Liberia gets Ebola drug; ponders who should get it

MONROVIA, Liberia — Liberian officials faced an excruciating choice Thursday: deciding which handful of Ebola patients will receive an experimental drug that could prove life-saving, ineffective or even harmful.

ZMapp, the untested Ebola drug, arrived in the West African country late Wednesday. Assistant Health Minister Tolbert Nyenswah said three or four people would begin getting it Thursday. The government had previously said two doctors would receive the treatment, but it was unclear who else would.

These are the last known doses of ZMapp left in the world. The San Diego-based company that developed it has said it will take months to build up even a modest supply.

The Ebola outbreak that was first detected in March in Guinea and spread to Liberia, Sierra Leone and Nigeria has killed more than 1,060 of the 1,975 people sickened by it, according to the World Health Organization.

The outbreak has overwhelmed the already strained health systems in West Africa and sparked an international debate over the ethics of giving drugs that have not yet been tested for safety or efficacy to the sick, and over who should get the drugs. So far, only two Americans and one Spaniard have received it. The Americans are improving — but it is unclear what role the drug has played. The Spaniard died.

Doctors Without Borders, which is running many of the Ebola treatment centers and whose staff have tussled with whether to provide ZMapp, said such choices present "an impossible dilemma."

Now Liberian officials are facing those questions.

"The criteria of selection is difficult, but it is going to be done," said Dr. Moses Massaquoi, who helped Liberia obtain the drug from Mapp Biopharmaceutical. "We are going to look at how critical people are. We are definitely going to be focusing on medical staff."

Massaquoi said people who were past the "critical phase" and looked likely to survive would not be treated with it.

In this outbreak, over 50 percent of those sickened with Ebola have died, according to the U.N. health agency.

Arthur Caplan, director of medical ethics at NYU Langone Medical Center, said the choice would have to balance helping the largest number of people with learning the most from the treatments. Since it's not clear whether the drug is effective, Caplan said the question is not, whose life do we save, but "who gets the chance to be experimented on?"

For that reason, recipients should be chosen at least partially based on whether they will make good experimental subjects. That could mean choosing people who have recently contracted the disease and are more likely to respond to treatment or younger patients. In order to study the long-term effects, doctors will likely prefer people who can be observed for months, he said, and that might eliminate people who live in remote places.

Liberian officials stressed that only people who signed a consent form would receive the drug. Caplan said it was important to inform people about the risks of taking the drug, but that "if you're terminally ill with a dread disease ... you almost can't imagine anybody saying no."

Nigeria announced Thursday that one more person has been infected with Ebola, bringing the country's number of cases to 11. Health Minister Onyebuchi Chukwu said the latest patient is a doctor who helped treat the first Ebola case in the country, Liberian-American Patrick Sawyer who flew in last month with the virus and died July 25.

All Nigerians who contracted the virus have had direct contact with Sawyer.