What to do about science denialists

This week's column from the Kingston Whig-Standard.

One of the privileges that comes with being an academic is that one is comparably mobile, the world really is one’s job oyster.
I chose to work between 2000 and 2005 in a medical school in Johannesburg, South Africa. Sub-saharan Africa at the time was the world’s region worst hit by HIV and AIDS. At a time when HIV infected people in the West got used to the idea of living to old age, people around me literally were dropping like flies. Talk about culture shock! In the condo-complex where I lived, several of our staff members died preventable AIDS-related deaths. One of my staff member’s life-partner died from AIDS, too. He had just matriculated from college.

Many of our students were infected and discussions began in the university whether we had a responsibility to sponsor medical insurance to ensure their survival while they were enrolled with us. To the outsider this might look like an issue best understood as people in the developing world being unable to afford access to life-preserving medication. And, to be fair, the price tags of essential medicines in many developing countries remain unacceptably high. However, this is not what actually caused in excess of 360,000 entirely preventable HIV-related deaths in South Africa.
The country’s president at the time, Thabo Mbeki, and his health minister, Manto Tshabalala-Msimang subscribed to wild conspiracy theories involving Western agencies wanting to crush African people’s aspirations. In their paranoid world AIDS medicines were a means to poison Africans. HIV was not the cause of AIDS, and AIDS didn’t quite exist as a new disease. They duly found a high-profile, ironically white, United States academic and a few of his, ironically white, allies to confirm their worst fears. Being the country’s president, Mbeki quickly set up a presidential expert panel involving mainstream scientists and a bunch of denialists. A funny idea to create a sparring match between discredited academics and mainstream academics and encourage them to entertain your paranoia. Mbeki clearly thought that a scientific consensus is reached not by evidence but by discussion and some kind of compromise (as if HIV could cause AIDS just a little bit, depending on the compromise reached).

Well, Mbeki and his side-kick Tshabalala-Msimang enforced policies aimed at keeping as many impoverished South African AIDS patients away from life-preserving medicines as was possible. HIV infected pregnant women were not given access to medicines proven to drastically reduce the risk for their newborns to be HIV infected. Thousands and thousands of HIV infected newborns came into this world as a result of these crazy policies. A Harvard University study estimated that in excess of 360,000 South Africans died preventable AIDS deaths during Mbeki’s reign. Some of the medical doctors in public sector hospitals who prescribed and provided AIDS drugs to their infected patients were disciplined by hospital managers carrying out the health minister’s orders.
Ask yourself how the world would have responded if such genocidal policies had been implemented by the apartheid regime preceding the ANC government that’s running the country today. No doubt international bodies would have busily prepared genocide charges. No doubt international campaigns would have got off the ground blaming the racist government for the preventable deaths of such a large number of South Africans. A black politician with liberation credentials presiding over what could demonstrably be described as genocide barely led to people batting their eyelids. Human lives clearly remain cheaper even today in that part of the world than elsewhere. Another, even crazier, head of state, Gambia’s president Yahya Jammeh insists that a herbal concoction he invented cures AIDS. Foreign aid workers disbelieving the story end up being kicked out of the country, and any Gambian criticizing his take on this medical problem end up in jail. Meanwhile Jammeh instructed HIV infected people to stop taking AIDS drugs.

What bothers me greatly is that government policies leading demonstrably to large numbers of preventable deaths remain unpunished. It is one thing if Mbeki had said that his government decided not to provide AIDS drugs due to their high cost. If you don’t have the resources to treat everyone it is fair game to allocate resources. But denying access to life-preserving medicine to large numbers of impoverished South African public sector patients because of truly crazy ideas about Western conspiracies is surely something else. Yet Mbeki walked away, enjoying today his generous retirement pay-out. His alcohol guzzling health ministerial side-kick died eventually of liver cirrhosis. Even there she remained true to her unethical form by jumping the queue toward a donor liver.

Well, enough on AIDS. This week United States talk show host Katie Couric used her show on national TV to peddle nonsense about the HPV vaccine. In Mbeki style she juxtaposed scientific mainstream views with anecdotes supplied by vaccine critics. The impression created was that there is a genuine debate, that there are genuinely two sides to this vaccine, when patently there are no two sides. While some of the stories presented were genuine human interest stories, they showed nothing relevant at all with regard to the safety and efficacy of this vaccine. It was clearly irresponsible of Couric to give a high-profile stage to quacks promoting their anti-science agendas. Almost certainly as a result of her action people who would clinically benefit from getting vaccinated won’t get vaccinated. Some of these women will eventually go on to develop cervical cancer. Is it acceptable, for the sake of ratings to promote quacks’ views on national television? I doubt it.

