This notion comes from Jewish history and approximates the mariner’s response to a divinely orchestrated tempest in which everyone on board was asked to call upon their “God” for a solution.29 If some metaphysical causality does shape the occurrence of natural disasters like earthquakes, then paying attention to, giving room to, and allowing people to appeal to a possible dissonance in the relationship nexus with the metaphysical or supernatural increases the possibility of connecting with the “angry god” in question as well as the possibility of repentance which may lead to the end of a given divinely-mediately disaster. Against this background, the next section of this chapter examines the limits of the context-specific secular ethical lenses that were developed in relation to engaging the ethical quandaries elicited by Ebola viral outbreaks, pandemic influenza, atypical-drug-resistant tuberculosis as well as the partly non-secular solidaristic lens developed in relation to the dilemmas of earthquakes.

6.2  M  oral Limits of Representative Approaches to Public Health Disasters This section attempts to tease out the limitations of the Ubuntuan ethic, the communitarian and care ethical lens, the anthropo-ecological ethic, and the solidaristic moral approach to public health disasters. An understanding of these limitations— in their local, global, personal, and institutional capacities—will set the proper tone for the systematic formulation and application of a GEF that this chapter ultimately seeks to develop vis-à-vis PHDs.

6.2.1  Limits of the Ubuntuan Ethic vis-a-vis Public Health Disasters The Ubuntu moral lens is a Bantu-derived African notion and praxis whose conceptual vestiges resound in different parts of the African continent.30 Yet, it is not the case that every African or Bantu person lives and orders their moral life using the Ubuntu moral frame of reference. Since culture and society often exist in a fluid  Holy Bible, King James Bible (Project Gutenberg, 1996). Jonah 1:4–6.  Leonard Tumaini Chuwa, African Indigenous Ethics in Global Bioethics (Springer, 2014). Pp. 1–7. 29 30

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state,31 it is no surprise that the forces of Westernization have so much altered the African local culture that to find a “purely” African man in this day and age may be likened to finding a needle in a haystack. This is partly due to the traditional axis of socialization that has been supplanted or conjoined with other agents of socialization such as radio, television, and Western education; the concerns of which communicate little (if at all) of the indigenous African values and moral vision of life. It is also because of the deliberate forces of neoliberal capitalism as well as the neocolonial interference of some foreign powers in the local affairs of African nations. This has been ascribed to the reluctant way through which political independence was granted to most African states and the formulation of former colonial powers of social and economic policies that contribute to poverty and underdevelopment in the African continent.32 The African local context is, therefore, neither genuinely African nor completely Westernized and does not reflect a systematic integration or synthesis of the two. It is a context of dislocation where the local sense of self constantly suffers erosion by the alien other aided by local and foreign actors.33 According to Verhren, one of the primary goals of ethics is the nature of life (description) and how it is to be lived (normativity).34 Hence, without a true description of the contemporary nature of the African cultural reality and the attendant moral ethos, it may be difficult to frame an ethical prism that reflects the cognitive frame of mind of the people. Without this, it will also be difficult to assess the impact and point of asymmetries with Western ethical prisms. This underscores the local and national limits of the Ubuntu moral framework in African societies as well as the need to forge a ­relational nexus amongst the people to unpack a social ethic which will help reveal real from perceived values. Unpacking such an ethic is necessary because community values reflect a blend of intellectual concepts, feelings, and dispositions,35 and it is the ideological discourses and interactions that occur within different social contexts and involving different social actors that will provide the intellectual basis for formulating an acceptable social ethic. Since every society often embeds internal cultural and moral

 Toyin Falola, The Power of African Cultures (University Rochester Press, 2008). Pp. 1–2.  Samuel Oloruntoba and Solomon Akinboye, “From African Union of Governments to African Union of Peoples?,” in Unite or Perish: Africa Fifty Years after the Founding of the Oau ed. Mammo Muchie, et al. (Pretoria: Africa Institute of South Africa 2014). P. 221. 33  Michael O.S.  Afolabi, “Re-Writing Realities through the Language of Healing; a Critical Examination” (paper presented at the Ibadan International Conference on African Literature Ibadan: Nigeria, July 3–6 2008). Pp. 5–15. 34  Charles Verharen, “Ancient African Ethics and the African Union,” in Unite or Perish: Africa Fifty Years after the Founding of the Oau, ed. Mammo Muchie, et al. (Pretoria: Africa Institute of South Africa, 2014). P. 7. 35  Peter J Whitehouse, “The Rebirth of Bioethics: Extending the Original Formulations of Van Rensselaer Potter,” American Journal of Bioethics 3, no. 4 (2003). P. 27 31 32

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plurality,36 such a task is also important because it will help unravel conflicting ethical values and visions within the African fabric. It should also reveal areas of possible synthesis. Because such a task is currently missing, multiple meanings, nuances, and priorities exist for issues such as vulnerability, human rights and dignity and resource allocation amongst health workers, policymakers, literate and non-literate members of the society. This will clearly weaken the effectiveness of communication during PHDs and may engender unfounded forms of mistrust while hindering cooperation, especially amongst members of the public. This may partly explain why a lot of people resisted quarantine, and many more went into hiding to foil contact tracing attempts in the last Ebola outbreak. This connotes the notion that logic hardly completely holds sway during public health disasters. Illogical behavior during health emergencies is, however, not new. For example, during a cholera outbreak on board a ship in New York in 1849, 150 passengers escaped from the quarantine facility.37 Practically, this creates some degree of uncertainty about possible expected patterns of attitude and behavior to a PHD. For instance, during the Ebola outbreak in Nigeria, a consultant physician agreed to treat one of the contacts of the index case (Patrick Sawyer) in a hotel for financial gain. The diplomat had escaped being quarantined in Lagos and fled to Port Harcourt, 300 miles southeast of Lagos. That singular action caused him his life, infected his wife, other relatives, and patients he had attended to in his private clinic. Ultimately, it put more than 200 people at risk.38 The consultant’s decision and action are clearly anti-Ubuntuan. However, if someone with advanced medical training could jettison personal safety, sacrifice family health, and community well-being for pecuniary reasons, one can only wonder how a lay member of the society may act when confronted with a similar scenario wherea choice that does not favor self is required during a public health disaster. In relation to other types of public health disasters, the Ubuntuan lens also has some limits. In the context of ADR-TB, for instance, Ubuntu offers little (if any) insights into the nexus of relationship between humans and microbial life and how this passively (e.g. existential vulnerability) or actively affect the welfare of people (e.g. harm from non-adherence to treatment regimen due to financial reasons) and how bacterial species such as M. tuberculosis respond by evolving drug-resistant mechanisms (e.g. biological vulnerability). Whereas some ubuntu-centric scholars try to extend the axis of the ubuntuan relationship beyond the human ambit to include biological categories,39 such broad claims go against its central logic: I am because we are, since we are; therefore,

 Jing-Bao Nie and Alastair V Campbell, “Multiculturalism and Asian Bioethics: Cultural War or Creative Dialogue?,” Journal of Bioethical Inquiry 4, no. 3 (2007). Pp. 165–166. 37  Sonia Shah, Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond (New York: Sarah Crichton Books, 2016). Pp. 81–82. 38  Richard Knox, “A Diplomat Infects a Doctor as Ebola Spreads in Nigeria,” Fox News http:// www.npr.org/sections/goatsandsoda/2014/09/05/346033875/a-diplomat-infected-adoctor-as-ebola-spreads-in-nigeria. 39  Chuwa. P. 60 36

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I am.40 Indeed, the I-we nexus is anthropocentric and leaves no room for interactions as well as interdependence on microbial forms of life such as viruses and bacteria. Also, Ubuntu specifically does not include the realm of the metaphysical in its relational purview (of course, this does not imply that Africans lack a religious, metaphysical, or spiritual frame of reference). As such, it offers little insights in relation to engaging non-anthropogenic issues raised by public health disasters such as earthquakes. Consequently, it does not offer a moral leeway vis-a-vis relating to a possible “angry god” who may be at the center of such an incident. On the other hand, if Ebola viral infections were to spread to Euro-American societies to constitute a significant health disaster, the Ubuntu moral lens will hardly work due to the non-relational bearings of most people in such societies. In other words, it is difficult to expect people who are accustomed to prioritizing personal interests to adopt an other-centric moral lens during public health disasters. How the individualistic lens runs counter and contrary against the Ubuntu prism strikingly played out when the American nurse Kaci Hickox refused to be quarantined, despite some prior exposure to Ebola in West Africa. Regardless of these limitations, the Ubuntu moral lens shows the importance of an other-centric frame of mind in relation to engaging the quandaries and practical challenges of public health disasters. The preceding analyses echo the local limits of the ubuntu lens in engaging the quandaries of Ebola viral outbreaks. It also shows some of the general global limits of the ubuntuan lens as well as indicate the need for a broader moral lens to engage PHDs in general.

6.2.2  L  imits of Ethics of Care & Communitarianism vis-a-vis Public Health Disasters Public health disasters such as pandemic influenza entail a web of agency involving humans, animals (such as birds which migrate globally41 and swine42), and the environment. However, this web of inter-relationship is hardly normatively enclosed within the obligational repertoire of most people. Therefore, a solely people-­ centered lens such as ethics of care (with its focus on human carers and the cared-­ for) and the communitarian lens (with its ethical gaze on the community of persons) have some limitations in relation to engaging some of the ethical perplexities elicited by public health disasters in general, and pandemic influenza in particular.  John S Mbiti, African Religions and Philosophy, African Philosophy (London: Longman, 1969). Pp. 204–211; Mariana G Hewson, Embracing Indigenous Knowledge in Science and Medical Teaching, vol. 10 (Dordrecht: Springer, 2014). P. 134. 41  MacPhail. P. 77. 42  Kendall P Myers, Christopher W Olsen, and Gregory C Gray, “Cases of Swine Influenza in Humans: A Review of the Literature,” Clinical Infectious Diseases 44, no. 8 (2007). Pp. 1084– 1087; Rebecca J Garten et  al., “Antigenic and Genetic Characteristics of Swine-Origin 2009 (H1n1) Influenza a Viruses Circulating in Humans,” Science 325, no. 5937 (2009). Pp. 197–200. 40

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Whereas human relationships ultimately reflect a nexus in which the shifting needs and interdependency of people actively or passively place them into contextual categories of carers (the one/s who offer some care, support or nurturing in response to the specific needs of others) and “carees” or “cared-fors” (recipients of care/nurturing), the self-absorbed nature of contemporary living runs against such a moral current. It also increasingly makes it difficult for individual-based kinds of care to flourish. In other words, while caring relationships occur at the institutional planes (in healthcare settings, for instance), spontaneous kinds of care seem to be fading due to the fragmented nature of modern living. However, public health disasters demand spontaneous kinds of care that reflect supererogatory inclinations to take on additional responsibilities often at the expense of personal comfort. Whereas scholars like Tronto argue that care ethics offers a better approach for situating the responsibility of moral agents,43 this ethical lens encounters some limitations in the context of PHDs. The care ethical lens seeks to transcend the depersonalized realm of asking “what obligations do I have to Mr. X” to the humane realm of asking “how can I help Mr. X” in scenarios of moral crises.44 This assumes some type of Kantian disposition and/or obsession in which moral agents always reflect prior to engaging in specific courses of action. This hardly ever happens in normal life because there is no place where only the moral rules reign supreme.45 Therefore, it is doubtful if it can consistently be expected to occur in a chaotic disaster situation. If this is true, then how person A will seek to help person B during a public health disaster will be influenced by how they have previously and ­habitually shown care to friends, neighbors, and strangers as well as the extent of self-­effacing that contextual situations demand from them during a disaster context. As such, while the EOC lens embeds a disposition towards doing something for another person,46 the current social reality where caring for others seems to reflect the exception rather than the rule implies its shortcoming in engaging the broad challenges generated by PHDs. The care ethical lens also lacks an avenue for inserting the role and possible influences of microbial and non-human metrics in its normative analysis. This suggests the need for novel kinds of relational-based form of interventions to engage the moral and pragmatic issues engendered by disasters. Nevertheless. The care ethical lens offers a general other-centric orientation vis-à-vis engaging the quandaries and health challenges elicited by PHDs.

43  Joan C Tronto, Moral Boundaries: A Political Argument for an Ethic of Care (Routledge, 1993). Pp. 131–132. 44  Steven D Edwards, “Is There a Distinctive Care Ethics?,” Nursing Ethics 18, no. 2 (2011). P. 188. 45  Alan Hunt, Governing Morals: A Social History of Moral Regulation (Cambridge University Press, 1999). P. 8. 46  Virginia Held, The Ethics of Care: Personal, Political, and Global (Oxford University Press, 2006). p. 30.

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The communitarian lens with its bearing towards collective interests in the context of public health47 is relevant to PHDs. However, because the common good may be trounced when individual values and visions differ from that of the community,48 the communitarian lens becomes limited in the context of a public health disaster where understanding the ideas and inclinations of the moral actors is key to ensuring successful outcomes. Also, that some values subsist and shape moral action in a given community does not make them good in and of themselves. For instance, the washing and burial of Ebola victims through cultural practices that increase exposure to the Ebola virus (provided the cadaver is Ebola-positive)  may be slightly modified without necessarily altering the cultural telos. However, a communitarian appeal will insist on repeating the cultural norm without alteration, and without minding the potential public health consequences. As such, the lack of contextual flexibility makes the communitarian lens unsuitable for engaging public health disasters, broadly conceived. Also, community values are not always shared by every member of a given community.49 The absence of a leeway for internal moral engagement, therefore, implies that certain viewpoints and ethical intuitions and convictions may be ignored within the communitarian tradition. This again echoes its limits in the context of PHDs. Lastly, communitarianism, like the ethics of care approach, lacks a conceptual channel for incorporating the sphere of microbial and metaphysical considerations into its normative analysis and application. The latter metrics are, however, integral to public health disasters.

