Wednesday, January 31, 2007

A world distorted by inequality

A cliché is a phrase, expression, or idea that has been overused to the point of losing its intended force or novelty -- or at least that's what Wikipedia says. This dour definition leaves room for optimism: a clichéd phrase could in principle regain its vitality. Take the hackneyed expression, "A picture is worth a thousand words." In a recent article in PLoS Medicine, Danny Dorling has managed to transform lifeless data about global health inequalities into a set of maps that are both visually arresting and downright appalling.

The usual maps on distribution of disease and health indicators start with Mercator-type maps, and just stick data on the different countries, like this. Or they use colors to indicate differences in disease prevalence, like this. But Dorling and other collaborators on the Worldmapper project do something else: they have designed a computer program where different kinds of global health data are visualized on cartograms in which territories are drawn in proportion to the health value being mapped. You can compare the results with a map depicting the planet's current population, just to see how out of whack we globally are.

The result is a whole new world, or rather, worlds. For example, have a gander at Worldmapper Poster 214, which charts private health spending. The United States looks as if it has been inflated by a giantic bicycle pump, ready to burst, while all of Africa shrivels to a narrow strip of land, except for the bulbous tip of South Africa. The map on Physicians Working (Poster 219) is much in the same vein. You can make Africa reappear (and India!) by calling up the Early Neonatal Mortality map (Poster 260), where the Democratic Republic of Congo by far dwarfs the whole of North and Central America. In the map on malaria (Poster 229), it is Africa's turn to burst. For those who find the health-related maps depressing, there is always Toy Exports (Poster 57), and the worldmappers are planning to issue a Films Watched map in the future.

Thursday, January 25, 2007

Let us compare disasters

For subscribers to Developing World Bioethics, there is an interesting online article comparing the responses of the international community to the tsunami in South East Asia in 2004, and to the AIDS epidemic in developing countries. According to the authors, the two responses were unethically different. The tsunami cost 273,000 people their lives, and ten billion dollars was pledged for the recovery efforts. In the same year, 3.1 million people died from HIV/AIDS, and there is a predicted 18 billion dollar shortfall between 2005 and 2007. The authors brush away any attempt to rationalize the differences between the two responses: whatever differences there are between a terrifying natural disaster and a deadly epidemic disease are not ethically relevant differences, and cannot justify why the tsunami relief effort received so much human, material and financial support while the effort to treat and control HIV/AIDS is painfully underfunded.

Maybe some of the differences can be explained like this. The tsunami was a concrete one-day event, even if its knock-on effects will be felt for quite some time. With HIV/AIDS, you are looking at a titanic struggle over generations: unless cures are found, all those who are HIV infected may need antiretroviral treatment and medical care for the remainder of their lives. Since no effective vaccine has been found, much of HIV epidemic control is about increasingly convoluted ways (condoms, microbicides, abstinence, circumcision, fidelity) of preventing people from getting the virus, and therefore found vast resources have to be devoted to saving abstract, 'statistical lives.' The chronic character of AIDS care and the abstract character of HIV prevention may help make AIDS less attractive to donors than a tsunami.

But the more fundamental issue is: how rational are communal ethical responses to disasters and crises, and how rational can we reasonably expect them to be? Consider the humanitarian responses in the United States in the wake of 9-11: vast resources were donated and allocated for an event that cost the lives of about 1% of the people who died in the Asian tsunami. Was this wrong? The donations of blood, time and money were at least partly expressions of grief and feelings of powerlessness, and not the result of an economic calculus. Can we be expected to make rational calculations about how much (or how little) should be spent on a given crisis, relative to other crises, in the general scheme of things? Should a panel of experts -- a kind of international crisis management team -- be convened to objectively allocate levels of resources to disasters, on the basis of dollars per death?

Tuesday, January 23, 2007

Gambian president claims cure for AIDS and asthma

It is a sad and terrifying thing when a head of state, drunk on power, starts to take complete leave of his senses. This is what seems to have happened last Wednesday with the president of Gambia, Yahya Jammeh. Speaking at State House before the Taiwanese and Cuban ambassadors and other dignitaries, Jammeh proclaimed himself as the possessor of mystical powers, capable of curing people of AIDS and asthma.

