Invisible epidemics: ethics and asymptomatic infection.

Interactions between microbes and human hosts can lead to a wide variety of possible outcomes including benefits to the host, asymptomatic infection, disease (which can be more or less severe), and/or death. Whether or not they themselves eventually develop disease, asymptomatic carriers can often transmit disease-causing pathogens to others. This phenomenon has a range of ethical implications for clinical medicine, public health, and infectious disease research. The implications of asymptomatic infection are especially significant in situations where, and/or to the extent that, the microbe in question is transmissible, potentially harmful, and/or untreatable. This article reviews the history and concept of asymptomatic infection, and relevant ethical issues associated with this phenomenon. It illustrates the role and ethical significance of asymptomatic infection in outbreaks, epidemics, and pandemics-including recent crises involving drug resistance, Zika, and Covid19. Serving as the Introduction to this Special Issue of Monash Bioethics Review, it also provides brief summaries of the other articles comprising this collection.

How Should Public Health Officials Respond When Important Local Rituals Increase Risk of Contagion?

During the 2014-2015 Ebola epidemic in Sierra Leone, people were required by law to call a trained "safe burial" team to dispose of the body of a person who had died from Ebola. It took days for a team to arrive, however, due to limited resources and rural travel obstacles, so some villagers felt obliged to bury their loved ones themselves. Even with timely arrival of a team, there can be cultural priorities that deserve attention. One man's case discussed in this article suggests the need for Ebola responders to consider villagers' perspectives and possibilities for compromise.

How Should Clinicians Integrate Mental Health Into Epidemic Responses?

The 2014 Ebola epidemic in Sierra Leone and the current outbreak that began in 2018 in the Democratic Republic of the Congo generated numerous mental health crises that remain unaddressed by global standard infectious disease protocols. This article explores how responders should integrate mental health care into standard Ebola care.

How Should Global Health Security Priorities Be Set in the Global North and West?

Epidemics threaten all countries, yet epidemic responses are not implemented in all countries. One reason why is that transnational disease containment efforts (to keep diseases from spreading across borders) differ in important ways from efforts to protect those in countries where an epidemic is active. This article explores these 2 approaches to global health security and suggests reasons to reconsider prioritizing the former first.

What Should Health Science Journalists Do in Epidemic Responses?

Journalists have long covered outbreaks of infectious disease. In the history of global health journalism-from the 1721 Boston smallpox epidemic to the 2002-2003 SARS outbreak in China and Singapore and to recent outbreaks of Ebola in West Africa and the Democratic Republic of the Congo-newsrooms have wielded their power both responsibly and irresponsibly. This article examines journalism practice during the 2013-2016 Ebola epidemic and recommends strategies for improving epidemic reporting.

Is the non-identity problem relevant to public health and policy? An online survey.

BACKGROUND: The non-identity problem arises when our actions in the present could change which people will exist in the future, for better or worse. Is it morally better to improve the lives of specific future people, as compared to changing which people exist for the better? Affecting the timing of fetuses being conceived is one case where present actions change the identity of future people. This is relevant to questions of public health policy, as exemplified in some responses to the Zika epidemic. There is philosophical disagreement about the relevance of non-identity: some hold that non-identity is not relevant, while others think that the only morally relevant actions are those that affect specific people. Given this disagreement, we investigated the intuitions about the moral relevance of non-identity within an educated sample of the public, because there was previously little empirical data on the public's views on the non-identity problem. METHODS: We performed an online survey with a sample of the educated general public. The survey assessed participants' preferences between person-affecting and impersonal interventions for Zika, and their views on other non-identity thought experiments, once the non-identity problem had been explained. It aimed to directly measure the importance of non-identity in participants' moral decision-making. RESULTS: We collected 763 valid responses from the survey. Half of the participants (50%) had a graduate degree, 47% had studied philosophy at a university level, and 20% had read about the non-identity problem before. Most participants favoured person-affecting interventions for Zika over impersonal ones, but the majority claimed that non-identity did not influence their decision (66% of those preferring person-affecting interventions, 95% of those preferring impersonal ones). In one non-identity thought experiment participants were divided, but in another they primarily answered that impersonally reducing the quality of life of future people would be wrong, harmful and blameworthy, even though no specific individuals would be worse off. CONCLUSIONS: Non-identity appeared to play a minor role in participants' moral decision-making. Moreover, participants seem to either misunderstand the non-identity problem, or hold non-counterfactual views of harm that do not define harm as making someone worse off than they would have been otherwise.

[Ethical and health issues posed by the recent Ebola epidemic: What should we learn?]. / Problemas éticos y de salud planteados por la reciente epidemia de Ébola: ¿Qué debemos aprender?

The recent Ebola epidemic that affected several countries in Africa, with very high mortality and a pandemic threat, posed problems of justice, public health, prevention, treatment and research, each of which has relevant ethical issues. Despite severe initial difficulties, an effective international response was achieved, whose outcome has left significant teachings to be considered in order to deal with future epidemics or pandemics. In this article, the authors analyze the main problems faced during the Ebola epidemic, including the unequal distribution of health resources between countries, the need for international collaboration, the requirement for a review of the ethical standards of clinical trials in emergencies, and the necessity of an organized global system of prevention and timely response to these outbreaks. Authors conclude that at the present time health is a global issue without borders, that insufficient healthcare resources in some countries poses risks and affects all countries and that the confrontation of the threats of epidemics requires a solution based in universal solidarity. At the same time, a moral duty to investigate should be acknowledged, seeking a balance between sense of urgency, scientific rigor and involvement of local communities.

