ABSTRACT The 2026 Ebola disease outbreak in the Democratic Republic of the Congo and Uganda is caused by Bundibugyo virus, a species for which, unlike Zaire ebolavirus , no licensed vaccine and no approved therapeutic exist. This commentary argues that this absence is not a misfortune of virology but a structurally produced injustice. Bundibugyo virus has been characterised since 2008, has caused lethal outbreaks, and was foreseeably capable of recurrence; more importantly, species‐specific and cross‐protective countermeasures were scientifically tractable more than a decade before, yet none reached licensure or field readiness. A recombinant vesicular stomatitis virus vaccine expressing the Bundibugyo glycoprotein — built on the same platform as the licensed Zaire vaccine — conferred complete protection in nonhuman primates in 2013; thirteen years later, no clinical‐grade material existed when the outbreak began. The gap, we argue, lay not in what science could build but in what the system chose to finish, because preparedness investment concentrated on the species that threatened wealthier and more connected populations. Drawing on the framework of structural injustice and on the authors’ prior field experience of concurrent epidemics in the DRC, we distinguish tragic scarcity from produced scarcity, answer the feasibility objection, and argue that closing the gap is an obligation rather than a charity.
ABSTRACT The inverse care law—the persistent pattern whereby those with greatest health need receive the least care—has remained stubbornly intact for over fifty years. Despite universal health coverage commitments, health systems continue to concentrate disadvantage in hospitals and exclude the most vulnerable from effective care. This paper argues that we lack a mechanism‐level explanation for why the inverse care law persists. It introduces Ecological Adverse Selection Theory (EAST) to fill this gap. Drawing on Akerlof's adverse selection framework, EAST argues that health systems are designed around implicit assumptions about patient capacities—stable housing, supportive caregivers, reliable transport—that are not universally held. When systems cannot distinguish patients who possess these capacities from those who do not, they inadvertently select for those who fit and select against those who do not. This process—structural sorting—operates in two dimensions: barriers to access for disadvantaged patients, and accumulation in hospitals when they do access care. EAST introduces three measurable constructs—Predictive Governance Intensity (PGI), Structural Scarcity Index (SSI), and Behavioural Diversity Distribution (BDD)—that enable empirical testing and accountability. Anchored throughout in a case from Manenberg, a Cape Town township where chronic gang violence and structural scarcity make visible the stakes of health system failure, the paper demonstrates how EAST contributes to structural approaches within public health ethics. The paper concludes by identifying the normative implications of EAST, including a capacities‐first principle, and by situating EAST within the broader fields of public health ethics and global health ethics.
A "go-bag" assumes an emergency with a beginning, a peak, and an end. This editorial asks what a family needs to keep for the years after that ending - not to survive the emergency, but to survive its administrative afterlife. Drawing on a decade of research with families living with congenital Zika syndrome in Northeast Brazil, and on Alagoas's compensation law, we examine how states convert the diagnostic limits of an emergency into an evidentiary burden borne by individual families. A decade after exposure, families are asked to reconstruct causation from medical fragments never designed to answer that question, and are held responsible for archival gaps produced by the uncertainty of the emergency itself. We propose ainda - Portuguese for "still" or "yet" - as a term for the temporal form this waiting takes: not a pause before resolution, but an extended present in which care, grief, and unproven harm remain open together. Bioethics has theorized triage, consent, and allocation during crisis; it has said far less about the years in which institutions have moved on while the people who lived through the emergency have not. We argue that the archive families are asked to produce - what it demands, of whom, and across how long a delay - deserves attention as an object of bioethical analysis in its own right.
The Diagnosis-Related Group (DRG) system has had a significant impact on the healthcare community, particularly in areas of financial management and care quality monitoring. It is widely implemented as a hospital reimbursement model aimed at controlling costs while improving efficiency. However, the system has given rise to several ethical concerns, including the risks of under-treatment, upcoding, inequitable access to care and moral distress and burnout among physicians. This article explores these ethical dilemmas in depth and discusses various mitigation strategies, such as DRG modifications, ethical safeguards and hybrid reimbursement models. Special attention is given to the Malaysian healthcare context, with recommendations tailored to address the ethical challenges unique to its dual healthcare system. The goal is to ensure that cost-effectiveness is achieved without compromising the quality and equity of patient care.
