Tuesday, May 20, 2014

CIA-sponsored vaccination programs: spin and tailspin

According to Wikipedia, the concept of 'spin' in public relations circles refers to "... a form of propaganda, achieved through providing an interpretation of an event or campaign to persuade public opinion in favour or against a certain organisation or public figure. While traditional public relations may also rely on creative presentation of the facts, 'spin' often implies disingenuous, deceptive and/or highly manipulative tactics."

It might be worth adding a related concept to the public health vocabulary: tailspin. Tailspin is when, in the attempt to massage facts to persuade the public, you make yourself look completely unreliable or absurd. It is spin gone wrong.

I think today's press conference by the CIA could work as an example of tailspin. Dean Boyd, CIA spokesman, announced that the CIA has stopped (since last August) using vaccination initiatives in Pakistan in its spying programs, or what CIA director more delicately called the 'operational use of vaccination programs.' The CIA has also stopped using such programs to obtain DNA or other genetic material for security purposes. Such use of vaccination programs is not unknown to the local Pakistani population, notably militants hostile to American interests. More than 60 polio workers and security personnel have been killed in Pakistan since 2012.

Admitting the existence and halting of the program seems fair enough. After all, causal -- if not moral  -- responsibility for the deaths of polio workers and the rise of polio cases could be attributed to it. Where does tailspin come in? It is all in what you don't say, and how you say what you do say.

What you don't say: sorry. Apology does not come into it. Or an explanation of why it was stopped, because that might lead back into questions of causality and wrongdoing.

How you say what you do say:

Mr Boyd, the CIA spokesman, said "many obstacles" stand in the way of vaccination programmes, including myths they cause use sterility or HIV and claims they are spy programmes run by Western governments.
"While the CIA can do little about the former, the [CIA] director felt he could do something important to dispel the latter and he acted," Mr Boyd said. 

"It is important to note that militant groups have a long history of attacking humanitarian aid workers in Pakistan and those attacks began years before the raid against the Bin Laden compound and years before any press reports claiming a CIA-sponsored vaccination programme."

The public health implications of vaccination myths is an important topic. The value of this important topic being addressed by a CIA spokesperson, all things considered? Not so much. The virtue of the CIA 'addressing the myth' that that vaccination programs are spy programs by ... stopping using them as spy programs? Smooth. Arguing that attacks on aid workers pre-dated the CIA-sponsored vaccination programs? Great, but where is the data about numbers of aid worker attacks over time? Did they rise after the word about spying came out? No matter, the spokesman has already gone into tailspin ...

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Friday, May 02, 2014

Workshop on ethical and social science implications of HIV cure research

Now here is a piece of shameless promotion. I am currently co-Principal Investigator (along with Dr. Joseph Tucker) of a NIH-funded research grant exploring the ethical and social implications of research currently taking place on a cure for HIV. As part of this project, our working group -- with generous support from the Brocher Foundation and the UNC Center for AIDS Research -- are holding a workshop next week on this topic at Brocher's swanky conference center on the shores of Lake Geneva. Roughing it, I know. We will even have a Tweetmeister (or whatever they are called), sending real time bird-like signals about the goings-on in the workshop out into the Tweetosphere. The tweets will show up at @HIVCureWorkGrp, and workshop highlights will flutter over to our website at: http://searchiv.web.unc.edu.

I think -- and why wouldn't I? -- that the workshop topic is intrinsically interesting on many different fronts. Clinical cases which have been given strange Hollywood-sounding names (the Mississippi Baby, the Berlin Patient, and the Visconti Cohort) have indicated that we might be able to control HIV longer and more comprehensively than current antiretroviral treatment does. Maybe even cure it, whatever that means. What sort of ethical challenges would research in view of a HIV cure involve? What happens, socially, when a disease of this magnitude and global reach changes its status from incurable to treatable to maybe curable? What will this do, for better or for worse, to ongoing HIV treatment and prevention efforts? Is there something to be learned from other diseases in which a similar transformation occurred? What questions of justice will be raised by early introduction of potential HIV cures, given the problems of access to HIV treatment faced for decades by HIV-positive persons in developing countries? How does the new biomedical research on HIV cure relate to the many cures  that have been claimed around the world, on a regular basis, since the beginning of the epidemic?

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Thursday, May 01, 2014

Physician involvement in legal amputations and lethal injections

The government of Kelantan, a state within Malaysia, is considering the implementation of hudud, a particularly strict form of Islamic law. Under hudud, the punishment for crimes such as theft, robbery,  adultery, rape and sodomy would be flogging, death by stoning or amputation. The prospect of amputation, in particular, being considered as a form of legal punishment has medical authorities in Kelantan cringing and objecting. After all, who else but doctors are in a better position to perform safe and effective amputations? And who is in a worse position to perform such non-medical amputations, seeing that they conflict directly with the Hippocratic tradition? Limb removal, when not medically indicated, is hard to reconcile with the principle of 'do no harm.' Should the hudud come into effect, physicians called upon to conduct amputations will find themselves in a lose-lose situation: fail to amputate, and they will likely run afoul of their own government; amputate, and risk having their license revoked by their medical association. The situation is likely to strike outsiders as strange and barbaric: what sort of state contemplates cutting bits off their own citizens in order to punish them?

The case seems exotic, but it is not difficult to bring it closer to home. This week, there was a botched execution of a convicted murderer in the United States. What botched it, apparently, were the chemicals in the injection. Drugs of choice to dispatch convicts (such as sodium thiopental and pentobarbital) are in short supply, partly due to their ban by the European Union. So the botched execution was in essence a botched experiment. US federal law has all sorts of protections for prisoners when they are used in medical research, but when an experimental cocktail of drugs is administered with the intent of killing convicts, those protections fall by the wayside. Worse yet, in
17 US states with the death penalty, a physician is required to be present at such disturbing events. But it is not as if having a more effective means of killing would make the health care professional's involvement morally palatable. Medical professionals have no place in facilitating state-legitimated execution by injection, amputation or public stoning. If governments wish to savage their non-law abiding citizens, they should not be allowed to use medicine to legitimize what they are doing.

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