6.2.3  Limits of an Anthropo-ecological Approach vis-a-vis Public Health Disasters The anthropo-ecological moral prism combines anthropological with microbial epistemic currents in developing a normative approach  public health disasters. It gives room for some existential compromise between humankind and microbial life, reflecting the stance of Lepora and Goodin on the need for ethical compromise in relation to disasters.50 Hence, it sounds the sobering notion that the cycle of human infections may never be completely eradicated. The anthropo-ecological approach is quite useful, as it can help to blur the distinctions between human rights, autonomy, and social responsibilities by placing everyone in the category of infectables, focusing attention on the victimhood and vectorhood of human beings in relation to public health disasters with infectious  Stephen Holland, Public Health Ethics (Polity Press, 2007). Pp. 51–5.  Ronald Bayer et  al., Public Health Ethics: Theory, Policy and Practice (Oxford: Oxford University Press, 2007). P. 20. 49  Will Kymlicka, “Liberalism and Communitarianism,” Canadian Journal of Philosophy 18, no. 2 (1988). P. 200. 50  Chiara Lepora and Robert E Goodin, On Complicity and Compromise (OUP Oxford, 2013). Pp. 14–17. 47 48

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dynamics such as Ebola, pandemic influenza and ADR-TB. The anthropo-­ecological approach also emphasizes the value of prior social trust in relation to cooperation with health institutions and instructions during public health disaster situations. However, it does not accommodate metaphysical consideration in its normative account and analysis. As such, it becomes limited in the context of PHDs that may have elements of the divine or metaphysical undertones in their causal nexus.

6.2.4  L  imits of a Solidaristic Approach vis-a-vis Public Health Disasters Solidarity focuses on and explores social bonds and connections.51 The solidaristic approach developed in Chap. 5 clearly states what needs to be done in relation to the human and non-human quandaries of public health disasters such as earthquakes. It also identifies primary actors (such as local government officials and health workers, the unaffected local populace, search and rescue teams, firemen, and international human and material aid) and the potential victims or local populace who need to be mobilized to realize the critical ethical agenda. To be sure, solidarity can help people to set aside self-interests and seek cooperation52 as well as pursue goals that may help address collective social challenges, thereby fostering useful social change.53 However, an anthropo-ecological moral prism offers no means of assigning responsibilities. It also offers no means of altering the social milieu to prepare and co-opt people into performing solidaristic and other supererogatory tasks prior to disasters. This is important because human nature is partially embedded within the social milieu and influenced by the prevailing social order.54 In order words, it is easier to join forces and cooperate with others in a public health disaster scenario if one is hitherto predisposed to doing so. On the other hand, the solidaristic lens is also not open to accommodating microbial interactions in its normative account. Nevertheless, it does affirm the place of non-anthropogenic forces in relation to PHDs such as an earthquake. It also underscores the need for self-reflection and proper self-positioning prior to coming into a disaster arena to help others. In other words, it emphasizes the role of coordinated local responses prior to engaging external moral actors to prevent overcrowding and unnecessary human and material resources. Whereas crowded, impoverished societies are associated with significant burdens of infectious diseases,55 public health  Ten Have. Global Bioethics P. 216.  Anthony Oliver-Smith, “The Brotherhood of Pain: Theoretical and Applied Perspectives on PostDisaster Solidarity,” in The Angry Earth: Disaster in Anthropological Perspective, ed. Anthony Oliver-Smith and Susannah M. Hoffman (Psychology Press, 1999). Pp. 157–163. 53  James Dwyer, Kenzo Hamano, and Hsuan Hui Wei, “The Disasters of March 11th,” Hastings Center Report 42, no. 4 (2012). P. 11. 54  Charles Horton Cooley, Human Nature and the Social Order (Transaction Publishers, 1992). Pp. xii, xv, xvii. 55  Shah. P. 6. 51 52

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disasters increasingly cut through the social and economic divides of societies. In this regard, the solidaristic lens shows how a classless but systematic response is an essential key to resolving the quandaries and challenges of PHDs. This section has shown the importance of an other-centric orientation to public health disasters. It has underscored the importance and contexts of solidarity as well as the need to incorporate microbial as well as religious or metaphysical metrics into a useful normative approach to public health disasters. These parameters are clearly essential for any global bioethical approach to a global problem such as PHDs. The notion and methodology of global bioethics, however, embed some challenges. The next section seeks a viable way to overcome these with a view to developing a global ethic for public health disasters.

6.3  Overcoming the Challenges of Developing a Global Ethic Scholars like Calman contend that extant bioethical frameworks are usually not adequate to engage the problems of public health.56 Indeed, it has been argued that bioethics needs a revision of its basic ethical concepts and principles, especially those inherited from the individualistic liberal tradition.57 Also, hundreds of pathogens encroach upon the human community with the possibility of triggering pandemics.58 This occurs more now than before and contributes to how human beings tend to die very easily.59 However, disasters accelerate the process of human death and destruction. Public health disasters come with the traditional barrage of disasters upon which are superimposed novel health-related challenges. They, therefore, warrant more urgent kinds of local and global responses. Benatar and other colleagues argue that bioethics, with an expanded scope and shared foundational values, can help improve global health through such means as facilitating the emergence of a global state of mind, long-term self-interest, and strengthening capacity.60 A different ethical approach—a global bioethics—distinct from the mainstream bioethical lens is believed to hold the key to this agenda. Global bioethics means different things to different bioethicists. It is sometimes seen as an expansion of the scope of bioethics with a view to uniting the East and West, North and South as they all confront the modern challenges of biomedicine to reach common solutions.61 Hellsten notes that global bioethics has arisen out of the 56  K Calman, “Beyond the ‘Nanny State’: Stewardship and Public Health,” Public Health 123, no. 1 (2009). Pp. e6–e7. 57  Battin et al. P. 274. 58  Shah. P. 198. 59  Atsushi Asai, “Tsunami-Tendenko and Morality in Disasters,” Journal of Medical Ethics 41, no. 5 (2015). P. 365. 60  Solomon R Benatar, Abdallah S Daar, and Peter A Singer, “Global Health Ethics: The Rationale for Mutual Caring,” International Affairs 79, no. 1 (2003). Pp. 107–108. 61   Alastair V Campbell, “Presidential Address: Global Bioethics— Dream or Nightmare?,” Bioethics 13, no. 3/4 (1999). P. 183.

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increasing interconnectedness of people and their ethical dilemmas. She regards it as an attempt to universalize a specific brand of normative principles and values, making them globally acceptable and applicable.62 For Drydyk, global ethics encompasses seeking a reasonable and responsible agreement on global problems based on diverse moral grounds.63 Global bioethics is often linked with globalization and does involve the currents of globalization. However, scholars like ten Have recently argued that it is not birthed solely by globalization but involves seeking broader solutions to the ethical issues elicited by health, disease, life, and death.64 Methodologically, scholars like Chiarelli believe that a global bioethical approach needs to involve humanistic as well as theological insights and perspectives.65 Sinaci notes that serious bioethical reflection cannot engage real issues without the religious dimension, thus, highlighting the need for a clear understanding of religious models and traditions, and their essential concepts: birth, life, health, sickness, suffering, and death.66 For ten Have, global bioethics should be inter-disciplinary and incorporate some scientific methodology.67 More recently, he has argued that it entails a broader view of the biological, social, political, and environmental dynamics of healthcare, biomedical sciences, and research.68 Others have noted that global bioethics also seeks to foster an agreement between mankind and nature.69 This is necessary because the health of humankind closely ties with and is shaped by the environment within which they live in a web-like ecosystem of competition (with other life forms) with varying degrees of dependency.70 For van Potter, secular morality and religious cooperation can drive global bioethics despite the modern mire of pluralism.71 In other words, a global bioethics can help tease out a sane and relevant voice amidst the cacophony of ideological voices that are present in today's’ intellectual discourse.

 Sirkku K Hellsten, “Global Bioethics: Utopia or Reality?,” Developing World Bioethics 8, no. 2 (2008). P. 70. 63  Drydyk. Pp. 16–17. 64  Ten Have. Global Bioethics P. 211. 65  Brunetto Chiarelli, “The Bioecological Bases of Global Bioethics,” Global Bioethics 25, no. 1 (2014). P. 20. 66  Maria Sinaci, “The Possibility of Global Bioethics in a Globalized World,” Communication Today: An Overview from Online Journalism to Applied Philosophy (2016). Pp.302–303. 67  Henk AMJ ten Have, “Potter’s Notion of Bioethics,” Kennedy Institute of Ethics Journal 22, no. 1 (2012). P. 77. 68  Henk ten Have, “Bioethics Needs Bayonets,” in Global Bioethics: What For? Twentieth Anniversary of Unesco’s Bioethics Programme, ed. German Solinis (Paris: UNESCO, 2015). P. 148. 69  Amir Muzur and Iva Rinčić, “Two Kinds of Globality: A Comparison of Fritz Jahr and Van Rensselaer Potter’s Bioethics,” Global Bioethics 26, no. 1 (2015). P. 26. 70  Benjamin A Kogan, Health: Man in a Changing Environment (Harcourt Brace Jovanovich, Inc, 1970). Pp. 12, 15. 71  Van Rensselaer Potter, “Global Bioethics as a Secular Source of Moral Authority for Long-Term Human Survival,” Global Bioethics 5, no. 1 (1992). P. 6. 62

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According to ten Have, a cardinal aspect of global bioethics which is reflected in the Potterian approach is the relatedness of persons to each other, the community, nature, other forms of life as well as the environment.72 If adaptive success is shaped by the outcome of human interaction with the environment and other life forms present,73 then a global bioethical framework implies the collaboration between specialists in different fields (philosophy, sociology, medicine, theology, psychology, etc.) who are interested in the same subjects and work with similar information sources74 and who reckon with the roles of microbial (e.g. bacteria and viruses) members of the ecosystem. Since there is often a dynamic relationship between nature and nurture,75 one can argue that a global ethic (and by extension global bioethics) should flexibly reflect the changing dimensions of the local and global nature of human experiences and ethical lenses in relation to the complex and multifaceted influences that may stem from some of the problems of nurture. Rosemarie Tong recently echoed this idea in describing global bioethics as a form of bioethical approach that takes into consideration the diversity of peoples and cultures in seeking ways to improve people's health across the globe.76 The idea of a global bioethics is, however, a very hotly contested issue. According to Hutchings, this arises in the context of realizing a global ethic whose aim is to control moral global policies, laws, and institutions, directly or indirectly.77 Objections are leveled against such an interpretation in terms of charges of neocolonialism, moral imperialism. intellectual hegemony, as well as cultural domination.78 At the heart of these conceptual contentions, however, is the nature and variations of moral reasoning and how to arrive at a consensus on this. To be sure, moral reflections and their outcomes or ethical perspectives reflect differing diversities because different moral building blocks constitute their foundations. For Tristram Engelhardt, these disagreements are perennial and may only be solved via the implementation of a forceful moral orthodoxy. This, according to him, is an intractable task because real consensus is philosophical, ideological, and is impossible due to differing moral premises. Pseudo-consensus, on the other hand, comes readily via the selective appointment of ethicists with little moral diversity.79 Another problem with reaching moral consensus is partly tied to the quest to realize  Ten Have. “Potter’s Notion of Bioethics”, P. 62.  Chiarelli. P. 19. 74  Sinaci. P. 298. 75  Whitehouse. Pp. 28–29. 76  Rosemarie Putnam Tong, “Is a Global Bioethics Possible as Well as Desirable? A Millennial Feminist Response,” in Globalizing Feminist Bioethics: Crosscultural Perspectives, ed. Rosemarie Putnam Tong (Routledge, 2018). Pp. 27–31. 77  Kimberly Hutchings, “Thinking Ethically About the Global in ‘Global Ethics’,” Journal of Global Ethics 10, no. 1 (2014). P. 26. 78  Alan Petersen, The Politics of Bioethics (Routledge, 2011). Pp. 7, 17–18; Heather Widdows, “Is Global Ethics Moral Neo-Colonialism? An Investigation of the Issue in the Context of Bioethics,” Bioethics 21, no. 6 (2007). Pp. 307–312. 79  Engelhardt, “Global Bioethics: An Introduction to the Collapse of Consensus.” Pp. 1–5. 72 73

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a global ethic that is grounded in acultural and asocial oughts.80 Such an approach neglects the social embedded nature of human beings, which invariably implies that differing socio-cultural realities will necessitate local nuances even to globally viable ethical prisms. Moral consensus come in at least two ways: foundational and contextual. Scholars like Engelhardt see moral consensus in a foundational sense. For Engelhardt, if the moral rubric between two moral strangers is dissimilar, reaching an agreement between them becomes difficult. Scholars like Jotterand, however, believe that contextual moral consensus is possible between person X and Y if there is some flexibility of interests and needs as well as tolerance and mutual commitment.81 But there is a third way of formulating moral consensus by focusing on restricted classes of global problems. This third option entails looking for local problems across different cultural divides which equally have some global dimensions. This may be followed by formulating context-suitable solutions to each of these representative problems with sensitivity to trans-national nuances and limitations. Finally, examining the common threats posed by the problems, unearthing common cores as well as overlapping quandaries and forging a flexible framework using the conceptual and ethical insights that intersect around the context-specific solutions may give a broader or global normative lens for approaching a specific class of global problems. In other words, if arriving at a comprehensive global ethic for bioethical problems, writ large, constitutes a complicated and controversial task,82 it is possible to arrive at theme-specific global “ethics” using the aforementioned methodology. Because there are hardly people who are in today’s global village existing in an abstract and decontextualized sphere,83 local moral problems often engender some level of global dimension, however weak. Ethicists like Drydyk describe global problems as those that will cause significant harm in the absence of cross-border and trans-national cooperation.84 This book has shown that public health disasters such as Ebola viral outbreaks pandemic influenza, atypical drug-resistant tuberculosis and earthquakes pose both local and global harms. In contemporary global health, no country can successfully insulate itself from major health hazards.85 By implication, they require trans-national cooperation and solutions. In other words, PHDs rightly belong to the class of global problems.  Heather Widdows, Donna Dickenson, and Sirkku Hellsten, “Global Bioethics,” New Review of Bioethics 1, no. 1 (2003). Pp. 101–102. 81  Fabrice Jotterand, “Moral Strangers, Prodeduralism and Moral Consensus,” in At the Foundations of Bioethics and Biopolitics: Critical Essays on the Thought of H. Tristram Engelhardt, Jr, ed. Lisa M Rasmussen, Ana Smith Iltis, and Mark J Cherry (Switzerland: Springer International Publishing, 2015). Pp. 211–212. 82  Drydyk. Pp. 16–22. 83  Ten Have. Global Bioethics P. 234. 84  Drydyk. Pp. 116–18. 85  Lawrence O Gostin and Ames Dhai, “Global Health Justice,” in Global Bioethics and Human Rights: Contemporary Issues, ed. Wanda Teays, John-Stewart Gordon, and Alison D.  Renteln (New York: Rowman & Littlefield, 2014). P. 319. 80

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In public health, the presence of individual nuances to standard protocols or clinical interventions or instructions is well-known. For instance, skipping breakfast may be bad for the health of many but not for all. Also, milk may be good for many people, yet, it nauseates some people.86 On this note, it is not unreasonable to forge a nuanced ethical framework for engaging public health disasters along relevant lines of divides in terms of individual, social, global, and ecological niches. If this is true, formulating a global ethic in relation to engaging global problems offers a normative lens for engaging global ethical problems, broadly conceived. On this note, the next section of this chapter specifically develops and describes the parameters of a relevant global lens vis-à-vis public health disasters.

