Part of C+’s investigation into Oxford’s role in the fight against Ebola

Imagine that one day, on your walk to the library, you notice a child has fallen into a shallow pond and appears to be drowning. To wade in and save the child would be easy, but it will mean that your brand new pair of shoes will get muddy. Do you have any obligation to save the child?

Initial thoughts: depends on the shoes. But when the moral philosopher Peter Singer posed this dilemma to his students, they exclaimed that they would save the child, for of course the importance of saving a child far outweighs the cost of getting one’s clothes muddy. It wouldn’t make any difference where the child was from, or whether or not others made an attempt to save her.

Passivity in this situation would be blatantly immoral, tantamount to murder. Singer raises the question: if I choose to spend money on a pair of shoes, a night out, or several cups of coffee without giving money to charity, am I effectively choosing these luxury items over the lives of others?

Put simply, yes. The analogy is crude but accurate. Since the first recorded death of a two year old on 28th December 2013, the current outbreak of Ebola has caused more than 9,353 fatalities in Guinea, Liberia, and Sierra Leone. I am not advocating that we give up all luxuries (Heaven knows I love my shoes and lattes) but the case for giving to charity, especially in the case of Ebola, is undeniable.

Of course there are problems with charity. It was disheartening to learn this week that one third of the money that Sierra Leone received from donations could not be accounted for, according to national auditors. There is a risk that aid can fall into the wrong hands, be it corrupt government officials or terrorist organisations. But even if only two thirds of the money given goes to the right place, that is better than no aid at all.

It is perfectly reasonable to want to know where your money is going, and if it is being used ethically and effectively. But we risk throwing the baby out with the bath water by concentrating on what goes wrong, rather than the great deal that goes right. The Ebola outbreak is a textbook example of when aid works. Thanks to the courage of health workers and volunteers in Sierra Leone, Ghana, and New Guinea, Ebola infection rates are falling as the disease is brought under control.

Thousands of children were able to return to school this week in Liberia, and a vaccine should be available for use in West Africa from next year. It is also worth, perhaps cynically, noting that many of the donors who gave money to fight Ebola were hardly disinterested parties. Fears of a more global epidemic might prompt some to self-interested action.

Ebola has been a problem in West Africa since the first outbreak in 1976, but it was only when the disease risked becoming an epidemic that would cross continents that the international community started to take serious action. We are a global community, and in an increasingly interconnected world, a problem for one country becomes a problem for all. Helping to contain the infection abroad helps to protect the UK. The same self-interested reasoning applies to many long term aid projects. Projects that promote education for those who would otherwise go without are hardly ever ineffective, as education stimulates long term economic growth, creating wealth for both donor and receiver.

Ultimately, the issue of whether or not it is Britain’s moral duty to help affected countries comes down to the question of whether you think that someone else’s suffering is as important as your own. We are often told that charity begins at home. But too often it ends there as well.

Other articles in this investigation:

Part of C+’s investigation into Oxford’s role in the fight against Ebola

Dr Tommy Rampling is the lead medical doctor on the first human Ebola vaccine trial at the Jenner Institute in Oxford. The trial examines the safety of two separate vaccines, as well as their ability to generate an immune response against Ebola.

Rampling has a strong sense of purpose in the importance of this mission, telling me, “Before the latter part of 2014, these vaccines had never been given to humans. Our aim, therefore, is firstly to demonstrate that these
vaccines are safe. The next real question is whether or not this vaccine schedule will work.

“There is no safe way of definitively answering that question in the UK, but after the vaccines have been given we can look at some specific parts of the immune system, such as antibodies and T-cells, to look for activation against parts of the Ebola virus. This will give some indication as to which strategies are worth pursuing further in the countries worst affected by the current outbreak.”

The issue that seems to dominate the fight against Ebola is the problem of adapting normal clinical trial practice to the extraordinary situation of an epidemic. A key aspect is the length of time it takes to get the trial running – 18 months in normal practice. However, where there is a will, there is a way, and Rampling has been surprised by the speed of progress, “What has been exceptional for this particular trial has been the speed and flexibility of the relevant authorities in expediting our applications in the face of a global health crisis.”

