Follow-up on 'Strange Bedfellows' post

Tommy Thompson was the Secretary of Health and Human Services from February 2001 to January 2005, and is currently Chair of the Deloitte Center for Health Solutions in Washington, D.C. Someone working at Deloitte -- after reading the October 19th post on this blog -- sent the editor a link to an op-ed piece by Thompson recently published in the Boston Globe. There Thompson passionately and explicitly states the connections he sees between US national security and the improvement of health in the developing world. The more investment there is in the health care of developing countries, Thompson suggests, the safer from threats (i.e. terrorism) Americans and American interests will be. He even has a catchy concept for this alliance of foreign policy and foreign health development: ‘medical diplomacy.’

Medical diplomacy must be made a significantly larger part of our foreign and defense policy, as we clean up from costly and deadly wars in Afghanistan and Iraq. America has the best chance to win the war on terror and defeat the terrorists by enhancing our medical and humanitarian assistance to vulnerable countries. By delivering hope we will deliver freedom.

If Tommy Thompson (ex-Secretary HHS) and Andrew Natsios (current Administrator of USAID) are anything to go by, the concept of ‘medical diplomacy ‘ is all the rage in certain Washington circles. It is, at the very least, a clever attempt to siphon some of the obscenely large ‘anti-terrorism’ budget into foreign assistance coffers.

Still, bioethicists have the obligation to examine the assumptions of the medical diplomacy approach. For example, is terrorism rooted in poor health circumstances such that improving global health will necessarily undercut global terrorism? Are these defensible causal claims? On what evidence are they based?

There are possible counterexamples to the fundamental claims of medical diplomacy. The majority of the 9-11 hijackers came from Saudi Arabia, a country which made considerable investments in its own health care system (US$16.4 billion in the years 1985 to 1990). The recent London bombings were perpetrated by men who were born and/or raised in Britain, whose health system is comparable to the US and other developed nations. And conversely: some very poor nations with weak health care systems (such as Swaziland) are hardly havens for terrorists. Is it possible that the roots of terrorism are political, rather than medical in nature, and that they may have to do with the ‘less compassionate’ face of US foreign policy over the years?

Perhaps one should not look a gift horse in the mouth, and be glad investments are made in impoverished health systems, no matter what the underlying motives are. Lives can be saved by questionable intentions too. But if the assumptions behind ‘medical diplomacy’ turn out to be false, if hearts and minds are not necessarily won by new hospitals and antibiotics, then expect the global health cash flow to dry up quickly – along with talk of ‘loving your neighbor’.

Contemporary American bioethics: a cautionary tale?

Daniel Callahan, co-founder of the Hastings Center, was present at the birth of bioethics in America and has been an articulate witness to its evolution. So it is with some authority that Callahan speaks of a crisis in contemporary American bioethics.

In a recent article in the Cambridge Quarterly of Health Care Ethics (‘Bioethics and the culture wars’), Callahan claims that bioethical discussion in the United States has degenerated into a clash of opposing ‘liberal’ and ‘conservative’ camps, with each side using bioethics to aggressively push its own political agenda. The recent case of Terri Schiavo and the heated debates on stem cell research have clearly demonstrated that bioethics is now a favored field of battle for the American culture war. Instead of bioethical thinkers, Callahan states, you increasingly see bioethics advocates for liberal and conservative positions. Instead of reasoned debates characterized by the usual give and take, there are shouting matches or a priori rejection of one’s ideological enemies. Callahan deems this recent development unhealthy, and says it could be the undoing of American bioethics altogether.

As bioethics is increasingly being taught and practiced globally, close attention should be paid to the current American situation. If American bioethics has (rightly or wrongly) stood for decades as example of what bioethics can and should be, it may now be providing important lessons about what bioethics worldwide should try to avoid.

To this end, it would be instructive to have a story explaining how American bioethics got to where it is today. Callahan goes some way in providing one. Interestingly, the story he suggests has a dominant theme: the crisis in American bioethics is due to it having been seduced, in four different ways, by power.

Seduction #1: policy formation. When bioethicists are invited to contribute to the formation of health policy – especially by sitting on national commissions – the sudden gain in social usefulness comes with a price. To be truly useful in a policy forming setting, bioethicists must rationalize concrete policy recommendations, rather than providing elaborate analyses or theoretical niceties.

