Global bioethics: selected highlights in 2007

The year's end is the traditional time to draw up lists. Below is a list of bioethics issues or events around the world that lingered on the desk during 2007. In the USA, probably the biggest bioethics news of 2007 revolved around new advances in stem cell technology that seem to undercut the scientific need to terminate human embryos, and the 'spare the embryo' story probably received more press than all of the following items combined.

1. Outsourcing health care and developing countries.

As health care gets more expensive or health resources become more scarce in the richer countries of the north, clinics offering access to cheaper health services are springing up like mushrooms in the poorer countries of the south. The patterns of global trade in organ translants is well known, but this is seemingly only the tip of the iceberg. Think of any possible health need or desire, and there is a company that offers a relatively inexpensive (fewer-questions-asked) service for it in Brazil, Malaysia or Turkey. Fertility problems? Need a surrogate mother for your child? Try India. The natural resources of developing countries may be starting to dwindle, but they still have bodies, body parts, clinics or physicians of interest to those with the ability to pay.

2. Global warming, health and global inequality.

In the future, Hurricane Katrina may be regarded as a harbinger of the connections between climate change and the health of those worse off in society. Individuals or countries with the wherewithal will be more able to adapt to rising coastlines or drought; poorer individuals or countries will be less able to prevent the untoward consequences of climate change or mount a significant response once they occur. Adverse health conditions -- in the form of disease outbreaks -- are not the only effects: there can be social disintegration and political turmoil. Vulnerability breeds vulnerability. In this light, New Orleans should adopt Dhaka, capital of Bangladesh, as a sister city. A low-lying and impoverished country, in one of the worst hurricane areas of the world, Bangladesh is recognized by experts as an inevitable victim of the effects of global climate change. Some have argued that the industrialized countries that have contributed most to greenhouse gases over the years have a moral responsibility to limit the future damage to Bangladesh -- an argument that currently has zero traction in international corridors of power. Bangladesh: New Orleans feels your pain.

3. Male circumcision and HIV prevention.

The year 2007 was largely disasterous for HIV prevention research. Important clinical trials on HIV vaccines not only showed no positive preventive effect, one important vaccine seemed to increase the likelihood of acquiring HIV. A similar setback occurred with microbicide research. Amazingly, two randomized controlled trials on male circumcision in Uganda and Kenya showed roughly a 60% related reduction in risk of men acquiring HIV. It is ironic that an ancient rite seemingly has a greater protective effect than highly sophisticated drugs. In the future, the trick will be to appropriately, safely and effectively implement this finding in the field, given the ethical, political and social baggage this practice bears in cultures around the world.

4. Multidrug resistant tuberculosis and the politics of epidemic control.

The chickens have come to roost in regard to tuberculosis. This infectious disease, typically afflicting the poor, was once a serious health threat in the developed world. Effective medicines, prevention and treatment programs led to a marked decline in TB prevalence in Europe and North America in the mid-twentieth century. In developing countries, tuberculosis control programs were only implemented half-heartedly, partly because of the sub-standard conditions of local public health institutions and clinics, partly because it is more interesting to fund research on new drugs for diseases affecting the affluent than to fund programs to provide old drugs for ancient maladies among the poor. However it came about, one thing is clear: multidrug resistant strains of TB are on the rise in the developing world, and they are coming back to haunt the richer northern nations, often by way of commercial aircraft. And with multidrug TB comes all the ethical problems associated with control of a potentially deadly infectious agent, including the use of quarantine.

5. The ongoing legal battle between Nigeria and Pfizer.

In 1996, the pharmaceutic company Pfizer conducted the controversial trials for the antibiotic Trovan involving 200 children during a meningitis epidemic were conducted in Kano, Nigeria. The state of Kano alleges Pfizer conducted the trials illegally, without the full knowledge and consent of the government and the parents, causing the death of 11 children and injury to some 118 others. Pfizer denies all allegations, stating that the children's death and adverse conditions were a result of the epidemic, and not their drug. In the case that is now before the Nigerian court, the government of Nigeria is seeking $7 billion in damages, and the state of Kano is seeking $2 billion. Over the holidays, arrest warrants were issued to three staff members of Pfizer for having failed to appear in court after having been subpoenaed. The story, increasingly complicated and partly obscure, goes on and on. It is a living symbol of the ethical challenges of doing biomedical research across stark differences in power and culture, but a symbol with real effects: the controversy has eroded public trust in Western medicine in some parts of Africa.