Bring out your infected!

Public health emergencies reveal a brutal survivalist ethic within societies that normally lies suppressed. Normally, we are supposed to care about the individual choices of fellow citizens and protect their rights, but when an easily transmissible, life-threatening and incurable disease spreads in communities and exceeds our control efforts, rights and choices are transformed into dangerous niceties. That is when the sharper tools in the public health toolbox get pulled out: the involuntary interventions for the common good, the isolation, the quarantine, the mandatory testing. This all sounds routinely ethically justified in a robust, hard-headed, no-nonsense utilitarian sort of way. But there is a plot twist: you don't want the sharp tools to scare or alienate the population so much that they run alway from (or sabotage) public health efforts altogether. Tough love can have perverse outcomes.

Which reminds me of Ebola. As an educator in bioethics, whenever you want to provide an example of a disease that seems to ethically justify industrial-strength public health actions, Ebola fits the bill  even better than HIV or TB. Easy to contract, impossible to cure, and associated with a nasty clinical presentation and a very high mortality rate, Ebola evokes extreme fear that makes extreme responses to it seem commonsensical. This seems to be the case in Liberia at the moment. West Africa is undergoing an Ebola epidemic, and for its part, Liberia has had 61 cases in the past few months, with 41 deaths. The response? Liberia President Ellen Johnson Sirleaf has declared that anyone caught hiding suspected Ebola virus disease (EVD) patients will be prosecuted under Liberian law.

Will this way of 'being serious about the epidemic' help with disease control or quite the opposite? Families and religious organisations currently taking care of/harboring those with Ebola-like symptoms will probably need to be reassured that these patients will be given respectful, effective care. Shouting at caregivers of the sick may not work, particularly when you realise that when you hand someone with Ebola over to the health authorities, it may be the last you see of them.

The politics of polio in Pakistan

A health official assisting in polio vaccination efforts was killed last week in Quetta, in the province of Balochistan, in Pakistan. It is not yet clear whether the killing was a personal dispute or if it was a Taliban supported attack against polio vaccination efforts in the region. The latter is a distinct possibility: the Taliban has made its opposition to polio vaccination campaigns clear, issuing a pamphlet back in June describing its position on the matter, and back in July another vaccination worker was killed and others wounded near Karachi. For its part, the Taliban argues that US efforts to eradicate polio in Pakistan contradict US efforts to combat terrorism in the region, more specifically its campaign of drone strikes. As Taliban officials argue, many more Pakistanis -- including women and children not involved in terrorist activity -- have died or been injured (psychologically and otherwise) from drone strikes than have died or are likely to die from polio.

When you can see the point in a Taliban ethical argument, the world is a dark place. The continuation of drone strikes in Pakistan, whose efficacy and legality has never been particularly clear, is a serious blemish on the current Obama Administration. (Some left-leaning Americans would abstain from voting in the upcoming US elections, largely for that reason). On the other hand, polio eradication goes beyond the depressing, dysfunctional and deadly relationship that US and Pakistan currently have. The eradication of polio is of global interest: it is important that it joins smallpox in the tiny category of eliminated infectious diseases, while we still have the chance.  

AIDS, gay men and Africa

Authorities in many African nations are deeply troubled by the prospect of having men who have sex with men in their midst. While living in South Africa a few years ago, I remember a heated debate in the letters to editor section of the Mail and Guardian about whether homosexuality was a purely imported phenomenon, something alien and originating from the fleshpots of (say) southern California, and dropped recently into Africa. The idea was that if it was something new and foreign, it could hopefully be returned to sender, like an unwanted package. But it eventually appeared that the phenomenon wasn't really new or entirely foreign to Africa. So what couldn't be denied would have to be repressed; while not unAfrican, the behavior was nevertheless an abomination. Many African churches have joined with political authorities over the years in their attempts to condemn and marginalize the sexual behavior of gay African men. In most African countries, homosexuality is still illegal.

