Rwandan mandatory sterilization kerfuffel

The impact of the internet on the processes of determining health policy, anywhere in the world, is worth studying in its own right. Case in point: last week, Human Rights Watch (HRW) came out with a press report condemning a draft human reproductive rights law proposed to the Rwandan parlement. The draft, HRW alleged, contained a provision stating that individuals with intellectual disabilities were not to be allowed to reproduce. The Rwandan draft bill contained a whole lot of controversial material besides, especially pertaining to HIV/AIDS: compulsory premaritial HIV testing; requirement of a married individual to be tested for HIV if their spouse requests it; permission of doctors to test children or incapacitated persons for HIV without consent and then disclose the result to parents, guardians or other care providers. But it was the forced sterilization that really hit the internet, here and here and here.

Rwandan government officials scrambled to do what politicians (first) do when faced with a public relations nightmare: deny everything. Damascene Ntawukuriryayo, deputy speaker of the Rwandan parliament, denied the claims of HRW, said that there was never a proposal for forced sterilization, and that plans for HIV testing before couples get married were always to be strictly voluntary, not compulsory. Apparently thinking that a good offense is the best defence, Mr Ntawukuriryayo stated that HRW should check its facts before releasing reports into the wilds of the internet.

It does not take much effort to find views that contradict Mr. Ntawukuriryayo's statements. Back on June 23rd, before the HRW report hit the web, Focus Media in Kigali published a fairly detailed article by Sam Ruburika on the shortcomings of the draft legislation, including quotations of the original text. The proposed legislation on forced sterilization appears as Article 22: "The Government shall have the obligation to suspend fertility for mentally handicapped people as long as the handicap is still persistent and upon decision by a medical team comprising at least three medical doctors. An order of the Minister in charge of health shall specify the list and implementation modalities for diseases accounted for by this article." According to Ruburika, the Chamber of Deputies approved of the draft legislation, including its articles on sterilization and compulsory HIV testing, and it was only when it reached the level of the Senate that red flags started flying.

How are we to understand this? It goes without say that pregnancy and sexual relationships involving mentally handicapped persons is a very difficult and important issue. Why the hamfisted approach? One possibility is that there are members of the Rwandan government whose views on reproductive policy, while they might express certain draconian community sentiments, are at odds with the Rwandan constitution. Fortunately there are checks and balances enough to stop these sorts of unreconstructed proposals from becoming law, but it is striking that the draft survived in that form as long as it did. It survived long enough to be detected by the internet radar -- spelling its immediate demise.

This blog has moved to Cape Town

From the beginning, this blog has explored emerging bioethics, research ethics and public health ethics issues in developing world contexts. But much of it has been, unapologically, about sub-Saharan Africa. Unapologically, because these fields have been -- and continue to be -- disproportionately orientated towards what goes on in more affluent, industrialized nations of the north.

Within this sub-Saharan focus, South Africa has had a prominent place in this blog. There are probably many sources for this. South Africa is a comparatively better-off country than (some of) its sub-Saharan counterparts, and therefore there is greater exposure of bioethical issues in the press and on the web. HIV/AIDS always brings with it dilemmas for researchers, clinicians and public health policymakers, and South Africa has a devastating HIV?AIDS epidemic, coupled with standard-fare tuberculosis, multidrug-resistant tuberculosis, and as if that was not enough, extremely drug resistant tuberculosis. The country has also had a spectacularly strange Minister of Health, some of whose pronouncements and policies about HIV/AIDS could have been written by Monty Python, but of course the unfunny part was that she really meant it. And an ex-President who denied HIV causes AIDS, and a bevy of medical charlatans running about. Plus conflicts between modern medicine and traditional healers, rising up (for example) in cases where young men die by the dozen in blotched ritual circumcisions. The country also has -- a legacy from the Apartheid era, no doubt -- a strong research infrastructure capable of conducting clinical trials and therefore dredging up all the research ethics issues of doing such trials with vulnerable populations. In short, a little bit of everything.

I accepted a sort of one-year visiting professor position in Cape Town awhile ago, and arrived here last week. It is not the first time I've been in the Cape: I completed my philosophy Ph.D. while living in nearby Stellenbosch some years ago, and left the country in 2001. Some things have changed, much has stayed the same. It remains to be seen whether this blog changes, now that it is being written out of Africa.