You heard right: AIDS and asthma. And he can cure people of AIDS in one day, as long as the day is Thursday, and on that day only ten cases please, five males and five females. Should you decide to go to Gambia to get the special presidential AIDS treatment, remember that while you may eat before getting cured, don't eat anything oily. For those who question his credentials as healer, Jammeh ended his rambling speech with these words of wisdom:

I am not a witch doctor and in fact you cannot have a witch doctor. You are either a witch or a doctor.

Jammeh does not consider a third possibility, i.e. that is he not a witch, or a doctor, but a dangerous liability. Dangerous, because of the message about AIDS he is sending to his people; a liability, because as commentators from Gambia politely put it, a man prepared to attribute mystical healing powers to himself is in no position to run a country in the modern world.
(Hat tip to Marin Gillis)

Monday, January 15, 2007

Male circumcision and HIV: a hard sell

A hard sell: that is how Bill Clinton, at the last International AIDS conference in August, soberly described the use of male circumcision as way of reducing the risk of HIV transmission from women to men. He was not doubting the science. After a string of randomized controlled trials, the science looks about as promising as HIV prevention science can look. Clinton was suggesting there may be pitfalls in the actual implementation of the science into policy and practice in the countries where HIV is most prevalent. This last month seems to have proved him right, and also showed how different perspectives on male circumcision and HIV can be.

As an early Christmas present perhaps, UNAIDS executive director Peter Piot is reported to have declared on December 19th that African countries should prepare to perform male circumcisions on a large scale, starting with baby boys first, then adolescents, then adults. Strangely, Piot stated that UNAIDS had no plans to promote male circumcision in high-HIV prevalent India 'where the issue is sensitive for the Hindu and Muslim communities.' Hopefully UNAIDS will catch wind of the idea that male circumcision is a sensitive issue everywhere that circumcision is not traditionally performed, or everywhere it is performed but not on the schedule (with baby boys) that UNAIDS might prefer.

The New York Times also ran a piece on male circumcision and HIV by Tina Rosenberg that profiled male circumcision as the only sort of HIV vaccine we've got, and even if it does not provide perfect protection, we should be darn happy with it. Since there is no vaccine of the immunological sort around, according to Tina, we should promote mass circumcisions right away.

The cold shower on circumcision came from the Ugandan President, Yoweri Museveni. At a discussion with medical students in Kampala, he claimed that the recent science on circumcision and HIV gives a 'mixed message' to men: if you are circumcised, you stand less of a chance of getting HIV if you practice unsafe sex. As is well-known, Museveni (and his backers among religious conservatives in the USA) prefer the unmixed message of abstaining from sexual activity until married, and then being unfailingly faithful to your wife or husband. From that perspective on HIV prevention, it does not matter if you are circumcised or not.

International agencies and domestic journalists should draw a lesson from Museveni's statements: just because a study shows that an intervention would have a big public health impact, it does not mean that everyone will be sold on it. The persuasive power of science only goes so far. The rest will be messy, and involve politics, morality, economics and culture. A hard sell, as Bill said.

Friday, January 12, 2007

Zimbabwe: health care in a tailspin

Observers of southern Africa have noticed two major factors that are negatively affecting development in the region. One is a deadly virus: HIV/AIDS. Another is a devastated country: Zimbabwe. The latter has devolved rapidly from breadbasket to basket case over the last two decades: life expectancy, a standard measure of human development, has plummetted from nearly 62 years in 1990 to around 37 years for men and 34 for women in 2006. According to the UN Food and Agriculture Organization, Zimbabwean women currently have the lowest life expectancy of all humans in the world. Naturally, the Zimbabwean government denied the validity of the statistics, and expressed its displeasure by cancelling a crop and food survey designed to assess the country's needs and avoid famine. Nothing new there: they rejected life expectancy figures back in 2001 too. Government denial seems to be growing in inverse proportion to the GDP.

