#ParisAttacks: Ethics and Freedom/Management of deviation in extraordinary occasions?

Nowadays, chaotic situations are no longer hypothesis or virtual but reality on a day to day. We have to learn on how to cope with chaos according to specs for a limited period of time, according to severity.

Tour EiffelWhatever crisis are, natural disaster or pandemics or terrorist attacks, living in XXI° century raises security concerns and threats which must be planned. By thinking about the answers to bring on the table, we have to think about the worse case scenario for developing new strategy to legitimate actions plan and prepare management of deviation for Ethics during conflicting situations or extra-ordinary environments (Political or sanitary); one point to be addressed is to carefully implement new decisions for a while and by explaining conditions required and necessary to activate it.

The Pandemic Preparedness Plan done in 2009 during the Flu H1N1 Pandemic was a good opportunity to review the key role of Ethics by launching talks and seminars on this topic, mostly Legal and Philosophy issues, on the best practices to be used during emergency care in a life-threatening environment, close to chaos also called Black Swan.

continent des imprévus

Recently, famous Patrick LAGADEC, author of “Le Continent des Imprévus”, is the head of new school of risk management teaching how to think the unthinkable by proposing to create a new task force “Quick thinking force”.

 Following the terrorist attacks which occurred in Paris on Friday November 13th 2015, French Parliament (National Assembly + Senate), gathered in Versailles for the Congress, is working on a Patriot Act in order to contain terrorism in link with Islamic State. Reinforcement of internal Security, by measuring risks versus impacts of new measures affecting individual human rights and freedom. This is the price to pay for keeping our population safe. Other measures could be voted to prevent individuals identified as High risk of Security threat, labelled “S” for “Special attention” with regards links with terrorism organisations or extremists.

EthicsNow and considering Health, mainly Public Health or disaster medicine, there are several situations where Medical Doctor has to deal with medical Ethics and Law in order to treat no longer on an individual practice but on a mass gathering medical care. It is not a first arrived first served but cares are prioritized based on gravity of injuries but also the better chance to survive if the rule “sooner is better” is applied. In a very critical situation, the main objective is to take care and save the highest number of lives. To achieve this objective, Ethics needs sometimes to be relocated backstage and for a while. That was recently the case during Ebola epidemic in West Africa which required to use military forces for helping containing People and villagers, also in custody. That affected human rights but also saved hundred of lives.

Remember what happened in Scandinavian countries during the AIDS and how ill People infected by HIV were isolated/jailed to prevent spread and to contain risk exposure.

statue-de-la-libertéFor sure there is a risk for abuses; this is why it is so important that national authorities and Public health department have time and work in advance not to be in a hurry and under pressure when elaborating a management of deviation which is impacting Ethics and human rights. To conclude, during extraordinary occasion, it remains of great importance to be able to explain (not to complain) the rationale behind a management of deviation impacting both Ethics and human rights that we normally refer to while in safe and peaceful environment.

Who’s WHO? (The World Health Organization)

As a French citizen, please let me use the Shakespeare’s language trying to understand the way WHO is following when managing Epidemics or Pandemics: “To be or not to be:That is the question.”


Looking back at the recent Ebola outbreak and MERS Coronavirus epidemics in the Middle-East since 2012, I am a bit disappointed by the role and responsibility of WHO with regards to the leadership of such an International Public Health concern. To be honest, I understand that being the chairman of this organization is not an easy task by managing without the full powers and funds allocated to cope with the increasing demands of assistance worldwide. Nevertheless, from the lessons learned and return of experience, time is to review how WHO is working and especially working in front line.

Doctors-without-Borders-logo-squareNobody can ignore the key role played by MSF (Doctors without Borders) as a whistle blower, raising the alarm then taking the lead in West Africa (WA) without delay and despite a lack of means of protection for its own health care workers (HCW). As a consequence, MSF reported a huge loss of HCW. As a NGO, MSF has the capablity and flexibility to cope with the ongoing environment of the Ebola outbreak, to move to front line and to install new medical facilities where required and accordingly.

