Sunday, January 15, 2006

Your blood's no good here

Last week, the Gay and Lesbian Alliance of South Africa staged an unusual protest. Some of its male members donated blood, violating the blood donation criteria of the South African National Blood Service (or SANBS), which forbids donations from men ‘who have had sex with other men in the last five years.’ The Alliance claims the SANBS donation criteria is discriminatory, because the blood of young women between the ages of 18-24 -- the group with the highest HIV prevalence in the country – can be accepted. Furthermore, the SANBS has high-tech equipment that detects HIV in donated blood before it is used, and this constitutes another layer of protection. While such equipment cannot detect HIV in the blood of newly infected persons, this is in itself no reason to reject ‘gay’ blood and accept the blood of young women. For its part, the SANBS argues that it is merely following international guidelines to protect the safety of the blood supply.

The issue of the ‘gay blood ban’ extends far beyond Africa’s borders. A few years ago, protests were staged in Hong Kong. In Australia, a gay man has recently filed charges against the Australian Red Cross. The ban has been the object of student protests from Ireland to Montreal. In the United States, while the scientific basis of the ban has been questioned a number of times, a proposal to relax the ban was narrowly rejected by a Food and Drug Adminstration committee back in 2000.

The FDA rules on blood donation are really the heart of the matter, because they form the basis of the donation criteria for the American Red Cross and the Red Cross in most (if not all) other countries. In 1985, the FDA proposed the rule that a man could not donate blood if he had sex with another man – even once – since 1977. The rule obviously harks to a time when HIV/AIDS was considered a ‘gay disease’.

But how should this rule be considered in areas of the world, such as sub-Saharan Africa, where HIV/AIDS is largely transmitted heterosexually? The WHO states that blood donations should come from groups with low risk of TTIs (transfusion transmissible infections) but seems to acknowledge that high risk groups may be different in different regions of the world. Should blood donation criteria be determined by the most current epidemiological data on HIV prevalence among social groups, or should one forget social groups altogether, and concentrate on the risk behavior of individuals who wish to donate their blood? In either case, it seems irrational -- if not unethical -- to exclude people from donating blood on the basis of their sexual orientation alone.

Tuesday, January 10, 2006

Like a virgin?

South Africa is a land of contrasts. One of the contrasts is between its post-Apartheid constitution – said to be one of the most liberal ever made – and South Africa’s patchwork of African ethnic traditions. Same-sex marriage was recently approved on constitutional grounds, a decision met by hostility and disbelief among South Africans of different races and classes. And last month, the Children’s Bill was adopted, which among other things bans virginity testing and male circumcision under the age of 16. This verdict was also greeted with a great deal of resentment. Traditional leaders don’t like it. Many Africans writing into blogs don’t like it. Some virgins don’t like it. (Warning: images of bare breasted virgins.)

Virginity testing? Yes, virginity testing. Whereas some American teenagers make virginity pledges and self-report their own virtue, South African girls go a step further by submitting to a pelvic examination aimed at ‘proving’ their chastity. Especially among Zulus, it has long been thought important that girls keep themselves pure for their future husbands; a young woman who has pre-marital sexual relations is thought to show intemperance and brings shame on her family. This is why a confirmation of virginity is accompanied by celebration, while failing to pass the test can lead to stigma and social exclusion. In Uganda, girls can even get a scholarship for remaining virgins, i.e. if they manage to scrape through years of poverty without exchanging sex for money and security from predatory older men.

The devastating HIV/AIDS epidemic has increased the popularity of virginity testing throughout Africa. It has given traditional leaders a modern, medical justification for an ancient practice. If girls are encouraged to pass the test, the thought goes, they will not have sex and will not acquire or transmit HIV. On the other hand, a hymen may be torn by means other than intercourse, and the pelvic examinations are performed in conditions where the hygiene leaves a lot to be desired. As the US example suggests, young people committed to virginity may have sex in alternative ways (i.e. anal and oral) that leaves them open to HIV and sexually transmitted diseases. The practice also feeds into a powerful and tragic myth in South Africa: that a man with AIDS can be ‘cured’ by having sex with a virgin. And of course, there is the detail that the practice of virginity testing is widely condemned by human rights groups as gender discrimination. If there was a reliable biomarker for male virginity, involving an invasive and possibly contaminating procedure, would that be as popular? It is hard to imagine.

Condemning the practice of virginity testing outright, however, may be unwise. One of the biggest mistakes of HIV prevention in the past is the failure (or unwillingness) to understand and take seriously the sexual culture of Africans, and the place of that culture in a network of related social practices. Here’s yet another job for African bioethicists: to help negotiate an acceptable path here between HIV prevention, gender rights and cultural traditions.

Wednesday, January 04, 2006

Radical international research ethics?

I am part of a public health research team in Kinshasa, Democratic Republic of Congo currently conducting a study of the use of free bednets supplied to HIV positive women. Recently I was called in, as ethics consultant, to help with the following issue. Despite receiving bednets and an educational session explaining their use, and despite receiving malaria prophylaxis, some of the women ended up with clinical malaria anyway. Is the research team responsible for their treatment and hospitalization costs?

The question was complicated by a variety of local factors: that some of the women given free bednets at the clinic exchanged them for food on the way home; that the local hospital was often unwilling to see the sick women without guarantee of payment, while almost none of the women had money to pay up front; that the local doctors misdiagnosed some of the women, who were treated, hospitalized but actually turned out not to have malaria after all. The ethical issue of researcher responsibility for ancillary care in failed states is one messy problem. No matter what you decide, there is a sense of unfairness.

In a provocative recent publication, the South African bioethicist Solomon Benatar argues that we should view these small, messy research ethics problems as signs of systematic dysfunction in a complex and unstable world. Pregnant women in Kinshasa are not poor, HIV positive, vulnerable to further disease and excluded from a (sub-standard) health care system ‘by accident.’ The larger forces responsible for their plight include: unfair global trade relations; the international arms trade; extractive and environmentally destructive foreign investments; debt repayments; despotic local leaders supported by powerful foreign nations; the lack of attention to economic and social rights; the tendency to direct development aid on emergencies and perceived security needs of privileged societies.

According to Benatar, this system of forces is powerful but not built to last: it not only undermines global health, but helps fuel ongoing wars, genocides, refugee crises, famines, terrorism and other forms of instability and social disruption. And in an increasingly interconnected world, wealthier nations cannot reasonably expect to continue reap the benefits of the system without feeling its ill consequences. Even if the poor do not rise up against the rich, multi-drug resistant tuberculosis and bird flu might.

When ethical problems are traced back to vast ‘upstream forces’, there is a danger of moral paralysis: what can we possibly do? Benatar argues that we, in the more privileged societies, first need to substantially change the way we see the relationship between ourselves and distant others. The citizens of wealthy nations are ‘implicated in the generation and maintenance of forces that perpetuate social injustice and poverty’ and therefore have a responsibility toward those most affected by those forces. Assuming this responsibility requires us to expand our moral imaginations and see ourselves as connected to all other human beings, and empathize with the deprived and vulnerable in a way that transcends national, religious and cultural differences.

Perhaps out of discretion, Benatar omits the next logical step: expansion of moral imagination in practice would come with a real cost. It would entail the sacrifice of power and wealth on the part of wealthier nations and its citizens. And while many of us in international biomedical research would consider ourselves liberals, and be sympathetic towards Benatar’s arguments, his vision is essentially for radicals. How far are researchers – and bioethicists – from developed nations honestly willing to go, considering that we too are beneficiaries of the system we deplore? In international research ethics, the global is all too personal.