6.3.1  Framing a Global Ethic for Public Health Disasters Public health disasters encompass a motley of issues with local and global dimensions. By nature, these issues are partly materialistic and partly non-materialistic and reflect different sets of relational dissonances at the level of human-human interaction, human-microbial life interaction, and human-non-human interaction. As such, any ethical framework geared towards engaging the moral quandaries as well as the attendant challenges of PHDs need to embrace these multifaceted dimensions. Pragmatically, PHDs as a class of global problems need solutions. Yet, the sociocultural nuances surrounding them demand that such solutions be flexible to attune to local and global contexts. At the heart of PHDs are relational dissonances encompassing human and non-human dynamics. Associated with these, also, are multiple epistemic facets including the secular, theological, medical, sociological, cultural, as well as philosophical, and ingrained within an ethical broth. Logically, this suggests that any viable global ethical approach to public health disasters will entail multi-disciplinary insights and ideas. Knowledge, broadly conceived, has become increasingly critical to doing ethics as well as understanding the different relationship axes, responsibilities, and duties87 that moral actors have toward one another. On the other hand, global health problems can hardly be solved today exclusively by countries of primary foci. For instance, a pandemic influenza outbreak can rapidly transfer across all the continents within 24 hours. To be sure, local health problems experienced in communities and nations increasingly entail some global dimensions.88 This observation partly highlights the urgency for cooperation across national lines to engage public health disasters that foist global vulnerabilities. It also partly underscores how the array of human and non-human interconnectedness that is central to PHDs demonstrate the idea that humans belong to a global neigh Kogan. P.8.  Eric J Cassell, “Unanswered Questions: Bioethics and Human Relationships,” Hastings Center Report 37, no. 5 (2007). P. 23. 88  Gostin and Dhai. pp. 318–320. 86 87

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borhood and, by this fiat, need some neighborhood-oriented or relational kind of ethics to solve their common global problems. Cassel contends that ethics is about relationships.89 If this is true, a relational ethical framework not only provides a good approach to engaging moral problems but offers an important way of engaging trans-national issues that have relational dissonances at their core. In other words, understanding such relational disparities should generate useful ways of resolving them. Such a framework cannot rely solely on bioethical epistemic currents and needs to relate with and employ non-bioethical knowledge, partly reflecting ten Have’s call for a language of several voices. Therefore, three distinct kinds of relational parameters are integral to framing a global ethic for engaging the moral quandaries of PHDs. The first is epistemic-based and involves novel combinations of knowledge across different scientific and social sciences spheres. This epistemic-based approach affirms the inescapability of a multi-disciplinary approach to global bioethics. The second parameter will require the application of the multidisciplinary epistemology to the human issues at the center of PHDs. This will involve orienting people within localities, nations, and across global planes to embrace values that facilitate solidarity, recognize mutual respect and dependency, as well as elevate human interests and values above pecuniary considerations. The third and last parameter requires incorporating and not stifling the possible role of non-human divine agency in shaping natural disasters such as earthquakes. This is important because if such a causal factor is at play, a response knitted solely on human agency will not always work. This three-pronged approach entails new ways of thinking and doing things and demands some form of moral change and moral evolution involving some pragmatically motivated moral changes in response to some of the practical difficulties in social life.90 Against this conceptual background, it is exigent to delineate the specific features of this “global ethic”. This book argues that such features involve at least five mutually reinforcing relational-based R’s. These are: respect for transnational moral values, respect for biological relatedness, respect for metaphysical frames of reference and diversity, responsiveness to vulnerabilities, and responsibility. The specific nature of each of these and their relevance vis-a-vis public health disasters is examined in the next section.

6.3.2  A  Five-Relational Global Ethic vis-à-vis Public Health Disasters This section delineates the specific ethical features of the five R’s and examines how they may help engage the quandaries of public health disasters. The notion of respect for transnational values reckons with the inevitable cultural and  Cassell. Pp. 20–22.  Richmond Campbell and Victor Kumar, “Pragmatic Naturalism and Moral Objectivity,” Analysis 73, no. 3 (2013). P. 446.

89 90

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sociopolitical realities that occur in different national, sub-national, and geopolitical territories. This will contribute towards resolving some of the disputes that arise due to what Hellsten describes as “universalistic imperialism” and “self-contradictory relativism”. This approach is also inevitable partly because included in the gamut of bioethical investigations are questions pertaining to human existence and well-­ being,91 which are intricately tied to human cultures and values. If community values reflect a blend of intellectual, social, and personal concepts;92 and if they are not always shared across the board,93—whether one is operating within a Western or non-Western context—94 then community values can only be deduced through social discourse and respectful deliberations as well as empirical sociological and anthropological data. This connotes the idea that global bioethics can no more rely on armchair speculation and reflection that takes place between and amongst scholars in books, conferences, and journals. Rather, it must more than ever engage empirical data derived from local, intranational, national and transnational contexts. Respecting transnational values may, therefore, help foster social, intranational, national and transnational cooperation on global health problems such as PHDs. Respect for biological relatedness entails recognizing and utilizing the significance of the biological ecosystem vis-à-vis ethical reflections.95 Arguing in this direction, Dupras et al. note that embracing and including biological insights present a Potterian approach to broadening bioethical concerns and engaging ethical issues of public health import.96 This approach is necessary because humans live in a larger ecosystem where microbial life-forms exist, seek flourishing, and are therefore co-legitimate tenants of the earth. Although people tend to see themselves as victors fighting a winnable war against pathogens, such a simplistic enemy-victor dichotomy does not capture the complexity of the human-microbe nexus.97 There are, however, some compelling reasons to balance the relationship between human and other biological forms of life.98 Drug resistance exemplified by such conditions as MRSA (methicillin-resistant Staphylococcus aureus), drug-resistant gonorrhea, and atypical drug-resistant tuberculosis demonstrate the urgency of finding this balance soon. That there may never be another golden age of antimicrobial

 Sirkku K Hellsten, “The Role of Philosophy in Global Bioethics,” Cambridge Quarterly of Healthcare Ethics 24, no. 02 (2015). Pp. 185–186. 92  Whitehouse. P. 27 93  Kymlicka. P. 200. 94  Hellsten, “The Role of Philosophy in Global Bioethics.” Pp. 189–190. 95  Van Rensselaer Potter, “Bioethics, Science of Survival,” Perspectives in Biology and Medicine 14, no. 1 (1970). Pp. 134, 151–152. 96  Charles Dupras, Vardit Ravitsky, and Bryn Williams-Jones, “Epigenetics and the Environment in Bioethics,” Bioethics 28, no. 7 (2014). Pp. 327–331. 97  Shah. Pp. 208–209. 98  Chiarelli. Pp. 19–20. 91

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drug development99 also highlights the importance of seeking microbial cooperation as opposed to the entrenched and mechanistically grounded elimination approach to infectious diseases. Microbes such as M. tuberculosis are, from an anthropocentric lens, parasites that require endless elimination through modern arsenals of antibiotics. However, respect for biological relatedness implies conceiving humans and microorganisms as partners in nature,100 each usually looking out to his and its interests. In the specific context of PHDs, respect for biological relatedness will contribute to reversing or tempering aggressive approaches to infectious diseases, favoring the adoption of rational antibiotic use as well as facilitating the pursuit of innovative non-antibiotic-­ based treatment options such as immunotherapies and immunomodulators, which may help curb reinfection and reactivation.101 These will positively impact the rate of microbial mutation and resistance, thereby helping to curb the social burdens of associated diseases such as ADR-TB. Respect for spiritual/metaphysical frames of reference and diversity entails avoiding the “intellectual smugness” with which appeals to spiritual frames of reference in relation to causality are often met in contemporary liberalized societies. It reflects what ethicists like Alastair Campbell describe as a global bioethical vision of respecting the diversity of ethical worldviews including the religious.102 It also reflects the Mariner’s pluralistic solution described earlier in this chapter as well as reflects the idea of Fritz Jahr, an independent pioneer of bioethics,103 that spiritual and unseen worlds need to be factored into the moral analysis  of the perplexing issues that humans face.104 Through this ethical prism, multiple attempts to solve a collective problem should be encouraged as long they do not impede the self-­ expression of others, the capacity of others to hold contrary vews, or lead to harm. Responsiveness to vulnerabilities constitute understanding and clarifying the underlying social, political, neoliberal, and institutional vulnerabilities that foster PHDs and mounting appropriate acts of solidarity or responses to them. This is necessary because relational dissonances underlie PHDs and the experience of vulnerability that negatively impacts people’s wellbeing is itself relational.105 If human beings are both capable and needy,106 responding to the multi-faceted vulnerability  Stewart T Cole, “Who Will Develop New Antibacterial Agents?,” Philosophical Transactions of the Royal Society B 369 (2014). P.1. 100  Radest. P. Ix. 101  Debapriya Bhattacharya, Ved Prakash Dwivedi, and Gobardhan Das., “Revisiting Immunotherapy in Tuberculosis,” Journal of Mycobacterial Diseases 4, no. 1 (2013). P.2. 102  Campbell. P. 189. 103  Amir Muzur, Iva Rinčić, and Stephen Sodeke, “The Real Wisconsin Idea: The Seven Pillars of Van Rensselaer Potter’s Bioethics,” Journal of Agricultural and Environmental Ethics 29, no. 4 (2016). Pp. 587–589. 104  Amir Muzur and Hans-Martin Sass, Fritz Jahr and the Foundations of Global Bioethics: The Future of Integrative Bioethics, vol. 37 (LIT Verlag Münster, 2012). P. xii. 105  Henk ten Have, Vulnerability: Challenging Bioethics (Routledge, 2016). P. 6. 106  Martha C Nussbaum, Frontiers of Justice: Disability, Nationality, Species Membership (Harvard University Press, 2009). P. 221. 99

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issues that echo before and during PHDs necessitates identifying, empowering, enhancing, and engaging the activities of the different moral actors involved  in mounting relevant responses. Finally, the ethic of responsibility entails holding individuals, governments, and institutions at the local and global level accountable to broad and specific acts or inactions. According to scholars like Finkler, to be human encompasses incurring responsibilities for others.107 For Benatar et al., rights should be enjoyed based on the willingness to accept responsibilities. 108 Other scholars like Chapman have also voiced the need to place less emphasis on rights rhetoric and focus rather on responsibilities of moral agents in specific contexts.109 Because appeals to rights are often demanding whereas proclivity to executing responsibilities often go with some degree of self-effacing and sacrificial tendencies, emphasizing the latter is necessary in disaster contexts where supererogatory and other-centric dispositions are critical to helping victims and survivors, as well as responders achieve successful outcomes. An examination of the five nuggets embedded in the relational-based global ethic shows how each one reinforces some of the others. For instance, respecting ­transnational values will help reinforce the tolerance and respect for religious views shared in such locations. For instance, it is known that variant religious ideas often come to the fore in the context of natural disasters such as earthquakes.110 Showing respect to such views by local responders and international NGOs will further spare victims and survivors of emotional trauma, thereby, contributing to ensuring that both parties achieve some of their desires, and succeed in the face of the tragedy. Against this background, it is important to examine how each of these five relational nuggets may help engage the quandaries of public health disasters.

