Wednesday, August 28, 2013

Going off HIV treatment in Tanzania

The ability to manage HIV with antiretroviral treatment, and turn it into (something like) a chronic disease, obviously constitutes important medical and public health progress. Before that, the only alternative was wasting and death. But it is normal that humans adapt to progress, and look for something better. After all, on closer inspection, HIV treatment may not be all it is cracked up to be, particularly as it plays out in low-resource countries. There may not be opportunities to receive the diagnostics that are needed inform optimum treatment. You may be switched from one treatment regime to another without any real medical justification. Patients may have some serious side-effects with certain medications, which may not be the drugs of choice in the better-off countries. And all too often, the supply of antiretroviral drugs may just plain run out. In the greater scheme of things, this fragile dependence on HIV drugs in order to survive can also be culturally and politically distasteful. The pills are little chunks of Western technology and culture, symbolizing an objectifying biomedical approach to human health and disease, and the pills are produced by multinational corporations in affluent Northern countries, some of them ex-colonizers. All in all, it can be a bit much to swallow.

In Tanzania this week, a news report states that quite a number of HIV-positive patients are going off their treatment and embracing traditional therapies. Some are dying in the process. Perhaps the time is ripe for the next phase: not HIV treatment, but HIV cure. No more pills, no more CD4 counts, no more going to the hospital and being ill-treated by staff. But who can say whether the cure would come without its own medical, cultural and political complications and dependencies.

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Friday, August 16, 2013

Gadgets for the poor and sick

How much can technological advances be expected to narrow the gap between the richer and poorer countries of the world, including the health gap in terms of life expectancy, morbidity, mortality, and the rest of the merry gang of indicators?

I guess I tend to be a bit skeptical about high-tech gadgets lifting people and communities out of situations of disease, oppression and squalor. For example: Kinshasa, capital of the Democratic Republic of Congo, is awash with cellphones. Unfortunately, that is not all it is awash with, and having a cellphone in itself is not much help when you struggle with a dodgy food supply, a cholera outbreak or an electricity grid gone AWOL.

So when Huffington Post asked me to comment on a TED talk about an innovative way of controlling malaria in Africa by zapping mosquitos with lasers ... my diminished enthusiasm was hard to hide. I hope I am proved wrong: maybe the lasers will rid Africa of the vectors of disease that cause so much mayhem. Who in their right mind wouldn't want that? But I have the feeling that technological inventions flourish in social, political and economic circumstances that are already in relatively good shape, while in the less favorable ones, they just add to the decor.

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Thursday, August 01, 2013

Research protections in India: a case of unethical ethics?

Yesterday, in the post below, I mentioned a controversy regarding a substantial withdrawal of research activities by the National Institutes of Health (NIH) in India. The controversy is gradually getting more media coverage, but little in the way of official explanation from the NIH. Here is one possible conjecture, however: the Indian regulations protecting human participants in research are problematic enough to necessitate halting NIH-funded biomedical research there, but the NIH is reluctant to pass official judgment on the regulations of another country with which it has collaborated fruitfully in the past. It is politically sensitive. This hunch can be supported to some extent by an editorial that came out yesterday in the BMJ, which states that the Indian regulations have three main problems, and that these problems are causally responsible for the recent decline in research activity in India overall, and not just by the NIH.

According to the authors, the three main problems are: (1) the regulations do not state how injuries suffered by research participants, and to be compensated by research institutions, are to be determined as 'research-related'; (2) the regulations have an overly broad interpretation of what counts as a research related harm, including (for example) use of placebo in a placebo controlled trial; (3) the regulations state that ethics review committees and licensing authorities have to help determine whether and to what extent compensation for harm is warranted, but it is unclear they have the relevant skills and resources to do so.

On this reading, it looks like a case of 'unethical ethics.' Unethical ethics occurs when, even with the best intentions, actions or policies meant to promote certain values end up doing serious damage to other important values. In this case, the drive to promote the welfare of research participants has apparently been taken to a point where it becomes difficult to conduct health research at all, including research focusing on important public health problems in India. The BMJ authors end on an optimistic note: the Indian government has the power to restore balance between the interests of research participants and research institutions by reforming the regulations. Time will tell.

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