Last week, the New York Times reported the sentencing of nine men in Senegal to eight years in prison for 'unnatural acts.' The men were arrested in the house of a leading gay HIV/AIDS activist in Dakar. The events in Senegal join a long list of repressive political actions against gay men in African countries, including Nigeria, Gambia, Burundi and Uganda. Now there is a lot that one could say, from a human rights or social justice perspective, about the political treatment of men who have sex with men in Africa. But there is also a public health ethics perspective: demonization of homosexuality is counterproductive in the fight against HIV/AIDS in Africa, just as it was in America during the early days of the epidemic. Condemnation and criminalization simply drives the behavior underground, away from prevention and treatment services, increasing risks of HIV transmission. The conclusion is hard to avoid: the HIV/AIDS epidemic has forced African countries to deal with homosexuality in their communities, but many have failed to develop responses that are justified from a public health point of view or even reflect basic human decency.

Governing unto death in Zimbabwe

If you were ever wondering if politics is a 'social determinant of health', well, just take a hard look at Zimbabwe. A few decades ago, the country was the breadbasket of the sub-Saharan region, and it is now heavily dependent on food aid and imports, with an economy crippled by massive debt and astronomical levels of inflation. In fact, its chief export in the coming months, besides Zimbabweans, could be infectious disease. This week, the Zimbabwean health minister, David Parirenyatwa, has declared the nation’s recent cholera outbreak a national emergency, and has asked for outside help in bringing the epidemic under control. But to bring the epidemic under control, you would need more than just oral rehydration therapy and truckloads of antibiotics. You would need a functional health care system. But that would require a government actually devoted to the welfare of its own people, rather than lining the pockets of some of its own people, and blaming foreign powers (while also asking them for stuff) whenever things go wrong. So what to do?

The Kenyan Prime Minister Raila Odinga -- in a rare display of backbone by an African leader -- has called for the isolation and ousting of Zimbabwean president Robert Mugabe. In the grander scheme of things, this could be as effective a public health intervention as any. Epidemiologist John Snow is said to have removed the handle on the water pump on Broad Street in London in 1854, once he discovered that contaminated water from the pump was responsible for the city's deadly cholera epidemic. The outbreak dissipated soon afterward. In Zimbabwe, Mugabe is the pump handle.

UPDATE: I was premature in calling President Mugabe the 'pump handle.' Today in a news conference he declared that there is no cholera epidemic in Zimbabwe. So it would be better to characterize him as a public health version of Jesus Christ the Savior, healing sick populations with his miraculous powers.

Follow up on the ethics of nurse recruitment from developing countries

A couple of posts back, the topic was the launching of a new ethics code, namely the Voluntary Code for the Ethical Recruitment of Foreign-Educated Nurses to the United States. The code is a response to the well-documented 'brain drain' of nurses from developing countries. In that post, I expressed some skepticism in regard to the code's enforceability and potential impact. Given that recruiting foreign-educated is interesting for powerful agencies in the United States from a cost-benefit perspective, why would they sign onto to Code and hold to its guidelines?

In a letter last Sunday to the Washington Post, Samuel Witten, Acting Assistant Secretary of the
Bureau of Population, Refugees and Migration within the US Department of State gives a flavor of the government's view of the Voluntary Code. Witten states that the Voluntary Code has noble ideals and makes some good points. But the point of the letter is to express one basic complaint: according to Witten, the Code " ... discourages U.S. companies from hiring nurses from countries with severe shortages of health workers, implying that a qualified nurse from a developing country has less right to apply for migration than a counterpart in a developed country."

In my reading, the Voluntary Code does not at all deny the right to migration. What it does is embed that right as one consideration among others in a larger context, which also includes the devastating social and health impact of the loss of nurses for developing countries. Its guidelines are the product of careful balancing of divergent concerns and interests. Apparently the US Department of State sees things quite differently: the individual's right to migration is taken to be the chief, overriding consideration in such cases, even when it comes to the poorest countries with the worst nurse/patient ratios.