6.3.3  A  Relational Global Ethic vis-à-vis the Quandaries of Public Health Disasters This section specifically attempts to explore how the five relational-based nuggets embedded in the proposed global ethical framework may help engage the moral quandaries of public health disasters.  Kaja Finkler, “Can Bioethics Be Global and Local?, or Must It Be Both?,” Journal of Contemporary Ethnography 37, no. 2 (2008). P. 174. 108  Benatar, Daar, and Singer. P. 120. 109  Audrey R Chapman, “Reintegrating Rights and Responsibilities,” in International Rights and Responsibilities for the Future, ed. Kenneth W.  Hunter and Timothy C.  Mack (Greenwood Publishing Group, 1996). Pp. –-4. 110  Kari A O’Grady et al., “Earthquake in Haiti: Relationship with the Sacred in Times of Trauma,” Journal of Psychology and Theology 40, no. 4 (2012). Pp. 289–290; Garvey Lundy and Felix Germain, “The Earthquake, the Missionaries, and the Future of Vodou,” Journal of Black Studies 42, no. 2 (2011). Pp. 247–251; Guitele J Rahill et al., “Shelter Recovery in Urban Haiti after the Earthquake: The Dual Role of Social Capital,” Disasters 38, no. s1 (2014). Pp. 73–81. 107

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6.3.3.1  Vulnerability Vulnerability often involves a decrease in as well as constraints to human capacities that engender some level of dependence  on others. During PHDs, the causes of vulnerability may be structural, social, epistemic, geographic location, biological, or existential. Responsiveness to these vulnerabilities through context-relevant acts of solidarity will help ameliorate the distress and pains of those affected. If vulnerability reflects a by-product of interactions between individual and contextual risks,111 then acts of solidarity must engage underlying causes, or what ten Have recently described as underlying structures of suffering and violence.112 In this vein, the nexus of power exerted by international agencies such as IMF and other neoliberal forces that weaken local contexts need to be eroded by cooperation within and across national boundaries. Showing solidarity should also entail seeking to understand the different monocultures that may be embedded in any given culture as opposed to the often-­ misleading Euro-American, African, Asian or Latin-American divides which assume ideological and ethical homogeneity. Finally, it should entail collective transnational responses to specific PHDs. For instance, assisting countries in earthquake-­prone regions to build more resilient houses and acquire better warning systems will help minimize losses and harms experienced during incidents. Similarly, supporting biopharmaceutical research to localized but global PHDs such as Ebola will help fast-track the development of therapeutic interventions such as vaccines and drugs. On the other hand, respecting biological relatedness by seeking non-aggressive therapeutic approaches to infectious diseases will partly slow down the capacities of microbes to mutate and evolve resistance mechanisms, thereby reducing the biological vulnerabilities of humanity to those organisms. The nugget of respecting religious appeals and spiritual diversity can help engage the existential vulnerability elicited by PHDs by allowing the pursuit of metaphysical measures, personally and socially. 6.3.3.2  Human Rights & Dignity Human rights issues come to the fore in different ways during PHDs. Some occur directly, while others occur as by-products of other specific issues such as triage and rationing. Scholars like Leslie Sklair have advanced the notion that taking human rights seriously entails eroding the distinctions between civil and political rights as well as social and economic rights.113 In other words, one way to engage the praxis of rights is to focus on the individual person in relation to specific issues that raise or may raise human rights-related violations. If this is true, emphasizing responsi ten Have, Vulnerability: Challenging Bioethics. P.71.  Ten Have, Global Bioethics, P. 214. 113  Leslie Sklair, “The Globalization of Human Rights,” Journal of Global Ethics 5, no. 2 (2009). P. 81. 111 112

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bility will help the moral actors involved in health disaster scenarios in various ways. However, this can best be achieved in pre-disaster conditions. For instance, the responsibilities of the moral actors such as healthcare workers, first responders, international agencies and NGOs in earthquake-prone regions can be debated, agreed upon, and specified before disasters. Although such an approach helps in the implementation of rights-related decisions such as triage,114 specifying and emphasizing responsibilities prior to disasters will also encourage supererogatory and other non-self-focused courses of actions. For instance, it would have been difficult for Nurse Kaci Hickox to reject being quarantined based on rights grounds if she had been explicitly briefed about the responsibilities and risks involved in going to help with Ebola in West Africa and if she had signed some form of waiver prior to traveling to West Africa. Clarifying responsibilities prior to entering disaster contexts also give moral actors (such as Kaci Hickox) the opportunity to make an autonomous choice of declining or accepting to render help for victims and surviros of disasters. For public health disasters that engender socio-political differences, respecting transnational values may help foster respect for the local cultural and political values. For instance, while it is true that China was slow to respond to the global impact of the 2003 SARS outbreak;115 respecting the ideological differences by responding to the Chinese attitude in ways that portray them as equal partners engaged in fighting a common threat would probably have led to better transnational cooperation; and consequently, help reduce the attendant global causalities. Campaigns for sanitary burial for Ebola victims or the suspension of traditional burial rites during the 2014 Ebola outbreak was done in a manner void of cultural sensitivity. International attitude as well as the attitude of international workers who traveled to countries like Liberia and Sierra Leone reflected a somewhat condescending approach to this culturally sensitive issue. The same attitude was adopted in relation to the connection between consumption of bats or “bush meat” and transmission of Ebola. Yet, as shown in Chap. 2, the scientific foundation for this connection is porous. Nevertheless, it negatively affected local cooperation.116 Hence, respecting transnational values can help create a context where the dignity of every moral actor is respected and an atmosphere where trust is fostered. 6.3.3.3  Uncertainty Šehović recently remarked that it is important to come to grips with the permanence of uncertainty in dealing with health emergencies including epidemics.117 There are three major kinds of uncertainty involved in PHDs; however, they all underscore  Hu Nie et al., “Triage During the Week of the Sichuan Earthquake: A Review of Utilized Patient Triage, Care, and Disposition Procedures,” Injury 42, no. 5 (2011). “Triage during the week of the Sichuan earthquake”, Pp. 515–519. 115  MacPhail. P. 90. 116  Anja Wolz, “Face to Face with Ebola—an Emergency Care Center in Sierra Leone,” New England Journal of Medicine 371, no. 12 (2014). Pp. 1081–1082. 117  Annamarie Bindenagel Šehović, Coordinating Global Health Policy Responses: From Hiv/Aids to Ebola and Beyond (Springer, 2017). P. 23. 114

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different facets of vulnerabilities. The nugget of responding to vulnerability may help address this moral quandary. Specifically, epistemic and biological uncertainty may be minimized through research and preventive approaches which can be facilitated through context-specific acts of solidarity. On the other hand, respect for religious causal appeals may help minimize uncertainty for those who subscribe to such an outlook, especially in natural disasters such as earthquakes and volcanoes that have for thousands of years been associated with elements of the divine. It is known, for instance, that religion can serve as a resource rather than constitute a hindrance during disasters.118 Not dissuading this approach also creates the possibility that some natural disasters may be stopped by divine intervention if the right kind of prayers is offered by the right type of people to the right type of “God”. Hence, leading not only to saving the lives of those that prayed but that of the rest of the at-risk community. A recent video clip about a tornado in the Philippines whose path was reversed by prayer seems to support this notion.119 6.3.3.4  Local and Global Justice Issues related to local and global justice are an important quandary in public health disasters. Responsiveness to vulnerabilities in terms of identifying weaknesses in extant local institutions will clearly help strengthen such agencies and enable them to better serve their relevant functions. For example, a lot of background situations make it difficult for health-related justice to be pursued efficiently in the African context. One essential core of this is the little connection that exists between indigenous forms of knowledge—which are orally but hardly ever systematically taught—and formal instruction.120 Bridging this gap is crucial to fostering conditions that will better allow the application of the relational-based global ethical lens to public health disasters. Global justice significantly shapes local contexts, and, perhaps, demand some urgent attention in the context of PHDs. For instance, The World Health Organization’s (WHO) activities are no longer driven by global health priorities but by donor interests such as the Gates Foundation.121 This may replace real concerns and global problems with idiosyncratic interests. Specifically, it has contributed to  Jean-Christophe Gaillard and Pauline Texier, “Religions, Natural Hazards, and Disasters: An Introduction,” Religion 40, no. 2 (2010). P. 83. 119  Kicker Daily News, “‘Power of Prayer’ Stops Tornado from Destroying Ph Village,” http:// k i c k e r d a i l y. c o m / p o s t s / 2 0 1 4 / 1 0 / w a t c h - p o w e r - o f - p r a y e r - s t o p s - t o r n a d o - f r o m destroying-ph-village/. 120  Hountondji. Pp. 135–140; Michael J Moravcsik and John M Ziman, “Paradisia and Dominatia: Science and the Developing World,” Foreign Affairs 53, no. 4 (1975). Pp. 699–705; Oscar OBrathwaite, “Promoting a Pan-African Education Agenda by Shifting the Education Paradigm,” in Unite or Perish: 50 Years after the Founding of the Oau, ed. Mammo Muchie, et al. (Africa Institute of South Africa, 2014). Pp. 156–159. 121  Shah. Pp. 117–118. 118

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the reality that 90% of worldwide medical research expenditure targets problems affecting only 10% of the world's population.122 It has also affected the drug-­ purchasing power of people living in developing economies where up to 90% of drug costs may be borne by individuals.123 Public health encompasses societal collective response to prolong life via creating healthy conditions, or factors that create healthy conditions,124 thus, global health problems cannot be fixed unless the underlying forces that have shaped its emergence are examined. One unsettling example is the role of neoliberal forces that generally conceives human beings as instrumental means to economic ends.125 Sonia Shah projected that by 2016, 1% of the world population will be in control of more than half of the world’s total wealth.126 However, health is incompatible with market forces.127 In relation to the problem of local and global justice, the relational-­ based global ethic can help mobilize and unite relevant moral agents and stakeholders with a view to identifying corporations and organizations that perpetuate this trend, sanctioning them (when applicable) and reversing extant laws (for instance, IMF agreements) that have created the situation ab initio. Having discussed some of the ways in which the relational-based global ethic may help address the quandaries of public health disasters, it is important to explore some of the possible justifications of this global bioethical approach  embodied within the GEF. The next section addresses this theme.

6.4  J ustifying a Global Ethical Framework vis-à-vis Public Health Disasters Beauchamp and Childress argue that pragmatic justification entails justifying moral norms on the basis of their capacities to achieve goals of morality.128 Global bioethics constitute trans-national moral responses to the ethical concerns of humanity.129 Hence, one relevant feature that a GEF should have is the capacity to help resolve  Wen L Kilama, “The 10/90 Gap in Sub-Saharan Africa: Resolving Inequities in Health Research,” Acta Tropica 112 (2009). Pp. 8–12. 123  Michael O.S. Afolabi, “A Disruptive Innovation Model for Indigenous Medicine Research: A Nigerian Perspective,” African Journal of Science, Technology, Innovation and Development 5, no. 6 (2013). Pp. 445–446. 124  Marcel F Verweij and Angus Dawson, “The Meaning of ‘Public’ in Public Health,” in Ethics, Prevention and Public Health ed. Marcel F Verweij and Angus Dawson (Oxford: Clarendon Press, 2009). P. 15. 125  Ten Have. Global Bioethics P. 219. 126  Shah. P. 112. 127  MacPhail. P. 201. 128  Tom L Beauchamp and James F Childress, Principles of Biomedical Ethics (Oxford university press, 2013). P. 419. 129  Ten Have. Global Bioethics P. 9. 122

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some of the ethical concerns and problems of humanity in general and in specific locations. On this note, this section seeks to offer some justificatory polemics in relation to the applicability of the relational-based global ethic via-a-vis public health disasters. It pursues this conceptual task through the lens of responsiveness to local, global, microbial, and metaphysical/spiritual realities as well as scientific causes/concerns.

6.4.1  Responsiveness to Local Realities Regardless of the interpenetration of peoples and cultures, sociopolitical contexts and cultural values remain distinct within and across continents. Individual nation states have particular legal obligations to offer security and health to her citizens based on available capacity and capabilities.130 Since PHDs like pandemic influenza are not just about microbes and science,131 dismissing local contexts and nuances is not a path fraught with wisdom. The relational-based global ethic offers a means of responding to local nuances and differences in several ways. In the African context, for instance, the notion of responding to vulnerabilities through relevant acts of solidarity can help mobilize relevant stakeholders and other moral actors to engage the underlying social, ideological, and political factors that shortchange responses to health related-issues, especially PHDs. This can help evolve what Farmer describes as models capable of incorporating change and complexity, and which reflect local variations.132 Public health in the African context encompasses some elements of unknown or uncharted territory that has scanty or no interaction with the public social system. Its needs are equally ever hardly anchored into public health policy and plans. On this note, it was observed (in Chap. 2) that public health within the African context incorporates the traditional sense of the science and art of promoting health and preventing disease133 as well as the state of health of those disconnected from the social system with the attendant need to critically understand this and develop relevant interventions. The relational-based global ethic developed in this book may help engage the uncharted “public” within the health system via its responsiveness to local realities. This underscores the need for societies to serve her citizens prior to expecting the same people to be selfless patrons in a time of public health emergencies. In addition, local solidarity may help change the current background conditions in the so-called developing economies in ways that reflect their own values and  Šehović. P. 19.  MacPhail. P. 197. 132  Paul Farmer, “Social Inequalities and Emerging Infectious Diseases,” Emerging Infectious Diseases 2, no. 4 (1996). P. 259. 133  Adetokunbo O Lucas and Herbert Michael Gilles, Short Textbook of Public Health Medicine for the Tropics (Arnold Publishers, 2003). Pp. 1–6; Verweij and Dawson. Pp. 14–16 130 131

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considered interests. This will help reduce external dependency through which some of these countries have hitherto been exploited by institutions such as the World Bank, IMF, and programs such as SAP. In the specific context of PHDs, identifying relevant moral actors and assigning responsibilities can help eliminate or reduce the chaos of disaster. This can also help halt the external influx of aid and NGO workers, which will help avoid unnecessary physical and material presence.134 Public health disasters require a great deal of other-centricity with a willingness to embrace additional and supererogatory responsibilities. In contemporary society, however, everyone seems to be sheltered within their own little bubbles, only finding just enough time to prepare a face to meet the faces that others will see, as Thomas Eliot once describes such a social attitude.135 Technology has probably worsened this trend.136 Yet, the inevitable demands of responding to PHDs also require that society reinvents itself, at least in its other-centric dispositions. The extent of this will probably vary across countries and continents, with traditional communalistic societies such as Asian and African contexts probably finding it easier compared to traditionally individualistic Euro-American societies. On the other hand, local sources of harm and potential harms that foster PHDs may be addressed by the proposed global ethic in that its capacity to rally stakeholders can stimulate critical internal discussions that may engender local solutions. For instance, concerns about the linkage between how dead bodies were being prepared for burial and transmission of Ebola infection might have been better engaged through internal debates as well as frames of reference that appealed to indigenous models of public health. Such viable indigenous models of preventive health abound in African cultural outlooks including the Yoruba, 137 the Acholi,138 the Ndembe, the Bantu, and the Akan.139 Hence, ignoring indigenous systems of response completely and attempting to impose or utilize only a Western model of causation and spread will isolate the people, foster ideological tensions for some, and may lead to time wastages that facilitate the easy spread of infection. Similarly, in the industrialized realm where man-made activities such as deep-water injections influence the occurrence of

