Forced trials of drug users in Cambodia?

This is one of these stories in ethical flux. Human Rights Watch (HRW) has claimed that earlier this month the Cambodian police rounded up at least 17 drug users and brought them to a government-run drug detention center on the outskirts of Phnom Penh, where they were forced to participate in a drug study. The drug being tested is 'Bong Sen', a herbal substance that is alleged (by the company that makes it) to detoxify heroin/opiate users in 4-5 days. HRW lays out the ethical problems with the experiment: coercive recruitment and lack of informed consent; lack of review of the study by the ethical committee of the Ministry of Health; unknown (and possibly shoddy) study methodology, including apparent lack of follow-up of research participants.

The British Medical Journal put out a small piece on this story last week, providing some interesting details. Bong Sen is produced by a private Vietmanese company, with a very strange looking (and long) name: Ben Tre Fataco General Import-Export Trading Service Company (kor Ben Tre Fataco, for short). According to NGOs in Cambodia, Ben Tre Fataco has formed a group with four Vietmanese doctors, a company in Cambodia marketing Bong Sen, staff from Cambodia's National Authority for Combatting Drugs (NACD) and its Secretariat-General, the Ministry of Health and the Orkas Knhom drug treatment center, which is run by the Phnom Pehn municipality's Department of Social Affairs.

Just to show how deep the government is involved in the Bong Sen trial, the Cambodian prime minister is said to have given the Vietnamese doctors written permission to administer Bong Sen to drug users. When the Orkas Knhom drug treatment center could not come up with sufficient 'volunteers', staff from the NACD are said to have demanded that clients at local NGOs take the medicine. The NGOs hesitated, given that the herbal medicine being pushed did not seem to go through routine drug trial procedures. Staff from the NACD then threatened the NGOs with closures and withholding their licences for needle-exchange programs. That is apparently what went on before the police arrested drug users and had them enter the Bong Sen study. For its part, the NACD has denied everything: the drug users were volunteers; the herbal treatment is not really a drug, and does not have to go through drug approval procedures; there is no real trial at all. Just giving out medicine.

One thing is certain: the relationship between the Cambodian government and Cambodian citizens who happen to be drug users is not very warm and friendly. Earlier this year, the Soros Institute put out a report entitled At What Cost? HIV and Human Rights Consequences of the Global 'War on Drugs'. One chapter of the Soros report is dedicated to the arbitrary detention and police abuse of drug users in Cambodia. But this is nothing new. There have been reports about government abuse of Cambodian drug users (many of whom are HIV-positive) for at least a decade. If the allegations are true, the question is why the Cambodian government would be so interested in corralling drug users for this particular trial. Is it just because Bong Sen is a non-opiate treatment? What interests does the government have in the success of Bong Sen treatment that they are deeply involved promoting as effective despite there being no evidence of its efficacy? As the BMJ piece notes, no one is talking: Ben Tre Facaco is not answering its phone or email, and the Cambodian Ministry of Health has nothing to say.

Hand-me-down vaccines?

There have been months of fear and trembling (especially in the United States) about shortages of H1N1 vaccine. The idea of shortage -- in this one context at least -- in the land of plenty has motivated a rapid increase vaccine production and distribution, on the one hand, while the number of new cases of H1N1 has in fact decreased on the other. In little time, everyone in the United States who wants (and can afford) to have the vaccine, can get it. In fact, there will most probably be way too much of the stuff.

What should be done with the surplus? In a recent editorial in the San Francisco Chronicle, immunology and bioethics experts argue that the surplus should be donated to the world's poorer countries. These countries have health systems under tremendous stress, unhealthy populations at risk for H1N1, and have very limited access to the vaccine despite promises made by powerful governments and pharmaceutical companies. The argument for giving is especially pertinent at time of year. It is, as they point out, Christmas season.

It is hard to know what to make of this. First, the public health issue. The burden of disease that H1N1 constitutes is paltry in comparison to the diseases and conditions faced in developing countries. (It was already not very significant in terms of mortality and morbidity in developed countries themselves.) Sure, H1N1 will exacerbate pneumonia, one of the great killers in these nations. But we don't see significant donations of antibiotics which could save many more lives.

