Thursday, July 23, 2015

Postmodernity and global polio eradication

Polio is getting closer to being eradicated. If it happens, it would join (along with smallpox among humans and rinderpest among cattle) that very rare class of pathogens that have been taken literally out of circulation by conscious human efforts.  That sounds good, but in the case of polio it also shows just how long it takes medical advances to deeply penetrate resource-limited and politically volatile settings: a safe and effective vaccine has already been around for half a century. In any case, due to the collective efforts by charitable organizations, civil society, government and religious leaders, Nigeria is getting nearer to being rid of polio, and tomorrow will mark a year since a case of polio has been diagnosed there. The remaining holdouts are Pakistan and Afghanistan. But potential threats to polio eradication may lie elsewhere, where you rationally would expect it less.

Like California. According to the California Department of Public Health, over 60% of children in the state have not received the full suite of vaccinations. This is partly a case of being victims of their own success: Americans have little experience of what it is like to be prey to infectious agents precisely because vaccines have worked so well on so many of them. It is a stance you have the luxury of taking from a position of relative privilege. But it is partly due also to a culture of gossip, suspicion and kneejerk mistrust of medical authority, and hence also from a position of ignorance. If vaccines are the product of Enlightenment faith in reason and science to improve society, rejection of vaccines -- when not itself based on sound reasoning and evidence -- is regression into a pre-scientific state where life was nasty, brutish and short. Privilege and ignorance is a toxic combination, and some people have to (re-)learn the hard way.

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Tuesday, July 21, 2015

The bioethics of austerity

One of the more depressing aspects of the crisis in Greece is the cartoonish way the plight of the Greek people has been portrayed. It is as if ordinary Greeks had all taken out massive and reckless loans, and when asked to pay them back, they stubbornly refused. The nerve of such people! Do they want money for nothing? Can't they pay off their debts like us, i.e. hard-working sensible people? How lazy and irresponsible of them.

Africans may view all this with a sense of dèja vu. In the years after independence, the ruling class of African countries brought their economies into debt, while rulers enriched themselves from revenue generated by the selling off of their natural resources to the developed countries in the North. In the 1980's and 1990's, the collection agencies of the international creditor community (i.e. the World Bank and the IMF) imposed 'structural adjustment programs' that involved reducing expenditures by the public sectors -- especially education and health -- opening up markets to foreign investment and establishing debt repayment schemes. This was austerity avant la lettre, whose effects in Africa were largely catastrophic and are still felt right up to this day. In this way, Africa was a laboratory for a new, 'bloodless' way of dominating and exploiting other countries, not by armed conquest, but by debt. Debt in this geopolitical context is not like the debt you incur when you voluntarily take out a loan to buy (say) a car. No ordinary African citizen voluntarily asked for despots and kleptocrats to siphon off national resources, run their country deep into the red, and then agree to repayment terms and conditions that gut their schools and hospitals. Africans are familiar with European powers doing this to them, and accusing them of laziness in the process.  Europeans doing it to one of their own: now that is new.

Just like the African case, the Greeks are getting hit ... right in the health sector. Crumbling infrastructure, doctor and nurse burnout and brain drain, use of cheap but unsafe materials, shortages of medical supplies, increasing inability of patients to pay for services: all the classic symptoms of austerity health care. The imposition of austerity will be predictably associated with avoidable morbidity and mortality -- and it is avoidable because austerity is a political construct, not a natural event. If the more powerful countries want to bail out or provide debt relief to certain countries or institutions, they can and they have. So they are at least partly responsbility for those consequences when they decide not to, both in the old African case and the new Greek one.