Once the trial gets regulatory and ethical approval, the next step is to recruit volunteers. As this trial is for a vaccine, it can take place in Oxford, unlike Peter Horby’s trial of potential cures, which, for obvious reasons, can only test those already infected with Ebola and therefore must be based in West Africa.

The selection of volunteers is a rigorous process. As Rampling describes, “Volunteers are identified by response to ethically approved adverts, and if suitable for the trial, they are invited to attend a face-to-face screening. This involves a thorough explanation of the trial, including the risks, with one of the trial doctors.

“If they are happy to proceed, and sign the consent form, we assess their medical health through a history examination and blood and urine tests. If, after all of this, the volunteers meet all of the requirements, they are offered an appointment for vaccination.”

The initial results of these trials have been promising, and using some of the information gained from them, the Jenner Institute is now working in collaboration with the University of Maryland to run a similar trial in Mali.

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The planned West African trials pose a very different set of challenges for Rampling and his colleagues, differences he is keen to stress in full. “A major difference will be the size of the studies. The African studies will need to be much larger than the early studies in order optimise the ‘power’ of the study to quantify the effect of the vaccine. Several trial designs have been proposed, each requiring several thousand subjects to be vaccinated to generate meaningful results.

“Furthermore, in order to detect a vaccine effect, the vaccinated group will need to be compared to an unvaccinated ‘control’ group who are at a similar risk of disease. This raises difficult ethical questions as to how best to fairly conduct these trials, and has been the subject of much discussion in the international scientific community.

“Finally, there are cultural differences, such as the scarcity of staff and resources, the difficulty of procedures (e.g. blood taking), all of which may put trial staff at risk of infection, and require that many adaptations to the trial design must be made to be suitable for the environment.”

Added to all of this is a new challenge, one that gets a conflicted response from Rampling, namely the recent fall in the number of new Ebola cases. For Rampling, “The decline in case incidence in the affected countries is extremely encouraging from a humanitarian and a global health perspective but it does pose novel challenges for analysing the effectiveness of drug therapies and vaccines. It is critical, therefore, to adapt scientific strategies to tackle this issue.

“Although there has been a sharp decrease in new cases in some regions of the worst affected countries, it is likely that there will continue to be sporadic outbreaks of disease in towns and villages for some time to come. New trial designs have been proposed that are suited to answering the key questions in this evolving disease burden.

“The global scientific community is in agreement that we must continue to act quickly and effectively, and glean as much information as we can from this tragic outbreak, so we can prevent similar occurrences in the future.”

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Part of C+’s investigation into Oxford’s role in the fight against Ebola

The key statistic is 9,353. That is the number of people who the World Health Organisation (WHO) has estimated have died of Ebola since the beginning of the current outbreak until February 16th of this year.

In the fight against Ebola, there are two parallel efforts: the attempt to find a vaccine, and the attempt to find a cure for those already infected. Peter Horby, as the Group Leader of Oxford’s Epidemic Diseases Research Group, is leading Oxford’s contribution to finding a cure. His role involves running the clinical trials needed to establish which drugs work and are safe to use. However, with the current circumstances far from ideal for a clinical trial, these trials bring up all sorts of ethical concerns.

The first issue was about whether there should be any trials at all. For, as Horby says, “None of the Ebola specific therapies had completed safety evaluations in healthy adults, so there were some questions about whether it would be okay to go straight to Ebola patients with these drugs.” Eventually, in August last year, WHO concluded that it would be ethical to go ahead, and it was at this stage that Horby’s group first received funding from the Wellcome Trust to set up a platform to evaluate “some of the most promising experimental therapeutics”. In choosing which drugs to test, the group had to consider not only which ones were most likely to work and were safest to use, but also which ones were most readily available. ZMapp, for instance, had shown great potential in animal studies, and the two people who took it recovered fully. However, there were only enough stocks in the entire world to treat seven people and little hope of mass production anytime soon. Horby had to turn his attention elsewhere. The drug they eventually chose was brincidofovir: it ticked all the boxes, was readily available, and administered as a daily pill, thus being easy to take.

