ebola and public health ethics (ebolaethics?)

via reuters, KFF recently posted a short article about the ethics of giving experimental treatment to the ‘hero doctor’ Sheik Umar Khan — and, really, to any of the trained health professionals who continue to show up to work even though they were at very real risk in Sierra Leone, in Liberia, in Nigeria and, now, contemporaneously but apparently unrelatedly, DRC.

there’s a complex of issues at stake, here, around rationing a scarce (and experimental) resource when need is greater than supply. i only going to wade in on the one issue i feel comfortable putting a point on; questions of ethics related to the nationality of who has been treated and where they were treated, or the ethics of using an experimental drug once other options were exhausted are important issues — but beyond the scope of this post.

this post is specifically about priority-setting for who gets treated: those who work in health care and those who do not. whether human resources for health (HRH) — Dr. Khan, medical volunteers from abroad, Sierra Leonean nurses, etc —  should be given priority in the face of a health crisis raises the Kantian issue of whether people should be used as means for ends (with Kant saying “no.”). if HRH are prioritized because of their ability to save more lives by having their own life saved, it is because they are being viewed as a means to an end — namely, the end of potentially saving more lives. this does not, inherently, treat all individuals of being of equal moral worth.

the case above at least keeps things within the “sphere” of health, rather than raising questions about favoring saving the young versus the old, or the powerful (say, the president or prime minister) over other citizens in the face of disaster. these too are difficult questions.

the debate will continue about whether and how Dr. Khan and others should have been treated with the experimental ZMapp, of which there is expected to be a long-term (rather than a quickly resolved) scarcity relative to need. demand significantly and dauntingly and heartbreakingly outweighs supply. but the question of whether Dr. Khan — or other HRH still fighting the fight — should be given priority to receive the treatment needs to be answered along several lines: should HRH be given preference? if so, should that preference be given based on whether, once cured, they will continue to treat patients? what happens once there are no more treatments to continue treating with — does the prioritization scheme shift?

this is a separate — but important — set of questions from the more politically charged question of the nationalities of recipients of the limited supply of ZMapp. i suspect these questions of power and race and exploitation, of where drugs were developed and where they were tested and who paid for them in what ways, will dominate the discourse. but other questions of ethics, desert, scarcity, and priority-setting require consideration for dealing with the present crisis and planning for future outbreaks, as well as strengthening health systems and equipping them to make decisions more generally.

further reading on these topics include: Norm Daniels, Frances Kamm, and Dan Brock. i hope these scholars will discuss and debate these issues in the near future.


nimboo pani: challenges and triumphs

there has been some complaint from some quarters that i have not recently provided any update about my life, reserving blog posts for slightly more wonky topics.

this post will be a small antidote.*

in delhi, one way of dealing with the energy-sapping heat is nimboo pani — literally “lemons water” but in actuality lemonade that is salty and possibly spicy/masala-ed in addition to sweet. (some people add mint but, of course, such frippery is not welcome in this household. i have only recently found a source for basil leaves, which is a far more sensible option.) in this salty way, nimboo pani approximates ORS and can help combat creeping dehydration, which seems to happen even if you are not noticeably sweating or doing anything at all.

i am curious as to why similarly salty lemonades did not catch-on in other hot places, for example, the southern US, which goes heavy on the sweet drinks in summer but, to my knowledge, doesn’t add salt (granted, the food may provide plenty, so things may balance out).

in any case, to celebrate having my flat nearly in order (yes, i know, people want pictures; patience is a virtue), i had a small open-house party at the beginning of july (HOT). i wanted to have nimboo pani on hand but was uncertain how to have ample drink prepared given the constraints of the refrigerator space and the need to have other drinks and food chilled as well.

one small triumph came in finding a shop that sold pre-squeezed lemon juice. nimboo (lemon) here are generally about golf- ball sized and the prospect of squeezing enough to quench thirst for 5+ hours was unappealing, no matter how many martha stewart points i would earn.

my first thought to dealing with the space issue was to make a lot of nimboo pani in advance and then freeze it. this seemed briefly promising until i thought about using salt to melt ice in the winter. this led to a string of probably unnecessarily dramatic texts to pop of the nature “I HAVE  A CHEMISTRY CRISIS.” it was agreed that freezing salty water would be difficult. (it was also likely, tacitly agreed that this was not a crisis.) (follow-up point, auto-correct suggested i might have meant “nimboo panic.” it does fit.)

the ice idea remained promising but how to dissolve all the ingredients on the spot? a friend (thanks, @urmy_shukla!) pointed out that sugar was particularly difficult to mix, given the temperature of the drink. simple syrup presented itself as a solution (ha!). so, in the end, i had frozen lemon cubes and frozen ice tea cubes (in hopes of nimboo pani palmers (go deacs) catching on, but must admit that brown ice has limited appeal, especially in a place where water quality and sanitation are such a serious concerns. perhaps green tea represents a future way forward.) so, people could drop lemon cubes into their glasses of water, which worked out well. i had bowls of rock salt, ground cumin, and ground ginger out so that people could salt and spice their drinks as per their own taste buds. and, i made plain and cardamom simple syrup, which veered slightly towards caramelized but seemed to be ok. this set-up was also good but there is at least one person in our midst who does not agree that drinks should be salty or spicy ever. i may have needed to add a little instruction on how sweet simple syrup is, as @sg402 discovered with VERY sweet nimboo pani.

anyway, party was a success, make-your-own nimboo pani seemed to be a success — so, the world’s problems are nearly solved. basil simple syrup will be pursued in the future.

please do be impressed that i smuggled two public health references into this post.


*a problem with blog-writing is that any word can be a rabbit hole. in typing “antidote,” i wondered if at any time “dote” was used to mean “poison,” in which case, antidote would be a sensible word. “dote” in the sense that we use it now, seems to be derived from the word for foolish. etymology.com implies that dotum comes from the greek “to give,” so that antidote was “to give against.” there you go.