How does this downward spiral play itself out within the Zimbabwean health care system? There are statistics that can be trotted out, but a piece today from the Zimbabwe Independent puts a human face on some of the inhuman conditions unfolding there. Junior resident doctors, grossly underpaid, terribly underequiped and with little promise of future employment, are on strike in order to leverage better working conditons. The more it is described, the more you can sympathize, until you witness the effect of the strike on the patients:

A junior resident medical officer stands in the consulting room doorway. He alternates between bobbing his head to register comprehension and twiddling with his stethoscope, while the younger son of a patient pleads: "He has been a regular patient here and has his medical records with him, please doctor."

He is one of the few striking junior doctors who decided they should only attend to emergency cases on a rotational basis.

A few paces from the doorway, the pleading man's brother tries to suppress spasmodic jerks from a languid body slumped in a wheelchair.

The sick man tries to draw his son's head down to tell him something, but the groping hand collapses into his lap in vain.

Moments earlier, the emptiness of the admissions ward at Harare Hospital had echoed with the tearless wail of a middle aged woman who had stomped out, too shocked to witness the tear-jerking spectacle of an equally disposed relative.

"The doctor says he cannot help," the son reports back to a group of relatives huddled in a corner.

What does medical ethics come to when medical practitioners are abandoned by their own goverment, and patients are abandoned by both?

Wednesday, January 03, 2007

Research ethics committees, Africa style

The Hastings Center's Bioethics Forum has an interesting post on the appropriateness of the 'American model' of research ethics committees for Africa. In the US, institutional review boards (IRBs) are housed mainly in research institutions (universities, usually), which are independent of the research funding agencies (such as the National Institutes of Health, CDC or the Gates Foundation). This allows members of the IRB to focus on the details of protocols, and to see if they meet regulatory requirements, without worrying about why (in the world) the funders saw fit to bankroll the project under review. In the US, the 'local IRB review' model has led to a frightening proliferation of IRBs, including professional IRBs for hire, as well as a whole industry surrounding human research protections.

In Africa, as authors Coleman and Bouesseau point out, things are both institutionally and contextually different. The creation of an extensive network of local IRBs in every research institution in low-resource countries would be impractical: who would pay for them all? And while local IRBs in the USA have political clout because they have the weight (including financial support) of their home research institution behind them, and a quasi-legal regulatory framework that their home institution must abide by, ethics committees in Africa start from a position of vulnerability and dependence. Decisions by African ethics committees may not be taken seriously by national regulative bodies, and since their home institution often relys heavily on money from externally sponsored research, these committees often find it difficult to reject protocols that bring in funds, infrastructual improvements and employment opportunities. The alternative model proposed by Coleman and Bouesseau is centralization: one ethics committee, working on a national level and housed in a government agency, would be cheaper and possibly have more credibility and clout than local ethics committees.

Perhaps. The viability of a centralization model depends on the condition of the government agency in question. Just last week, reports of corruption severely disrupting supplies of AIDS drugs to patients in Cameroon were all over the African and international press. How credible would an ethics committee housed in the current Ministry of Public Health in Cameroon be? In any case, the centralization model can only be a stopgap solution. To the extent that African-led research is encouraged (and it should be) and more and more biomedical research is conducted in Africa, no centralized committee could reasonably review all the protocols properly. Right now, every research protocol in Zimbabwe is double-reviewed: once by a local committee, once by the National Ethics Board. This is not a system that is built to last.

Coleman and Bouesseau make the important point that ethics committees in Africa -- unlike their counterparts in America -- should not be 'neutral' in regard to the issue of why a certain research proposal has been funded and whether it should take place at all. A key ethical concern for ethical committees in Africa should be whether the research in question will actually bring a significant benefit to the local community that weighs favorably with the risks the participants are taking. Of course, African ethical committees would have to be empowered to take such a principled stand, and power is precisely what is in unequal supply.