To be fair, Couric’s case is different to Mbeki’s actions. Women choosing not to get vaccinated did it on bad information they received through her TV show. Arguably women making such important health care choices would do better than to listen to anecdotes on a talk show when making important health care related choices affecting themselves. Let the buyer beware, as the old Romans said. On the other hand, the impoverished HIV infected South Africans depended on the national health care system to deliver life-preserving medicines. They did not have the luxury of choice to begin with. So, while the blame for bad choices in Couric’s cases arguably should be shared between those who act on anecdotes heard on her talk show and those who produced the show, the blame in South Africa falls squarely on Mr. Mbeki’s shoulders. Remarkably until today he was neither prosecuted nor did he ever utter an apology for the genocidal policies he presided over.

Udo Schuklenk teaches bioethics at Queen’s University, he tweets @schuklenk.

Circumcision time again

The time honored barbarism of killing young (South) African men in that traditional practice of circumcision has again yielded a decent crop of dead men in South Africa. Reportedly about 150 young men died in circumcision ceremonies (or as a result of their participation) between the beginning of 2008 and the end of 2009. So-called traditional healers (elevated to a profession under the able guidance of the late Dr Beetroot, the former South African health minister and arch AIDS denialist Manto Tshabalala-Msimang) are frequently involved in botched circumcisions, causing so substantial numbers of avoidable deaths. The opposition DA party suggests that the actual circumcision should take place in a hospital. Now that's a thought.

Of course, there will be those who say that circumcision is always wrong, and - my own preferences to the contrary notwithstanding - there's some truth in that. The thing is though, since we have fairly strong evidence that circumcision dramatically reduces the risk of catching HIV there's probably a public health argument to be had - in Southern Africa - for undertaking circumcisions. Wouldn't it be nice though, if authorities in that country managed to have them conducted in such a way that not so many young men needlessly lose their lives over them?

A study that should not have been done

Here is a piece Sean Philpott and I have published today in the Hastings Center Forum.

The New England Journal of Medicine in February published the results of a deeply flawed clinical trial in South Africa. The SAPIT (Starting Antiretroviral Therapy at Three Points in Tuberculosis Therapy) trial was designed to determine the most effective way to treat patients infected with HIV and tuberculosis. But it raises a number of disturbing questions about the oft-debated and vexing issue of appropriate standards of care in clinical trials undertaken in developing countries like South Africa. It also raises serious concerns about the quality of ethical review undertaken in those countries, and it highlights some surprising deficiencies in existing U.S. regulations regarding when ethical review should be undertaken by American IRBs.

