Africa does not need your (dirty) underwear

Friends of mine notified me about a company in Canada, Nectar Lingerie, which is promoting a campaign to send women's 'gently used' underwear to Zambia. The campaign is advertises its humanitarian motivations as follows:

In many parts of Africa, women go without bras and panties because they cannot afford them. Bras and underwear are considered luxury items. Wearing these items raises the social status of women in their communities, which reduces the instance of rape and helps stop the spread of infectious diseases. 

But this statement does not seem to be evidence-based. This is the first time that I have heard of a widespread African panty and bra shortage. And I have not seen data from the Journal of African Knickers comparing how many women are going commando in low-resource countries as compared to their more affluent counterparts. In any case, it is hard to say how wearing drawers could raise the social status of women, unless they flash them, wear them on the outside of their clothes, or otherwise make their smalls known to the community. And as for the idea of undies as means of combatting rape and infectious diseases in Africa, it is hard to know what to say. It seems analogous to sending (used?) plastic forks to Africa to combat malnutrition. But this is more insulting: with rape and gender violence being such a serious and pervasive structural problem in Africa, the idea of sending drawers -- used drawers for god-sake -- as a response is appalling. In addition, once you remove the 'humanitarian justification', you are left with a company that shamelessly and cynically proclaims itself to be 'helping Africa' in order to raise sales among the developed world ladies. Exploitation anyone?

After a few pointed emails from friends, Nectar Lingerie took down their Undies for Africa webpage. But they cannot take down everything, and you can find remnants of it, for example here and here. But this made me wonder whether there similar campaigns around. And sure enough. How would you like your drawers to have been previously aired on Shildon High Street, by a funeral company no less? The maternity underwear company in New Zealand Hot Milk has its Knickers for Africa campaign, which also trots out the idea that panties are an unbelievably effective barrier against rape, HIV and sexually transmitted diseases, based on the musings of a local priest in Zimbabwe. I am sure there are more of the same.

Bottom line: just like Haiti does not need your Superbowl t-shirt, Africa does not need your Victoria's Secret hand-me-downs.

Newborn circumcision for HIV prevention in Zimbabwe

It is fair to say that the connection between male circumcision and HIV prevention is known by now, i.e. the idea (supported by a number of research studies) that being circumcised reduces your chance of gaining the virus from an HIV-positive woman during sex. There are those who doubt the results of the studies, which is predictable when you are talking about a controversial surgical intervention to control a highly stigmatizing infectious disease in circumstances of poverty. And, perhaps less known, are the initiatives taking place throughout sub-Saharan Africa, backed by powerful donors like the Bill and Melinda Gates Foundation, to circumcise males for this purpose. If estimates are to be believed, hundreds of thousands of circumcisions prevent thousands of new HIV infections. HIV will not be circumcised out of existence, but in the face of a deadly epidemic you take what you can get.

Previous efforts have been focused on circumcisions among adolescent and adult males. These are men who are (just about to be) sexually active and likely to acquire HIV. These were also the populations for the studies showing that circumcision lowers HIV risk. This is why the new plan in Zimbabwe to promote circumcision among newborns is interesting and potentially explosive, for different reasons. Circumcising infants would only have an effect on HIV prevalence in the next generation. By the time that the infants become sexually active, the landscape of HIV/AIDS may have changed: perhaps there will be more effective means of prevention, perhaps there will be a cure, perhaps there will be a vaccine. Importantly, infants are in no position to give informed consent: there are strong arguments in favor of allowing persons to choose for themselves in such a case. It is also not clear how the public health approach in Zimbabwe relates to traditional male circumcision practices, nor how the intervention is going to be 'sold' to parents in communities who do not traditionally circumcise. Worries about circumcised men feeling more protected than they really are abound. And as for the newborn circumcision policy: recommended circumcision? Incentivized circumcision? Mandatory circumcision? So this is very much a work in progress, and we will see where it goes.

The politics of polio in Pakistan

A health official assisting in polio vaccination efforts was killed last week in Quetta, in the province of Balochistan, in Pakistan. It is not yet clear whether the killing was a personal dispute or if it was a Taliban supported attack against polio vaccination efforts in the region. The latter is a distinct possibility: the Taliban has made its opposition to polio vaccination campaigns clear, issuing a pamphlet back in June describing its position on the matter, and back in July another vaccination worker was killed and others wounded near Karachi. For its part, the Taliban argues that US efforts to eradicate polio in Pakistan contradict US efforts to combat terrorism in the region, more specifically its campaign of drone strikes. As Taliban officials argue, many more Pakistanis -- including women and children not involved in terrorist activity -- have died or been injured (psychologically and otherwise) from drone strikes than have died or are likely to die from polio.