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Friday, April 24, 2015

Penile transplants and ritual male circumcision in Africa

It should not be going to too far out on a limb to say that ritual male circumcision is not, and never has been meant to be, a medical intervention. Certainly in sub-Saharan Africa, where it has generally been understood as part of a larger rite of passage from boyhood to manhood, questions of safety, hygiene, pain relief or psychological trauma are typically not concerns central to the ritual. If they were, the use of unsterile instruments by non-surgeons on the un-anesthetized would have led to the disappearance of the practice long ago. The ritual is about risk, not safety; it is about testing an initiate's response to fear, not making the youth feel comfy. And what is more fearful that the threat of a sharp instrument being brought to bear on your private bits? One can be appalled by the practice, but you have to at least acknowledge that it is not an attempt to do the same thing as medical circumcision, except more primatively and with higher complication rates. It has unsafe practices partly because it serves a whole other purpose.

Nevertheless, it is hard to say that penile amputation or death are just the price you pay for ritual male circumcision, and those who think otherwise should just man up. Are you culturally ignorant if you care about and want to protect those who are harmed by traditional circumcision? Are you culturally insensitive if you want to change the practice to reduce harm to persons? One interesting development related to the issue has been the announcement of the first penis transplant. A nine-hour surgery by a South African surgical team late last year transplanted the penis of a dead donor to a young man who had lost his own member due to ritual circumcision complications. To barely-contained chuckles in news reports and the twitter-sphere, the patient enjoyed a rapid recovery, successfully putting his Johnson through its sexual paces only five weeks after surgery. Bad knifework corrected by better surgery, giving hope to all those harmed by ritual.

There are some puzzling and disquieting aspects to the story though. I suppose the first is that I never realized that you could donate your penis. Is this a checkbox on a form? The second is the question -- never answered in any news report that I saw -- whether the donated penis was itself circumcised. If it  wasn't, this could be a first: the first man to be circumcised twice. But most of all I wondered: how many of those who suffer from penile amputation via ritual circumcision are in a position to afford a nine-hour operation? And how will having another man's penis play itself out in their communities? Will it be considered more or less strange than not having one at all? And to what extent is this surgical achievement an adequate response to the deaths and dismemberments of ritual initiates occurring each year, rather than showcasing what powerful medical institutions are able to do?

Prevention rather than treatment is probably the only realistic way to cut down on the morbidity and mortality associated with ritual male circumcision. The problem is that it is unclear how to minimize the harm associated with the practice without significantly altering its meaning. Probably no headway will be made until the adherents themselves (and not just outsiders) regard the deaths and mutilations as matters of deep moral concern, rather than something that just comes with the ritual territory.

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Wednesday, March 04, 2015

Whose risk/benefit ratio is this, anyway?

It's a good question. An analysis of risks and benefits for study participants is considered central to the ethics of research, but how risks and benefits are determined remains tricky. Part of the job description of research ethics committees is to make such determinations, and the Belmont Report encourages use of quantitative risk data whenever possible, but it is unclear how often that actually happens. Anecdotally, there is a lot of eyeballing and back-of-the-envelope estimation of risks, if not outright speculation and magnification. And as for benefits, there is much disagreement as to what should count as a benefit in the risk/benefit assessment. Compensation and inducements are traditionally thought to be inadmissible; benefits that come with study participation ('inclusion benefits') are permitted in the mix by some, ruled out by others.

The problem of risk/benefit determination is not just a problem about how, but also about who. Traditionally, the work of making such judgments is something reserved for experts: bioethicists, researchers, research ethics committees, policy makers. This is one area in which the whiff of paternalism in research ethics is particularly strong. If anything, the perspectives of research participants and communities are regarded as ethically dangerous and problematic, particularly in cases where communities are poor and the prospective participants are hoping to gain medical benefits by joining research studies. An article in a recent edition of Tropical Medicine and International Health suggests that local communities make their own risk/benefit calculations about particular studies, which go far beyond whatever risks and benefits may be directly connected to study interventions. For example, the thought "How could my participation in this study possibly benefit my family?" is a consideration unlikely to appear in your standard risk/benefit discussions. What could be a benefit for participants may, from the perspective of an ethics committee, be literally invisible.

The authors state that much more research is needed into the complex links between socio-economic vulnerability, access to health care and the freedom to decide on participation in medical research. Seems reasonable. But whether such research will lead to a participant perspectives being more determinative of 'official' assessments of the risks and benefits of health research remains to be seen.

