Saturday, February 25, 2006

Avian flu, the Africa version

Some observers have complained that news stories about Africa are treated differently in the global media, and that the differences are driven by a kind of 'exoticism' about the Dark Continent that harks back to the colonial era. Kenyan writer Binyavanga Wainaina has recently written a sarcastic (and very funny) piece in Granta on the use of stereotypes and clichés about Africa. Those who claim to 'love Africa' may harbor a sick kind of love.

And it is not just in the mainstream media: even academic researchers, public health policy-makers and bioethicists may find themselves locked into the same neo-colonial discourse. A couple years ago, the Danish anthropologist Quentin Gausset wrote in the journal Social Science and Medicine that that when a correlation is found between HIV and a traditional African practice (such as polygamy, circumcision, dry sex, and so on) the practice is regarded as a 'barrier' to be eradicated, whereas if there is a correlation between HIV and modern phenomena (sub-standard health clinics, sex workers, drug use) then talk about 'barriers' and 'eradication' fall away -- we talk instead about those things being made safer. This 'double discourse' seems to assume that African traditional practices are irrational, backward and, with the emergence of HIV, deadly liabilities.

In this light, perhaps we should keep a careful eye on how Avian flu in Africa -- having emerged in Nigeria earlier this month -- is being handed in the international media. So far, it seems to be getting a 'tinderbox' reading: the virus is bound to spread like wildfire on a continent that is already so messed up in so many ways (Of course, unless the cavalry from the North in the form of WHO and USAID step in to save the day.).

Hopefully this way of seeing things will be tempered by African perspectives on the virus. The prospect of a new untreatable, infectious and deadly virus may look different to Africans than it does to those who write for the international media. The majority of patients in Africa do not have access to treatment for AIDS, malaria and tuberculosis right now, so it is understandably difficult to get worked up about a virus that has claimed 200 total deaths worldwide. But complacency would be short-sighted, and there are already calls to mobilize the African media to help local communities protect themselves.

Thursday, February 16, 2006

Got AIDS? Take two cloves of garlic and call me in the morning

South Africa's Ministry of Health announced on February 13th that it promotes 'free will' in regard to the use of traditional medicines by those living with HIV/AIDS. The Ministry, in other words, is officially neutral: when a South African's immune system becomes compromised by HIV, they can use drug treatment, or they can go to their local sangoma and get the latest concoction. The Ministry of Health does not want to state a preference for anti-retroviral drugs above herbs, micronutrients, garlic or whatever.

Lurking behind this position of neutrality is a longstanding battle between the South African government, health care professionals, biomedical researchers and AIDS activists. The current South African president Thabo Mbeki used to publicly state that HIV does not cause AIDS, relatively few people in South Africa die of AIDS, and that anti-retroviral drugs are unsafe and part of a neo-colonial plot on the part of Western pharmaceutical companies. He no longer needs to, because now he has a Health Minister (Manto Tshabalala-Msimanga) who says anti-retroviral drugs are merely an 'option' for AIDS patients, and a healthy diet can be just as effective in controlling the virus. Mbeki has a theory, but Tshabalala-Msimanga translates it into health policy, under the fashionable guises of 'patient choice' and 'respect for indigenous culture.'

This policy of 'neutrality' needs to be evidence-based. The South African Ministry of Health should sponsor an independently monitored clinical trial comparing herbs, micronutrients, garlic, lemon rind (and whatever) against first-line antiretroviral drugs on persons with CD4 count of <200. Nearly everyone in the scientific community would predict a whole lot more death in the 'garlic' arm of the trial, but since the Ministry of Health claims they are equally effective, they at least have clinical equipoise. So they can do it. But they won't.

Wednesday, February 15, 2006

Botswana: Update on routine HIV testing

The latest report from Botswana gives a mixed review of the policy of routine HIV testing that has been in place there since 2004. On the one hand, it is undeniable that more people are being tested in Botswana for HIV, and more of those testing positive receive treatment and care. That's good news.

At the same time, there are growing concerns about confidentiality, stigmatization, informed consent and burdens on health care staff. Predictably, there are doubts about whether the option of 'opting out' of testing is being communicated adequately, and there is the suspicion that counseling of individuals is being rushed in order to get more people tested. Members of BONELA (Botswana Network of Law and Ethics) are understandably concerned: the organization was involved in the creation of the routine HIV testing policy, on the understanding that the need for increased testing would be balanced with human rights considerations. Has the balance tipped?