An epidemic of health care worker strikes

This seems to be a summer of strikes among health care workers, raising again the ethical issues surrounding hospital strikes, particularly in resource-poor countries. On the one hand, state-paid doctors often work in abysmal conditions for relatively meagre wages, and when a strike breaks out, it is often a matter of doctors and nurses finally reaching the end of their tether. On the other hand, patients suffer when health care workers strike. They must wait longer or seek alternative care -- if such care is available and affordable. In many poor countries, the alternatives to health care in state hospitals are few. Traditional healing is one. No care at all is another. The impact of such strikes on patients are rarely the object of scientific study, but surely long and lingering strikes, where only the bare minimum health services remain in place, must be a source of avoidable morbidity and mortality. In the middle of all this you have the Ministries of Health: sometimes acting as mediators, and sometimes (because they are arms of government) the origin of the dispute and an obstacle to its resolution.

The provinces of Kwazulu-Natal and the Eastern Cape in South Africa are in the midst of a prolonged strike. State health care workers in Zambia are facing dismissal by the government if they do not show up to work by next Monday. In Adamawa state in Nigeria, health workers have started an indefinite strike and patients seem to be leaving the abandoned wards of clinics and hospitals in droves. And in the Democratic Republic of Congo, a health care workers strike has been going on for ages, though generally unreported in the press. Our sister blog, The Francophone African Bioethics Blog had a piece about this (in French) back in May, and the strike is still unresolved.

Each strike has to be judged, from an ethical point of view, on a detailed and (ideally) balanced account of the relevant facts. But some basic principles should be followed. Urgent medical services should always continue to be provided during a strike, and those providing them should not be regarded as 'scabs' or strike-breakers. Health care strikes should be regarded as qualitatively different than strikes in other labor sectors, due to the special value of health. For that reason, a as-swift-as-possible resolution of the strike should be the top priority of the health ministries involved, because of the impact that every day of the strike has on the ethical core of the issue: patient health.

Mandatory male circumcision in the Zambian police force

In the last couple of years, there have been a number of high-profile studies exploring the relationship between male circumcision and HIV acquisition. Three randomized clinical trials in Africa confirmed an association suggested by less rigorously designed studies, i.e. that men who are circumcised are significantly less likely to acquire HIV from infected women during vaginal intercourse. But what to do about these findings in terms of public health policy? The professional views and lay public opinions are highly diverse and sometimes highly emotive. Some in public health circles consider male circumcision as effective as a vaccine and the promotion of male circumcision in regions of high HIV prevalence as an ethical imperative. Others, who have ethical objections to (especially neo-natal) male circumcision in general, criticize the methodology of the clinical trials, question their conclusions, and view the promotion of male circumcision as deeply misguided and harmful.

Whatever side one takes on this issue, the approach of the Zambian police force is bound to raise eyebrows. According to the Lusaka Times, the national police force is planning to make male circumcision a requirement for all new recruits. The police force has apparently been losing male police officers to HIV/AIDS. Male circumcision is being strongly promoted in other professional contexts in sub-Saharan Africa, such as Rwanda, which has included it as part of an HIV prevention strategy within its army.

Of course, the Zambian approach is not 'mandatory male circumcision' in the strict sense: it is only mandatory among those who have chosen to join the police force. At the same time, the idea of mandatory irreversible preventative genital surgery on healthy males bound to be controversial. Making the practice obligatory, rather than a matter of choice, raises the ethical stakes: you need a very strong justification to move from voluntary to mandatory. Is the HIV incidence among policemen in Zambia very high? If so, what explains that incidence? Is male circumcision likely to counteract whatever forces are driving the high incidence? To pull off a utilitarian justification of the policy, you need to clearly show that the overall benefits of the policy will outweigh the overall costs. And even if you do, not everyone will be impressed: not everyone is a utilitarian.

For a flavor of the online debate this sort of story inspires, have a look over at the Universal Circumcision blog.

Hat tip: Daniel Westreich.

Are countries that ratify human rights treatises more healthy than others?

One might think that a country which has ratified human rights treaties, and thus has made them to some extent law, will have better health outcomes than countries where this is not the case, all things being equal or at least controlled for. A study just published in The Lancet indicates otherwise. The researchers looked at some key and often-measured health and social indicators, and sought correlations between number of treatises ratified and changes in health/social indicators before and after ratification of health-related human rights treatises, as well as making comparisons between health/social indicators in a total of 170 countries that did or did not ratify certain treatises.