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The next step was to set up the trial. This process normally takes 18 months, but Ebola does not work to the time frame that scientists are used to. Horby’s team got the time down to three and half months, and, according to him, even that was “still too slow by the standards of an Ebola epidemic”. It was at this stage that other ethical questions arose. For instance, Horby asks, “Should we give these experimental drugs to children and pregnant women?” The drugs had never been tested on children before and there was a worry that the drug would cause foetal abnormalities if given to pregnant women. However, at the same time, both groups have high case fatalities and are therefore in need of the drugs the most. Indeed, Horby points out that the argument against giving it to pregnant women is fairly theoretical as “to date, none of the foetuses of pregnant women that have had Ebola have survived”.

The other big ethical debate focused on whether to “randomise” the trial, which means randomly giving some patients a placebo so that they can act as a control for the trial. Whilst this is fairly standard practice in normal clinical trials, the question had to be asked as to whether it would be appropriate in this one. After all, those who get the placebo would then only receive the regular standard of care for Ebola that they would have received had they not taken the trial. However, given that this standard of care, consisting of intravenous fluids and symptom relief, has a roughly 60 per cent death rate, Horby wonders if this practice is truly ethical. It is a controversial debate, and according to Horby, “In the USA, the Food and Drug Administration [FDA] have been strongly in favour of randomised trials. We have not done that because we felt it was doubtful that we would be able to implement that sort of trial design.”

He went on to point out that the trials presented practical as well as ethical problems. “You are working in an environment where you can only see the patients whilst wearing protective equipment, and you can only stay inside for about a hour because it is too hot otherwise. You have limited access to medical equipment: for instance, how do you measure blood pressure or monitor heart sounds when you cannot put a stethoscope in your ears with protective equipment on?” The team has been forced to be ‘creative’. For instance, “We have been putting scanners in the treatment centres. You take the patient records and you scan them before destroying them.”

Unfortunately, after all the work that went into the brincidofovir clinical trial, the drug company pulled out earlier this month, citing concerns about the low number of patients involved. The trial had to end. Whilst this was “very disappointing”, the research group is already setting up a different trial for a different drug, TKM-Ebola, in Sierra Leone.

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We then moved onto the question of what it is like to work with such a dangerous disease. Horby is upfront with his answer, telling me, “It is a very harrowing disease. There are a lot of children affected, a lot of families affected because of the way it is transmitted by close contact. You often get multiple family members affected, so you will get mothers, fathers, their children, and their siblings all being admitted and then dying. So, you see some very tragic situations where there will be children who will have lost most of their family members.”

However, we ended the interview on a note of hope, with Horby giving his predictions for the future. “The epidemic seems to be coming under control in Liberia, Sierra Leone and Guinea. My feeling is that it will grumble on for several more months but will likely be contained towards the second half of this year completely.”

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I have never really understood people’s disgruntlement at Christians’ attempts to convert them. I just can’t get on board with the whole “I’m fine with them doing whatever they want so long as they don’t try to force it on me” thing. Firstly, they’re hardly commandeering in their approach. In fact, they are always really, really polite and there is usually a toastie involved. Secondly, I personally would be insulted if Christians actually believed that there was an all powerful god who would provide us meaning and save us from burning for eternity in hellfire but they decided to let us just do our thing and wander aimlessly into the endless horror of hell. 

In spite of my empathy with what the Christian Union were trying to achieve when I heard about their ‘Uncover Week’, I still seriously doubted that a single soul would be ‘saved’. I felt like they could throw all the free sandwiches and cookies they liked at it and not make much of a dent. I reckoned religion is something about which most Oxford students have probably had a reasonably long think and they have probably come to a pretty definite conclusion.  You couldn’t really half-heartedly slip into faith by attending a lunchtime talk.

