Friday, March 30, 2007

Vaccines for neglected diseases in Africa

The big news this week in health and the developing world was the announcement by super pharma giant Glaxo Smith Kline (GSK) has initiated the registration process for Globoxis, a conjugate meningitis vaccine. The press releases have been careful to note that GSK will marketing its vaccine at a price that stands zero chance of recuperating the R&D costs (estimated at $400 million) the company put into Globoxis. GSK’s initiative aims to showcase the company’s commitment to the eradication of preventable but neglected diseases suffered by impoverished populations. Undoubtedly, here is another corporate public relations exercise, but if the hype-and-spin saves hundreds of thousands of African infants through low-cost, mass vaccination campaigns, bioethicists shouldn’t sniff too much at it.

Another item out this week offers a cautionary note. In a PLoS Medicine article, Ayodele Samuel Jegede analyzes why three states in Nigeria boycotted the polio immunization campaign back in 2003. As Jegede describes it, there were a number of factors at play, including the rumor (fed by US military involvement in Iraq) that the vaccine would be used by the Western world to make people in the Muslim areas of Nigeria infertile or infect them with HIV. Another factor was the 1996 scandal of the Pfizer Trovan trial, where the experimental antibiotic trovafloxacin was tested against the standard of care during a meningococcal meningitis outbreak in Northern Nigeria. But the factor that struck me was that communities in Nigeria were reluctant to embrace the very idea of free vaccines. Jegede quotes from a report in the Baltimore Sun:

The aggressive door-to-door mass immunizations that have slashed polio infections around the world also raise suspicions. From a Nigerian’s perspective, to be offered free medicine is about as unusual as a stranger’s going door to door in America and handing out $100 bills. It does not make any sense in a country where people struggle to obtain the most basic medicines and treatment at local clinics.

Successfully vaccinating a population apparently involves more than just making it cheap. It remains to be seen whether GSK’s commitment extends to the nitty-gritty work of engaging with local communities to find appropriate ways of putting new high-tech drugs into the bodies of African children.

Friday, March 16, 2007

The Lancet: a whole new meaning

Technically speaking, a lancet is a sharp pointed, two edged surgical instrument used in venisection and for opening abscesses. It is a symbol of how medicine sometimes has to be cruel to be kind, opening wounds in order to promote healing. Of course, the lancet is better known for the medical journal of the same name. What is a bit less known, until recently, is that the publishing company that owns the Lancet, Reed Elsevier, has interests in the arms trade. One of its subsidiaries, Spearhead, organizes arms fairs. You heard correctly: a leading health journal -- the same one that published a controversial study estimating the number of Iraqi civilian deaths -- is connected to arms dealers. This is not a result of deep investigative journalism either. It has been public knowledge for the last couple of years. It is even on Reed Elsevier's wikipedia entry, forgodssake.

Former BMJ editor Richard Smith, in a recent editorial published in the Royal Society of Medicine entitled 'Reed Elsevier's hypocrisy in selling arms and health', calls for authors and readers to act. Acting means: don't buy subscriptions to Reed Elsevier journals, and don't write for them. That's a tall order, though: Elsevier publishes everything from Cell to Social Science and Medicine. It also owns ScienceDirect, which is one of the largest online collections of published scientific research in the world, containing over 8 million articles from over 2000 journals. Perhaps the better route is continuous public shaming until hopefully Reed Elsevier stockholders scurry into less conspicuously compromising investments.

No better time than the present.

Dear Reed Elsevier:
It is difficult to express the depth of suffering that the arms trade involves, particularly in developing countries. Where I work, in the Congo, an estimated 4 million people -- the majority non-combatants -- have died from war-related causes in the last 15 years. This is a terrible injustice, and by failing to divest from companies that (among other vectors of death) peddle cluster bombs, you place your company on the wrong side of the moral equation, as well as making yourself a laughing stock of the global health community. Unless you want people to think 'Reed Elsevier' when they see African children holding AK-47's, rethink your portfolio.

[Disclaimer: The author of this post once published a research ethics article in the Elsevier journal Trends in Parasitology in 2004. He would like to point out that this was before he heard about Elsevier's connections with the arms trade, and that absolutely no one read the article anyway.]

Indian Journal of Medical Ethics and bioethics from an 'axis of evil'

The last post was about India, and since we're in the neighborhood, let me make a plug for the Indian Journal of Medical Ethics. Established in 1993 by the non-profit Forum for Medical Ethics Society, the IJME focuses on medical ethics issues in India and the developing world. The medium is the message of the IJME, because its articles are open-access and in simple html format, unlike certain journals whose offerings require Adobe Reader and/or a pricey subscription.

This month's issue has an eye-opening article on abortion practices and policy in Iran. According to the authors Larijani and Zahedi, Iranian abortion policy is based on Islamic conceptions of fetal development, more specifically the notion of 'ensoulment', the point 120 days after conception that the fetus becomes a full human being. Before that, abortion may be permitted under certain conditions: to save the life of the mother or if the fetus has a serious pathology. Interestingly, the Iranian government no longer requires the consent of the father for a woman to have an abortion under these conditions, and even when women have an illegal abortion, they can count on care within Iran's private or public hospitals. The emergency contraception is also available in family planning clinics. Even more interestingly, perhaps, is that the same conception of ensoulment that supports limited forms of abortion seems to allow for embryonic stem cell research and therapeutic cloning.

This nuanced policy and the lucid prose in which it is expressed does not jive with the current image of Iran and Iranians as 'hardline Muslims with missiles.' In the current geopolitical climate, one is less likely to find much discussion of bioethics from Muslim nations in any mainstream American or European journal, though Cambridge Quarterly of Healthcare Ethics (subscription required) did publish an article in 2005 with the rather off-putting title 'Pakistan and biomedical ethics: report from a Muslim country', and The American Academy of Pediatrics put out a fascinating primer on Islamic biomedical ethics for pediatricians, alas, just before the 9/11 attacks. The journal Developing World Bioethics, as usual, makes no bones about publishing articles from countries deeply out of favor with US foreign policymakers, having issued another piece co-authored by Larijani and Zahedi in 2006 (free access to low income countries via HINARI) on establishing medical ethics programs within the Iranian national health care system.

The richer countries continue to dominate the bioethics scene, but it is good to see a glimpse, through the prism the IJME, of what the other 80% are doing.