Monday, May 27, 2013

Poverty and Health

Here was an interesting piece of research that is being reported on the website of the Canadian Broadcasting Corporation. It links into debates on the social determinants of health. It has been argued (and shown) on many occasions that folks lower down the socio-economic pecking order are more likely to suffer from a whole host of chronic (as well as sometimes even infectious) diseases. It turns out, they're more likely to suffer from ' increased rates of death and illness including diabetes, mental illness, stroke, cardiovascular disease, gastrointestinal disease, central nervous system disease and injuries.' Indeed, kids brought up in situation subjecting them to what professionals refer to as 'toxic stress', that includes substandard housing, living with adults who are also stressed due to their socioeconomic circumstances, experience stunted brain development according to a technical report published in 2013 in the journal Pediatrics. The American Academy of Pediatrics issued a large-scale technical report in the end of 2012 that reaches similar conclusions.

No wonder a family medicine specialist in Toronto, Gary Bloch, is quoted in the CBC article as follows, 'Treating people at low income with a higher income will have at least as big an impact on their health as any other drugs that I could prescribe them.'

Such findings must have an impact on ongoing ethics debates among public health ethics experts on how to deal with illnesses such as obesity. Would nudging or stigmatising people who have already lost out on much of what constitutes a good life due to the poverty they experiencing be truly fair? Or would it place additional unfair burdens on those already struggling to live a decent life? Perhaps campaigning for better education and jobs for all would be a better placed priority than figuring out what drugs best control obesity? Difficult one.

Thursday, May 09, 2013

On sex selective abortion - again

Unless you live under a rock some place in Canada you cannot have missed this year's instalment of the annual procession of anti-choice campaigners on Ottawa's Parliament Hill. Of course, Canadians overwhelmingly are happy with the country's liberal take on abortion. So, much like Christian conservatives fudge the euthanasia issue by pretending that it is about protecting the 'vulnerable', the same people are at it when it comes to re-opening the abortion issue. They claim concern for what they describe as 'female gendercide'. Of course, there is nothing in Canada approaching a female gendercide, but like the vulnerability rhetoric in the euthanasia debate, they hope to garner at least some support when they make it look like they are protecting women. The real question is whether or not you believe that women should have the right to choose an abortion. The Canadian answer has been for a long time that they do. Once that answer is given, there are no 'right' or 'wrong' motives in that context, because a woman could even have an abortion for no reason at all. It is completely up to her. End of story. The nonsense about female gendercide defies belief, but it fits into a change of religiously motivated anti-choice activists' agitprop. Like in the euthanasia debates they no longer wave just their religious books, they do present actually public reason based arguments. It turns out these reasons are flawed, but they serve the agitprop purpose they have been invented for.

I repost below a commentary I wrote in January 2012 on this issue. Nothing really needs to be added, but it's well worth keeping it in mind in the context of the current anti-choice activities in Ottawa.

Odd CMAJ Editorial

There is a big of an outcry in Canada over an Editorial by the current Interim Editor-in-Chief of the Canadian Medical Association Journal, Dr Rajendra Kale. Kale argues that pregnant women in Canada should not be provided with information about the sex of the fetus to avoid female feticide among Indo-Canadians. Kale proposes that women should only be told 30 weeks after conception to make it more difficult for them to have an abortion based on an arbitrary marker such as the sex of the fetus. Indeed, The Toronto Star newspaper reports that there is some empirical evidence suggesting a not insignificant gender balance in parts of the country: 'Though Canada does not collect statistics based on ethnicity at birth, population statistics show the country, now home to more than a million Indo-Canadians, has a skewed gender ratio. According to the 2006 census figures, nationally there are 932 girls to 1,000 boys under age 15 in the South Asian community, compared to 953 girls to 1,000 boys in the general population. The numbers in the South Asian community in the Toronto area are further skewed with 917 girls to 1,000 boys in the Toronto Central Metropolitan Area. Broken down further, it shows 904 girls to 1,000 boys in Mississauga, and 864 girls to 1,000 boys in Brampton.'

The gender imbalance itself is not really a great deal of concern in the country as a whole, the differential between the South Asian community and the general populations is a mere 20. Not exactly a dramatic figure. That doesn't mean that this differential is not higher in certain parts of eg Toronto, but in the big swing of things this isn't a dramatic situation. Baldev Mutta, a staff member in a Punjabi Community Health Centre notes in the Star that there is a preference among recent immigrants in favour of male off-spring. Women are reportedly threatened with divorce if they don't agree to to abort female fetuses.

It goes without saying that putting women under such pressures is unacceptable. It also seems, for most circumstances, bizarre to me that - recent migrant or not - anyone would have strong preferences for the sex of his or her off-spring. However, there can be at least some ethically unproblematic reasons, too. For instance, a family might have a preference for a 50:50 ratio among their off-spring and so decide to abort a male or female fetus in favour of a future child of the desired sex. Having knowledge of their off-springs sex sooner rather than later arguably is better overall, because the aborted fetus would be less advanced in its development. There could also be good health reasons for wanting to know, for instance in the case of sex linked genetic diseases.

