Saturday, May 27, 2006

Backstreet plastic surgeries: caveat emptor

A recently published book edited by David Benatar calls plastic surgery a 'contested surgery.' Here in the United States, there is a tendency to make plastic surgery purely a matter of consumer choice, though the facts that most consumers are women, and many surgeries involve lips, buttocks, and breasts are something that leaves the practice open to criticism from a feminist point of view. Aren't women who alter their bodies in these ways paying lip service (pun intended) to male power? Or conversely: isn't it a legitimate way for women to improve the circumstances of their lives? Wouldn't opposing the practice be unduly 'paternalistic'?

In developing countries, inequitable access to 'elective interventions' is very pronounced: quite a few women seem to desire plastic surgery, but very few can afford it. The rich alter whatever the natural lottery bestowed on them, while poor generally make do. Which brings us to the story of Rosa, a Chilean woman who wanted to regain the good looks of her youth and find a partner, but could only afford a backstreet breast-and-lip job. After Rosa got drunk (the cheapest anesthetic), some guy called Claudio injected each of her breasts with a litre of silicon gel that is normally used to lubricate industrial machinery. Neither the aesthetic or medical results, according to Rosa, are very pretty. And she is apparently not alone: possibly hundreds of women in Chile undergo similar procedures in pursuit of happiness and love.

Thursday, May 25, 2006

The NEJM and the developing world

A recent article highlights how the diseases of resource-poor nations are under-reported in the world's most prestigious medical publication, the New England Journal of Medicine. Bernard Lown and Amitava Banerjee reviewed 416 issues of the NEJM over an eight year period, from January 1997 to December 2004, and found that less than 3% of the articles were relevant to developing countries. Just when people are starting to become familiar with the 90/10 gap -- that 90% of health research expenditures worldwide are devoted to diseases afflicting only 10% of the earth's population -- now we have a 97/3 gap in health research publishing and the NEJM is its unfortunate poster child.

As the authors point out, NEJM is not solely to blame for this. Global socio-economic inequalities inhibit quality research in developing countries by its own citizens, and the NEJM is not the only major medical journal that slants its content towards the interests of its subscription base and advertizers. But the underlying theme of the article seems to be: in an increasingly interconnected world, where health inequalties cannot be ignored, and new journals and centers for global health are springing up like mushrooms, the NEJM has to broaden its scope if it is not to lose its relevance.

Tuesday, May 23, 2006

Undone by development

Often it is said that poverty creates 'ecological niches' where infecticious diseases can thrive and spread, and therefore fighting disease can boil down to fighting its roots in poverty. And that can be true. But sometimes, ways of improving living conditions can inadvertently foster disease prevalence. Case in point: the spread of cholera in Angola, which according to the World Health Organization is largely due to recent improvements in the transportation infrastructure.

Friday, May 19, 2006

Another cure for AIDS bites the dust

As a recent issue of Newsweek points out, the AIDS epidemic has been with us now for 25 years, and has resulted in at least 25 million deaths. Given the magnitude of the suffering, the desire for a cure is strong. So it is not surprising that people come forward from time to time with the claim of a cure for AIDS. Probably the most interesting is the cure for AIDS attributed to Luigi Scrosoppi, an Italian priest, who died back in 1884. Peter Changu Shitima, a young catechist in Zambia, was in the terminal stages of AIDS in 1996. The local parish prayed to the Blessed Luigi, and Scrosoppi appeared in a dream to Shitma, who was miraculously returned to health. Scrosoppi was canonized in 2001 for this feat. Unfortunately, this is not the sort of cure that can be generalized for whole populations. But neither can mopane worms, for that matter. And as for Dr Abalaka in Nigeria, always willing to inject himself with blood from HIV positive patients to prove the efficacy of his homebrewed HIV vaccine, not much news of late.

Last week, the Iranian Elahi Allahgholi was arrested for making and peddling his own AIDS cure, which goes by the evocative name of Khomeini. An 11-member team established by the Ugandan Ministry of Health determined that Khomeini is composed of olive oil, honey, and minerals, and while it could be an excellent base for making baklava, it will not cure AIDS.

