Monday, May 20, 2013

Health care strike in Mozambique

When I was in Maputo last week, the big ethics issue in the country had nothing to do with biomedical research. There was a buzz about a possible doctor's strike. But the doctors I met said it was actually a bluff: the government would open negotiations before the strike deadline, the medical association would craft some sort of compromise, and the whole thing would blow over. On the other hand, Doctors in Mozambique did go on strike back in January for nine days, though there are conflicting reports as to the extent of the strike.

Well, today they are striking again. According to the newspapers, doctors are demanding a base salary of $3000 per month, while the government is offering between $600 and $1200. Much of the problem has to do with equity: the doctors in the public sector in Mozambique are government employees, and there is a strong sense (rooted in Mozambique's Marxist tradition) that there should not be significant inequities in pay between public sector jobs. If the government raises the base salary of doctors, but does not offer something similar to other public sector employees, they may have a more general strike on their hands. However, if they do not satisfy the demands of the doctors, the lives and welfare of citizens may be in danger: even if the Mozambique Medical Association insists that essential services will remain open, I heard much dispute about what should count as 'essential' in such circumstances. In any case, it would not take much of a strike to have a significant impact on patient health, given that the physician/patient ratio is 1 to 22000.

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Thursday, May 16, 2013

Ethics of implementing male circumcision in Swaziland

Dispatch from Maputo, Mozambique. As far as I know, the European Union has sent me here to discuss ethical issues in research with new ethics committee members. In the past, there was only one ethics committee in Mozambique, whose original mission was to review all health-related research. As requirements to get ethical approval (for funding, for publication, etc.) get more strict, and the number of local research studies involving human participants rises, having just a single committee is no longer workable or sustainable. So they are wisely decentralizing into a number of institutionalized ethics committees around the country. I am here to discuss the ins and outs of ethics committees, their ups and downs, their virtues and vices.

During downtime in the Hotel Cardoso, I noticed this piece about implementation of male circumcision initiatives in Swaziland. Apparently, these HIV prevention initiatives have not come close to reaching their targets, after millions of dollars have been spent, causing both soul-searching and finger-pointing. (The program spent almost 500 dollars per circumcised male in a country which has an average per capita annual income of roughly $5000). I've thought for a long time that much more bioethics attention -- to its detriment -- has been spent on research ethics than the ethics of implementing research results into practice. The latter has its own particular conundrums, such as: what do you do about a (less than) half-implemented program? Particularly when part of the reason why the implementation was partial is due to significant community reluctant/resistance towards the very idea of male circumcision for HIV prevention? Where should you go from here?

Community concerns about male circumcision and HIV prevention include: why do circumcised men still get counseling about using condoms? What happens with the foreskin? Is there any connection between these circumcision programs and witchcraft? Why must men need to refrain from sexual activity for some time afterward? Other forms of resistance or reluctance, in the Swazi case, reach up to the highest levels of policymaking. Local public health authorities may have been interested in gaining funds and collateral benefits from male circumcision initiatives, while being skeptical about the value of the intervention itself. Low community and governmental 'buy in' (as they call it) can derail any public health program. Add to this the work of the anti-circumcision groups and individuals worldwide, who can be found on the comments section of any news item on male circumcision and HIV, whipping up fears and debunking the science. For the latter, the ethics of implementing male circumcision programs is simple: just make it stop.  

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