My point is that it is unacceptable to view certain reasons for wanting an abortion acceptable and other reasons sufficiently dodgy that one chooses ('doctor knows best', it goes without saying!) which women will be told of the sex of their off-spring and which women must not be told. It is clear from the statistics quoted by Kale in his Editorial that the overwhelming majority of Indo-Canadians do not actually choose abortions based on the sex of their off-spring. Preventing them -and anyone else -for that matter from knowing the sex of their off-spring is plain offensive. No wonder that a woman from such a cultural background is quoted along these lines in the Toronto Star, “It’s upsetting, to be honest with you,” says Hussain, who worries Kale’s editorial will further push this kind of discrimination. “It’s a stereotype that brown people will abort a child who is not a boy.” 

I might be mistaken, but I suspect that Kale's real agenda is anti-choice to begin with. He confuses fetuses and 'girls' as well as fetuses and 'women' in his Editorial as this quote shows quite nicely, 'Postponing the transmission of such information is a small price to pay to save thousands of girls in Canada. Compared with the situation in India and China, the problem of female feticide in Canada is small, circumscribed and manageable. If Canada cannot control this repugnant practice, what hope do India and China have of saving millions of women?'

Of course, the lives of neither women nor girls are at stake here. The issue is whether or not pregnant women have a right to know the sex of their off-spring. In Canada they do. It's a good thing. Cultural biases need to be confronted where they occur, there mustn't be technical pseudo-solutions to them that infringe on hard-won individual liberties that women can rightly take for granted today in Canada. If the argument really is about the morality of abortion, Kale should have argued that case and should not have chosen to engage in skirmishing activities to do with Indo-Canadians.

Wednesday, May 08, 2013

Long live the Open Access Movement ... Not!

And here we go again, true story, I received this email today from an Open Access 'publisher'. Obviously I am not qualified to assess this manuscript, yet the administrators of this publisher see fit to invite me to review a manuscript that clearly I am not qualified to review. As far as email mass mailings are concerned, this crap shoot takes the crown. I hope you appreciate the 'journal' title, 'Science Journal of Medicine and Clinical Trial'. You could not make it up. The worst thing is that academics in a number of countries are forced by government edict to submit to Open Access 'publishers'. Quality requirements: zero, as long as it is Open Access. So, please do submit to 'Science Journal of Medicine & Clinical Trial' to get your governmental brownie points. Academic freedom be damned. Make sure to swipe your credit card though, otherwise 'Science Journal of Medicine and Clinical Trials' and its infinite number of sister publications won't be interested in your output any longer.

Dear Colleagues

How are you? I am sure you are busy with many activities right now. However, I hope you could help us review a manuscript, entitled"Quantiferonassay versus tuberculin skin test in detection of latent TB in hemodialysis patients" that has been submitted for publication in SCIENCE JOURNAL OF MEDICINE & CLINICAL TRIAL if you are able to take on this task as well as whether you can return the Review Form by 15TH May, 2013 or earlier.

The Manuscript, Reviewer's Guide and Author Guidelines will be E-mail to you if you are interested.

In particular, please make sure that the paper addresses issues of value to our broad-based audience, and that it cuts through the thick layers of theory and verbosity for them and makes sense of it all in a clean, cohesive manner.

On behalf of the Editorial Team of the Science Journal Publication, I thank you very much in advance for your effort in this endeavor.

Background:Patients with end-stage renal disease (ESRD) and Mycobacterium tuberculosis infection pose a high risk of developing active TB disease. It is therefore important to detect latent TB infection (LTBI) to be able to offer treatment and prevent progression to TB disease.
Objective: to compare the performance of Quantiferon-TB Gold test (QFT-G)in the diagnosis of latent tuberculosis infection with tuberculin skin test (TST) among patients undergoing hemodialysis.
Patients and methods: sixty patients undergoing hemodialysis at Al-Azhar and Assiut university hospitals were subjected to TSTand QFT-G. Theagreement between both tests was evaluated with respect to age, sex, BCG vaccinationand history of contact to a known TB case.
Results: The percentage of positive TST results (induration cut off 10 mm) and positive QFT-G test results was found to be 45% & 31.7% respectively. The overall agreement between the QFT-G and the TST in hemodialysis patients was 44/60 (73.3%) and it was found to be statistically significant (P=0.001). BCG vaccination had no effect on either TST or QFT- G results in hemodialysis patients. Positive TST and QFT-G results were found to be 90% and 100 % respectively in hemodialysis patients with history of contact to known TB cases. Both QFT-G and TST results were not significantly related to age or sex. In conclusions, Both QFT-G and TST may be complementary to each other in the diagnosis of latent tuberculous infection in hemodialysis patients.

Thursday, May 02, 2013

Infanticide Symposium in the Journal of Medical Ethics

To those interested in the continuing aftermath of the Journal of medical ethics decision to publish a paper endorsing infanticide, the current issue of the journal has a plethora of articles for and against the substance of said paper, as well as arguments on the question of whether the paper should ever have been published. It's a well-worth-reading collection of articles, including some of the best-known folks in bioethics and moral philosophy, among them (in alphabetical order) Tony Coady,  John Finnis, Robert George, John harris, Jeff MacMahan, Anita Silvers, Peter Singer, and a whole gaggle of other authors, yours truly included. Check it out, here. In case you are coming to this blog entry a bit late in the day, note that the link I've just displayed likely will lead you to what is then the current issue. Try to track the May 2013 issue of the journal on its website. My own paper, for what it is worth, reflects on the implications significant political pressures on bioethics journal editors have for the exercise of academic freedom. The piece is here.

COVID19 and the ethics of hospital triage decision-making

There is a lot of talk these days about the predicted coming wave of COVID19 patients needing ICU beds and ventilators in particular, and th...