Health care strike in Mozambique

When I was in Maputo last week, the big ethics issue in the country had nothing to do with biomedical research. There was a buzz about a possible doctor's strike. But the doctors I met said it was actually a bluff: the government would open negotiations before the strike deadline, the medical association would craft some sort of compromise, and the whole thing would blow over. On the other hand, Doctors in Mozambique did go on strike back in January for nine days, though there are conflicting reports as to the extent of the strike.

Well, today they are striking again. According to the newspapers, doctors are demanding a base salary of $3000 per month, while the government is offering between $600 and $1200. Much of the problem has to do with equity: the doctors in the public sector in Mozambique are government employees, and there is a strong sense (rooted in Mozambique's Marxist tradition) that there should not be significant inequities in pay between public sector jobs. If the government raises the base salary of doctors, but does not offer something similar to other public sector employees, they may have a more general strike on their hands. However, if they do not satisfy the demands of the doctors, the lives and welfare of citizens may be in danger: even if the Mozambique Medical Association insists that essential services will remain open, I heard much dispute about what should count as 'essential' in such circumstances. In any case, it would not take much of a strike to have a significant impact on patient health, given that the physician/patient ratio is 1 to 22000.

Ethics of implementing male circumcision in Swaziland

Dispatch from Maputo, Mozambique. As far as I know, the European Union has sent me here to discuss ethical issues in research with new ethics committee members. In the past, there was only one ethics committee in Mozambique, whose original mission was to review all health-related research. As requirements to get ethical approval (for funding, for publication, etc.) get more strict, and the number of local research studies involving human participants rises, having just a single committee is no longer workable or sustainable. So they are wisely decentralizing into a number of institutionalized ethics committees around the country. I am here to discuss the ins and outs of ethics committees, their ups and downs, their virtues and vices.

During downtime in the Hotel Cardoso, I noticed this piece about implementation of male circumcision initiatives in Swaziland. Apparently, these HIV prevention initiatives have not come close to reaching their targets, after millions of dollars have been spent, causing both soul-searching and finger-pointing. (The program spent almost 500 dollars per circumcised male in a country which has an average per capita annual income of roughly $5000). I've thought for a long time that much more bioethics attention -- to its detriment -- has been spent on research ethics than the ethics of implementing research results into practice. The latter has its own particular conundrums, such as: what do you do about a (less than) half-implemented program? Particularly when part of the reason why the implementation was partial is due to significant community reluctant/resistance towards the very idea of male circumcision for HIV prevention? Where should you go from here?

Community concerns about male circumcision and HIV prevention include: why do circumcised men still get counseling about using condoms? What happens with the foreskin? Is there any connection between these circumcision programs and witchcraft? Why must men need to refrain from sexual activity for some time afterward? Other forms of resistance or reluctance, in the Swazi case, reach up to the highest levels of policymaking. Local public health authorities may have been interested in gaining funds and collateral benefits from male circumcision initiatives, while being skeptical about the value of the intervention itself. Low community and governmental 'buy in' (as they call it) can derail any public health program. Add to this the work of the anti-circumcision groups and individuals worldwide, who can be found on the comments section of any news item on male circumcision and HIV, whipping up fears and debunking the science. For the latter, the ethics of implementing male circumcision programs is simple: just make it stop.  

Bioethics and guns, home and abroad

Bioethics workers, particularly in the United States, rarely talk about guns and gun-related violence. The issue is perhaps too baldly political: in the US, discussions generally center on the 2nd Amendment right to keep and bear arms, and to what extent can government create policies infringing or limiting that right. Somehow the public and personal health risks of gun possession get lost in the shuffle, or at least bioethicists in the main seem less morally worried about guns than they are about the dilemmas generated by life-saving technologies. Nevertheless, when guns are around, poor health outcomes occur that wouldn't happen otherwise: children who accidentally shoot themselves or others when they come across a gun in the home; adults who reach for a deadly weapon in the heat of a dispute, or those who injure and kill in the commission of a crime. Some discussions on the bioethics of guns exist, but they are few and far between.