When you can see the point in a Taliban ethical argument, the world is a dark place. The continuation of drone strikes in Pakistan, whose efficacy and legality has never been particularly clear, is a serious blemish on the current Obama Administration. (Some left-leaning Americans would abstain from voting in the upcoming US elections, largely for that reason). On the other hand, polio eradication goes beyond the depressing, dysfunctional and deadly relationship that US and Pakistan currently have. The eradication of polio is of global interest: it is important that it joins smallpox in the tiny category of eliminated infectious diseases, while we still have the chance.  

New work on ancillary care responsibilities

Health researchers in low-resource settings -- wherever they are located in the world -- are familiar with the following ethical problem: what if your research participant has a significant health problem that is unrelated or tenuously related to what your research is about? Do you have an ethical responsibility to do something about, and if so, why? Why is it your responsibility, rather than (say) the responsibility of your funder or the local government? And what exactly are you responsible for: giving health advice, giving a referral, or giving medical treatment? If participants in health research were not often poor, or were in better health, or had better access to adequate health care, this sort of thing wouldn't happen. But that is not the world we live in, and so we are left with the ethical conundrum of what is has been dubbed 'ancillary care responsibilities.'

Congolese colleagues of mine and I are convinced that the question of ancillary care responsibilities is a particularly fruitful angle for teaching research ethics in low-resource countries. The topic has a bit of everything, intricately related: the relationship between research and medicine; the problem of undue inducement; community engagement; the roles of research ethics committees; obligations towards research participants versus non-participants; provision of care as obligation versus act of charity; politics of international research priorities; benefiting participants versus concerns about data integrity; the social determinants of ancillary care needs. And so on. Our shared view is that approaching research ethics through the prism of ancillary care rather than the usual approach (history of appalling research abuses followed by discussion of informed consent) is a stimulating and locally relevant option in low-income settings that do not share that history and are not aggressively individualistic. With ancillary care, you can go from very theoretical discussions about the nature of the researcher-participant relationship to practical specifics about what responsibilities may hold for research on a particular condition in a specific setting. And back. A full workout for mind and heart.

The best bioethicists currently working on this issue, in my opinion, are Maria Merritt at John Hopkins University and Henry Richardson at Georgetown University. Merritt has published a number of articles on ancillary care (most recently with Holly Taylor in the Journal of Nutrition) which are models of the best bioethics can offer, both philosophically rigorous and relevant for real world decision-making. Richardson has just published an illuminating, sophisticated, and elegantly written book-length treatment of ancillary care. Critics of bioethics, read them and weep.

Visual recording for biomedical purposes: Islamic perspectives

The Journal of Medical Ethics just came out with a short article on the Islamic perspective regarding  taking photographs or making video recordings of people's bodies for medical purposes. Not surprisingly, there are many similarities with 'conventional', non-Islamic ethical standards: informed consent is important, as well as respect for dignity, confidentiality and privacy. It matters how the images are to be used and how they are stored; the recording should also have a legitimate scientific purpose, which could not be realized by alternative, less infringing or less identifying means.

But there are some interesting differences: for medical recording to be ethical, the process of gaining and using the images has to adhere to (or at least not contradict) Shari'ah law. One important consideration is what part of the body is being photographed or video recorded. The concept of awrah refers to a body part that is forbidden to be shown to specific individuals, either in person or in photographs. While it is forbidden to record body parts considered awrah, there are rare exceptions: when a trustworthy Muslim specialist certifies that there is a necessity to store, use or view images involving awrah (such as reporting of sexual abuse), then this is justified and does not contravene Shari'ah law. Interestingly, there are strong gender differences in what is considered awrah. For men, awrah is the area between the navel and the knee. For women, awrah is the whole body except the hands and face, and in some circumstances the feet also fall into the category of the 'unrecordable.'

For an outsider, it seems strange that photographing a woman's elbow for medical purposes is considered as prima facie unethical as photographing her vagina for medical purposes. The discrepancy also seems to foster to gender inequity in health, given that recordings are commonly used in clinical care, biomedical research and medical education: I imagine that, given the strictures, most of these images are of male bodies. Whether or not you agree with them, these are considerations important to know when delivering care or conducting research with devout members of this faith.