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Saturday, January 10, 2015

Big Pharma feeling misunderstood

The CEO of Bayer, Marijn Dekkers, was last month reported to have said the following:

"We did not develop this [cancer] drug for Indians. We developed it for Western patients who can afford it."

What Dekkers said was in response to a question about a decision by an Indian government official to grant a compulsory licence to patents on said cancer drug, on the grounds that Bayer's price for it ($65,000) was far too expensive for Indian patients. Dekkers added that he thought the move towards a compulsory licence -- permitting low-cost generic equivalents to be produced and sold by companies other than Bayer -- was "essentially theft."

A couple of websites condemned the comments as the usual 'profits before persons' standpoint of Big Pharma, albeit stated much more brutally than CEOs of major drug companies generally do.  It turns out that Bloomberg News, who originally ran the quote, actually manipulated it a bit. What Dekkers actually said was:

"Is this going to have a big effect on our business model? No, because we did not develop this product for the Indian market, let's be honest. We developed this product for Western patients who can afford this product, quite honestly. It is an expensive product, being an oncology product." 

Plus compulsory licensing is theft. Bloomberg News rightly corrected itself, although if anything the actual quote sounds even worse.

What is really ironic is that Dekkers' statement was made at a conference called Buffering the Pharma Brand: Restoring Reputation, Rebuilding Trust. It could alternatively been called: we make you sophisticated drugs, that you can't make yourself, so where is the love? The participants in the conference seem bewildered that the public trusts pharmaceutical companies less than producers of alcohol and tobacco. How is this possible? In this regard, Dekkers' statement may have inadvertently been the most insightful 'take home' message of that particular get-together.

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Wednesday, January 07, 2015

New Year ruminations on global bioethics

The New Year is a good time to reflect on where one has been and where one is going. What have I accomplished or failed to accomplish? What can I do better? It is hard to know whether Julian Savulescu wrote his recent essay in the Journal of Medical Ethics (‘Bioethics: why philosophy is essential for progress’) in a bit of a fin d’annee funk. But it certainly sounds like it: his conclusion is that bioethics and medical ethics as fields have largely failed, and he seriously doubts that he as a bioethicist has made much of a positive impact over the past two decades. What is the malaise, and what is the antidote?
According to Savulescu, bioethics and medical ethics have failed because the philosophical engine that powers ethics has been allowed to wither. In fact, much of his article is devoted to deftly exposing what he considers crappy ethical reasoning. While one may not be a fan of Savulescu’s brand of consequentialism, and/or why he thinks certain positions are untenable, you cannot fault him for failing to present clear ethical arguments in support of his views. This is part of his point: bioethics is being overrun by intellectual laziness in the form of unreflective adherence to ethical-sounding catch phrases (‘humans have dignity’), slavish appeal to existing codes and regulations, or failures to distinguish empirical claims from normative ones. The paragraph that really struck me was the following:
I left a promising career in medicine to do bioethics because I had done philosophy in 1982 and attended Peter Singer’s lectures in practical ethics. The field was new and exciting and there were original proposals and arguments. Singer, Glover, Parfit, Lockwood and others were breaking new ground, giving new analyses and arguments. Now medical ethics is more like a religion, with positions based on faith not argument, and imperiously imposed in a simple minded way, often by committees or groups of people with no training in ethics, or even an understanding of the nature of ethics.
The remedy for this, according to Savulescu, is to go back to basics. Bioethics is a branch of ethics. Ethics is a philosophical discipline, and philosophy (certainly in its Western, Socratic form) is all about critically examining claims and offering the best arguments one can. 

