Outbreak: Ethical Questions for the Next Great Plague

YiQi asked me to write something about Outbreak. You might have heard of it. The film takes place in Africa where a dreadful disease could be the next great plague of humankind. There are naughty little monkeys in it....and Dustin Hoffman. I haven't seen it in a while, but to be honest, movies like that always make me cringe becuase 1) That kind of thing probably would never happen and dramatizations are always so sensationalistic, and 2) I'm terrified of the off-chance that it could.

The film, to my knowledge, was the first Hollywood attempt at discussing some tough issues related to national security and where the right for the healthy to survive supercedes that of the sick. Outbreak's timing was pretty important too... it came out about 6 years after the US had its own epidemic of Ebola, now known as Ebola Reston.

I was about 8 at the time, so I don't remember much about the mood of the nation or even how the media publicized the fact that the Ebola virus had been imported into the United States from the Phillipines via cynomolgus macaques and infected 12 people (thank you Tara's Ebola Site). The good news is that the version of Ebola the humans caught did not make them sick.

They say there are no atheists in fox holes and I tend to believe there are no atheist virologists. Say what you like, but the fact that the bengin Ebola Reston and wicked Ebola Zaire are virtually indistinguishable under an electron microscope leads me to believe there are more things on heaven and earth than are dreamt of in our philosophy.

But Ebola's, ahem, fatal flaw is that the virus is exceedingly good at what it does. Ebola replicates too quickly and kills too quickly to have any real staying power. So it comes out every once in a while, takes lives, and goes back into hiding. Even the unfortunate tourist to catch the disease on safari and bring it outside of its natural habitat to Europe or somewhere else in Africa, so far, have not assended to Patient Zero status. They are usually ushered into a cold hospital room, quarantined as much as possible, and most often die.

Let's not forget, while we're talking about this that there are real people faced with the resurgence of this dreadful disease every day. They have lost loved ones to one of the most horrible deaths I can imagine. It's easy to talk about things in such a detached way, living in an industrialized country, as I do, where a victim would have a chance in hell to survive given our excellent acute and infectious disease care.

But Outbreak, and many other films after it, have raised an uncomfortable question about how we, as Americans may be asked to deal with a dreadful plague that could happen at any moment. Now more than ever, as we share airplane rides with patients infected with XDR-TB, clean up cruise ships from norovirus, and pray our spinach is safe from cattle and pig waste, we are keenly aware we may one day need to decide what should be done if an epidemic is serious and pervasive enough to threaten our homeland security.

Most people, when faced with the terrifying threat of your entire body (cells, tissues, organs and all) hemorraghing in one final bloody death shudder--see Richard Preston's Hot Zone--would probably say "Lock them up, kill them! I don't care, just don't let them near me!!"

And if that person clutching at life is your neighbor, your best friend, or your spouse? What then?

Sadly, the United States learned an awful lesson about humanity with the 1918 flu epidemic. Partly becuase Americans had no information about the disease, thanks to gag orders on the press by President Wilson and partly because people were literally dropping dead in the street, many ill people died because their friends and family members literally abandoned them to dehydration and starvation among other things (Thank you John Barry).

Mary Mallon
, doomed forever to be known as "Typhoid Mary" never understood why she was forced to spend most of her life exiled to an island and publicly shamed for the deaths of her employers. Living in the late 19th and early 20th century, when even the greatest scientists had a limited understanding of typhoid, Mary couldn't comprehend how she could carry a disease that made people sick if she wasn't ill herself. Perhaps if her legacy has taught us anything, it's that the same moral obligations and concerns we have about genocide and slavery apply to how we treat victims of disease.

Is humankind really worth saving if we don't value human life? Is one life or a town of a hundred people worth potentially 10,000 of lives? Is the quick and painless death of an innocent at the hands of a well-meaning government, truly in the best interest of the people?

And if we are ever damned enough to one day look at spreading cases on a map and compare numbers with our vaccine or drug stockpile, we will have to ask ourselves the real questions--the ones where statistics and numbers are no longer a useful tool for calculation. Whose lives should we value? Should we save the weakest first, the children and the elderly? Or should we save the ones who know how to turn the lights back on and protect the public?


The Trivial Pursuit for Sick Days

Lately, I've been a little addicted to this site, whoissick. It's like trivial pursuit for epidemiologists, with little multicolored wedges (symptoms) that fill in a round based on who reports what symptoms (fever, headache, etc...) in a given combination. If you look up your own zip code, you can find out who in your general vicinity has a tummy ache or runny nose.

From: http://whoissick.org/sickness

It's not GoogleEarth enough yet to help you avoid these people unless they willingly provide their exact location, but at the very least, if you're feeling poorly, you can easily find out if what you've got is going around. Cold comfort if your doctor tells you to drink plenty of fluids and get some rest. On the other hand, it is evidence for a skeptical boss: "Oh yeah, it's definitely contagious--look at all the people in Northdale who've got it!"

Some offices are fantastic about employees working from home when they're sick--others are practically glue factories about it. I've noticed it often depends on the industry. Physicians can't/shouldn't work sick and infect their patients. Many teachers come in sick if they can't get a substitute in time.

HR professionals know that allowing employees to take sick days helps the office avoid epidemics of flus, colds, etc...as well as keep up better morale. I knew someone who was poking around the office in between chest x-rays to check up on his pneumonia.

Do we do this to ourselves? This guy seems to think we enjoy working longer hours and taking less vacation and that we're better for it than the Europeans. I blame the Puritans for this delusional sado-masichism.

It seems while family medical leave is fine and dandy, and legally enforceable, paid sick days are not. According a 2004 report, almost half of the private sector or 59 million Americans have no paid sick leave. And even if a firm offers them, employees aren't using the time off.

It's easy to conjure examples of the single mother with a high school degree, working as a greeter at Wal-Mart or in the food service industry--thanks to Barbara Ehrenreich, we know that cautionary tale all too well. Yet, this disparity strikes at the heart of all Americans who thought they were safe becuase they were fortunate enough to go to college and get a white collar job. Even then, you may be afforded no relief if your kids have the chicken pox or your elderly father has regular appointments with his cardiologist.

This isn't ethical and it isn't good business practice, but it's also a tough argument to make when 45 million Americans (many of whom work full-time jobs) are uninsured and employers are dropping health plans like Britney drops her panties. In times like these, it's almost a moot point that we're even talking about expanding paid sick leave.

Yet we should and here's why:

The Urban Institute, recently found that businesses would save about $8 billion a year if they just let people be sick for seven days of the year. The flu can last longer than that and what about doctor's appointments, or a bad experience with fried rice?

Think for a minute what $8 billion could do if the savings weren't stuffed into the pockets of CEOs. Well, heck, it could just about cover the tab for the State Children's Health Insurance Program for one...

But let's get back to actually being sick and what that means to the average employee/patient.

According to the Institute for Women's Research, avoiding office outbreaks of the flu, alone, can save offices more than 2 days of lost productivity and employees would be spared more than $100 in doctor's visits and prescriptions each.

Obviously, those numbers might differ if you don't have health insurance and can't afford to see the doctor or buy the tamiflu.

So whoissick in America? A lot of people. It's really up to us whether we give them the tools to get better. To me, it's all about who's got a piece of the pie.