Friday, February 22, 2008

Criminalizing the brain drain

There are many numbers around to express the inequalities in health care between developed and developing nations. In Malawi, there is one physician for about 50,000 persons; compare with Great Britain, where it is considered shocking when there are districts with only one doctor per 3500. In Zambia, there is one nurse for about 3000 patients; in the United States, studies have shown that even an increase from a 1:4 nurse/patient ratio to 1:10 can have a significant impact on surgical patient death rates, as well as job dissatisfaction and burnout. Who knows what a 1:3000 ratio does for patients and nurses. But for all the contrasting figures that can be found in the scientific literature, an unscientific anecdote stands out for me. In Kinshasa, somewhere off the Boulevard du 30 Juin, there is a small dental clinic, which I noticed was absolutely jammed full every single evening, with some patients spilling out onto the trottoir. Someone told me that there are 12 registered dentists in Kinshasa, a city with estimated population of 8 million. That struck me as terribly low, though in the meantime I have learned that according to WHO estimates (2004), the average dentist/patient ratio in Africa is 1 per150,000.

Nevertheless, the industrialized world regards itself as having serious doctor, nursing and dental shortages, and part of the solution to the crisis currently involves recruiting from ... the developing world. You don't need a fully articulated theory of justice to see a deep problem here. In fact, it is old news: the brain drain of health professions from developing countries has long been discussed, moral outrage has been expressed, and various professional bodies have issued policies condemning the practice. Not that all this has had much of an impact so far. This week's Lancet, however, has a new twist on the old story. A group of authors have apparently decided enough is enough: they propose that the predatory recruitment of developing world health professionals be considered an international crime.

The idea is laudable, because the gravitas of 'crime' at least matches the seriousness of the issue. But how would it work in practice? It is difficult enough to enforce crimes against humanity, much less crimes against the universal right to health. Can one envision CEOs of recruitment bureaus being hauled off to the Hague and awaiting trial along with Charles Taylor? Besides, the defence lawyers would argue that the recruitment bureaus do not intend to endanger the health of developing nations; they are providing opportunities to skilled individuals who have the right to work where they want. It might be wiser (but not much easier) to press for enforceable national laws -- in abuser countries like Canada, United States, the United Kingdom, Australia and New Zealand -- that pose clear restrictions on the import of health human resources from developing countries, while working on the international front to address the conditions of poverty and neglect that push doctors, nurses and dentists towards greener pastures.

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Wednesday, February 20, 2008

Don't feed the bears

The BBC reports on a new and somewhat frightening study on emerging infectious diseases worldwide. Researchers from the Zoological Society of London (ZSL), and University of Georgia and Columbia University's Earth Institute analysed 335 emerging diseases from 1940 to 2004. Using computer models, they attempted to correlate emerging diseases with human population density or changes, latitude, rainfall or wildlife biodiversity, and then plotted the 'hotspots' for disease emergence on a global map. One surprise was the location of the hotspots. Instead of arising in northern industrialized nations -- with its better surveillance systems and (over)use of antibiotics -- new infectious diseases tended to spring from tropical Africa, Latin America and Southeast Asia. Another surprise is that the majority of emergent diseases are zoonotic pathogens, i.e. pathogens that leapt from animals to humans, and that of these zoonotic diseases, 72% came from wildlife, not domesticated animals. As we increase the earth's population, and increasingly encroach on wilderness areas, the probability of zoonotic transmission increases; once the pathogen has made the leap from animal to man, it then can spread fairly rapidly by international travel and trade. The SARS epidemic -- likely originating from horseshoe bats in rapidly industrializing China -- is a paradigm case for the future emerging epidemics.

Hopefully the results of the study will enable us to predict outbreaks. Now we only need to work on the man-made causes of these outbreaks, and the global inequalities in capacity to respond to the infectious disease epidemics that we partly dish out to ourselves.

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Saturday, February 16, 2008

Unhealthy health policies

Do we believe that good health policies can reduce mortality and morbidity at a population level? The answer is yes: scientific research, meetings, consultations, reports and all the other magical ingredients that go into health policy formation are driven by the idea that if our policies are well-constructed and implemented, they will have a beneficial effect on public health. The whole process assumes that policies can have real and widespread effects. Conversely, it seems to follow that if the process of health policy formation goes awry, and we end up with wonky policies, needless death and disease can be produced in substantial numbers. Normally, the production of human death and suffering on an industrial scale raises strong ethical objections. Especially when guns are involved, we have strong words to describe this sort of thing: massacre, slaughter, carnage, genocide. Oddly, when errant health policies produce similar 'end points', in similar numbers, the ethical (and legal) responses are quite different. Ministers of health do not normally get hauled off to The Hague. And there really are some unhealthy health policies: there is an interesting book of case studies describing a selected few of them.