Tuesday, February 14, 2006

The ethics of urgency

According the latest figures of the WHO, in sub-Saharan Africa, 3.2 million people became HIV infected in 2005. Even more shocking is the fact that roughly 90% of HIV positive persons in the region do not even know they are infected. This can easily be interpreted as a failure of traditional HIV testing policy of voluntary counseling and testing (VCT). As the name suggests, VCT involves people coming of their own free will to clinics to be tested, and being counseled about the implications of a positive (or negative) test result. For decades, VCT has been the standard HIV testing strategy for decades in sub-Saharan Africa. It has obviously not proven a rousing success.

In the light of this, the WHO has recently embraced routine HIV testing in areas of high prevalence where AIDS treatment is available. Routine testing basically means informing persons presenting at clinics that they will be tested for HIV, unless they choose not to. Opt-out policies can increase the numbers tested, but also diminishes the ‘voluntary’ component in HIV testing. The WHO believes that since routine testing involves possibility of refusal, the policy balances public health and ethical concerns.

Some commentators, however, worry about the implementation of routine testing policies in low-income countries. What will routine testing for this still-stigmatized disease really involve for individuals, particularly for women? There is also a ‘slippery slope’ concern: if routine testing does not increase the numbers of tested individuals, what more aggressive HIV testing policies will be proposed next? Frankly, I am one of those commentators.

In the most recent issue of Developing World Bioethics, Peter Clark argues that the time for more aggressive HIV testing policies within sub-Saharan Africa has already arrived. Clark argues that mandatory HIV testing of all pregnant women in Botswana – i.e. testing them for HIV whether they consent or not -- is economically, scientifically and ethically justified. Actually, he goes even further: since those who get tested do not sometimes adhere to treatment regimes, Clark is also ready to defend mandatory treatment of pregnant Botswanans and their children – though he thankfully spares us the gory details of how to implement forced medication. Restricting the privacy and autonomy of individuals, he writes, is a lesser evil than the death and social destruction caused by HIV/AIDS.

As far as awareness of the horrors of the epidemic is concerned, Clark’s heart is in the right place. But it is unclear that he put all the potential costs of the policy into his utilitarian calculus. Privacy and autonomy are not the only concerns. There is also stigmatization (and possible harm) of being found HIV positive. There is also the fact that this mandatory testing policy targets pregnant women, not the men they likely received the infection from. How are local communities likely to react to mandatory testing (or treatment)? And what, if this policy did not work, would come next?

Tuesday, February 07, 2006

Doctors without Borders versus Gilead Science: round one

Bashing pharmaceutical companies: no self-respecting international AIDS conference seemingly can do without it. It happened at the 2002 International AIDS conference in Barcelona. It happened at the previous conference in Durban two years before that. The 2004 International AIDS conference in Bangkok saw the kiosk of Gilead Sciences, a California-based producer of the anti-retroviral drug Viread (or tenofovir), being thoroughly trashed by activists.

This year’s international Conference on Retroviruses and Opportunistic Infections (CROI) in Denver is no exception. And it is Gilead Science being taken to task again, not by AIDS activists, but by the Nobel Prize-winning Doctors without Borders, better known outside the United States as Medicins sans Frontieres (MSF). According to MSF-USA, Gilead unveiled its ‘global access program’ for developing countries to great fanfare over three years ago, promising to eventually reduce its prices for tenofovir to 97 countries. They looked like the good guys. But in the meantime, tenofovir has actually only been registered in 6 developing countries: the Bahamas, Gambia, Kenya, Rwanda, Uganda, and Zambia.

According to MSF, the company has not bothered to request marketing clearance or gone through other regulatory procedures to make its drugs available in most developing countries – the typical behavior of a drug company faced with unprofitable markets. (Gilead’s HIV/AIDS products made $1.39 billion last year, up 47% from 2004, presumably in the better-off regions of the world.) Unfortunately, Gilead is the sole producer of this efficacious, low-side effect antiretroviral drug. No generic equivalent is currently being made. So if MSF’s side of the story is correct, many AIDS patients in low-income countries will just have to wait until Gilead sees a market advantage in registering its product and lowering its prices. Since ‘waiting for treatment access’ in low-income countries is often a polite way of talking about death, this is a serious accusation.