 Eric K. Noji, “The Nature of Disasters: General Characteristics and Public Health Effects,” in The Public Health Consequences of Disasters, ed. Eric K.  Noji (New York: Oxford University Press, 1997). Pp. 17–18. 135  Thomas Stearns Eliot, Prufrock and Other Observations (Filiquarian Publishing, LLC., 2007). P. 6. 136  Keith N Hampton et al., “Social Isolation and New Technology,” Pew Internet & American Life Project 4 (2009). Pp. 29, 55–56. 137  Edward C Green, Indigenous Theories of Contagious Disease (Rowman Altamira, 1999). P. 44. 138  Barry S Hewlett and Richard P Amola, “Cultural Contexts of Ebola in Northern Uganda,” Emerging Infectious Diseases 9, no. 10 (2003). Pp. 1246–1247. 139  Afolabi, “Re-Writing Realities through the Language of Healing; a Critical Examination.” Pp. 1–3. 134

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earthquakes;140, 141 local stakeholders can push for laws that prohibit and/or restrict such activities based on scientific evidence. Responsiveness to local realities affirms the position of bioethicists such as Callahan and Jennings. In this regard, it specifically echoes the idea that ethics and public health issues can hardly be successfully advanced and pursued without considering the values of the general society as well as that of the specific communities where public ethical course of action is to be carried out.142

6.4.2  Responsiveness to Global Realities Karl Popper describes the world as emergent and in need of explanatory approximations of its state of affairs that are non-static.143 If this is true, and if people across cultures and geographies are now inevitably caught up in an intricate web of mutuality;144 a flexible global nexus is needed. This is partly because of the increasing rate at which the world is “shrinking” via the currents of globalization145 and the ease with which infectious disease dynamics of PHDs (e.g. through Ebola and pandemic influenza) and the emotional components (e.g. through earthquakes) may readily traverse national and international borders. To be sure, there are multiple means through which infection enters and exits the human body as well as the means of infection transmission from one individual to the next,146 and from one community to the next, and globally. In short, global problems including those with infectious dynamics now spread with ease across national borders.147 Hutchings notes that a global ethic should help disintegrate and destabilize hierarchies of power, identity and wealth.148 Such a global ethic will seek to prevent harm and encourage courses of actions which are amenable to this end, explore the cooperation of nations and multi-national organizations relevant to socio-political

 James W Stratton, “Earthquakes” in The Public Health Consequences of Disasters ed. U.S. Department of Health and Human Services (Atlanta: Georgia.: Center for Disease Control 1989). P. 15. 141  Nicholas Deichmann and Domenico Giardini, “Earthquakes Induced by the Stimulation of an Enhanced Geothermal System Below Basel (Switzerland),” Seismological Research Letters 80, no. 5 (2009). Pp. 784–788. 142  Daniel Callahan and Bruce Jennings, “Ethics and Public Health: Forging a Strong Relationship,” American Journal of Public Health 92, no. 2 (2002). P. 172. 143  Karl R Popper, The Open Universe: An Argument for Indeterminism, ed. W.W. Bartley (London: Routledge, 1982). Pp. 46, 130. 144  Verharen. P. 21. 145  ten Have. “Potter’s Notion of Bioethics” 67. 146  Kogan. pp. 154–155. 147  Nancy Kass, “Ebola, Ethics, and Public Health: What Next?,” Annals of Internal Medicine 161, no. 10 (2014). P. 744. 148  Hutchings. Pp. 28–29. 140

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and economic contexts to promote wellness and eliminate avoidable diseases.149 The relational-based ethic developed in this chapter offers several channels through which an agenda like this may be realized. In addition, evolving a global warning system is one way through which a practical approach150 may be brought to PHDs such as ADR-TB. This is partly supported by the idea that constant vigilance is essential to freedom from infectious diseases.151 Hardly would anyone deny the idea that poorer nations are unable to meet the economic demands that are necessary to engage PHDs at the institutional and social levels. These include procuring vaccines and bearing the financial burdens of temporary pandemic-associated losses due to the closure of businesses as well as any form of compensation (from the government) that may positively influence compliance to public health directives. In this vein, richer nations should be obligated to show  differing degrees of pecuniary solidarity. This form of solidarity, however, differs from an act of charity because it is a preventive action that will decrease the possibility of a trans-national and global dissemination of infection cycles.

6.4.3  Responsiveness to Microbial & Metaphysical Realities Pathogens and their human hosts are engaged in an endless cycle of epidemics.152 Indeed, microbial life forms such as bacteria and viruses as well as possibly unseen forces influence public health disasters in different ways. The relational-based global ethic helps incorporate this idea into the normative response to PHDs. This is important because values derive partly from a normative understanding of human nature and from a transcendental or secular perspective on life and the world.153 Whereas scholars like Annas argue that useful disaster-related policies and practices should override individual interests,154 a global ethic that is sensitive to the metaphysical frame of reference that victims and survivors may autonomously choose to adopt does not support such an idea. Rather, it respects the individuality, dignity, and intrinsic capacity of such people to make choices that cause no harm to others. Obviously, religious claims to causality are difficult to reproduce under controlled experimental conditions. However, the fact that science does not offer  Andrew D Pinto, Anne-Emanuelle Birn, and Ross. E.U. Upshur, “The Context of Global Ethics,” in An Introduction to Global Health Ethics, ed. Andrew D Pinto and Ross E.G Upshur (London: Routledge, 2013). Pp. 8, 11. 150  Nathan D Wolfe, Claire Panosian Dunavan, and Jared Diamond, “Origins of Major Human Infectious Diseases,” Nature 447, no. 7142 (2007). P. 283. 151  Kogan. P. 179. 152  Shah. P. 188. 153  H Tristram Engelhardt Jr, “Consensus: How Much Can We Hope For?,” in The Concept of Moral Consensus, ed. Kurt Bayertz (Springer, 1994).p. 23. 154  George J Annas, Worst Case Bioethics: Death, Disaster, and Public Health (Oxford University Press, 2010). Pp. 1–23. 149

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answers to deep existential questions that have confronted humanity since antiquity underscores the need to respect the choices of those individuals that adopt metaphysical ideas to explain and cope with natural disasters such as earthquakes. To be sure, if global bioethics needs to take into account the sphere of the spiritual and unseen in pursuing moral analysis,155 ignoring this dimension limits the depth of its praxis.

6.4.4  Responsiveness to Scientific Concerns The concerns of traditional bioethics and global bioethics are inexorably connected with the ethical quandaries that arise from scientific progress, challenges, and their direct and indirect impact on healthcare and biomedicine. As such, any feasible global ethic should contribute to this. Public health disasters underscore certain scientific challenges. The limits of therapeutic approaches to pandemic influenza and the potential harms, the lack of viable and ample vaccines for Ebola, the high index of untreatability of ADR-TB and the benefits of natural gas extraction from deep within the earth and possible risks of triggering earthquakes fall into this category. In this vein, the relational-based global ethical framework can help (through its responsibility and response to vulnerability nuggets) stimulate responsible research as well as garner relevant actors and stakeholders in relation to confronting these common challenges of PHDs that face humanity today. Specifically, it can help gear up more local, regional, and global funding and participation for Ebola research as well as engender scientific studies that seek to understand the complex causal relationships within the earth’s crust with a view to developing clear-cut guidelines on where and when to pursue earth-meddling activities without triggering seismic waves. Research-related issues also come to the fore during public health disasters. Some of these may be contextually allowed such as vaccine trials during influenza and Ebola outbreaks provided they have tested safe in comparable animal models. Since enrolled human subjects may be more vulnerable compared to ordinary clinical research contexts, responsiveness to their double vulnerability demands that there are more monitoring avenues to detect any form of unacceptable harm, which should halt the research, if need be. In other words, human considerations should always trump scientific ones. The relational-based global lens does not offer justification for clinical research on victims of other PHDs such as earthquakes. This is partly because research in such a scenario is largely a form of scientific luxury,156 and partly because asking people already burdened with severe emotional, physical,  Muzur and Sass, 37. P. xii.  Evelyne Shuster, “Interests Divided: Risks to Disaster Research Subjects Vs. Benefits to Future Disaster Victims,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Donal P. O’Mathúna, Bert Gordijn, and Mike Clarke (Springer, 2014). P. 110.

155 156

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and other kinds of traumatic stress to enroll in research reflects asking too much from fragile people as well as a possible violation of their dignity. Lastly, a global ethical lens that is sensitive to scientific concerns will attempt to network with scientists with a view to using ethical rhetoric to motivate them into pursuing relevant biological questions. For instance, the evolution of typical tuberculosis bacteria species into atypical strains.

6.5  Conclusion Public health disasters reflect the conceptual, ethical, and practical intersection between the concerns of traditional public health ethics and the emerging academic discourse on disaster bioethics. Specifically, they reflect public health issues of serious proportions such as infectious disease outbreaks, the attendant public health impacts of natural or man-made disasters, and “silent”, latent or low prevalence public health issues with the potential to rapidly acquire pandemic capacities. They are also a class of global problems. Since global bioethics seeks solutions to global problems, PHDs warrant a global bioethical lens to help resolve the moral quandaries as well as the other health-related pragmatic challenges. This chapter has examined some of the contentious issues central to the debate on global bioethics in terms of its normativity and the methodology of engagement which make arriving at a comprehensive global ethic for bioethical problems a complicated and controversial task.157 The chapter argued that these contentions may be avoided by using local problems across different cultural divides that have some global dimensions. This may be followed by formulating context-suitable solutions to each of the representative problems with sensitivity to trans-national nuances and limitations. Finally, it argued that examining the common threats posed by the problems, unearthing common cores and forging a flexible framework using the conceptual and ethical insights that intersect around the context-specific solutions may give a broader or global normative lens for resolving a class of global problems. The chapter has also shown that public health disasters have human and non-­ human dynamics. These dynamics cannot be adequately addressed by each of the context-specific moral approaches developed for specific PHDs in Chaps. 2 through 5, that is, the Ubuntu ethic, care ethics, communitarianism, anthropo-ecological ethics and solidaristic moral lens. While each of these may have limited normative power in engaging the broader ethical issues that public health disasters generate, they clearly underscore the relevance of an other-centric orientation, the importance and contexts of solidarity as well as the need to incorporate microbial as well as religious or metaphysical metrics into a useful normative approach to public health disasters. The chapter also showed that the moral quandaries at the heart of PHDs reflect some differing degrees of relational dissonances. Therefore, to properly engage 157

 Drydyk. Pp. 16–22.

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these quandaries as well as the other practical challenges, it is important to understand the complex human, biological and, possibly, metaphysical variables that resonate around them. On this note, the chapter developed a global ethical framework based on five relational moral nuggets. These are respect for transnational values, respect for biological relatedness, respect for spiritual/metaphysical causal appeals and diversity, responsiveness to vulnerabilities, and responsibility. The chapter also highlighted how a relational-based global ethic may be applied to public health disasters as an important contemporary global problem. Because personal morality often differs from public morality, and because other-centricity is hardly a norm in contemporary society, it is important to seek creative ways to create some level of other-centricity in the populace  prior to the occurence of a PHD. Social and formal education and a right psychological mindset158 are essential to realizing this goal. Finally, this chapter offered four levels of justification for the proposed global ethic. In this vein, it argued that the proposed ethic is justified for engaging public health disasters as a class of global problems because it is responsive and sensitive to local realities, global realities, microbial as well as spiritual realities and scientific concerns. By reflecting these four values, the GEF is sufficiently nuanced to engage different Western and non-Western contexts. This is important because nuances permit challenging and unusual scenarios to be flexibly engaged using the same frame of reference.159

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Chapter 7

Theoretical & Pragmatic Implications of a Relational Global Ethical Framework

Abstract  Developing a broad ethical lens for engaging the complex ethical issues elicited by public health disasters implies that it will be applied, in part or wholly, to real life scenarios. As such, it is pertinent to systematically examine some of the possible implications and attendant social change sequelae of the proposed relational global ethical framework vis-à-vis PHDs. This chapter first presents a summary of all that has been discussed and elaborated from Chaps. 1 through 6. It then teases out the public health policy implications of the relational-based GEF. It also examines the UNESCO Declaration on Bioethics and Human Rights in relation to engaging public health disasters compared to the relational-based GEF proposed in this book.

7.1  Summary This book began in Chap. 1 by demonstrating that public health disasters constitute a distinct arena of inquiry that is at the intersection of the emerging domain of disaster bioethics1,2 and traditional public health ethics. It elaborated the conceptual, ethical, and global dimensions of this novel bioethical terrain. The chapter specifically underscored the gaps in the extant bioethics literature which further justifies the claim that PHDs as a notion as well as an ethical category has not received needed scholarly attention. The chapter showed that analyzing the notions of “public health”, “disasters”, “public health ethics”, and disaster ethics/bioethics” hold the key to untangling the conceptual interpetation of a public health disaster. It argued that they refer to three distinct phenomena, namely: public health issues of serious proportions such as infectious disease outbreaks, the attendant public health impacts of natural or man-­ made disasters, and currently latent or low prevalence public health issues with the 1  Bert Gordijn and Henk Ten Have, “Disaster Ethics,” Medicine, Health Care and Philosophy 18, no. 1 (2015). Pp. 1–2. 2  James D Hearn, “Disaster Bioethics: Normative Issues When Nothing Is Normal,” Journal of Bioethical Inquiry 12, no. 1 (2015). Pp. 151–152.

