New report on a forgotten non-pandemic

There are certain things we know about the avian flu scare back in 2009. First, that the initial fears, amplified tremendously by the media, culminated in a non-pandemic. When the World Health Organization (WHO) announced that H1N1 was no longer a global health threat, the news appeared somewhere deep in the back pages of newspapers. Second, pharmaceutical companies made a massive amount of money by producing and distributing Tamiflu in vast quantities. Third, critics suspected the World Health Organization of being in the pockets of pharmaceutical interests by whipping up fears of mass infection and death on the one hand, and fully integrating private for-profit companies into the global response on the other. The fact that advisors to WHO's Emergency Committee had undeclared potential conflicts of interest with pharmaceutical firms did not help matters.

Last year, an International Health Regulations (IHR) Review Committee was convened, consisting of an independent panel of 25 experts, to examine the WHO's response to the avian flu threat. The draft report is now available online, and it seems somewhat unsatisfying to conspiracy theorists and defenders of the WHO alike. The Committee contends that while the WHO could have done a better job in managing apparent conflicts of interest among its advisors, there is no evidence that the advisors' judgments were adversely influenced by their drug company connections (though one wonders what would count as evidence). There is also no hard evidence that the WHO 'sexed up' the data on avian flu in order to make the epidemic appear more threatening; there was no way of knowing at the beginning that the rate of new infections would fizzle out rather than explode. The report is less about ethically criticizing the relationship between the WHO and big pharma, and more about practicalities of improving global pandemic response in the future. The avian flu scare exposed serious weaknesses in systems of global pandemic control. In other words, the IHR report seems to mimic the pattern of the 2009 avian flu scare: the prospect looks urgent and compelling at first, but on closer inspection, there seems to be less to meet the eye, at least from an ethical perspective.

The President's Commission ponders global safeguards in research

An article by Mike Stobbe on global research ethics is doing the rounds: my Google Alert has been sending me its many incarnations, as the piece seems to have been sold and resold to various news outlets. Titles vary from 'Ugly US medical experiments uncovered' to 'Shameful past of medical trials prompts new US investigations' and all sorts of other permutations. The first line of the article, though, is not promising:

Shocking as it may seem, US government doctors once thought it was fine to experiment on disabled people and prison inmates.

It should not be too shocking, because the National Institutes of Health sponsor and conduct research studies involving the disabled and prisoners right now. It was not just the populations that were the problem with those experiments, of course. It were the procedures, and more specifically, studies in the past that involved deliberate infection of healthy (but vulnerable) persons. Stobbe has himself sniffed around in the archives to find some more skeletons in the US research closet, and adds them to the scandals we already know: Tuskegee, Willowbrook, the Jewish Chronic Disease Hospital, the AZT trials, the Trovan study. He leavens his account with an indication of how health research has gone global: drug studies, once almost exclusively conducted in the US on prison populations, has been redirected to developing countries in order to evade stricter regulations at home and to hold down study costs.

This potted history is a lead-in to last week's meeting of the Presidential Commission for the Study of Bioethics Issues. The Commission devoted an afternoon to comments and discussion about global health research ethics, Commission having been given two tasks by President Obama: to investigate dubious US government funded studies in Guatemala in the 1940's, and to see what system of protections and safeguards exist to ensure that similarly abusive research does not happen. This is an enormous task, and the Commission has little time to complete its mission. They did invite an amazing array of experts for the session on March 1st that is well worth watching. What struck me, however, was the public comment session: a fair number of people stood up to give personal testimony of how they were subjected to secret government experiments, involving electroshock treatments, mind control, torture and so on, followed by way too much information about physical and psychological symptoms. Either mentally unbalanced persons are drawn to commissions about abusive research like moths to a flame, or there is much more abusive research taking place in the United States than we know about.

UPDATE (March 10th): I was amazed by the testimonies during the public comment session of the Presidential Commission. Those over at Are You Targetted? are not amazed at all by the content of the testimonies, where citizens claimed to be victims of abusive and covert state-sponsored research, but are amazed by the fact that the news outlets did not seem to cover this part of the proceedings at all. It is strange that the high drama and vividness of these testimonies was not considered newsworthy.

Pneumoccal vaccine in Africa: one step forward, one step back?

It is pretty well known that many routine medical interventions in the world's more affluent countries make infrequent appearances -- or sometimes none at all -- in the world's poorer ones. The publicly-financed health care systems in some sub-Saharan Africa look to be decades behind the United States, Canada or the United Kingdom when it comes to devices, drugs and procedures. For that reason, initiatives that seek to close the gap are, in principle, to be welcomed. Oftentimes, however, these initiatives are accompanied by moral baggage.

Take for instance the launch of a new pneumoccal vaccine among children in Africa. Considering the number of childhood deaths attributable to pneumonia in this part of the world, the effort has an initial air of nobility. Many lives will be saved, many illnesses avoided. But if one looks more closely, serious ethical problems seem to emerge. There are two multinational pharmaceutical companies involved in the campaign -- GlaxoSmithKline and Pfizer/Wyeth -- who have agreed to sell 30 million doses every year for ten years at $10.30 per child vaccinated. These companies also stand to each gain $225 million in subsidies through their involvement in this scheme. Doctors Without Borders worries that this price for vaccination is very high for many countries, and that the lock on the market exercised by GSK and Pfizer/Wyeth will strongly discourage local companies from developing cheaper generic equivalents. The companies are establishing their brand under favorable circumstances to themselves; after that, all bets are off.

Some people argue that pharmaceutical companies should be given incentives to focus greater attention on developing countries, otherwise they will simply develop whatever is likely to sell to richer consumers elsewhere. But the pneumoccal vaccine example can make you think twice about the wisdom of 'incentivizing'. In the short term, many children will be vaccinated. But in the long term, unless prices are made to go down, children of wealthy elites within developed countries are most likely to benefit. The usual pattern threatens to repeat itself: big business wins, the higher classes win, and the rest struggle on.