Outbreak or Epidemic? How Obama's Language Choice Transformed the Ebola Outbreak Into an Epidemic.

OBJECTIVE: Our aim was to examine in what terms leading newspapers' online sites described the current Ebola crisis. METHODS: We employed a quantitative content analysis of terms attributed to Ebola. We found and analyzed 582 articles published between March 23 and September 30, 2014, on the online websites of 3 newspapers: The New York Times, Daily Mail, and Ynet. Our theoretical framework drew from the fields of health communication and emerging infectious disease communication, including such concepts as framing media literacy, risk signatures, and mental models. RESULTS: We found that outbreak and epidemic were used interchangeably in the articles. From September 16, 2014, onward, epidemic predominated, corresponding to when President Barack Obama explicitly referred to Ebola as an epidemic. Prior to Obama's speech, 86.8% of the articles (323) used the term outbreak and only 8.6% (32) used the term epidemic. Subsequently, both terms were used almost the same amount: 53.8% of the articles (113) used the term outbreak and 53.3% (112) used the term epidemic. CONCLUSIONS: Effective communication is crucial during public health emergencies such as Ebola, because language framing affects the decision-making process of social judgments and actions. The choice of one term (outbreak) over another (epidemic) can create different conceptualizations of the disease, thereby influencing the risk signature. (Disaster Med Public Health Preparedness. 2016;10:669-673).

Problemas éticos y de salud planteados por la reciente epidemia de Ébola: ¿Qué debemos aprender? / Ethical and health issues posed by the recent Ebola epidemic: What should we learn?

The recent Ebola epidemic that affected several countries in Africa, with very high mortality and a pandemic threat, posed problems of justice, public health, prevention, treatment and research, each of which has relevant ethical issues. Despite severe initial difficulties, an effective international response was achieved, whose outcome has left significant teachings to be considered in order to deal with future epidemics or pandemics. In this article, the authors analyze the main problems faced during the Ebola epidemic, including the unequal distribution of health resources between countries, the need for international collaboration, the requirement for a review of the ethical standards of clinical trials in emergencies, and the necessity of an organized global system of prevention and timely response to these outbreaks. Authors conclude that at the present time health is a global issue without borders, that insufficient healthcare resources in some countries poses risks and affects all countries and that the confrontation of the threats of epidemics requires a solution based in universal solidarity. At the same time, a moral duty to investigate should be acknowledged, seeking a balance between sense of urgency, scientific rigor and involvement of local communities.

Estrategia individual y poblacional en las intervenciones frente a la epidemia del tabaquismo / Individual and population-based strategies for tobacco control

La estrategia poblacional de las intervenciones frente a los factores de riesgo se dio a conocer por los trabajos de Geoffrey Rose en el campo de la salud pública y la medicina preventiva de las enfermedades cardiovasculares a finales del siglo XX. En la actualidad, uno de los factores de riesgo con mayor impacto sobre la salud es el tabaquismo. El objetivo de este trabajo es describir y aplicar las estrategias de la medicina preventiva propuesta por Geoffrey Rose en el control de la epidemia del tabaquismo. Para ilustrarlo hemos utilizado los datos de concentración de cotinina ensaliva de una muestra representativa de la población adulta de la ciudad de Barcelona. En conclusión, las políticas públicas de control de tabaquismo en todo el mundo deberían tener en consideración la utilidad de la estrategia poblacional para el abordaje de este importante problema de salud, sin menospreciar intervenciones seleccionadas dirigidas a colectivos de “alto riesgo” que sean de probada eficacia (AU)

The population strategy for intervention on risk factors became known through the work of Geoffrey Rose in the field of public health and preventive medicine in relation to cardiovascular diseases in the late twentieth century. Currently, one of the risk factors with the most impact on health is the smoking epidemic. The aim of this study is to describe and put into practice the preventive medicine strategies proposed by Geoffrey Rose in the control of this smoking epidemic. To illustrate the situation, we have used the data on salivary cotinine concentration from a representative sample of the adult population in the city of Barcelona. In conclusion, public tobacco control policies worldwide should take into account the utility of the population strategy for addressing this important health issue, without ignoring “high risk” interventions of proven effectiveness (AU)

[Contagion - some notes on the epistemology and the ethics of public health]. / Contágio - contribuição para a epistemologia e a ética da saúde pública.

European Medical thought on epidemics - ranging from the opposition clean/dirty, pollution, malaria, pestilential seeds to 19th century microbiology - has always been ruled by figures such as the miasma, the repulsive, the excrement, the filth, the corrupt, the contagion. Theoretically framed, in general, by Foucault's ideas, this research focuses on some aspects of the historical epistemology and ethics of Public Health. Based on the history of Tuberculosis (TB) management in Portugal and, more briefly, on the flu pandemics, we thematize aspects of Biopolitics, namely, the disciplinary power and the processes of indifferentiation and reification. We will focus on the disjunction between contamination and transmission, on the systems of inclusion and exclusion and on the differences between uncertainty, risk, danger, precaution and prevention, aiming to contribute to the public debate on an ethic of precaution. It will be attested that the praxis of Public Health inevitably calls together, at various levels, the old categories of medical ethos, among which are the catharsis, the crisis, and the kairos.