© Springer International Publishing AG, part of Springer Nature 2018 M. O. Afolabi, Public Health Disasters: A Global Ethical Framework, Advancing Global Bioethics 12, https://doi.org/10.1007/978-3-319-92765-7_7

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potential to rapidly acquire pandemic capacities given the right combination of ­biological and social conditions. Ebola and pandemic influenza outbreaks, atypical drug-resistant tuberculosis and earthquakes were employed to reflect this conceptual interpretation in various ways. Chapter 1 also presented the general ethical quandaries of public health disasters encapsulated by social, existential, biological and geographic vulnerabilities, human dignity and rights-related issues, balancing local and global justice issues, and uncertainty. The local and global dimensions of these quandaries were highlighted as well as the compelling ethical and pragmatic need—illustrated by several shades of the six Ds—3 to engage them. In Chap. 2, an Ubuntuan ethical lens was developed in relation to resolving the moral dilemmas generated by Ebola viral outbreaks. The chapter argued that Ebola viral outbreaks are a type of public health disasters with local and global dimensions. It rendered a description of the nature of the virus, its virulence and transmission patterns, as well as the moral quandaries that come to fore during outbreaks such as vulnerability, human rights, and dignity, as well as local and global justice. The chapter showed that some sort of relational dissonance is at the heart of these quandaries and, therefore, necessitate a relational ethical system to engage them. Because of its relational bearing, the African indigenous Ubuntu lens was used to engage the moral quandaries of Ebola outbreaks. The chapter noted that tailoring public health policy for engaging the ethical issues elicited by EVD on the mental and experiential fabric of Ubuntu offers some benefits. These include its focus on other-centricity and its capacity to help deal with certain local and global nuances associated with the quandaries of EVD (such as in the context of rationing and justice). Yet, while the ubuntuan moral logic is indigenous to Africa, it does not follow that every potential moral actor that will be involved in disaster situations think in ubuntic terms. This realization has the potential to limit the power of the Ubuntuan moral framework in relation to the ethical dilemmas of EVD. However, this problem may be addressed via carefully planned pre-disaster social interventions. In relation to this idea, a systemic re-education which increasingly makes the ubuntuan logic and praxis part of everyday life during pre-disasters was suggested as a focal point for garnering cooperation during disasters as well as handling specific moral quandaries including issues of vulnerability, rights and human dignity, local and global justice as well as rationing. Since disaster preparedness does not entail one-time planning,4 the specific question is how the ubuntu idea may shape and influence the pre-disaster phase. A key ingredient to such an agenda will involve re-formulating the trajectory of educational paradigms. Some commentators have observed that the African reality is often distanced from the Western model of educational instructions in schools, from the kindergar3  Aasim Ahmad, Mahmud Syed Mamun, and Dónal P O’Mathúna, “Evidence and Healthcare Needs During Disasters,” in Disaster Bioethics: Normative Issues When Nothing Is Normal, ed. Dónal P O’Mathúna, Bert Gordijn, and Mike Clarke (Netherlands: Springer, 2014). p. 96. 4  Stefano Lazzari, “Health Aspects of Disasters,” in The Challenge of African Disasters, ed. WHO (UN. Institute for Training and Research). P. 14.

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ten to the university. Hence, little connection exists between indigenous forms of knowledge that are orally but hardly ever systematically taught and formal instruction.5 Overhauling the educational structure to reflect local forms of knowledge  offers a platform through which the notion and praxis of ubuntu may be systematically and gradually brought back into the African consciousness on a significant level. The educational reform may enable the key moral actors to practice ubuntu as part of the repertoire of daily life such that the challenges of PHDs may be readily dealt with. For instance, the designation of an elderly woman or man for the task of caring for those victims of public health disasters in traditional African societies6 highlight the ubuntu idea of cosmological linkage and sacrifice. Specifically, it reflects what the Yoruba describe as b’ogede ba’ku afi omo e ropo (old banana trees die off so that the young shoots may live), signifying that elderly members of the community can relive their lives through ensuring that the younger ones live on. This ethnophilosophical notion suggests that elderly members of the community are morally obligated to give up their lives for the sake of the young because in so doing life is ultimately preserved, and communal existence remains unbroken. Chapter 2 also argued that an ubuntuan background favors the participation of all in the stress and sacrifice of Ebola viral outbreaks. Compliance with quarantine may, for example, improve as opposed to its current view as a prison yard. For health professionals, a grounding in ubuntu moral thinking will facilitate an easier transition into taking on the supererogatory task of accepting the higher than normal levels of risk associated with Ebola outbreaks. This should contribute to dousing some of the tensions traditionally associated with the duty of care and boundaries of acceptable risk during incidents of virulent epidemics.7 Finally, chap.  2 argued that the ubuntu ethical approach has a short-term and long-term appeal. The former comes to the fore in relation to the disaster phase of Ebola viral outbreaks where it is relevant in addressing local quandaries and may help drive relevant public health policies. The latter or long-term benefit of the Ubuntu moral lens lies in its capacity to systematically shape the cognitive, social and educational climate of the African people to ultimately foster a Ubuntu-centric way of life. This has a twofold importance. One, a ubuntically oriented way of reasoning can shape pre-disaster phase health policies and help prepare the local healthcare system to better engage the sudden and profound challenges posed by PHDs. Secondly, background issues such as those involving corruption and mis5  Paulin Hountondji, “Distances,” Ibadan Journal of Humanistic Studies 3 (1983). Pp. 135–140; Michael J Moravcsik and John M Ziman, “Paradisia and Dominatia: Science and the Developing World,” Foreign Affairs 53, no. 4 (1975). Pp. 699–705; Oscar OBrathwaite, “Promoting a PanAfrican Education Agenda by Shifting the Education Paradigm,” in Unite or Perish: 50 Years after the Founding of the Oau, ed. Mammo Muchie, et  al. (Africa Institute of South Africa, 2014). Pp. 156–159. 6  Barry S Hewlett and Richard P Amola, “Cultural Contexts of Ebola in Northern Uganda,” Emerging Infectious Diseases 9, no. 10 (2003). Pp. 1246–1247. 7  Daniel K Sokol, “Virulent Epidemics and Scope of Healthcare Workers’ Duty of Care,” ibid.12, no. 8 (2006). Pp. 1238–1239.

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management of health funds may be addressed through the ubuntu ethical gaze by using the disservice that accrues to the community as a rallying ground to punish those found guilty and deter potential culprits. In Chap. 3, two people-centric moral lenses were used to engage the quandaries engendered by pandemic influenza outbreaks. During disasters, there is the utilitarian goal of doing the most good for as many people as possible with minimal harm.8 A people-oriented moral lens is useful in realizing such an agenda. The chapter explored the strengths of the communitarian and care ethics moral lenses in relation to engaging the moral quandaries elicited during pandemic influenza outbreaks. Because it is difficult to engage pandemic outbreaks with little prior preparation,9 these moral lenses become important largely because they facilitate both an other-­ centric orientation as well as sensitivity to the needs of others. To systematically drive the importance of a people-centered approach to pandemic influenza, Chap. 3 explicated the biological make-up of the influenza virus as well as the social and global features of the associated pandemic. This helped underscore the local, regional, and global seriousness of pandemic influenza as a distinct type of public health disaster. The chapter went on to show how an understanding of the social and biological dynamics of influenza has shaped the therapeutic and non-­ therapeutic approaches to engaging the outbreaks. It also articulated some of the attendant limitations of pandemic influenza countermeasures. Chapter 3 also highlighted the ethical quandaries generated by influenza outbreaks. These are issues related to epistemic and social uncertainty, biological, social, geographical and political vulnerabilities, potential violations of human rights through some of the therapeutic and non-therapeutic approaches, as well as issues of local and global justice. Against this conceptual background, the chapter pointed out how helping people is a central concern in pandemic influenza, and how the thorny ethical issues constitute difficulties encountered in accomplishing this goal. On that note, it showed how people-centered lenses such as communitarianism and ethics of care may be useful in engaging the associated practical and moral challenges. To clarify the importance of each of these approaches, the chapter elaborated each of these ethical lenses, and showed how each may help orient different moral players in the context of a pandemic influenza towards acquiring a sense of community and an other-centric sensitivity which will be essential to resolving the moral dilemmas as well as realizing the central public health objective. However, partly because there are limited grounds for deciding what the limits of practical reasoning will be ab initio,10 and partly because of the complexities and nuances that are associated with the global dimensions of the issues at stake in pandemic influenza situations, the care ethical and communitarian lenses may suffer some limitations.  Ahmad, Mamun, and O’Mathúna. Pp. 100–101.  Dorothy E Vawter, Karen G Gervais, and J Eline Garrett, “Allocating Pandemic Influenza Vaccines in Minnesota: Recommendations of the Pandemic Influenza Ethics Work Group,” Vaccine 25, no. 35 (2007). P. 6535. 10  Will Kymlicka, “Liberalism and Communitarianism,” Canadian Journal of Philosophy 18, no. 2 (1988). P. 203. 8 9

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In Chap. 4, how atypical drug-resistant tuberculosis reflects a form of silent public health disaster was systematically laid out. By examining the biological foundations and nature of antimicrobial drug resistance, chap. 4  showed how the phenomenon of ADR-TB constitutes a survival mechanism that bacteria employ generally to ensure species survival. An examination of the public health implications of ADR-TB in terms of local and global contexts, however, shows the urgency with which it needs to be addressed. This is supported by the associated biological and social nuances which further give the phenomenon a subtle form and sheds some insight into its silent disaster feature. Atypical drug-resistant tuberculosis elicits some moral quandaries such as uncertainty, vulnerability, autonomy, human rights, harm and social justice. These issues partly reflect some derangement in the harmonious balance in the relationship nexus between human beings and other humans, and what one set of people may do or fail to do for other sets of people. They are also a by-product of a sociobiological dissonance in the relationship nexus between humans and microbial life. An understanding and clarification of these different sets of relatedness thus constitutes a viable locus for examining the causes, subtleties, and extent of the moral and pragmatic  challenges  elicited by ADR-TB.  In this regard, the chapter developed an anthropo-ecological ethic. Specifically, an anthropo-ecological ethic constitutes a combination of the anthropological dimensions of human experiences and capacities with an understanding of microbial life forms vis-à-vis framing a normative moral lens. It involves identifying the different social, biological, and existential vulnerabilities that inevitably plague humankind, the realization that antimicrobial drug resistance may hardly be eliminated as well as paying attention to and enhancing some of the naturally-­occurring anti-microbial tools inherent in the human physiology. It also involves passive and active forms of solidarity as well as adaptive learning. This moral lens, it was argued, can help address the moral quandaries generated by atypical drug-resistant tuberculosis in several ways. These include helping to garner local and global solidarity from relevant moral actors in relation to engaging the common threat, drawing attention to the relevant socio-economic and institutional dimensions, helping to blur the distinctions between human rights, autonomy and social responsibilities by placing everyone in the category of infectables, focusing attention on the victimhood and vectorhood of human beings, and emphasizing the value of prior social trust in relation to eliciting cooperation with health instructions during public health disaster situations. In Chap. 5, it was argued that earthquakes constitute another type of public health disaster. The chapter presented a conceptual picture of the nature of earthquakes, the social and geographic dynamics and the ethical issues that come to fore when they occur. It argued that such ethical issues arise largely out of the public health dimensions of earthquakes which revolve around issues of triage, mental health issues, infectious diseases, and trauma-related issues. The moral quandaries that are embedded in earthquakes are broadly anthropogenic or completely human-related and non-anthropogenic. Whereas appropriate behavioral modifications may help address the anthropogenic issues, the non-anthropogenic issues may not be adequately addressed without some human reach out to the metaphysical or spiritual sphere.

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But at the heart of the needs created by earthquakes is the desire by the non-­ vulnerable local and international members of the human community who are instinctually and morally moved to offset some of the financial, social, material, and other costs and burdens of natural disasters such as earthquakes. On this note, the chapter developed and applied a solidaristic moral lens. Specifically, the chapter examined and explored how an anthropogenic type of solidarity may help address the human-related challenges and quandaries of earthquakes via modifying the behavioral patterns of principal actors, the geoscientific community, and the local populace. It also examined how a non-anthropogenic type of solidarity may help address the theological  and/or metaphysical issues at the heart of earthquakes through fostering an atmosphere that encourages giving attention to existential questions. Ultimately, the chapter showed how the third-tier axis of solidarity in terms of generating formal instruments through dialogue and consensus of stakeholders constitute the means through which the solidaristic normative insights may be crystalized and used to shape the local context as well as create a means of enlisting global actors in relation to addressing the public health challenges engendered by earthquakes. The idea that public health disasters reflect the conceptual, ethical, and practical intersection between the concerns of traditional public health ethics and the discourse on disaster bioethics was further underscored in Chap. 6. It was argued that because global bioethics seeks solutions to global problems, public health disasters warrant a global bioethical lens to help resolve the moral quandaries as well as the other healthrelated challenges. In this regard, chap. 6 examined some of the contentious normative and methodological issues central to the debate on global bioethics. Such issues tend to make the task of arriving at a comprehensive global ethic for bioethical problems complicated and controversial.11 The chapter argued that contentions about the nature and normative value of a global ethic may be partly circumvented by using local problems across different cultural divides that have some global dimensions. This may be followed by formulating context-specific solutions to each of the representative problems with sensitivity to trans-national nuances and limitations. Finally, examining the common threats posed by the problems, unearthing common cores, and forging a flexible framework using the conceptual and ethical tools as well as insights that intersect around the context-specific solutions should generate a broader normative lens for approaching specific classes of global problems. Chapter 6 also demonstrated the human and non-human dynamics of PHDs. These dynamics cannot be adequately addressed by each of the context-specific moral approaches developed for specific PHDs in Chaps. 2 through 5. While each of these moral prisms (that is, Ubuntuan approach, people-centeric moral lenses such as communitarian and care ethical approaches, an anthropo-ecological ethical framework, and a solidaristic approach) tend to have limited normative powers in engaging the broader ethical issues central to public health disasters, they clearly underscore the relevance of an other-centric orientation, the importance and con Jay Drydyk, “Foundational Issues: How Must Global Ethics Be Global?,” Journal of Global Ethics 10, no. 1 (2014). Pp. 16–22.

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texts of solidarity as well as the need to incorporate microbial as well as religious or metaphysical metrics into a useful normative approach to public health disasters. The chapter also showed that the moral quandaries at the heart of PHDs reflect some differing degrees of relational dissonances. Therefore, to properly engage these quandaries as well as the other practical challenges elicited by public health disasters, it is important to understand the complex human, biological and, possibly, metaphysical variables that resonate around and across them. On this note, chap. 6 developed a global ethical framework based on five relational moral nuggets, namely, respect for transnational values, respect for biological relatedness, respect for spiritual causal appeals and diversity, responsiveness to vulnerabilities, and responsibility. How such a GEF may be applied to public health disasters as an important category of contemporary global problems was also elaborated. Because personal morality often differs from public morality, and because other-centricity is hardly a norm in contemporary society, it is important to seek creative ways to foster some level of other-centricity in the populace. Social and formal education as well as a right psychological mindset12 are critical to realizing this  ethical  end. Finally, chap. 6 offered four levels of justification for the proposed relational-based global ethic. It argued that the proposed ethic is justified on the basis of its responsiveness and sensitivity to local realities, global realities, microbial as well as metaphysical or spiritual realities, and scientific concerns. Having offered a summary of the analyses and insights derived from Chaps. 1 through 6, it is necessary to explore some of the translational implications of the global ethical framework proposed in this book. In other words, the possible ways through which stakeholders may help translate the GEF into action guides and actionable policies.