And then there is the symbolic issue. When the richer nations have had their fill of vaccines, and are getting out of danger, then we can think about the poor. The image is that of hand-me-downs, leftovers. Things we no longer need or want and can afford without sacrifice to give away as charity. Of course, it is not that it would be better if such donations were withheld. Some lives could be saved. But what do such acts of charity express about the relationship between richer and poorer countries? Should either party feel good about such a donation initiative? Perhaps some will find the spirit of Christmas in it somewhere, but the whole thing strikes me as deeply, deeply sad.

Ugandan government takes dead aim at HIV positive gays

Many Africans seem to believe that men having sex with men, or women having sex with women, is unAfrican. It is as if such sexual behavior never took place on the continent during its very long history, and if it has appeared recently, this is due to external, non-African influences -- as if it were a new fashion craze helicoptered in from San Francisco. In this way, gays in Africa are doubly marginalized: they not only deviate from heterosexual norms, they aren't 'real Africans.' And being stripped of cultural identity is often a prelude to (and justification for) exclusion, humiliation or physical violence. Not everyone in Africa sees things this way, of course, but it is a real and strong tendency.

The tendency is strongly manifest in a provisional bill ("The Anti-Homosexuality Bill") currently being proposed and discussed by the Ugandan government. There already are anti-homosexual laws in Uganda, harking back to colonial times, but members of the government are seeking to beef them up, and how. Among its provisions, single gay sex acts could be punished by life sentences; repeated gay sex acts could lead to the death penalty; gays who test HIV positive could be executed; members of organizations who engage in the 'promotion of homosexuality' (i.e. gay rights groups) would be outlawed; even an attempt to commit a homosexual act would be considered a felony and a conviction would lead to a seven year prison sentence.

The proposal bill is worth reading in the original. It starts off with a number of unargued assertions: that homosexuality is not innate (hence mutable, or 'curable'), and that the bill aims to protect the traditional family values of Ugandans, apparently under serious threat by sexual rights activists hell bent on imposing their agenda of promiscuity and adoption of children by gay couples. One of the last provisions in the proposed bill is aimed to deflect any and all criticism from a human rights point of view: "Any International legal instrument whose provisions are contradictory to the spirit and provisions enshrined in this Act, are null and void to the extent of their inconsistency." A lot like saying: this is the way we intend to treat our gay Ugandan citizens, and outsiders, if they don't like it, can go to straight to hell. Highly reminiscent of Zimbabwean president Robert Mugabe's old trick: use a lot of nationalist and anti-colonial rhetoric against outsiders to justify abuses on the enemies within.

Ugandan government officials generally don't mind listening to right-wing religious groups from the United States (or taking their money) as long as the latter says what the former wants to hear or already believes in. But US anti-gay groups are pulling back (a bit) from this one publicly, even if they are happy with its spirit of the proposed laws. The Ugandans, it seems, are on their own. Or maybe not. Given the extent of gay hatred on the continent, the bill if approved could function as a template for similar legislation in neighboring countries. So it is important to see how this situation evolves.

It is also important from the perspective of HIV prevention. Plenty of men have sex with men in Africa, if you bother to look closely enough, and these men have a disproportionally higher incidence of HIV. Reaching this population with HIV prevention messages and strategies is already difficult enough, without laws that treat them as sub-human.

Condoms, Marriage, Catholicism and HIV

Today is World AIDS Day and I can think of nothing better than recommending a paper on HIV, sex and religion. The current Editor's Choice in the Journal of Medical Ethics is an article with the self-explanatory title, 'Can the Catholic Church agree to condom use by HIV-discordant couples?' by Luc Bovens. There are many married couples, particularly in sub-Saharan Africa, who are Catholic or deeply influenced by Catholic teachings. Some of these couples are HIV-discordant, i.e. one in the marriage is HIV-positive, and the other HIV-negative. The Catholic church is opposed to pre-marital sex using condoms, but what about condom use among HIV-discordant married couples? Would the Church accept the use of condoms to prevent transmission of HIV during marital sex? Or would the Church's position be that such married couples should simply abstain from sex altogether?

Bovens argues that the Church should permit the use of condoms in such cases. I will not give away the argument, which is well-constructed and attempts to take Catholic objections to condom use as much into account as possible. One way to celebrate World AIDS Day: thinking of how Catholics -- including HIV-positive ones -- can experience the pleasures of (safe) sex in good conscience.