The results are sobering, or perhaps predictable, depending on one's pre-existing opinions about the power of human rights approaches to health. Ratification of human rights treatises does not seem to have any significant effect on maternal mortality, infant/child mortality and life expectancy. The researchers try to put a brave face on the data, by adding that ratification of human rights treatises can have some indirect (but hard to pin down) effect on health by strengthening legal arguments aiming to ensure access to health care. But in the end, money trumps law: there is much greater evidence of an association between economic conditions and health than there is between the ratification of human rights and health.

One might object by saying that ratification is the mere promise of action, just the signing of a paper, and we should only expect an effect in terms of health outcomes in countries that rigorously monitor, enforce and make its human rights commitments real. In other words, in finding no significant association, what the researchers have actually done is study the global absence of political will in regard to human rights relevant to health.

Bioethics and democracy in developing countries

The fields of bioethics in many developing countries -- despite some important 'capacity-building' initiatives -- have a very limited impact. There are a few people trained in bioethics here and there, some (underfunded) centers and attenuated networks, a few scattered publications. But why should that be the case? Bioethics is decades old by now, and research and medical practice among vulnerable populations in such settings raise a great many ethical challenges. So you would think there would be more activity, more interest.

In BMC Medical Ethics (free online access here), Ghaiath Hussein takes a shot at an answer. And his answer is: politics. The flourishing of bioethics, according to Hussein, depends on a number of political factors that are not present, or only faintly present, in developing countries. The first is an 'atmosphere of freedom' where people can engage in moral reasoning without fear of censorship of or punishment for their beliefs. That atmosphere of freedom in turn depends on a socio-legal framework in which the rights, duties and responsibilities of individual citizens -- both in regard to health and other important values -- are spelled out, understood by the populace, and protected by legislative and judiciary systems. Of course, the development of bioethics is aided to some extent by economic factors, in particular the progress in health systems development and creation of medical technologies. But these would not give rise to bioethics debates they did not engage with public expectations of receiving decent medical care, and citizens having some say in health policy decisions.

It is easier to see what Hussein is saying by reflecting on the place of bioethics within totalitarian or politically oppressive regimes. Where there is little press freedom, there will be less (and less diverse) public debate about controversial issues in medical research and practice. Where those working in bioethics are regarded as 'human rights activists' and subject to special state scrutiny, it will be difficult to motivate people to pursue these interests. Where people think of health care as a 'gift', and death as a common (and mostly unavoidable) event, the provision of sub-standard medical services will not be regarded as a failure of government and a moral outrage. Where Ministries of Health have historically acted (or currently act) as an arm of an oppressive state, and are as corrupt as any other branch of government, there will be little public trust in ethical codes, regulations, licencing boards, or ethics committees that are attached to these ministries or have received their seal of approval. All of these factors, according to Hussein, have diminished the impact of bioethics in many developing countries, and have reduced it to a mere academic pursuit, tolerated by the powers that be because it is poses no threat to them.

Hussein suggests that bioethics, in some places, is a deeply subversive activity. If real bioethical activity took place in some developing countries (he includes his own Sudan), there would be an ugly and dangerous clash with the established political order. So he suggests a softer approach: depict bioethics as a mere aid to decision-making (rather than embodying important rights and values); couch bioethics in religious or religious-friendly terms; adapt bioethics to local contexts rather than depict it as a fancy 'Western' import. Once it is conceptualized this way, it becomes clearer how long and difficult the road will be before bioethics becomes a social force in developing countries.

Motherhood as danger

Nicholas Kristoff, columnist for the New York Times, has an interesting piece (and accompanying video) on maternal mortality in Africa. Women in many places in Africa, die during childbirth at a depressingly high rate: 1 in 10 births in some areas. What Kristoff piece does well is give a succinct impression of the different, and often avoidable, causes of maternal mortality during childbirth: poverty and lack of education; gender inequality and the associated low priority for women's health issues; brain drain of medical personnel to richer countries; overworked health staff and abusive attitudes towards (especially female) patients; sub-standard medical facilities; transport barriers to reaching health care centers, particularly for pre-natal services. The avoidability of death in such cases -- sometimes a mother's life could be saved with a few dollars -- makes this an ethical issue, and not just a medical one.