7.2  T  ranslational Implications of a Global Ethic vis-à-vis Public Health Disasters If public health disasters constitute a class of global problems, and if a global bioethical framework such as the relational-based global ethic developed in this research can help address the associated moral quandaries as well as some of the health-related challenges, then the question of how to translate this global ethic into reality, partly through policy and partly through other relevant stakeholders becomes inevitable. This is especially so because the value of bioethical reflection is not confined to the sphere of intellectual and academic fancy but must necessarily shape on-the-ground realities.13 This translational process, however, is often fraught with

 Fatimah Lateef, “Ethical Issues in Disasters,” Prehospital and Disaster Medicine 26, no. 4 (2011). P. 296. 13  Henk ten Have, “Bioethics Needs Bayonets,” in Global Bioethics: What For? Twentieth Anniversary of Unesco’s Bioethics Programme, ed. German Solinis (Paris: UNESCO, 2015). P. 149. 12

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some difficulties and require some moral courage.14 Nevertheless, it is a worthwhile task. Although the triad of the government, populations, and individuals constitute the principal foci in public health actions and policies,15 NGOs, local and international health-related agencies increasingly play some role in public health as well as in disaster settings. These groups can be described as stakeholders because they participate in producing, consuming, managing, regulating, or evaluating the activities in a given social system.16 To be sure, stakeholders range from an individual residing within a community to national governments to global organizations. Their importance lies in the flexible channel they offer for interventions from multiple angles.17 In the global bioethics context, stakeholders may be described as those that enable ideation to evolve into talking, and talking to translate or morph into acting.18 Against this conceptual backdrop, this section seeks to point out the specific roles of some of the moral actors as well as some of the relevant stakeholders that need to be engaged in translating the relational-based ethic into lived experiences in the context of public health disasters. It engages this task through the lens of local and transnational moral actors as well as local and international stakeholders.

7.2.1  Policymakers While policymakers are not direct health providers, they may promote innovative public health services19 by the whisk of their pens. As such, they can be considered as separate, distinct moral actors. This is true largely because healthcare in all its diverse ramifications cannot be experienced without some group of people taking affirmation steps and action.20 Local and transnational policymakers have some roles to play in relation to the value of the global ethical framework developed in this book. First, because not all public policy people have had some interaction with bioethicists or are familiar with bioethical reflection. For instance, during the Ebola outbreak in Nigeria, no bioethicist was invited into the government-convened com Stephen Sodeke, “Bioethics Skill Sets Can Work, but It Would Take Moral Courage to Apply Them and Get Desired Results,” The American Journal of Bioethics 16, no. 4 (2016). P. 19. 15  Stephen Holland, Public Health Ethics (Polity Press, 2007). P. 33. 16  Lloyd F Novick and Glen P Mays, Public Health Administration: Principles for PopulationBased Management (Jones & Bartlett Learning, 2005). P. 369. 17  A Hyder et al., “Stakeholder Analysis for Health Research: Case Studies from Low-and MiddleIncome Countries,” Public Health 124, no. 3 (2010). P. 160. 18  Henk ten Have, “Globalizing Bioethics through, Beyond and Despite Governments,” in Global Bioethics: The Impact of the Unesco International Bioethics Committee, ed. Alireza Bagheri, Jonathan D. Moreno, and Stefano Semplici (Springer, 2016). P. 9. 19  Gary S Becker, Accounting for Tastes (Harvard University Press, 1996). P. 156. 20  Michael J Green and M Boylan, “Global Health and Justice: Is Healthcare a Basic Right,” in Public Health Policy and Ethics, ed. Michael Boylan (New York: Kluwer Academic Publishers, 2005). P. 203. 14

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mittee. That is, scientific measures were solely pursued in engaging the health emergencies of the outbreak.  This underscores the need for local nationals including bioethicists and medical sociologists to always reach out and build bridges with policymakers. Such bridges will be necessary to share relevant insights in relation to formulating pre-disaster, disaster, and post-disaster policies. Secondly, it should lead to specific policies that invite relevant stakeholders to brainstorm on the ethical guidelines such as those articulated by the GEF as well as those that positively shape the other-centric disposition or virtues in people. This is important because the presence of virtuous disposition in persons responding to disaster situations makes up a richer and more efficient way of dealing with the associated moral dilemmas.21 Although, interaction with relevant moral actors and members of the populace prior to PHDs will foster a favorable social climate that enables people to know what to expect and how to act as well as who to get in touch with during specific disasters, it is obvious that the nature and orientation of policymakers are not the same across the globe. Hence, their role in relation to the ideas and insights of the relational-based global ethic will be context-defined.

7.2.2  Health Professionals Health professionals working in disaster situations confront urgent choices which diverge from their normal and accustomed deontological ethos.22 To help address this difficulty, the need to educate health professionals in some type of bioethics training has been articulated in the literature.23 However, emergency contexts such as PHDS underscore the critical importance of such an education. In relation to this end, Bold has argued that ethics education can help nurses make ethical decisions during disasters.24 Whereas health professionals in industrialized nations are increasingly adopting such a training, this cannot be said to be true in developing economies. For instance, the National Emergency Management Agency in Nigeria has no guidelines for addressing ethics-related issues. Hence, it is probably the case that none of the staff has received an ethics-related education. Therefore, bioethicists must draw attention to this gap, locally and internationally, and seek feasible ways to address the knowledge gap(s).  Eleni M Kalokairinou, “Why Helping the Victims of Disasters Makes Me a Better Person: Towards an Anthropological Theory of Humanitarian Action,” Human Affairs 26, no. 1 (2016). Pp. 26–29. 22  Pierre Mallia, “Towards an Ethical Theory in Disaster Situations,” Medicine, Health Care, and Philosophy 18, no. 1 (2015). P. 3. 23  Solomon R Benatar, Abdallah S Daar, and Peter A Singer, “Global Health Ethics: The Rationale for Mutual Caring,” International Affairs 79, no. 1 (2003). Pp. 108–109. 24  Joan A Bold, “Ethics, Confidence, and Training as Predictors of Decision-Making by Nurses During Disasters” (Walden University, 2012). Pp. 1–3. 21

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7.2.3  Non-governmental Organizations Some of the underlying issues that have created differing degrees of vulnerability in economically developing and less developed nations are borne out of international policies such as through the IMF and the World Bank. The aforementioned agencies are known to employ capitalist globalization and other neoliberal mechanisms to weaken the economic rights of people as well as weaken the economy of partnering nations.25 To mitigate such policies, extant local NGOs need to be involved and engaged in mounting pressure on the culprit local governments to end and/or reverse anti-development policies and agreements they might have entered into with culpable organizations. On the other hand, international NGOs need to understand the value of not rushing to disaster locations without official invitations in order not to further disrupt extant chaos. They also need to be sensitive to cultural notions and practices and learn to partner with locals to explore internally-generated solutions in order not to alienate the very people they seek to help.

7.2.4  Bioethicists If part of the goals of global bioethics is to positively influence realities, then in the context of public health disasters, bioethicists need to form several bridges. For instance, they need to reach out to the diverse range of moral actors that may be involved in disaster scenarios. They also need to share their insights with local and international agencies doing disaster-related work as well as organize and participate in  local and international conferences and meeting to share their ideas and insights. Bioethicists, as modern-day gadfly in the skin of  a given society,26 can form local Associations or use extant ones to mount pressure on government agencies not only to implement policies that are amenable to the polemics rendered in the GEF but also to reverse some of the international agreements that foster social vulnerabilities and weaken the capacity of local health institutions to engage public health emergencies and disasters. The importance of engaging bioethicists and bioethical insights in designing public health policies is partly reflected in Kenya’s Public Health Act that prescribes imprisonment for persons who act in ways that jeopardize the health of the public.27

 Leslie Sklair, “The Globalization of Human Rights,” Journal of Global Ethics 5, no. 2 (2009). Pp. 81–82. 26  Henk Ten Have, Global Bioethics: An Introduction (Routledge, 2016). P. 236. 27  JD Brian Citro et al., “Developing a Human Rights-Based Approach to Tuberculosis,” Health and Human Rights 18, no. 1 (2016). P.3. 25

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7.2.5  International Agencies International agencies such as MSF and the WHO often play key roles during disasters. The WHO, for instance, has a Global Health Ethics Unit to build and strengthen capacity in the Member States to develop mechanisms that enable reflection on and incorporation of ethics in relation to a wide range of public health programs and policies. During the 2014 Ebola outbreak, the WHO formed an ethics panel and a working group that had a global representation offer advice to the Organization on various aspects of the epidemic.28 Collaboration with the Global Health Ethics Unit of the WHO should help bioethicists not only share their personal expertise, but these can be better disseminated through the WHO nexus. However, the WHO seems to have been partially compromised because her global health priorities are now largely influenced by donor interests.29 This is an ethical issue that demands a separate analysis as well as moral and social engagement. It is useful to formulate a relevant ethical framework for engaging the moral dilemmas elicited by public health disasters. It is also useful to engage relevant stakeholders in order to transform and translate some of the core values of such a framework from talking points to action guides. However, the latter task will inevitably need some legal ratification. In this vein, scholars like Dworkin espouse the need to connect moral and ethical values with legal force to crystalize them into viable social tools.30 Nevertheless, whether or not the principles articulated in the relational-based global ethic may transform into laws for shaping public health disaster contexts will be partly dependent on time, chance, and the response of people who come across the framework developed in this book, and choose to adopt it, wholly or in part.

7.2.6  Members of Public Every human being may be described as a moral agent. The moral nature of people plays out in the context of public health where the actions and inactions of an individual may positively or negatively shape the health of another person or a group of persons. Public health disasters generate different kinds of ethical quandaries and health challenges which may only be addressed via an other-centric orientation. For instance, antiviral prophylaxis critically depends on the identification of index cases in households, pre-schools, schools, and other institutional settings.31 This clearly entails  Andreas Reis and Abha Saxena, “Who,” in Encyclopedia of Global Bioethics, ed. Henk ten Have (Switzerland: Springer International, 2016). Pp. 1–4. 29  Sonia Shah, Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond (New York: Sarah Crichton Books, 2016). Pp. 117–118. 30  Ronald Dworkin, Justice for Hedgehogs (Harvard University Press, 2011). 31  Ira M Longini et al., “Containing Pandemic Influenza with Antiviral Agents,” American Journal of Epidemiology 159, no. 7 (2004). Pp. 630–631. 28

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the importance of personal, social, and institutional cooperation and self-­effacing visa-vis PHDs. In other words, without adequate education and sensitization of members of the public to facilitate cooperation, the success of the GEF may be limited.

7.3  T  he Global Ethical Framework vis-à-vis the UNESCO Bioethics Declaration Some global bioethical instruments such as the UNESCO Universal Declaration on Bioethics and Human Rights have been developed for engaging global moral perplexities. However, none of these explicitly address public health disasters. The UDBHR offers a global approach that seeks to develop and employ shared fundamental goals to engage the problems of (clinical) medicine and the life sciences, taking into consideration their social, legal, and environmental ramifications. In reference to a public health emergency context, the UDBHR only holds that any response to such must be done via an approach that respects human dignity, human rights, and freedom.32 Scholarly works that have specifically used the UNESCO framework to engage the sphere of disasters are also sparse. For example, Stanton-Jean recently stated that Article 16 of the UDBHR may be used to garner support for combating global disasters such as infectious diseases. However, she does not provide any specific conceptual engagement or specific guidelines.33 However, three articles of the UDBHR shed some insights that tend to overlap with some of the ethical nuggets proposed in the relational-based global ethic. These are examined in this section.

7.3.1  T  he Relational-Based Global Ethic vis-à-vis Solidarity & Cooperation The UNESCO principle of solidarity and cooperation states that solidarity among human beings and international cooperation towards that end are to be encouraged. It seeks to foster cooperation between nations and holds that such a nexus presents

 Michèle S Jean, “Article 20: Risk Assessment and Management,” in The Unesco Universal Declaration on Bioethics and Human Rights: Background, Principles and Application, ed. Henk ten Have and Michèle S Jean (UNESCO, 2009). P. 272. 33  Michèle Stanton-Jean, “The Unesco Universal Declarations: Paperwork or Added Value to the International Conversation on Bioethics? The Example of the Universal Declaration on Bioethics and Human Rights,” in Global Bioethics: The Impact of the Unesco International Bioethics Committee, ed. Alireza Bagheri, Jonathan D.  Moreno, and Semplici Stefano (Springer, 2016). P. 19. 32

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the only way to know what values are shared, and what values are not.34 This mirrors the notion of respect for transnational values articulated in the relational-based global ethical framework. However, the UNESCO principle offers no specific guidelines in relation to the ethical issues that arise in public health disaster contexts such as Ebola and pandemic viral outbreaks, atypical drug-resistant tuberculosis and earthquakes. This is, of course, understandable as the document does not set out to directly engage disaster-related ethical issues.

7.3.2  T  he Relational Based Global Ethic vis-à-vis Social Responsibility & Health The UNESCO principle of social responsibility and health emphasizes the importance of health promotion activities and access to health for all without discrimination. It also advocates empowerment of individuals through improvement in living conditions, access to water, and nutrition.35 Hence, it may offer a preventive axis to health. This also directly does not have a bearing on disaster contexts. However, its preventive approach to health via addressing underlying conditions and susceptibilities echo the ethical nugget of responsiveness to vulnerability that is articulated in the relational-based global ethic.