The most recent American massacres have drawn bioethicists indirectly into the fray. Gunmen responsible for the attacks in Aurora and Newton seem to have been mentally unstable, leading to questions about the adequacy of the procedures required to get guns and gun licenses in the first place. More specifically, physicians are increasingly being requested to help law enforcement in assessing a person/patient's competence to carry or safely use a concealed weapon. The more technical issues are how such competence is to be determined and how physicians are to be trained to reliably make such determinations. A larger issue is whether giving a green light to concealed weapon possession is -- as a matter of professional ethics -- the sort of thing physicians should be involved in. Guns put holes in human bodies where they are not meant to be, after all. Predictably, the legal questions loom large: will a physician be held liable if a person/patient deemed competent decides to unconceal his/her weapon and go on a rampage?

The American debate typically presupposes the intrinsic goodness of guns for ordinary citizens. An attempt last week to occupy the bioethical high ground on guns comes from a source not normally associated with pacifism: Pakistan. The Karachi Bioethics Group (KBG) is calling for the 'deweaponization' of Pakistani society, observing that gun-related deaths in the country have tripled in the last two decades. (An interesting account of the genesis of the KBG can be found here in the book Observing Bioethics by Fox and Swazey.) The KBG states simply that licenses and provision of guns should only be permitted for the armed forces and the police. No talk of hunting, target practice for pleasure, or fantasies of heroic self-defence. Healthy position on deadly weapons or acquiescence to the power of an authoritarian state? In any case, here we have a bioethics group not shy about taking overtly political positions.

Whose ethics code is this anyway?

The Times of India reports that the Medical Council of India (MCI) is contemplating changing its Code of Medical Ethics (2002; updated 2010) to permit physicians to accept travel and hospitality sponsorship from pharmaceutical companies. This proposed amendment is aimed directly at Article 6.1.8., which excludes the acceptance of gifts, travel support, accommodation, and cash or monetary grants (unless the latter is in the context of working in pharma-funded medical research).

It should not be a surprise that pressure to change this part of the code comes from ... pharmaceutical companies. Representatives of the pharmaceutical industry argue that they are merely trying to help: Indian doctors do not earn very much, often not enough to attend domestic and international conferences, and it is crucial that they are kept up to date with the latest medical advances.  The amendment is merely meant to improve medical education. Detractors recast the 'sponsorship' as bribery: pharma's interest in hosting such conferences is not to improve physician's knowledge, but to enhance brand recognition among (and prescribing practices of) doctors.

These struggles between pharmaceutical companies and professional medical associations are familiar in developing countries, but in countries like India the power relationships are somewhat different: the pharmaceutical companies wield significant economic and political power, and underpaid doctors would be understandably tempted by their siren's song. The MCI is supposed to regulate a responsible relationship between these two. Whether it is able or inclined to do so remains to be seen.

The medical neglect of the African mouth

In some ways, dentistry is the black sheep of the medical family. The social status of dentist in most places does not seem to be on a par with that of a (real) medical doctor. It is not entirely clear why this is the case, but there are conjectures. Perhaps because a trip to the dentist is commonly associated with pain, despite advances in dental anesthetics. Maybe it has to do with historical associations: what later was called 'dentistry' emerged from the Medieval practices of barbers, who besides cutting hair were self-proclaimed experts in tooth extraction. Or it could be that oral conditions are just not to be taken seriously, in the sense that they are generally not life-threatening: this is what separates the dentist from the cardiologist or neurosurgeon. In any case, when dentistry is taken less seriously, it is seen as a lesser priority by funders and policy makers, not to mention the faint attention it is generally given by bioethicists.

A recent article reminded me of the sorry state of dental research, practice and policy in Africa. When health care systems are compromised by poverty and civil conflict, dentistry is regarded as a luxury and treated accordingly.  The article is focused on Swaziland: a country of 1.2 million persons served by nine private dentists, along with another 15 public dental practitioners, although the latter do not have the specialized skills to conduct root canal procedures or the fitting of dentures. What's worse is that the diet of Swaziland (like much of Africa) is becoming more 'Westernized', i.e. more processed and sugary foods are hitting the markets, leading to cavities unlikely to be filled. A rise of a neo-Medieval practice of tooth extraction is likely to accompany the change in food habits.