My congratulations to the MSF’s International president, Dr Joanne Liu for identifying the limits of the exercice of the NGO and by declaring a state of emergency towards United Nations (UN) and requiring support and assistance for logistics and peace keepers.

What a sense of duty of care and vision when the situation is worsening to an outcome which compromises Public Health and Safety, leading to chaos of emergent countries.

At this stage, the second key actor was United State of America (US) and its president B.Obama who decided to support and sponsor the fight against Ebola. I do not remember having seen a President taking the time to explain and train People about the symptoms and the best practices to prevent contamination; empathy, charismatic and education delivered by B.Obama…Whoooo, impressive! Such as the contest for R&D addressed to designer for new personal protective equipment/coverall safer and more comfortable while working with extreme high temperature (>35°C).

CDC logo_smallUnder the commitment of the Chief Commander, the CDC quickly joined the crisis team by taking the lead in Liberia. I would say leading by example for the other countries involved in WA, France and EU in Guinea, UK in Sierra Leone.

After local assessment, it was clearly identified that military forces would support the NGOs by providing logistics, ground and air transportation and security.

In WA, the entire Public Health system has been overwhelmed, affecting medical staff and leading to closure of medical facilities and community hospitals. A new risk exposure is related to sub-urban and highly crowded locations; a bit like a fire spreading from house to house.

Taking into account this social environment and adding a lack of sanitation, cultural and religious issues related to burials, it is not surprising to understand that the Ebola outbreak was not under control and that WA needed strong support and help. We might have expected that was the mission for WHO, supported by UN.

Astonishing to note how WHO was unable to take the lead and coordinate without unbearable delay. Two major key factors are:

  1. Fund raising from UN members: recent and continuous decrease of the incomes;
  2. Emergency response team, fully equipped and trained to cope with epidemics:not implemented,not existing.

Surprising to note how long it took for health risk assessment, lack of impact assessment on security and economy.

To anticipate, to plan are key figures of pandemics preparedness. Where are the lessons learned from SARS and Flu H1N1?

Be pro-active and ready to cope with disasters whatever the cause is: isn’t it the mission of WHO?

  • So, how explaining the last minute Ethics committee notice to attend? in charge of a statement about clinical trials of new drugs (was that the first time WHO was exposed to?);
  • Underestimation of gravity due to under-reporting from WHO Regional Committee;
  • Lack of support on the front line with PPE, sanitizing, then water and food for quarantine People in villages/towns.

Findings based on facts and evidences are damning about the role and responsibility of WHO during Ebola outbreak in WA. WHO is acting as a Client who requires assistance from sub-contractors like MSF or CDC.


WHO: Towards a New Deal.

WHO has to remain a policy maker and a guard keeper of the International Health Regulation. But WHO has to take care to stay away from a politically correct language in order to act efficiently and timely while dealing with emergencies.

Criticisms are easy but useful only if leading to new beneficial proposals. I am not the authorized person allowed to speak about the organization of WHO but my outside position allows me to be an observer:

  • In order to act as soon as possible and by avoiding duplicating the resources: to implement partnerships with NGO like MSF and/or National Health agencies like CDC in US or EPRUS in France. WHO coordinates and reports to the stakeholders;
  • To create a Crisis management team and an investigation team coordinating or delegating scientific pluridisciplinary skills;
  • To anticipate Legal and Ethical issues related to Global Health/One Health (including veterinary health);
  • To allocate the necessary logistics on due time to cope  with hazards or threats;
  • To initiate R&D based on innovation for improving the Health and Safety of personnel on the front line; same whenever new drugs or vaccine are required by developing partnerships with Laboratories and chemical industry.

In this kind of organization, WHO is less exposed to operational issues which is not the best quality to describe WHO.

On July 31 2015: WHO Press Conference…  http://terrance.who.int/mediacentre/presser/WHO-RUSH_Ebola_WHO_reform_presser_CHANm_NABARROd_31JUL2015.mp3