Saturday, May 29, 2010

Global research ethics lecture series

For a few months now, the kindly editor of Yourprof (Michael Valerio) has been asking me to check out his website. Yourprof is in the business of commissioning learned folks to talk about their fields of expertise. Michael asked some of the most experienced people in research ethics to explain some of the challenges of conducting health-related research around the world, particularly in resource-poor settings. They go beyond the standard questions about informed consent to issues about community engagement, the impact of culture, priority setting in health research and the growth of private health research institutions.

Being still neck-deep in work for the moment, I have not been able to watch them all yet. I have promised Michael to write a review when I finally do. But you don't have to wait for me to get my act together. The link to the list of all talks on Yourprof is here; just scroll down to the global research ethics talks.

Wednesday, May 12, 2010

Obama and the ethics of reining in global AIDS treatment programs

Tomorrow, May 13th, President Obama will be at a fundraiser for the Democratic Congressional Committee at St. Regis Hotel in New York. Outside the building, AIDS activists from around the world will be gathering to protest the Obama's administration's approach to the funding of global HIV/AIDS treatment programs. These same groups most likely celebrated Obama's election in 2009: so how did this happen?

On the face of it, one can see the protests as a reaction to broken promises: the Obama administration promised, during the election campaign, to add one billion US dollars per year to the funding of the President's Emergency Plan for AIDS Relief (PEPFAR). But this year he asked Congress for only $366 million, the lowest increase in funding since PEPFAR began, citing the recession as justification. But this is part of a general pattern. The US government has also reduced its contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria by $50 million. There are memos from major US funders circulating around, instructing clinics and programs abroad not to enrol new patients unless they are replacing others who have left or died. The general slowdown in funding is bound to have the concrete consequence of excluding HIV-positive persons from accessing needed treatment. Sick persons will be turned away. No wonder the activists are up in arms.

On the other hand, there is something Frankensteinian about PEPFAR and similar HIV/AIDS treatment programs. The first decade of the twentieth century saw calls for aggressively increasing access to AIDS treatment in the developing world: ambitious targets were set, and programs strove to meet them. Clinics and labs were built. Persons were hired and trained. There were (partial) successes, measured in numbers of persons on treatment. But oftentimes the infrastructure and manpower developed by these foreign-funded programs sat uneasily beside (chronically underfunded) local health care systems. Local governments did not 'take ownership of them' (as the public health jargon goes), for the simple reason that they did not really own them. In the recent past, foreign funders have simply kept on increasing funding to AIDS treatment programs, but there are good reasons to doubt the wisdom of this approach: treatment for AIDS is lifelong, and more and more persons are in need of AIDS treatment each year. Are these global AIDS programs to be bankrolled by foreign institutions, at increasing rates, forever -- or at least until a cure for AIDS is found? Of course, stopping or severely reducing funding is not an ethically palatable option either: it condemns very poor and sick persons to death. Stopping treatment risks creating resistant strains of the virus. Once you start up with these programs, lives literally depend on them.

The Obama administration seems to acknowledge that increasing funding ad infinitum to non-sustainable AIDS treatment programs is untenable, recession or no recession. The administration is banking on smarter ways of using available funds, including treating the sickest patients first, shifting attention and resources to HIV prevention, and (importantly) working towards the goal of local governments supporting and delivering HIV/AIDS-related services themselves. The chance of this pragmatic approach appealing to AIDS treatment advocates is next to nil, so expect a lot of heated speeches outside the St. Regis tomorrow night.

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