Seduction #2: the media. The media love the provocative topics which are standard fare within bioethics, but the media also want from bioethicists clear moral judgments in the form of sound-bites, not sophistication and nuance.

Seduction #3: political activism. Over the last decades, there seems to be a growing sense in America that the task of bioethics is to change the world, not to study it. The line is thin, however, between politically engaged bioethics and the mere deployment of bioethics to defend a political ideology and attack those of others.

Seduction #4: biotechnology firms and research institutions. Decades ago, many bioethicists used to take a critical stance towards the science industry, but this venerable tradition has waned in the last years. Perhaps it is due to the high regard that scientific progress has within a ‘liberal bioethics’ mindset, or perhaps it is due to the increasing number of bioethicists who sit on the ethics committees of drug companies, or perhaps it is due to the fact that some bioethics centers receive funding from ‘big pharma’. In any case, bioethics may gain social prestige and economic support by aligning itself with powerful scientific institutions, but go from watchdog to lapdog in the process.

The moral of the story: bioethics, no matter where it is practiced, should be careful who it gets into bed with. But can bioethics in developing countries reasonably avoid such seductions, while at the same time becoming a positive social force?

Global health and the 'war on terror': strange bedfellows

Last May, Andrew Natsios, the Administrator for the U.S. Agency for International Development (USAID), told leaders of the world’s non-governmental organizations (NGOs) that they should aggressively promote connections to the U.S. government and measure results of their work, or the Bush administration would find new partners for overseas assistance programs. Many beneficiaries, he complained, don’t know where the money is coming from, and therefore US-government funded NGOs should communicate explicitly their role as ‘arms of the US government.’ According to Interaction, a network of 160 NGOs, Natsios went so far as to say that if such organizations fail to make the connection to the US government crystal-clear, he would ‘personally tear up their contracts and find new partners.’

Following Natsios’ diktat would seem to imply that NGOs should be silent on US government policies. For it seems difficult to criticize the workings of the US government while aggressively profiling yourself as an arm of the same government. But, according to some, enforcing silence may be the point.

This week, Natsios is in the news again, claiming that poor countries like it when the US government links its spending on aid to the ‘war on terror’. They really enjoy the idea, according to Natsios, that the US gives aid not out of compassion or any other ethical imperative, but rather to prevent fragile states from disintegrating and becoming havens for terrorists and hence a threat to US national security. On a similar note, he argued that the US should devote funding to combat bird flu in developing countries, not primarily to reduce mortality and morbidity of non-American human beings, but because developing countries can be considered the ‘frontline of the epidemic’. Some people’s frontline is other people’s front yard.

Natsios has claimed insight into the needs and preferences of developing countries before. For those who may have forgotten, Natsios is famous for saying in 2001 that Africans should not receive antiretroviral treatment, because their ‘alternative conception of time’ would render them incapable of taking their medication properly.

Most of the US-funded NGOs in the developing world focus on health-related issues. It will be interesting to see how this new ideology – which brazenly links funding for health in the developing world to US national security interests – plays itself out in the coming years.

Sleeping with the devil in the struggle against AIDS

In his 2003 State of the Union address, President George W. Bush unexpectedly announced a vast increase in support for the struggle against HIV/AIDS in the developing world: “I ask the Congress to commit $15 billion over the next five years, to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.” By May, the United States Leadership Against HIV/AIDS, tuberculosis and malaria Act of 2003 was signed into law. The President’s Emergency Plan for AIDS Relief, or PEPFAR, was born.

The next step was implementation: how can antiretroviral treatment for AIDS, drugs for opportunistic infections (such as tuberculosis), testing kits, gloves, injection supplies, sterilization equipment and other medical resources be delivered in a sustainable and reliable way in countries marked by varying levels of poverty, poor transport infrastructure, weak communication systems and corruption? What is needed is a supply chain management system, or SCMS as it is called in the business.

And it is a business. In October 2004, the US government started soliciting proposals for probably the largest contract for international health service delivery in the history of humanity. Two weeks ago, the contract was awarded to a consortium of fifteen institutions, referred to somewhat ominously as ‘the Partnership’. The consortium is a mix of private sector, non-profit and faith-based organizations. But the eye is naturally drawn to one particular member of ‘the Partnership’: Northrop Grumman.