Thursday, February 02, 2006

Corruption is bad for your health

Transparency International has just published its 2006 Global Corruption Report which highlights corruption in health care systems globally and its effects on human health. Corruption is estimated to siphon away some 5% of the 1.7 trillion dollars in global health care budgets, and practices of thief, bribery and extortion may be responsible for lowered standards of care and the spread of drug resistant diseases. Of course, the ones who pay the most for this are the world’s poor, who may not have the kwacha, pesos or francs to pay bribes, or the means to avoid taking fake drugs, or the choice not to fall victim to what ends up passing for care in under-resourced clinics.

The BBC Health site has some commentary on the report, both on why health care systems are so prone to corruption worldwide, and what can be done about it. Fighting global corruption in health care looks like an uphill battle, however, when it is viewed as stemming from the nature of health care systems within a competitive market context: “What marks the health sector out is that there are large sums of money - often public - washing around in complex systems involving a variety of players from doctors and patients to drug firms and government officials, all of whom have competing interests.” Maybe the plot of The Constant Gardener was not so farfetched after all.

Wednesday, February 01, 2006

Is bioethics a 'rich country' affair?

The BMC Medical Ethics site has recently published an interesting article by a group of Belgian researchers entitled 'How international is bioethics? A quantitative retrospective study.' The group sought to determine the nationalities of those who wrote for nine bioethics journals that profile themselves as 'international' between 1990 and 2003. Perhaps it should come as no surprise that bioethics authors from the United States, Canada, the UK and Australia are overrepresented, claiming between them authorship of roughly 80% of all bioethics articles published by those journals. Only 3.4% of articles published by those nine journals over that period were penned by bioethicists from developing countries. Of course, bioethics is not alone as far as this is concerned. Underrepresentation of the work of developing world health researchers in peer-reviewed medical journals has been a matter of discussion for years.

In bioethics, the problem is not (just) underrepresentation of developing world authors. It is also an overrepresentation of developed world topics in bioethics. Just as 90% of the world's health research resources are devoted to the study of the diseases afflicting 10% of the world's population, a large percentage of bioethics discourse may be devoted to the discussion of the ethical implications of medical technologies that only a small fraction of the world's population can even comprend, much less access. (This month's editor's choice at the Journal of Medical Ethics is about cyborgs and moral identity, by the way.) An another quantitative study should be designed that focuses not on who does the talking, but what the talk is mostly about, and what the talk says about the current state of bioethics and the world.

Ethical review of research in Africa: sobering reading

There have been a number of initiatives in the past to -- as the jargon goes -- strengthen capacity in the ethical review of research in Africa. This blog is sponsored by one such initiative by the Fogarty International Center. A recent article in BMC Medical Ethics by Kirigia et. al. ('Status of national research bioethics committees in the WHO African region') shows that there is still a long way to go. The study arose from a suspicion, expressed by WHO's Regional Committee for Africa back in 2001, that some health-related studies in the region were not subjected to ethical review at all. If The Constant Gardener is anything to go by, the suspicion is alive and well.

One of the startling features of the Kirigia study is the terrible response rate: the researchers sent a questionaire concerning the existence and nature of ethical research committees to 46 countries, and only 28 bothered to reply. Of those that bothered, only 64% confirmed the existence of an ethical review committee, while at the same time 85% acknowledged that reviewing scientific research involving human subjects is, um, required. Which means that 15% of the respondent countries did not think that ethical review of protocols was necessary at all, though fortunately Kirigia et. al. had the wisdom not to disclose the names of those countries to the pharmaceutical world.

Let's look on the bright side. The study focuses on the existence of national research ethics committees, and seemed to consider regional or local review as something less than the real thing. But this can't be right. The DR Congo is noted as having a national research ethics committee, but this hardly inspires confidence, because few know whether the committee actually reviews protocols (or its inner workings in general). And Malawi is recorded as not having a research ethics committee, but the College of Medicine in Blantyre has a very capable ethics review board.

While I'm at it, I should mention the existence of a new, European initiative to reinforce the ethical review of research in Africa. The European and Developing Countries Clinical Trials Partnership (or EDCTP) is a European Union project to support biomedical research on neglected diseases in Africa, and part of the funding goes to the strengthening of ethics review in the countries of interest. They have put out calls for proposals, so African bioethicists and research institutions -- particularly those with European partners -- should take note.