While oral conditions are not typically life-threatening, anyone with a toothache (or other dental conditions) can attest to their negative impact on quality of life. And quality of life, on that level, anything but a luxury. Given the track record on affordable and equitable access to primary health care on the continent, as well as the traditional subservient position of dentistry within the culture of medicine, the road to better dental health and dental practice in Africa looks to be long, hard and bumpy.



 

The ethics of disseminating research results

Article 33 of the Declaration of Helsinki (2008) reads:

At the conclusion of the study, patients entered into the study are entitled to be informed about the outcome of the study and to share any benefits that result from it, for example, access to interventions identified as beneficial in the study or to other appropriate care or benefits.

As usual with ethics guidelines, they do not come with practical guidance. So how, in concrete terms, do you best carry out this ethical requirement? What if fulfilling this requirement actually involves risks to participants? And do you have to only disseminate at the conclusion of the study?

There is an interesting recent article in PLoS Medicine on this topic. In part, researchers were provoked to disseminate results back to participants in a longitudinal observational HIV treatment study, when a participant said: "You have been asking me questions and taking my blood for years, but I do not know anything about what you have found." Acting on this remark while the research is still ongoing seems to have taken the research team -- and the participant community -- on a challenging but very positive journey. Dissemination of research means translating them in two ways: from the dominant scientific language (English) into the local language, and translating technical terms into more accessible ones to those without extensive formal education. Bringing HIV positive persons in a research study together at the same event poses potential issues of stigma and loss of confidentiality, and subsequent involvement of ethics committees. And the format of dissemination has to be culturally appropriate: powerpoint slides and handouts are not going to do it. In the dissemination event described in the article, everything seems to have gone as it should among researchers and participants, resulting in a greater understanding of and respect for one another. This is an embodiment of what the 'ethical conduct of research' means far beyond the usual fixation on the contents of consent forms.

Glass ceiling for developing world bioethicists?

The Journal of Bioethical Inquiry has recently published a Letter to the Editor entitled: Bioethics and Its Gatekeepers: Does Institutional Racism Exist in Leading Bioethics Journals? The authors have done an analysis of 14 leading bioethics journals in regard to the composition of their editorial and advisory boards. Their question was: how many editorial and advisory board members are located in countries ranked very high, high, medium or low in the Human Development Index? The answer is chilling: approximately 95 percent of editorial board members are based in (very) high-Human Development Index (HDI) countries, less than 4 percent are from medium-HDI countries, and fewer than 1.5 percent are from low-HDI countries. Eight out of 14 leading bioethics journal have no medium- or low-HDI country editorial board membership. Eleven bioethics journals in their sample of 14 have no board members from any low-HDI country.


How is this to be understood? The authors claim that the underrepresentation of developing countries on bioethics editorial and advisory boards suggests 'institutional racism' on the part of bioethics journals. This broadside misses the mark, for reasons other than the obvious, i.e. that membership in a developing country does not constitute membership in a 'race.' The barriers to professional advancement in bioethics are not (just) racial, and run deeper. The dominant educational centers for bioethics (as well as the journals) are in North America, Western Europe and Australia; many educational institutions in developing countries do not include (or barely cover) medical ethics, research ethics or public health ethics in their curriculum. The dominant language of bioethics is English, which poses linguistic problems for many.  In the current situation, those in the developing world who devote a substantive amount of their professional life in bioethics do so at their economic peril, unless they manage to combine it with a lucrative occupation. So the near absence of the developing world at the tables of bioethics editorial and advisory boards is not simply institutional racism on the part of those journals, but that for the most part (despite a number of educational initiatives) bioethics as a professional interest remains largely a mainstay of rich and powerful countries, despite their being no shortage of pressing and fascinating bioethical problems in low-resource settings.