Northrop Grumman is the third largest military contractor in the United States. This is the company that brought us the B-2 stealth bomber (at a cool $2 billion per unit), the unmanned Global Hawk ($10 million each), and a $10 billion contract with the Pentagon to build a missile defense system. The company is also exceedingly well connected, with at least seven former Northrop Grumman officials, consultants or shareholders now holding posts in the Bush administration, including Deputy Secretary of Defense Paul Wolfowitz, Vice Presidential Chief of Staff I. Lewis Libby, Pentagon Comptroller Dov Zakheim, and Sean O’Keefe, director of NASA. Even the President himself finds himself visiting Northop Grumman facilities from time to time.

Perhaps it is unusual that a multinational corporation that makes much of its money from instruments of death would now be involved in the struggle against HIV/AIDS in developing countries. On the other hand, Northrop Grumman has some prior experience with supply chain management issues, considering its support of the US State Department’s ‘war against drugs’ in Columbia, though this is another sort of drugs, and another sort of management.

Relatively speaking, the other 14 members of ‘the Partnership’ are small fry compared to Northrop Grumman. The company will probably be playing a central role. So what are the arguments in support of this defense contractor, with its ethical baggage, being crucially involved in PEPFAR? The main one is baldly pragmatic: the logistics of setting up, administering and monitoring a supply chain on this scale is simply beyond the means of any non-governmental or non-profit organization, and certainly beyond the present capacities of the governments of PEPFAR countries. In short, Northrop Grumman may be ugly, but they are big, and powerful, and they arguably could get the job done where the alternative agencies cannot.

On the other hand, the fiscal mismanagement of US defense contractors is legendary. In 2003, Northrop Grumman itself paid $112 million out of court to settle a suit that its subsidiary, TRW, overcharged the US government’s space program. The question of efficiency is also open: Grumman’s $48 million contract to train the Iraqi National Army produced such dismal results that the Jordanian army has taken over the job. And already ‘the Partnership’ has taken on one regrettable feature of defense contractors: lack of transparency. The consortium members are not to divulge the total amount of the contract (rumored to be $7 billion), and have been given strict instructions on what they can say to the media.

Give or take a few million deaths

Last week has seen renewed fears about the possibility of a global avian flu epidemic. The United Nation’s new coordinator for avian and human influenza, David Nabarro, said on Friday that if a mutated form of avian flu develops which is transmissible between humans, it would cause between 5 and 150 million deaths. “It's like a combination of global warming and HIV/Aids ten times faster than it's running at the moment,” he told the BBC. Perhaps we should all be glad Dr. Nabarro did not add the Holocaust, Rwanda and the Black Plague to drive his point home.

No sooner than Nabarro’s words hit the press, the WHO issued a counterstatement. No, they assured, it would really not be that bad. Dick Thompson, the WHO spokesman on influenza, cheerfully claimed that only between 2 and 7.4 million persons would perish in the event of an avian flu epidemic. But when further pressed, Thompson admitted that all mortality projections concerning the avian flu were speculative. "You could pick almost any number. There is this vast range of numbers, absolutely. One of those numbers will turn out to be right. All of this is guesswork, nobody knows."

If the numbers are based on guesswork, it is worth asking why these ‘mortality estimates’ are publicized by global health authorities, rather than having them say that an avian flu epidemic would be really, really, really bad. Why the big numbers at all? It is not good enough to say that the high figures are publicized to ‘raise public awareness’, since the public itself can do little to protect itself against a deadly flu epidemic anyway. Public awareness is compatible with mass death. We largely depend on governments and public health authorities to take measures to protect populations against the spread of deadly disease. It is not a do-it-yourself project.

Who knows? Maybe after Hurricane Katrina, Dr. Nabarro’s high mortality range is based on an expectation that the governments and public health authorities won’t be up to the task. This raises an interesting question: besides the usual factors, shouldn’t political incompetence, neglect and corruption be factored into epidemiological models and their mortality estimates? Or is it in bad taste to suggest that the actions and inactions of governments may be causes of citizen death?