That standpoint about 'individual rights' is convenient: it maintains the status quo in regard to the brain drain of medical human resources from developing countries to more affluent ones. The US Department of State is apparently much more concerned with US capacity to cheaply meet nursing care demands for its aging population than it is for the fate of health care and health in general in some of the poorest countries in the world. I suppose this is to be expected, but it is depressing nevertheless.

***Many thanks to Kristen Rosengren at AcademyHealth, who alerted me to Witten's letter in the Washington Post. AcademyHealth was one of the agencies involved in the writing of the Voluntary Code and is, as it describes itself, ". . . the professional home for health services researchers, policy analysts, and practitioners, and a leading, non-partisan resource for the best in health research and policy."

Backlash against the 'AIDS industry'?

This week sees the launch of the XVII International AIDS Conference in Mexico City. Some of what is going on in the conference can be followed on the website that the Kaiser Family Foundation has set up. But you really have to be there to get the buzz, the celebrities, the infighting, as well as whatever new research results are on offer. Part of my summer reading has included Elizabeth Pisani's The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS, in which she describes the XV International AIDS Conference as follows:

In 2004 Thailand hosted the Fifteenth International AIDS Conference. Once upon a time, these conferences were about science. Nowadays they are about institutional posturing, theatrical activism and money. Lots of money. The Bangkok conference cost US $18.5 million. Nearly 19,000 people rocked up to it, scrummaging for the goodie back-packs given out by pharmaceutical companies. Big pharma paid handsomely to nab the best real estate, the exhibition booths in the center of the main hall. They paid again to get their booths dressed to impress, with cappucino bars, and indoor waterfall and larger-than-life photos of gleaming Western labs and grateful African children. Conference goers could admire a fabulous selection of ball gowns by Brazilian designer Adriana Bertini, all made of condoms. They could gawp at dancing elephants and Puppets against AIDS. Delegates paid around US $1000 each to attend this jamboree.

In the bad old days, the complaint was that not enough was being spent on HIV/AIDS: it was a disease of gay men and junkies, and no one wanted to touch it. The newer complaints are that too much is being spent on HIV/AIDS (relative to other serious health-related conditions) or that too much is being wastefully spent on wrongheaded approaches to the epidemic. Why so much spending on HIV/AIDS and so little for maternal and child health? Why was the importance of partner reduction neglected amid fruitless battles between those (liberals) promoting condoms and those (conservatives) promoting abstinence? To the extent that these complaints are true, these shortcomings would constitute a massive ethical failure, not just a public health one.

So while the official slogan of the conference is Universal Action Now, the unofficial buzzword seems to be: backlash. There is talk of a backlash against the struggle against HIV/AIDS. It is not the misfortune of research into new HIV prevention interventions (in microbicides and vaccines) having gone south last year. This does not help, but that is a setback, not a backlash. The backlash starts from the observation that a kind of private-public industrial complex has developed around a single disease to an extent unparelleled in the history of public health, leading to questions about whose interest(s) this burgeoning industry ultimately serves, especially when -- despite the increasing funding of research and programs -- new HIV infections continue apace and only a fraction of those who need AIDS treatment receive it. Even the head of the HIV/AIDS department of the World Health Organization has muddied the waters by stating that a generalized HIV epidemic outside sub-Saharan Africa may be over, which many took as meaning that HIV is a non-issue if you are not gay, a drug user, or African. Against this background, the International AIDS Conference, with its bling and glitter, can act as a lightning rod for skepticism, conspiracy theories, and general ridicule.

