Friday, January 13, 2012

Failing to treat TB, until TB treatment fails

There are reports coming out of India of patients who have tuberculosis that responds to none of the existing drug regimes. When you have MDR (multidrug resistant) TB, the first-line drugs will not work on it, and your physician has to resort to second-line drugs that tend to be more expensive, less effective, have more side effects, and take longer to cure you from TB. When you have XDR (extensively drug resistant) TB, there is no point in you taking the first-line drugs as well as several of those in the second-line. Your clinical options and prognosis dwindle. Now there is the concept of TDR (totally drug resistant) TB, where patients are cast back into medical history, back to the time of the sanitorium and folk remedies.

TB is curable and, as is well recognized, failure to cure has to do with non-adherence to lengthy TB treatment, poor diagnostics, weak health care systems, and lack of political will. TB, in principle, could have been as prevalent today worldwide as polio. Instead, primary TB continues to kill millions every year, and if that is not bad enough, we now apparently have pockets of TDR in the world to control and contain. It is striking that a recent letter to Clinical Infectious Diseases states that systematically poor clinical management -- lack of medical ethics at the most basic level -- is helping to fuel TB drug resistance:

The vast majority of these unfortunate patients seek care from private physicians in a desperate attempt to find a cure for their tuberculosis. This sector of private-sector physicians in India is among the largest in the world and these physicians are unregulated both in terms of prescribing practice and qualifications. A study that we conducted in Mumbai showed that only 5 of 106 private practitioners practicing in a crowded area called Dharavi could prescribe a correct prescription for a hypothetical patient with MDR tuberculosis. The majority of prescriptions were inappropriate and would only have served to further amplify resistance, converting MDR tuberculosis to XDR tuberculosis and TDR tuberculosis.

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Tuesday, January 10, 2012

Playing good cop/bad cop with Guatemala

Last year, the discovery that abusive sexually transmitted disease (STD) research was funded and conducted by the US government in Guatemala in the 1940's was headline news. This week, we are hearing two quite different responses to those events in the press. The US Department of Health and Human Services announced that it will commit roughly 1.8 million to strengthen public health activities on HIV and STDs in Guatemala as well as help bolster ethical protections for research participants in that country. It is hard to see this newfound interest in Guatemala, STDs and ethics as a coincidence, and also hard not to see it as partly driven by public relations interests. But if it does good, it does good.

Then there is the other voice. Hundreds of Guatemalans who were participants (or family members of participants) are suing the American government for compensation. The US Department of Justice is apparently having none of it. The DOJ is quite willing to state that the research in Guatemala was shameful, unethical and downright wrong, but also quite happy to draw a very firm line between morality and legality: what is immoral is not necessarily grounds for a legal claim. So the DOJ is asking a federal judge to throw out the lawsuit. You can see the reasoning: President Obama and Secretary of State Clinton already formally apologized for the US government's role. President Obama set up a commission to express, to the countries in the world where the US does research as well as the American electorate, that those abuses are being taken seriously and steps are being taken to ensure no repeat performances. Isn't this enough?

Not everyone is comfortable about sticking purely with moral outrage and disapprobation when it comes to serious abuses of persons in biomedical research. Doesn't the whole pious talk about 'respect for persons' just blow hot air around if there is no place for punishment and compensation, at least in the most egregious cases? Obama's Commission itself seems to think that compensation for harm -- which governments and private companies have historically shied away from for obvious reasons -- needs to be rethought. We will see in the coming years which voice about Guatemala makes itself heard.

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Tuesday, January 03, 2012

Bioethics of food in the DR Congo

An article in the New York Times about the Democratic Republic of Congo had me thinking about bioethics on a very basic level. As organisms, humans need food to survive. This is clear. So if a society has become incapable of providing conditions where its citizens -- even formally employed ones -- can reasonably gain access to food for themselves and their families, something has gone really terribly wrong. This situation is not something that gains much attention in bioethics, despite the known impacts of undernutrition on health. For sure, nutrition makes an appearance once in awhile, say when discussing laws to ban trans fats in restaurants or sweetened beverages in schools. And the obesity epidemic will raise the profile ethical questions surrounding food production and consumption in the coming years. But the New York Times piece is not about how to regulate the consumption certain kinds of foods in order to promote health; it is about people being forced to chose who can get anything to eat at all. Choosing which of your children can eat today: that is a bioethical dilemma in a very raw sense.

Tracking the bioethics of food in the Democratic Republic of Congo would require a truckload of philosophy, history, anthropology, and most of all, economics and geopolitics. The well-known irony of the DR Congo is that it is one of the world's worst-off countries with one of the greatest reserves of precious natural resources. But it is not really an irony: it is closer to a causal relationship. Since colonial times, the Congo's lucrative natural resources (cobalt, coltan, gold, uranium) have drawn the attention of local and foreign governments away from the Congolese people and towards their own gain. The end result at this point in history is a kind of reductio ad absurdum of libertarianism: a country where the average citizen does not pay taxes, and is subsequently free not to receive much help from the government at all, in terms of roads, sanitation, education, health care, agriculture or food security. The recent farcical election in the DR Congo and the shameful near-silence about it in the aftermath indicates that it is not in the interest of any major power to change the status quo. So there will be food dilemmas and empty stomachs in Kinshasa households for the foreseeable future.

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