An epidemic of health care worker strikes

This seems to be a summer of strikes among health care workers, raising again the ethical issues surrounding hospital strikes, particularly in resource-poor countries. On the one hand, state-paid doctors often work in abysmal conditions for relatively meagre wages, and when a strike breaks out, it is often a matter of doctors and nurses finally reaching the end of their tether. On the other hand, patients suffer when health care workers strike. They must wait longer or seek alternative care -- if such care is available and affordable. In many poor countries, the alternatives to health care in state hospitals are few. Traditional healing is one. No care at all is another. The impact of such strikes on patients are rarely the object of scientific study, but surely long and lingering strikes, where only the bare minimum health services remain in place, must be a source of avoidable morbidity and mortality. In the middle of all this you have the Ministries of Health: sometimes acting as mediators, and sometimes (because they are arms of government) the origin of the dispute and an obstacle to its resolution.

The provinces of Kwazulu-Natal and the Eastern Cape in South Africa are in the midst of a prolonged strike. State health care workers in Zambia are facing dismissal by the government if they do not show up to work by next Monday. In Adamawa state in Nigeria, health workers have started an indefinite strike and patients seem to be leaving the abandoned wards of clinics and hospitals in droves. And in the Democratic Republic of Congo, a health care workers strike has been going on for ages, though generally unreported in the press. Our sister blog, The Francophone African Bioethics Blog had a piece about this (in French) back in May, and the strike is still unresolved.

Each strike has to be judged, from an ethical point of view, on a detailed and (ideally) balanced account of the relevant facts. But some basic principles should be followed. Urgent medical services should always continue to be provided during a strike, and those providing them should not be regarded as 'scabs' or strike-breakers. Health care strikes should be regarded as qualitatively different than strikes in other labor sectors, due to the special value of health. For that reason, a as-swift-as-possible resolution of the strike should be the top priority of the health ministries involved, because of the impact that every day of the strike has on the ethical core of the issue: patient health.

Mandatory male circumcision in the Zambian police force

In the last couple of years, there have been a number of high-profile studies exploring the relationship between male circumcision and HIV acquisition. Three randomized clinical trials in Africa confirmed an association suggested by less rigorously designed studies, i.e. that men who are circumcised are significantly less likely to acquire HIV from infected women during vaginal intercourse. But what to do about these findings in terms of public health policy? The professional views and lay public opinions are highly diverse and sometimes highly emotive. Some in public health circles consider male circumcision as effective as a vaccine and the promotion of male circumcision in regions of high HIV prevalence as an ethical imperative. Others, who have ethical objections to (especially neo-natal) male circumcision in general, criticize the methodology of the clinical trials, question their conclusions, and view the promotion of male circumcision as deeply misguided and harmful.

Whatever side one takes on this issue, the approach of the Zambian police force is bound to raise eyebrows. According to the Lusaka Times, the national police force is planning to make male circumcision a requirement for all new recruits. The police force has apparently been losing male police officers to HIV/AIDS. Male circumcision is being strongly promoted in other professional contexts in sub-Saharan Africa, such as Rwanda, which has included it as part of an HIV prevention strategy within its army.

Of course, the Zambian approach is not 'mandatory male circumcision' in the strict sense: it is only mandatory among those who have chosen to join the police force. At the same time, the idea of mandatory irreversible preventative genital surgery on healthy males bound to be controversial. Making the practice obligatory, rather than a matter of choice, raises the ethical stakes: you need a very strong justification to move from voluntary to mandatory. Is the HIV incidence among policemen in Zambia very high? If so, what explains that incidence? Is male circumcision likely to counteract whatever forces are driving the high incidence? To pull off a utilitarian justification of the policy, you need to clearly show that the overall benefits of the policy will outweigh the overall costs. And even if you do, not everyone will be impressed: not everyone is a utilitarian.

For a flavor of the online debate this sort of story inspires, have a look over at the Universal Circumcision blog.

Hat tip: Daniel Westreich.

Are countries that ratify human rights treatises more healthy than others?

One might think that a country which has ratified human rights treaties, and thus has made them to some extent law, will have better health outcomes than countries where this is not the case, all things being equal or at least controlled for. A study just published in The Lancet indicates otherwise. The researchers looked at some key and often-measured health and social indicators, and sought correlations between number of treatises ratified and changes in health/social indicators before and after ratification of health-related human rights treatises, as well as making comparisons between health/social indicators in a total of 170 countries that did or did not ratify certain treatises.

The results are sobering, or perhaps predictable, depending on one's pre-existing opinions about the power of human rights approaches to health. Ratification of human rights treatises does not seem to have any significant effect on maternal mortality, infant/child mortality and life expectancy. The researchers try to put a brave face on the data, by adding that ratification of human rights treatises can have some indirect (but hard to pin down) effect on health by strengthening legal arguments aiming to ensure access to health care. But in the end, money trumps law: there is much greater evidence of an association between economic conditions and health than there is between the ratification of human rights and health.

One might object by saying that ratification is the mere promise of action, just the signing of a paper, and we should only expect an effect in terms of health outcomes in countries that rigorously monitor, enforce and make its human rights commitments real. In other words, in finding no significant association, what the researchers have actually done is study the global absence of political will in regard to human rights relevant to health.