On the other hand: HIV has entered human ecology, and is not going to go away anytime soon. Millions of people continue to die of AIDS, and it is incurable. The virus is extremely complex and adaptive. It impacts low-income countries disproportionately. Basic research, epidemiological studies and the implementation of HIV/AIDS programs around the world don't come cheap. Perhaps a way of dealing with the backlash is to advocate for greater funding and human resources devoted to all diseases (including HIV/AIDS) responsible for high levels of preventable morbidity and mortality worldwide, while fighting against the politicization of approaches to prevent sexual transmission of HIV, and practicing vigilance in regard to the role of pharmaceutical companies within the fight against HIV/AIDS. The HIV/AIDS community has to combat the virus as well as its own tendencies. This is going to continue to be messy, but there is no way back.

Human rights abuse in the name of public health: HIV, ethics and Egypt

In the industrialized nations of the north, it is easy to take for granted the progress made in the control of the HIV virus, and some of the hard-fought, positive changes in the social, ethical and legal treatment of people living with HIV/AIDS. In the United States, regimes of increasingly effective drugs have been developed to control the virus and transform HIV/AIDS from a death sentence into a chronic disease; legal protections specific to persons with HIV/AIDS have been bolstered; social stigma, while by no means absent, has had some of its sharper corners blunted by therapeutic advances and improved public understanding of the modes of HIV transmission.

The fact that this is not the case globally was driven home by a recent report by Human Rights Watch. In Egypt, an HIV positive man -- or even a man suspected of being HIV positive -- is apparently in a far worse situation than their Canadian, American or Western European counterparts. Rather than being able to call on their government for protection, Egyptian authorities strictly enforce a national law against the 'habitual practice of debauchery', i.e. consensual sex between men. Or rather: they go beyond enforcement and towards state-sponsored sadism when it comes to suspected HIV positive gay men, chaining them to hospital beds and eventually jailing them because they are alleged to constitute a threat to public health, testing them for HIV without consent, and subjecting them to abusive and intrusive physical examinations.

Aggressive state action against homosexuals/HIV positive persons in Egypt is a fairly recent phenomenon, and requires an explanation. Hossam Bahgat ventured that the crackdown on gay men is motivated by a desire to (a) distract the public from the country's economic woes and (b) profile the government as a defender of 'Islamic values' (in order to counteract the growing Islamic opposition in the country) rather than a question of public health. There must have been something in those explanations, since Mr. Bahgat was fired from his position at the Egyptian Organization for Human Rights two days after he published them.

Belgians Jailed for Refusing Polio Vaccination

Polio remains a widespread problem throughout the world, despite the existence of a successful polio vaccination. What are doctors and heads of state to do when people reject the vaccination? In Belgium, refusal could now result in incarceration.

Recently, the Associated Press reported that two sets of parents in Belgium were sentenced to five months in prison and fined $8,000 because they refused to have their children vaccinated for polio. A delay was put on the sentencing to give the parents a second chance to comply with the vaccination. However, they will definitely go to prison if they still refuse. This raises many questions about freedom of choice.

On one hand, polio is a terrible disease that can be easily eradicated with widespread vaccination. However, forcing citizens to become vaccinated is deemed as extreme as some. Those who refuse vaccinations for religious reasons will probably be the most troubled by mandatory vaccinations.
Miguel A. Faria, Jr. of the Medical Sentinel has addressed the ethics of forced vaccinations, stating "…the historic record also reveals that when physicians become agents of the state rather than advocates of their patients, everyone suffers. Physicians become preoccupied with preventive health measures and the 'rational allocation of scarce resources,' rather than the health of their individual patients."

The head of Belgium's vaccine center, Dr. Victor Lusayu, doesn't see it that way, however. Lusayu maintains that "The discovery of the vaccine has eliminated polio from Europe and it is simply the law in Belgium that you have to be vaccinated. ... At the end of the day, the law must be respected."

Polio vaccinations are the only vaccinations in Belgium that are required by law. France has also made the vaccination mandatory, as Europe is desperately trying to stem polio outbreaks. It is a highly contagious disease that is spread through water and children are especially susceptible, making any outbreaks all the more tragic. Whether or not these vaccination laws will improve Europe's polio problem remains to be seen.

