Ebola: Teachable Moments

“So, what did you learn about Ebola this weekend?”

This is how Jennifer Dohrn, DNP, CNM, FAAN, assistant professor and director of the Office of Global Initiatives at Columbia Nursing, greets students in her global health class every Monday morning. As the epidemic rages, leaving a path of disrupted lives in its wake, Dohrn pushes students to confront in real time many of the same questions of fairness, ethics, politics, and clinical discovery that stymie many of the leading medical decision makers in the U.S. and around the world.

“Teaching has to be connected to what is happening in the world,” Dohrn says. “In teaching a class for future nurses about global health equity, it is imperative to address in concrete examples what is affecting societies and how we, as a global community, are responding.”

On this particular Monday, one student notes that a surgeon infected with Ebola is being transported from Sierra Leone to the Nebraska Medical Center, one of four hospitals in the U.S. with a specialized biocontainment unit to treat Ebola patients. Even as the class begins discussing the pros and cons of evacuating health workers from West Africa for treatment, the news changes. A hospital official in Nebraska reveals that the surgeon, Martin Salia, has died. Dialysis, a ventilator, and numerous medications weren’t enough to reverse his rapid decline.

“Should he be put on a plane?” one student asks. “Is this the right use of limited resources?” another student wonders. “Don’t we have an obligation to give the best care possible to health workers who volunteer to treat Ebola?” a third student muses.

Dohrn answers questions with questions, challenging students to think through the repercussions of each course of action. In this rapidly evolving epidemic, at this moment in time, the class concludes that foreign aid workers are essential to the response on the ground. And those medical volunteers are less likely to sign up for a tour at the epicenter of the Ebola epidemic if they have no hope of repatriation when they fall ill. A video The New York Times shot inside an Ebola ward in Liberia, which Dohrn plays during the debate, helps bring current conditions with their lack of resources into sharp focus. 

This turns out to be the easy debate of the day.

The larger, longer, and more tangled conversation centers on clinical trials. There are currently no drugs approved to treat Ebola. Two developments over the weekend put the ethics of testing experimental therapies in sharp relief. One plan calls for giving all trial participants access to the unproven remedy, and measuring effectiveness against the current death rates from Ebola. The other plan advocates placebo-controlled trials, offering a more precise way to measure the impact of treatment.

Both approaches come backed by influential health organizations. Doctors Without Borders, the leading force behind treatment efforts on the ground, and the World Health Organization favors the first plan. The second plan is supported by senior officials at the U.S. Food and Drug Administration and the National Institutes of Health.

Without offering her own opinion, Dohrn divides students into two teams, setting the stage for a lively debate. She offers just this preamble: “These are efforts with incredible ethics and human rights implications,” Dohrn says. “You’re starting trials in a situation with a lot of unknowns and you have to take responsibility for whatever the outcome may be. Lots of clinical trials are stopped early – it may be because of too many side effects or it may be because it’s so effective you don’t want to keep giving a placebo.”

The outbreak is so horrible that there is a need for immediate treatment that must outweigh the need for the ideal, gold standard clinical trial, argues the first student to speak for the pro-WHO camp. In West Africa, about half of all patients infected with Ebola die. In the face of this overwhelming risk, it makes sense to give experimental drugs to all eligible patients who want them.

“We are talking about countries that have been written off by the world,” another student on team WHO argues. “If this was your community being ravaged would we really be talking about the idea of research being more important than giving a potential cure?”

To this, students arguing for the U.S. approach say that it would be unethical to ignore the potential long-term side effects of experimental drugs. If we had attempted randomized controlled trials when Ebola was first identified in the 1970s, we might have a treatment developed by now, or at least a clearer path to finding one.

“We might cure people in the moment and then find out years down the line that the experiment caused birth defects or cancer or who knows what,” one student on the U.S. team says. “If that happens, and we didn’t have a control arm in the trial, there’s no way to go back in time and find out what might have been caused by treatment.”

"As nurses, we have to be prepared to weigh these questions. The Ebola epidemic offers a real time lesson in the complexities of global health, Dohrn says. “Teaching Ebola is more than a teaching opportunity; it is a teaching necessity if we are committed to graduating global nurses. Our students will always remember the heroic nurses in West African countries making these enormous contributions on the frontline of care.”

The clinical trials up for debate on this particular Monday will be under way early this year. 

“Before you get your white coats late spring, you will actually know the results of some of this,” Dohrn says at the end of class. “And you’ll also know what it takes to make these kinds of decisions.“