7.3.3  T  he Relational Based Global Ethic vis-à-vis International Cooperation The UNESCO principle of International cooperation embeds three key insights. The first obligates nations to foster international cooperation in the arena of scientific and technological knowledge. The second obligates nation states to foster cultural and scientific cooperation, with more affluent nations helping the less affluent ones. The third and final insight obligates nations to seek cooperation within their nation states, within families and groups, and between other nations.36 This principle partly echoes the respect for transnational values as well as the responsiveness to vulnerability ethical nuggets elaborated in the relational-based global ethic. Against the background of these conceptual comparisons, it is obvious that the UDBHR offers no specific ethical signpost in relation to engaging public health  Elungu Alfonso, “Solidarity and Cooperation,” in The Unesco Universal Declaration on Bioethics and Human Rights: Background, Principles and Application, ed. Henk ten Have and Michèle Jean (Paris: UNESCO, 2009). Pp. 211–212. 35  Adolfo Martinez-Palomo, “Social Responsibility and Health,” ibid. Pp. 220–222. 36  Ousmane Biondin Diop, “International Cooperation,” in He Unesco Universal Declaration on Bioethics and Human Rights: Background, Principles and Application, ed. Henk ten Have and Michèle Jean (Paris: UNESCO, 2009). P. 309. 34

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disasters. However, the limited conceptual similarities that the UDBHR share with the relational-based global ethic framed in this book may be used as a point of ethical engagement for disaster contexts for global health policy makers who are already familiar with the UNESCO principles.

7.4  Conclusion If there is a need for a re-understanding of the nature of the individual agent in terms of infectious diseases,37 public health disaster contexts underscore such a  need. They equally highlight the urgency with which to propose ethical solutions to the associated quandaries. The relational-based global ethical framework developed in this book seeks to formulate new ways of engaging public health disasters by engaging different segments of the local and international community. This chapter has offered a summary of the insights and analyses developed from Chaps. 1 through 6 of this book. It underscored the roles of relevant local and international stakeholders in translating the thrust of this research into action guides. It also specified some of the roles of relevant actors such as policy-makers, NGOs, bioethicists, healthcare professionals, and international agencies. The chapter also underscored how extant international documents such as the UDBHR have not directly engaged the moral quandaries elicited by public health disasters. It compared possibly overlapping principles of the UDBHR with the five ethical nuggets contained in the GEF. In this vein, it showed that principles such as Solidarity and Cooperation and International Cooperation have areas of conceptual synergies with the nuggets of respect for transnational values as well as ­responsiveness to vulnerability. Ultimately, the chapter noted that the limited conceptual similarities that the UDBHR shared with the relational-based global ethic may be used as a point of ethical engagement for engaging disaster contexts already familiar with the UNESCO bioethics principles. Against this conceptual background, the specific contributions that this book makes to the bioethics and global bioethics literature may be examined. First, it describes the novel concept of public health disasters as the uncharted ethical and conceptual intersections between disaster bioethics and public health ethics. Through its methodology, it offers a path to engaging the normative problem associated with global bioethics via focusing on a class of global problems with local and trans-national parameters. Thirdly, it develops a nuanced global ethical framework for engaging PHDs as a class of global problems with sensitivity to local, global, microbial, and spiritual/metaphysical realities, as well as scientific causes/concerns. Lastly, if the goal of bioethics involves furthering a global revolution in human consciousness towards a holistic worldview,38 this book contributes to this revolu Leslie P Francis et al., “How Infectious Diseases Got Left out–and What This Omission Might Have Meant for Bioethics,” Bioethics 19, no. 4 (2005). P. 321. 38  Paulo Nuno Martins, “A Concise Study on the History of Bioethics: Some Reflections,” Middle East Journal of Business 13, no. 1 (2018). P. 37. 37

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Index

A Anthropo-ecological, 19, 97–135, 183, 188, 189, 219 Anthropogenic, 19, 144, 146, 151–156, 159, 161–164, 167, 168 Antibiotic resistance, 1, 100 Antibiotics, 33, 99–101, 106, 110, 126–128, 133, 197 Antimicrobial drug resistance, 9, 10, 99–101, 126–130, 134, 219 Atypical drug-resistant tuberculosis (ADR-TB), 10, 11, 13, 17–19, 97–99, 102–134, 175, 183, 185, 189, 193, 196, 197, 206, 207, 216, 219, 227 Autonomy, 17, 39, 40, 78, 115–120, 131, 132, 134, 135, 152, 163, 188, 219 B Bats, 26–28, 200 Behavior, 8, 11, 30, 38, 39, 49, 112, 113, 118, 122, 126, 128, 131, 145, 146, 150, 153, 158, 168, 169, 182, 185, 219, 220 BigPharma, 13, 42, 43, 114 Biological nuances, 107 Biological solidarity, 127, 129 Biomedical model, 125 Body fluids, 27, 28 C Care ethics, 60, 85–90, 183, 187, 208, 218 Causality, 10, 31, 155, 166, 183, 197, 200, 206 Communitarianism, 60, 81–85, 91, 122, 186–188, 208, 218

Community, 6, 9, 14, 15, 17, 27, 31, 33, 35, 39–41, 44, 47, 49–53, 62, 63, 70, 72–74, 78, 79, 82–85, 99, 102–109, 111–113, 115–117, 119, 120, 123, 124, 126, 128, 132, 133, 147, 150, 154, 157, 164, 168, 169, 177, 184–186, 188, 190, 192, 194, 196, 201, 205, 217, 218, 220, 222, 228 Culture, 12, 29, 30, 41, 45, 89, 105, 112, 116, 161, 168, 183, 192, 196, 199, 203, 205 D Drugs, 9, 43, 67, 97, 150, 175, 216 E Earthquakes, 4, 143, 175, 216 Ebola, 9, 10, 12–16, 18, 19, 25–53, 175, 177, 178, 180, 183, 185, 186, 188, 189, 193, 199, 200, 204, 205, 207, 216, 217, 222, 225, 227 Ebola virus outbreak, 9, 10, 18, 49 Ecosystem (eco), 19, 100, 110, 113, 124, 125, 127, 128, 191, 192, 196 Ethical issues, 2, 4, 6, 8, 13, 19, 25, 26, 32, 34, 49, 51, 72, 80–82, 85, 91, 98, 102, 111–123, 130, 132, 144, 151, 159, 163, 168, 169, 176, 177, 191, 196, 208, 216, 218–220, 225, 227 Ethics of care (EOC), 19, 60, 81, 85–91, 186–188, 218 Extensively drug-resistant, 97, 105 Extremely drug-resistant, 97

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232 F Fever, 16, 27, 33, 60, 151 G Global bioethics, 2, 7, 176, 190–192, 195–197, 202, 207, 208, 220–222, 224, 226, 228 Global community, 14, 15, 78, 85, 103, 125 Global ethical framework (GEF), 1, 2, 7, 14, 19, 20, 175–176, 183, 202, 209, 215–229 Global health, 6, 18, 97, 99, 102, 105, 151, 168, 179, 190, 193, 194, 196, 201, 202, 225 Global problems, 18, 51, 130, 176, 190, 191, 193–195, 201, 205, 208, 209, 220, 221, 228 Global solidarity, 15, 85, 134, 219 God, 4, 13, 46, 145–147, 157–159, 165, 166, 175, 177, 181, 183, 186, 201 H Harm, 3, 6, 8, 12, 25, 35, 43, 74, 75, 78, 83, 90, 103, 109, 110, 113, 114, 120–123, 127, 131–134, 148, 149, 151–153, 176, 180, 185, 193, 199, 204–207, 218, 219 Healthcare, 3, 7, 9, 12, 17, 27, 37, 38, 40–42, 44, 51, 53, 59, 75–77, 79, 83, 85, 88, 89, 105–107, 109, 111, 116, 119, 129, 149, 150, 155, 162–164, 178, 179, 191, 200, 207, 217, 222, 228 Healthcare workers, 7, 9, 12, 27, 36–38, 40, 51, 76, 89, 163, 200 Hemorrhagic fever, 26, 27 Homelessness, 152 Hospital, 9, 11, 27, 33, 35, 38, 89, 103, 105, 110, 112, 119, 133, 150, 164 Human dignity, 20, 37–40, 51, 52, 175, 176, 216, 226 Humanitarian, 2, 90, 151, 152, 168 Human rights, 3, 4, 12, 13, 18, 39, 40, 45, 47–49, 59, 75–78, 83, 84, 89, 91, 106, 115–120, 131, 132, 134, 135, 152, 154, 163, 176, 185, 188, 199, 216, 218, 219, 226 I Immune response, 129 Immunosuppression, 108, 113 Individualism, 17, 18, 47, 60, 78, 81, 116, 117 Infections, 11, 12, 16, 18, 26–29, 31–33, 35, 36, 38, 40, 41, 43, 52, 60, 63–65, 67–69, 71, 74, 76, 77, 79, 85, 89, 98–100, 102–107, 110–112, 114, 115,

Index 119, 121, 123, 126, 128, 129, 131–133, 150, 180, 186, 188, 204, 205 Influenza pandemic, 10, 61, 63, 65, 71, 73, 79, 80, 89 Influenza virus, 12, 60–64, 68, 69, 73, 79, 81, 90, 218 International Monetary Fun (IMF), 178, 179, 199, 202, 204, 224 J Justice, 4, 6, 12, 13, 20, 40–43, 45, 47, 50, 51, 79–81, 83–85, 87–89, 91, 120–123, 131, 133, 134, 166, 175, 176, 178, 180, 201–202, 216, 218, 219 M Magic bullets, 100, 105, 110, 126, 127 Man-made disasters, 8, 20, 175, 208, 215 Mental health, 9, 75, 116, 122, 148–150, 155, 168, 219 Microbes, 4, 19, 100, 101, 110, 124–126, 128, 197, 199, 203 Microbial life, 14, 18, 110, 111, 113, 123–125, 127, 129, 134, 185, 188, 194, 196, 206, 219 Moral actors, 51, 134, 156, 167, 168, 180, 182, 188, 189, 194, 197, 200, 203, 204, 216, 219, 222–224 Moral dilemmas, 1, 5, 11, 20, 85, 87, 91, 117, 118, 154, 216, 218, 223, 225 Moral frameworks, 7, 16, 19, 45–47, 51, 85, 156, 176, 184, 216 Mycobacterium tuberculosis, 102, 126 N Natural disasters, 3, 4, 10, 16, 35, 147, 149, 151, 153, 155–158, 160, 161, 165–168, 181, 183, 195, 198, 201, 207, 220 NGOs, 168, 198, 200, 204, 222, 224, 228 O Other-centric, 19, 47, 51, 89–91, 103, 133, 160, 186, 187, 190, 204, 208, 218, 220, 223, 225 P Pandemic capacities, 8, 105, 175, 208, 216 Pandemic influenza, 10, 13, 14, 16, 19, 175, 179, 183, 186, 189, 193, 194, 203, 205, 207, 216, 218

Index Pathogens, 15, 74, 99, 125, 126, 129, 190, 196, 206 Patients, 7, 8, 11, 27–29, 33–38, 40, 44, 48, 64, 65, 71, 75, 77–79, 81, 88, 89, 101–103, 105–107, 110, 112, 113, 116, 119–121, 124, 149, 150, 154, 164, 177–180, 185 Pneumonia, 60, 68, 99, 101 Policymakers, 8, 88, 177, 179, 185, 222, 223 Public health disasters (PHDs), 1, 2, 25, 29, 33, 35, 36, 39, 40, 42, 44, 45, 47, 51, 52, 63, 66, 73, 76, 78, 79, 83, 87–91, 97–135, 143–169, 175–176, 215–229 Public health ethics, 1, 2, 5–8, 10–12, 17, 19, 49, 117, 128, 175, 208, 215, 220, 228 R Rationing, 44, 45, 47, 51, 52, 76, 77, 80, 90, 176, 180, 199, 216 Relational dissonances, 13, 14, 45, 51, 110, 111, 123, 194, 195, 197, 208, 216, 221 Relational nexus, 4, 49, 184 S Self-medication, 101, 109 Silent public health disasters, 11, 17, 97–135, 219 Six Ds (destruction, death, disease/disorders, displacement, disappearance, and disarray), 2, 8, 10, 11, 15, 16, 20, 98, 216 Social context, 8, 33, 81, 87, 99, 101, 108, 113, 128, 153, 155, 184 Social justice, 41, 79, 120–123, 131, 133, 134, 219 Social nuances, 107, 108, 110, 111, 134, 219 Solidarity, 15–17, 47, 82, 127–131, 134, 156, 159–167, 169, 189, 190, 195, 197, 199, 201, 203, 206, 208, 219, 220, 226, 228 Stakeholders, 8, 19, 33, 156, 167, 169, 202–205, 207, 220–223, 225, 228 Supererogatory, 51, 52, 76, 162, 167, 187, 189, 198, 200, 204, 217

233 T Teleological, 19, 100, 110, 124, 126, 127, 129, 133, 158, 160, 182 Telos, 9, 49, 72, 99, 119, 159, 188 Therapeutic failure, 104 Triage, 5, 12, 44, 51, 149, 152, 154, 163, 168, 176, 180, 199, 200, 219 Trust, 8, 33, 39, 45, 47, 74, 84, 87, 110, 133, 135, 178, 189, 219 Tuberculosis, 9–11, 13, 17–19, 97–99, 102–134, 175, 180, 183, 185, 193, 196, 208, 216, 219, 227 U Ubuntuan, 19, 25–53, 183–186, 216, 217 Uncertainty, 2, 5, 13, 20, 28, 35, 72–75, 83, 88, 91, 111, 113, 130–132, 134, 167, 175, 185, 200–201, 216, 218, 219 UNESCO Declaration on Bioethics and Human Rights (UDBHR), 2, 226–228 Utilitarian, 3, 40, 90, 111, 130, 155, 218 V Vaccines, 13, 43, 50, 51, 65–70, 74–76, 80, 83, 84, 89, 199, 206, 207 Virtue ethics, 5, 86 Vulnerability, 11, 13, 34–36, 45, 47, 48, 51, 63, 78, 79, 84, 88, 111, 113, 114, 123, 129, 131, 132, 152, 155, 160, 162, 175, 177, 179, 185, 197, 199, 201, 207, 216, 219, 224, 227, 228 W World Health Organization’s (WHO), 201, 225 Y Yoruba, 30, 37, 41, 46, 52, 160, 204, 217 Z ZMapp, 43, 50