This is a guest post by Susan Jacobs. Susan is a part-time teacher, as well as a regular contributor for NOEDb, a site for learning about and selecting an online nursing degree program. Susan invites your comments and freelancing job inquiries at her email address susan.jacobs45@gmail.com.

Unhealthy health policies

Do we believe that good health policies can reduce mortality and morbidity at a population level? The answer is yes: scientific research, meetings, consultations, reports and all the other magical ingredients that go into health policy formation are driven by the idea that if our policies are well-constructed and implemented, they will have a beneficial effect on public health. The whole process assumes that policies can have real and widespread effects. Conversely, it seems to follow that if the process of health policy formation goes awry, and we end up with wonky policies, needless death and disease can be produced in substantial numbers. Normally, the production of human death and suffering on an industrial scale raises strong ethical objections. Especially when guns are involved, we have strong words to describe this sort of thing: massacre, slaughter, carnage, genocide. Oddly, when errant health policies produce similar 'end points', in similar numbers, the ethical (and legal) responses are quite different. Ministers of health do not normally get hauled off to The Hague. And there really are some unhealthy health policies: there is an interesting book of case studies describing a selected few of them.

I was led to these thoughts by a recent case in South Africa of a physician who was suspended for giving HIV-positive pregant women a more effective drug combination to prevent them from transmitting the virus to their infants. You read that sentence correctly. A doctor in KwaZulu Natal, Dr. Colin Pfaff, gave dual therapy (nevirapine and AZT) to HIV positive mothers, rather than the 'nevirapine only' regime that is currently government health policy. But the government policy is behind the times. Dual therapy has already been recommended by the World Health Organization for a year, and has been shown elsewhere in South Africa to reduce the chance of mother-to-child HIV transmission down to 8%, while monotherapy with nevirapine has only reduced chances of transmission down to 22% in KwaZulu-Natal. The Southern African HIV Clinicians Society have condemned the decision to threaten Dr. Pfaff with discipinary action, and petitions have been written. It is a strange world when a physician is threatened with punishment for providing a superior standard of care, and when doing so cost the local health department nothing, because the AZT had been donated by a British NGO.

There has been pressure for sometime for the South Africa health ministry to alter their mother-to-child HIV transmission policy (last revised in 2001) to keep up with scientific advances and international recommendations, but its responses have been ambiguous, hesitant and sometimes openly hostile. This is part of a larger and deeply entrenched pattern in the country. From the beginning of the epidemic in South Africa, president Thabo Mbeki made no secret of his embrace with 'HIV dissidents' -- who believe that HIV does not cause AIDS or that HIV does not exist at all -- or his suspicion that drugs like AZT are harmful and promoted in Africa only to make money for corporations. By appointing health ministers sympathetic to his views, Mbeki has guaranteed that national responses to the epidemic will be marked by foot-dragging and denial. For almost ten years now, health minister Manto Tshabalala-Msimang has been responsible for a kind of 'Alice in Wonderland' approach to health policy leadership, carefully cherry-picking whatever scientific research seems to support her own beliefs about HIV in Africa, sidelining the rest, while touting the benefits of herbal concoctions and aligning herself with quacks. She was, for example, very quick to abandon provision of nevirapine when some studies indicated its use led to drug resistance among HIV positive mothers. Now, when it comes to providing dual therapy, Minister Tshabalala-Msimang wants to stick with nevirapine. Or she did, until the story with Dr. Pfaff hit the newspapers.

In South Africa, the struggle against HIV/AIDS is especially hard, because it partly a struggle against a government whose commitment has never been more than lukewarm. True, in the beginning of the HIV epidemic in the United States, there was strong government reluctance to engage in the control of a 'gay disease.' But that changed after a few years. In South Africa, that kind of obstructionism in high places endures, with deadly effect. In the future, perhaps it will be possible to estimate how many people in South Africa became infected by HIV or died of HIV-related causes due to the country's delinquent style of HIV policy-making. Will anyone be held responsible? Very unlikely.