In 2007 almost two million people died of TB and over nine million people were newly infected. TB-related morbidity and death is profound among people living with HIV/AIDS; nearly 7 percent of new cases and over a quarter of all TB-related deaths occur among people living with HIV/AIDS. Doctors treating TB in this population face a difficult challenge. Serious side effects can occur with concurrent HIV and TB treatment, leading some clinicians to suggest that antiretroviral therapy for HIV be delayed for several weeks after treatment for TB is started. But serious side effects are also a risk of delaying ART therapy. Guidelines state that ART therapy should be started as soon as possible, but there is disagreement over when that should be.
In the SAPIT trial, 642 individuals co-infected with HIV and TB were randomized to receive one of three treatments: early integrated ART (started during the intensive phase of TB therapy), late integrated ART (started during the continuation phase of TB therapy), or sequential ART (started after completion of TB therapy).
Individuals randomized to the two integrated arms received ART within three months of study entry. Antiretroviral treatment of individuals randomized to the sequential treatment arm, however, was delayed on average for almost nine months. For several unlucky study participants, ART was delayed even longer; mean time to initiation of ART in this group was six to 11 months (260±71 days), regardless of CD4 cell count, an indicator of HIV disease progression, at study entry. This matters, as patients with CD4 cell counts lower than 200 cells per cubic millimeter face a significantly increased risk of death.
Forty-four months after the first SAPIT participants were enrolled, the study’s Data Safety Monitoring Board stopped the sequential treatment arm and required that all of its participants be started on ART immediately. In its interim analysis, the DSMB had found that participants in the sequential treatment arm had a much higher rate of death than participants in the integrated treatment arms.
The majority of these deaths occurred among patients with CD4 counts below 200 cells per cubic millimeter at study entry. Twenty-seven of 213 participants, or 12.7 percent, in the sequential therapy arm died during the abbreviated treatment and observation period, of whom 21 had CD4 counts of less than 200 per cubic millimeter at study entry, while only 25 of 429, or 5.8 percent, in the integrated therapy arms died over the course of the study. Integrated HIV and TB treatment thus reduced the likelihood of death among study participants by more than twofold.
The trial conclusively showed that integrated HIV and TB treatment is more effective than sequential treatment. The question is whether obtaining that data justified the 10 or more preventable deaths that occurred among trial participants. Even before the study began, years of observational data had shown that the risk of HIV-related death among patients not receiving ART therapy was highest during the first few weeks of TB treatment, calling into question the need to conduct a randomized, controlled trial in which ART was delayed by as long as 11 months for some study participants.
The side effects of concurrent HIV and TB treatment can often be managed by observant clinicians; given this, the WHO Global TB/HIV Working Group recommended as far back as 2003 that “any decision on treatment should be individualized, based on response to anti-TB therapy, side-effects, and readiness for ART.” More recently, based primarily on data from the SAPIT trial, WHO urged that ART be given within eight weeks of starting TB treatment in co-infected individuals.
Current treatment guidelines recommend that patients infected with both TB and HIV should start ART as soon as possible. Where CD4 testing is routinely available, these guidelines recommend starting ART when CD4 cell counts drop below 350 cells per cubic millimeter, and they require ART once cell counts drop below 200 cellsper cubic millimeter. Where routine CD4 testing is not available, these guidelines suggest that HIV-infected individuals with TB should start ART immediately.
In a recent article in The Lancet, several of the SAPIT investigators argued that “an estimated 10,000 deaths could be prevented every year by the initiation of ART in HIV/tuberculosis co-infected patients with CD4-cell counts below 500 cells per cubic millimeter.” However, the level of care provided to participants in the sequential treatment arm of the SAPIT trial fell considerably below this standard. The level of treatment provided to these volunteers even violated existing domestic standards of care for patients in South Africa, which recommend starting patients with CD4 cell counts of less than 200 per cubic millimeter on ART after just two months of TB treatment.
Although the SAPIT investigators noted that trial participants’ primary care physicians were free to start them on ART as necessary – in keeping with the 2003 recommendations of the WHO Global TB/HIV Working Group – this ignores the reality of public sector HIV care and treatment in South Africa. It is unlikely that most of the study participants even had a primary care doctor, let alone a physician who would initiate ART despite the restrictions imposed by the SAPIT protocol. Who then could have started these patients on life-preserving treatment if not the clinician-investigators on the study? Individualized treatment decisions based on medical need were not made in the sequential arm of the study, despite the ethical obligation of study clinicians to ensure the safety and well being of individual study participants.
Aggravating these problems, the trial design violated the golden rule of ethical study design and conduct: No clinical equipoise existed between the trial arms. Given decades of research showing that untreated patients with CD4 cell counts of less than 200 cells per cubic millimeter are at great risk of HIV-related complications and death, coupled with observational data showing that this risk is even higher during the first few weeks of TB treatment for co-infected individuals, the sequential treatment arm never should have been considered a viable treatment strategy. Patients randomized into the sequential arm were knowingly subjected to substandard clinical care.
The fundamental ethical (and legal) issue is this: the SAPIT study caused foreseeable harms and preventable deaths for a substantial number of impoverished and poorly educated South African trial participants. In doing so, the trial violated the Declaration of Helsinki’s requirements on standards of care of the then-applicable 2000 revision:

The benefits, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic, and therapeutic methods. This does not exclude the use of placebo, or no treatment, in studies where no proven prophylactic, diagnostic or therapeutic method exists.

For the South African researchers involved with the SAPIT trial, the Declaration of Helsinki is not only a moral exhortation but also a legally binding obligation. South Africa’s Good Clinical Practice Guidelines require that all investigators “follow fully the guidelines set out” in the Declaration of Helsinki, in addition to other national research ethics guidelines.
Organizations such as the Welcome Trust in the U.K. and the National Institutes of Health in the U.S. have directed millions of dollars to train members of African ethical review committees, and yet this trial was reviewed and approved by a committee in South Africa. The failure of this research ethics committee to recognize the clinical, ethical, and legal deficiencies in this study is shameful and, we hope, will be investigated by the relevant South African authorities.
Another issue is worth noting. As published in the New England Journal of Medicine, the study boasts a large number of authors. This is not an uncommon practice for large clinical trials like SAPIT. The authors of the article are located in South Africa and the U.S., and some authors list both South African and U.S. institutional affiliations. It is unfortunate, however, that U.S. research ethics guidelines (at least as interpreted by the American institutions involved) did not require these authors to submit the study protocol for ethical review by committees in the U.S.
If, as these institutions suggest, the study investigators were not acting on behalf of the U.S. institutions or were not engaged in what these universities define as human subjects research, it is worth asking why these institutions are listed on the published research papers. If they want to share in the academic glory associated with a study published in a prestigious journal like the New England Journal of Medicine, then they have the obligation to ensure that the trial meets accepted standards of ethical conduct and the responsibility to protect the rights and safety of all study participants. Further review might have made an appreciable difference to the ethical design and conduct of this study.
Sean Philpott is an assistant professor of bioethics at Union Graduate College and a former science and ethics officer for the Global Campaign for Microbicides. Udo Schüklenk holds the Ontario Research Chair in Bioethics at Queen's University, Canada, and is the joint editor-in-chief of BIOETHICS. 