To the extent that Savulescu’s diagnosis is right, bioethics may be in globally rough shape. To make my own start-of-the-New-Year confession, I have been involved with initiatives to strengthen bioethics in sub-Saharan African countries for a decade now. One of the greatest challenges faced by those initiatives is to stimulate critical philosophical thinking. Trainees often expect the ‘right answers’ or ‘correct values’, which are then to be applied mechanically to particular problems.  This may be due to educational systems that elevate professors high above students, and encourage learning by rote while downplaying critical engagement with what is being taught. In addition, I have found that much of the interest in ‘bioethics’ in developing countries too often boils down to the (institutional) interest in establishing and sitting on research ethics committees. Whatever the causes of the trend may be, the net result may be the globalization of a diluted bioethics that ‘is more like a religion.’ Those of us involved in such initiatives need to seriously reflect on this phenomenon, to what extent we contribute to it, and what can be done to minimize or counteract it.

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Thursday, November 20, 2014

Ebola and the ethics of research design

A couple of recent articles stimulated my interest on the ethics of conducting ebola research, particularly with those conducted in low-resource settings and having a randomised controlled design. It interested me enough to write a letter to JAMA, where it got bounced.  I thought about submitting to Lancet, but hip replacement surgery got in my way: just too much work. So it goes. Part of what is fascinating about the topic are the underlying issues regarding whether doing anything other than the 'gold standard' of clinical trials is justified. I am diverting this piece to Global Bioethics Blog just in case a reader finds something of value in it. 

Two recent commentaries in this journal argue for and against conducting randomized controlled trials (RCTs) of new Ebola drugs during the current epidemic.[i] [ii] Those in favor argue that only RCTs can deliver the evidence required to treat future Ebola patients in ways superior to the current standard of care, which is largely palliative. Other observers hold a similar view.[iii] Those opposed to RCTs in this context argue that if patients were randomized to study arms of either (a) a new drug or (b) the baseline 70% mortality rate for Ebola, such a trial would not possess equipoise, because (arguably) the intervention arm would likely provide at least some benefit. In addition, opponents argue that local communities ravaged by Ebola – whose trust in authority, including medical authority, has been profoundly shaken -- are unlikely to accept a randomized controlled trial design.  They therefore advocate for experimental drugs to be offered to patients within non-RCT research designs, even if they have not been tested by the ‘gold standard’ methodology.   

On the face of it, this seems like a conflict between advocates of evidence-based medicine and those who understandably, but misguidedly, want to provide less-than-well-tested drugs to the sick as soon as possible. But while the former position seems rational and impartial, history reveals some unsettling patterns. When the HIV epidemic was raging in the United States decades ago, advocacy groups mobilized aggressively for expedited access to new experimental treatments, bypassing the full FDA approval process.[iv] The alternative then, for many AIDS patients, was death. Current policies surrounding ‘compassionate use’ were borne out of this experience. This raises the question: is it easier to take a hard utilitarian position on the need for RCTs when it is someone else’s epidemic?

The faith placed in scientific knowledge to resolve deep social problems is also part of an old pattern. When health crises occur in developing countries, international efforts often focus on fast-tracking biomedical interventions rather than also engaging the social, economic, and political factors contributing to emerging infections. Citizens of low-resource countries have every right to be skeptical here. Drugs to prevent mother-to-child HIV transmission were tested and developed two decades ago; only 57% of women in sub-Saharan Africa currently have access to it.[v] The same (or worse) can be said for a host of other diseases. Access to new Ebola drugs, should they be successfully developed, will likely to follow the same trajectory. Again, the argument that we should only encourage RCT trial designs for new Ebola drugs, out of scientific concern for the evidence base, may be more compelling in places other than Monrovia.

[i]Shaw S. Randomization is essential in Ebola trials.  Lancet 2014; 384: 1667. 
[ii]Adebamowo C, Bah-Sow O, Binka F, et al. Randomised controlled trials for Ebola: practical and ethical issues. Lancet 2014; 384: 1423-1424.
[iii]Joffe S. Evaluating novel therapies during the Ebola epidemic. JAMA 2014; 312(13):1299-1300.
[iv]Dresser R. When Science Offers Salvation. 2001. Oxford: Oxford University Press.
[v]WHO/UNICEF/UNAIDS. Global Update on HIV Treatment 2013: Results, Impacts and Opportunities.

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