I was led to these thoughts by a recent case in South Africa of a physician who was suspended for giving HIV-positive pregant women a more effective drug combination to prevent them from transmitting the virus to their infants. You read that sentence correctly. A doctor in KwaZulu Natal, Dr. Colin Pfaff, gave dual therapy (nevirapine and AZT) to HIV positive mothers, rather than the 'nevirapine only' regime that is currently government health policy. But the government policy is behind the times. Dual therapy has already been recommended by the World Health Organization for a year, and has been shown elsewhere in South Africa to reduce the chance of mother-to-child HIV transmission down to 8%, while monotherapy with nevirapine has only reduced chances of transmission down to 22% in KwaZulu-Natal. The Southern African HIV Clinicians Society have condemned the decision to threaten Dr. Pfaff with discipinary action, and petitions have been written. It is a strange world when a physician is threatened with punishment for providing a superior standard of care, and when doing so cost the local health department nothing, because the AZT had been donated by a British NGO.

There has been pressure for sometime for the South Africa health ministry to alter their mother-to-child HIV transmission policy (last revised in 2001) to keep up with scientific advances and international recommendations, but its responses have been ambiguous, hesitant and sometimes openly hostile. This is part of a larger and deeply entrenched pattern in the country. From the beginning of the epidemic in South Africa, president Thabo Mbeki made no secret of his embrace with 'HIV dissidents' -- who believe that HIV does not cause AIDS or that HIV does not exist at all -- or his suspicion that drugs like AZT are harmful and promoted in Africa only to make money for corporations. By appointing health ministers sympathetic to his views, Mbeki has guaranteed that national responses to the epidemic will be marked by foot-dragging and denial. For almost ten years now, health minister Manto Tshabalala-Msimang has been responsible for a kind of 'Alice in Wonderland' approach to health policy leadership, carefully cherry-picking whatever scientific research seems to support her own beliefs about HIV in Africa, sidelining the rest, while touting the benefits of herbal concoctions and aligning herself with quacks. She was, for example, very quick to abandon provision of nevirapine when some studies indicated its use led to drug resistance among HIV positive mothers. Now, when it comes to providing dual therapy, Minister Tshabalala-Msimang wants to stick with nevirapine. Or she did, until the story with Dr. Pfaff hit the newspapers.

In South Africa, the struggle against HIV/AIDS is especially hard, because it partly a struggle against a government whose commitment has never been more than lukewarm. True, in the beginning of the HIV epidemic in the United States, there was strong government reluctance to engage in the control of a 'gay disease.' But that changed after a few years. In South Africa, that kind of obstructionism in high places endures, with deadly effect. In the future, perhaps it will be possible to estimate how many people in South Africa became infected by HIV or died of HIV-related causes due to the country's delinquent style of HIV policy-making. Will anyone be held responsible? Very unlikely.

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Friday, February 01, 2008

Dirty Ugly Things

Okwe is a Nigerian cab driver who moonlights as a hotel desk clerk. Because he was a doctor in Africa -- but not able to practice in London -- he finds himself giving what medical treatment he can to fellow immigrants. Okwe shares an apartment with Senay, a Turkish Muslim woman, who works as a maid in the same hotel as Okwe. She has a rough time of it: a visit from the immigration service forces her to quit her job in the hotel and work in a clothing sweatshop, where the boss threatens to report her to the authorities unless she perform oral sex on him. Juan, the manager of the hotel, runs an illegal operation at the hotel where immigrants sell their kidneys for something precious: a new passport, a new identity. Senay, in desperate financial need, agrees to exchange a kidney for a passport, but not (of course) before Juan forces her to have sex with him first. When Okwe hears of Senay's plan, he tells Juan that he will perform the operation in order to ensure its safety. Here is the plot twist: Okwe and Senay drug Juan, harvest his kidney, sell it to Juan's contact, and lead new lives with new passports. The victims become victimizers and visa versa. This is the basic plot of Stephen Frear's Dirty Pretty Things.
Dirty Pretty Things is basically about how things go between haves and the have-nots within the global economy, and accompanying violence, coercion (sexual and otherwise), stigma, shame, fear. The film highlights how the disempowered are caught up in a system that strips them of what little control over their lives they still have. That's where the kidney comes in. To the extent that you belong to the so-called 'less fortunate', your body is not your own, because it (or bits of it) may be one of the few things of interest to the 'global market.' Globalization spawns new niches for prostitution.
I was reminded of Dirty Pretty Things when the scandal of kidney thefts in India broke out a couple of days ago. It is not news that there are unscruplous groups persuading mostly illiterate day laborers to sell their kidneys: this has been known to be going on for years. It is not new that some impoverished Indians seek to sell their kidneys: an expression of terrible human suffering, rather than the spirit of enterprise. What is somewhat new are emerging cases of forced trade -- persons lied to, held against their will, drugged, operated on and left to their own devices. A whole network of medical professionals and institutions seem to be entangled in the gruesome business, and it looks like police were paid to look the other way.

What is the significance of this scandal? There are some who might argue that these incidents will happen time and again until trade in organs is legalized. It is simple: there are significant demands for transplant organs, criminalizing organ trade drive it underground, and those who operate (literally) in a criminal underground are unsurprisingly weak in the ethics department. But given global and regional disparities, how could a regulated, legal, 'free' trade in organs be anything other than another way for the rich to cannibilize the poor? Would a legal organ trade in circumstances of poverty really be so morally superior to the outright stealing of body parts?

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