In sub-Saharan Africa, only approximately 11% of those in need of AIDS treatment have access to anti-retrovirals, and anti-retrovirals have sometimes terrible side-effects and are made by pharmaceutical companies that do not always have the interests of individuals in mind. So it is tempting to think that an indigenous, herbal cure will come out of Africa, and defy all the well-funded attempts of Western medicine to control the virus. The scenario is delightful enough, but at the moment it is still too good to be true.

Monday, May 08, 2006

A report from Nigeria comes to light

Last year, a U.S. Federal judge dismissed a lawsuit that claimed that Pfizer, the world’s largest drug company, was guilty of wrongdoing when the company conducted experiments on children during a meningitis epidemic in Nigeria in 1996. The judge recommended that the case be heard in a Nigerian court. The case apparently had already been discussed in a government report, but it was mysteriously suppressed for the last five years. In that report, released last Saturday, the allegations are unambiguous: Pfizer is accused of violating Nigerian law, the Declaration of Helsinki and the UN Convention on the rights of the child.

The Washington Post has been following this story since its ‘Body Hunters’ series in 2001. Although what precisely happened is still obscure, at least the accusations and counteraccusations are getting clearer. According to Nigerian families and some of the doctors involved, Pfizer tested an unproven experimental antibiotic (Trovan) during a meningitis epidemic, caused the death of six children, and did not obtain adequate consent – the parents did not know the drug was experimental, that they could refuse to give consent for their children’s participation, or that other treatments were available. According to Pfizer, they acted with full knowledge of the Nigerian government and with the approval of the ethics committee at the local hospital where the trial was conducted. Verbal consent was obtained. It has since been alleged that the letter of approval from the (as it turns out, fictitious) hospital ethics committee was written long after the trial ended and backdated – in other words, a forgery.
It will be interesting to see what happens next. Is it really conceivable that Pfizer will be sanctioned, compelled to pay compensation and offer an apology, as the Nigerian government report recommends? It is commonly said that as trials become ‘outsourced’ to developing countries, the latter need to strengthen research ethics capacity and integrate research regulations into law in order to protect their citizens. The ongoing Pfizer case may act as an indicator for how much (or how little) protection such measures currently amount to.

Wednesday, May 03, 2006

Failed state bioethics

Many people are familiar with bioethics. Among those who are familiar with bioethics, some of them have heard of 'developing world bioethics', i.e. the study of bioethical problems specific to resource-poor countries. There is even a very good journal devoted entirely to this field. But perhaps something has been left out. Some states are not just developing, or resource-poor, but regarded as failed states. So is there such a thing as failed state bioethics? What would be the role of a bioethicist in a so-called failed state? Is bioethics superfluous in such circumstances, or does it have an important role to play?

This blog is part of a project to help build capacity in bioethics and the ethics of biomedical research in the Democratic Republic of Congo. So it was hard not to take note of yesterday's release of the 2006 Failed State Index, which placed DR Congo second in the world, only surpassed (if that is the word) by Sudan. The index uses the following 12 indicators to arrive at its rankings, which (as one would expect) not everyone agrees with:

1 - Mounting Demographic Pressures
2 - Massive Movement of Refugees and IDPs
3 - Legacy of Vengeance - Seeking Group Grievance
4 - Chronic and Sustained Human Flight
5 - Uneven Economic Development along Group Lines
6 - Sharp and/or Severe Economic Decline
7 - Criminalization or Delegitimization of the State
8 - Progressive Deterioration of Public Services
9 - Widespread Violation of Human Rights
10 - Security Apparatus as "State within a State"
11 - Rise of Factionalized Elites
12 - Intervention of Other States or External Actors

There is something odd about putting out a report card on states, as if they were wayward pupils, especially in an era of globalization when the idea of nation states is supposedly becoming increasingly irrelevant. And there is little acknowledgement of how some of the better-off states that are lower down on the list have helped (and are still helping) push up other states into the higher realms of failure. But be that as it may, according to the indicators, DR Congo is a failed state if there ever was one. There's a good book that starts from this premise.

Those living in failed states will have to create the social role of bioethics themselves. Perhaps it will involve ethical reflection on the different ways that the 12 indicators impact on health, health care, and health policy. And also health research: for just as arms dealers and mining companies are happy to do business in the Eastern Congo, pharmaceutical companies and research organizations are not at all shy to run trials in failed states.