Complete list of civilised countries now available

Very interesting stuff: the UN (that beacon of hope for human rights - NOT) voted on a resolution demanding basic civil rights for gays, lesbians, bisexual and transgendered (lgbt) people. Some 66 countries supported the resolution, and not unexpectedly, to quote Donald Rumsfeld, Old European countries with their respect for civil rights feature prominently on the list. No surprise, unfortunately, that thuggish places like Saudia Arabia, Russia, Jamaica and others are missing in action. No surprise either that the USA and the Vatican cannot be found on the list of supporters of the human rights of lgbt people. No surprise also that South Africa, sliding ever faster itself into a Zimbabwe type failed state, is absent among the signatories of the resolution, despite the fact that the country's progressive constitution binds the government of the day to recognize the rights of lgbt folks.

It's probably useful to reflect on this also in the context of high hopes that people have for the incoming Obama administration in the USA. This guy (leaving aside for a moment the fact that he doesn't even support the idea of universal health care in the USA) has announced today that a known homophobic evangelical preacher will hold the sermon during his inauguration ceremony.

Here then the complete honor list (keep em in mind, next time you plan a vacation!):

Albania, Andorra, Argentina, Armenia, Australia, Austria, Belgium, Bolivia, Bosnia and Herzegovina, Brazil, Bulgaria, Canada, Cape Verde, Central African Republic, Chile, Colombia, Croatia, Cuba, Cyprus, Czech Republic, Denmark, Ecuador, Estonia, Finland, France, Gabon,
Georgia, Germany, Greece, Guinea-Bissau, Hungary, Iceland, Ireland, Israel, Italy, Japan, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Mauritius, Mexico, Montenegro, Nepal, Netherlands, New Zealand, Nicaragua, Norway, Paraguay, Poland, Portugal, Romania, San Marino, Sao Tome and Principe, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, the former Yugoslav Republic of Macedonia, Timor-Leste, United Kingdom, Uruguay, and Venezuela.

The UN statement, which includes a call for the decriminalisation of homosexuality worldwide, was read by Argentina.

Here's a Background briefing from IDAHO, the organisation that launched a campaign to get this resolution off the ground:

On May 17 2006, the International Day Against Homophobia (IDAHO), the IDAHO Committee launched a campaign « for the universal decriminalisation of homosexuality », and published a list of the first signatories, which include several Nobel Prize winners: (Desmond Tutu, Elfriede Jelinek, José Saramago, Dario Fo, Amartya Sen), entertainers (Merryl Streep, Victoria Abril, Cyndi Lauper, Elton John, David Bowie), intellectuals (Judith Butler, Noam Chomsky, Bernard-Henri Lévy), and humanitarian organisations like ILGA, Aids International and the FIDH. On IDAHO 2008 (17 May this year) the French government announced that it would bring a LGBT human rights statement to the General Assembly of the United Nations. The text was read today in New York, and was supported by 66 countries in the world, and it clearly inscribes sexual orientation and gender identity as human rights.

The IDAHO Committee is the NGO coordinating the International Day Against Homophobia. This day is celebrated in more than 50 countries in the world, and is officially recognised by the European Union, Belgium, United Kingdom, France, Mexico, Costa-Rica, etc. These actions support international campaigns, like the call launched in 2006 "for a universal decriminalisation of homosexuality"
http://www.idahomophobia.org/

Correlation and causation

Just a correlation or possibly causation? Neither South Africa nor Canada, both countries I lived in, have managed so far to grab an Olympic medal. The wailing about their failing national teams is great in both these great nations. Let us hope that not too many people will commit suicide due to Olympic failures. Let us also hope that nobody thinks that there's more to this then just a correlation.

Hey, come to think of it, perhaps causality related suspicions might be the underlying rationale for the theft of my bike yesterday. Perhaps someone tried to punish me for the Canadian failure. I kind of doubt it, after all, had I not left it unlocked under a tree outside my house, quite likely it would still be there.

