Saturday, February 24, 2007

HIV, male circumcision and India

This blog has dealt with ethical questions about male circumcision and HIV before, but somehow the assumption crept in that this is a distinctively African controversy. Maybe it was because of the high HIV prevalence in that part of the world. Maybe its was because of the longstanding interest -- especially among anthropologists -- with circumcision rituals in Africa. Let us make a confession here: the author of this post has co-authored an article in the Journal of Medical Ethics called Male Circumcision and HIV Infection: Ethical, Medical and Public Health Tradeoffs in Low-Income Countries. And it too is guilty of identifying the issue a bit too much with sub-Saharan Africa.

Whatever way this came about, the ethical questions concerning the promotion of male circumcision to lower risk of HIV transmission have to embrace India. For one thing, the number of new HIV infections has rising in India dramatically over the last years. For another thing, male circumcision is a highly charged matter, both politically and religiously, when Hindus do not traditionally circumcise and Muslims do.

An article in the Times of India today gives an indication of just how sensitive the question is. The National AIDS Control program in India will not even think of conducting randomized controlled trial to test whether being circumcised lowers a man's risk of getting HIV infected: not because three such studies have been done before, but the whole idea seems too hot to handle. When Richard Feachem, Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said that he expected that Hindus would increasingly have more HIV infections because their men do not get circumcised, his inbox was inundated by hate mail. An interesting post on the Olive Ridley Crawl shows some of the passion the debate raises, and the issue is inseparable from the larger relationship between mainly Hindu India and its Muslim neighbor and rival, Pakistan. The foreskin has geopolitical significance.

The question is: when circumcision acts as a religious/cultural marker from neighboring groups, will men still agree to do it, to reduce their chances of getting HIV? A World Health Organization/UNAIDS meeting in Switzerland on March 6 is set to tackle these tradeoffs between cultural identity and public health, among others. When HIV infections globally are increasing, vaccines are probably at least 10 years away, and the once-promising microbicides are crashing and burning, the ancient practice of male circumcision is strangely enough carrying the torch in the fight against HIV/AIDS.

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Tuesday, February 20, 2007

The Lancet, global justice and bird flu vaccine

Emergencies and crises, according to conventional wisdom, bring out the best and worst in individuals and societies. They test character and moral fabric: the virtues and the fault lines get vividly exposed.

This seems to hold for potential emergencies too, like the possibility of an avian flu epidemic. Back in 2004, the WHO already sensed that the developing world would only have belated, if any, access to effective vaccines in the event of an avian flu pandemic. This only makes sense, given the spotty developing world access to anti-retroviral treatment for AIDS, years after its invention. Of course, not everyone will have equal access to vaccines in industrialized countries either: the CDC has developed its own way of rationing bird flu vaccine. But the global picture is pretty clear: the poorest countries, those with the worst health systems, will basically act as 'natural history studies' of what happens with human populations when exposed to avian flu virus without real defences. It will not be pretty.

An editorial this week in the Lancet finds this prospect morally indefensible, and calls for global solidarity in regard to avian flu vaccine access. It recognizes that developing world countries do not have the sophisticated means of production of vaccines in their own hands, and, if the future is anything like the past and the present, access will be dependent on the prices that powerful pharmaceutical companies sets on vaccines. The editorial calls on the WHO to "seek an international agreement that would ensure that developing countries have equal access to a pandemic vaccine" motivated by concerns of justice. Whether WHO has the clout to forge such an agreement is debatable, and the word 'access' hides a hornet's nest of problems concerning the delivery of vaccines in resource-poor settings, starting with scarcity of health care workers. But the heart of the editorial is at least in the right place.

Monday, February 12, 2007

The ethics of disaster research

At first glance, it does not look good: a disaster occurs in a resource-poor country. The response, usually bankrolled by the richer nations, partly consists of humanitarian aid and partly ... research involving humans. In addition to receiving the standard blankets and food packages, disaster victims may be enrolled in research, which can range from clinical trials involving medical interventions to social science research involving focus group discussions. Is research involving disaster victims inherently unethical? Is such research all a piece with the voyeurism of disaster media coverage, where suffering or dead bodies of the global South are displayed for visual consumption by the global North?

Stakeholders in the developing world seem to take a more sophisticated view than the knee-jerk accusation of exploitation. For one thing -- as an article by Sri Lankan researchers in the Lancet pointed out a couple of years ago -- some disaster research has revealed that some well-intentioned psychological counseling offered to disaster victims disasters is useless or even harmful. Disaster research is like emergency research: the predicament of the participants may open the door for exploitation, but such research is also useful and could be ethically conducted if appropriate protections are proposed and enforced.

Sri Lanka seems in fact to be taking the lead in the ethics of disaster research. The Institute for Research and Development last month organized an international conference with the title, 'Disaster Related Research Ethics: Developing world Perspective'. For a welcome change, 'international' here meant participants from south-east Asian countries affected by the recent tsunami were invited, rather than the usual suspects from the Eastern United States and Geneva. Members of the conference have formed a working group that aims to craft guidelines of the ethics of disaster research. Standard ethics guideline manufacturers -- such as the WHO or UNESCO -- should take note.