When the nice Christian Union representative came round to deliver my toastie and hand me the program of events I felt a little guilty. I didn’t want their effort to be wasted and so I agreed to attend one the talks. I have always been a pretty definite atheist. Faith in the Christian God, or any god, is to me completely incomprehensible. I can see how maybe this viewpoint is a creation of my circumstance. I also get that Christians raised in different circumstances may view my lack of faith as equally incomprehensible.

My parents are both non-believers and I have attended only one church service ever. Admittedly I did love that church service. It was such a novelty that the memory of it has stayed with me. I couldn’t believe that a group of educated middle class people had gathered in a hall, faced towards an icon of what they thought was a magical man sent on a special mission, bowed their heads, closed their eyes and muttered together to an invisible being. I remember thinking that the closest thing I had seen to this was a scene in the ‘Indiana Jones and the Temple of Doom’ film. There was a lot of humming and chanting, the characters almost sacrificing an actress to some god.

Nevertheless, I attended the Friday ‘Uncover’ talk on evil hoping to undo some of my prejudices. I believed there must be some element of Christianity that I was missing. I knew there were plenty of people much cleverer than me who were devoutly religious. I doubted I would be converted but I thought I might learn to empathise with their viewpoint a little better. I was wrong. I left that talk with a completely changed and burningly passionate approach to religion. I had been transformed. I was no longer an atheist but instead an angry Dawkins style anti-theist.

The title of the talk was “Evil: How do we make sense of it?” In his opening remarks the speaker smugly reminded the audience that in the talks he had already given, he had proven that Christianity was a rational religion, or an “examined” religion as he put it. It was one that could withstand logical rational scrutiny. He then began by alluding to some sort of scientific approach to an explanation by setting out that there were “stages” to be worked through in understanding evil. So far so promising, I waited to be shown a logical argument for the Christian faith in the face of the problem of evil. I awaited an answer to the age-old question that recently went viral having been re-articulated by Stephen Fry, “Why would an all powerful, all loving god create animals whose sole purpose was to burrow up through the eyes of children?“

What I got instead was a completely vacuous speech. The format was painfully familiar, the desperate obfuscation of the unprincipled politician or of my own essays in weeks where I haven’t done the reading and I don’t know what I am saying.  The speaker filled the first fifty five minutes propping up his non-existent argument with snippets of bible verse, irrelevant truisms  (see ten minute exploration of the sources of evil) and references to his own life which I think were designed to boost his credibility by showing that he had suffered evil (as if this was a unique and special qualification). This was all relatively harmless but a real wrong was done when he filled his time by ‘summarising’ and dismissing alternative philosophies. Primo Levi, author, chemist, holocaust survivor and great thinker had his works ‘summarised’ into a thirty second snippet. Levi’s suicide was held up as a demonstration of the way atheists cannot cope with evil in the world. “The eastern family of religions” was next on his hit list and, after an in-depth two-minute explanation of the entire Buddhist philosophy, its weaknesses were exposed and it was dismissed. With five minutes to spare he conceded he would not have time to properly and thoroughly address the manner in which Christians deal with evil but at last he did engage with the problem at hand.

He admitted that there is an inconsistency between the existence of evil and an all-loving and all-powerful god. His grand solution to this problem came in the form of an analogy in which French resistance fighters had to trust blindly in people during World War Two. I have some impression that this is a famous and nuanced argument but in his presentation it seemed pretty flimsy. This was partly because I think it would be pretty easy to distinguish the type of faith required by members of the French resistance and the type of faith required for the denial of a logical inconsistency. Its key weakness however was that in essence this great propounder of Christianity as an ‘examined’ faith had just attempted to answer this key question with a rephrasing of ‘God works in mysterious ways’.

As the speech came to a close I could feel nothing but revulsion at this most dishonest and slippery of non-answers. This was an inward-looking non-critical exercise in self-congratulation. His argument was a cult-like denial of proper debate or engagement with alternative ideas. If this is what Christianity is, not only do I not ‘get’ it, I don’t like it. I no longer feel admiration for a kindly moderate Christian’s gentle attempts at conversion. Instead I feel the same sadness and distaste I feel when I see scientologists offering a free cup of coffee to take their personality tests.