Zimbabwe in a health tailspin

If you are not one of President Mugabe's ZANU-PF party supporters, or one of the sycophantic cronies to whom the President regularly allots land or other privileges, you would probably say that Zimbabwe is not doing too well at the moment. The country has the world's highest rate of inflation (900%) and one of world's lowest life expectancies (39 years). Once the breadbasket of Southern Africa, the Zimbabwean government's land reform program damaged the commercial farming sector, and now Zimbabwe has become a net importer of food products -- to the extent that its citizens can afford to pay for them. One should not forget to mention the recent government program Operation Restore Order, supposedly an urban renewal program, in reality a systematic destruction of the homes or businesses of 700,000 mostly poor opponents of the government. Faced with this crisis, the government did the only humane thing: it raised public hospital fees by 333%.

This week finds Zimbabwe running out of AIDS drugs. This is a serious issue, both for the patients and for public health. There are an estimated 180,000 persons in Zimbabwe in need of antiretroviral drugs. Patients that interrupt treatment tend to deteriorate rapidly, and treatment interruption can lead to the development of drug resistant strains of HIV. Those living with HIV/AIDS in the rural areas are especially hard hit, with fuel shortages having led the government to resort to ox-drawn ambulances since 2004.

World Bank's malaria plan gets bitten

Malaria is one of the world's neglected diseases, accounting about 1 million deaths a year, but receiving far less press -- and far less funding for research and treatment -- than HIV/AIDS. In Africa, the disease is the leading parasitic cause of death for Africa's children and impoverishment for their families. So when the World Bank decided to step in with its Global Strategy and Booster Plan to tackle malaria in resource-poor countries, there was a sense that finally something is really being done.

According to a recent online article by Attaran et. al. in the Lancet (summarized here), the World Bank is doing something alright: it has failed to uphold a pledge to increase funding for malaria control in Africa, has claimed success in its malaria programmes by putting forward false epidemiological statistics, and has approved clinically obsolete treatments for a potentially deadly form of malaria. Instead of scaling up recruitment of malaria staff, it downsided it. According to the authors of the piece, the Bank possesses little expertise in malaria, and basically should give leave malaria control to other institutions that know what they are doing. Ouch, that stings.

Tuesday, May 02, 2006

When ideology met reality: the Catholic Church on condoms and AIDS

Catholic Online has a sensitive and thoughtful piece on the Catholic Church's position on condom use and the AIDS epidemic in Africa. It is striking that Catholics who live or work in countries with a high AIDS mortality rate seem to be more likely to try to reconcile condom use with Christ's teachings, while those far removed from the horrors (often comfortably tucked away in Europe or America) are more comfortable with a principled stand on the absolute unacceptability of using prophylactics. Conclusion of the piece, written by Dr. Marcella Alsan (a physician in the Hiatt Global Health Equity Residency at Brigham and Women’s Hospital in Boston) is worth quoting in full:

If men did not stray, if women had rights, if AIDS did not kill, perhaps the church’s strict ban on condom use would be morally defensible. But none of these conditions applies in Africa today. As a consequence, the cost of the church’s inflexibility may mean not only untold human suffering, but the loss of millions of innocent lives.

Perhaps there is also a general lesson to be drawn. The HIV epidemic not just fail to obey traditional Catholic teaching: it does not obey anybody's cherished ideology. It does not obey liberal sexual ideology, and its reluctance to embrace partner reduction and fidelity, either. Contrary to the views of earlier moralizers, HIV turned out not to be the monopoly of sinners in the form of gay men and injection drug users. Contrary to those opposed to male circumcision in principle, the circumcision may well have a protective effect against HIV such that it could be unethical not use it in the fight against HIV/AIDS. Contrary to those who think traditional healers are 'backwards' and part of the problem of HIV transmission, they may well turn out to part of the solution. And contrary to those who think the right approach to the epidemic must exclusively be secular and medical, faith-based approaches to HIV/AIDS education can sometimes make a difference where it counts: reduction in new infections.

The epidemic has killed millions of persons and left scores of dead ideological positions in its wake. The Catholic position on condom use just may be the next.