Sex between strangers

Here's a true story my friend Anita Kleinsmidt kindly forwarded to me... enjoy

Was it rape or was it not? That was the question the Pretoria High
Court had to deal with.

But as it turned out, it was in fact a case of mistaken identity, says a report in The Star. The 'victim' is a Pretoria woman in her 20s. The man had received a 10-year jail sentence for the one night of passion he had with her, but the High Court intervened and acquitted him of any wrong-doing. About three years ago a man in a car asked the woman for her telephone number. Without looking at him, she gave him her number and walked on. This was the start of a phone relationship. They eventually agreed to meet and the man, known as Jacky, arranged to pick up his new love. She in turn - without knowing what Jacky looked like as they had never met - waited for him at the restaurant with her overnight bag in tow. It emerged during the trial in the Pretoria Magistrates' Court that a man walked towards her and hugged her. She testified that they later had repeated sex that night and when she switched on her phone the next morning, she discovered a message from the 'real Jacky'. Kenneth Vilakazi (30) was subsequently arrested and later convicted for the rape in the lower court. He received a 10-year jail sentence, but turned to the High Court to appeal his conviction.

Vilakazi maintained that they had consensual sex. The woman said he was not the man she thought he was. She claimed he misrepresented himself to her, but the court disagreed. Judge Cathy Satchwell and Acting Judge JC Labuschagne found that the 'victim' had made the
mistake herself. The court found that they were all strangers and it was a case of one stranger having sex with another stranger.

Responsibility to Protect

The UN Security Council's decision to do nothing about Zimbabwe is remarkable and it isn't. It isn't remarkable to anyone who considers the UN to be a by and large useless, and deeply corrupt organization, the disappearance of which would barely be noticed by most people except those who have their hands in the UN salary troughs. Of course, the UN can only be so good as its weakest links, and there's plenty of weak links. South Africa's voice on the Security Council has fairly routinely been supportive of the worst criminals as far as human rights violating states go. China couldn't possibly bring itself to issue a vote condemning Mugabe's junta because it's in bed, pardon, in business with the kleptocratic dictator and his minions. Indeed, just today the BBC reports that China, despite an official UN arms embargo, has busily sold weapons to the Sudanese regime. It is still training the Sudanese army in the use of these weapons. These weapons have demonstrably been used to murder innocent people in the ongoing genozide in Darfur.

Thankfully many heads of states, from George W Bush to Angela Merkel are falling over each other to promise to the Chinese government that they will attend the opening of the olympic games. It is business as usual. So, surely, if permanent members of the UN Security Council are actively supporting governments like the Zimbabwean and Sudanese, we cannot seriously expect the Council to act in any meaningful way. Indeed, if it acted against Zimbabwe, why should China not be next on its list. It seems then that we cannot seriously expect the Security Council to enforce the UN's 'Responsibility to Protect' doctrine - after all, we all know the saying 'don't throw stones while you're sitting in the glasshouse'. China, South Africa (and its President Thabo Mbeki) are anything but genuinely concerned about civil rights and the duty to protect citizens of UN member states from serious abuses of such. So, Bob Madhatter, go on... nobody is gonna stop you until someone finds oil in Zim. No wonder you declared, in view of the international community's failure to deal with you and your fellow thugs, that you're 'happy'. So would I be, if I was in your shoes.

Bob Madhat and 'God'

South Africa's seemingly unstoppable march into oblivion

Na, I'm not going to rave again about Pres Thabo-the-man (Bob Madhat's significant other) or health prevention minister Whiskey-Manto-new-liver-for-me-ASAP, but here's a tell-tale sign as to how rapidly South Africa's heading south: Amazon has stopped delivering to the country, because theft of parcels has become so rampant that it's bad business to do business any longer with South Africans.

Thank you Paddy Ashdown!

At long last, someone is speaking sense in the 'international community'. While the slaughter in Zimbabwe continues unabated, and the delusional, syphilitic and somewhat deranged dictator running the show there declares that he can only be removed from office by God, Africans are once again paying the price for the useless leaders they elected to high office. The one country that could long have made a difference in Zim, South Africa, has been governed by Zanu-PF's (oops, the ANC's) Thabo Mbeki. Remember: Thabo-the-man hasn't seen anyone yet die on AIDS in the country that he has misgoverned for the last 8-10 years or so, and (while holding hands with Bob Madhat Gabrielle Mugabe) he declared that he doesn't think there's a major problem in Zimbabwe. So, the millions of illegal Zim refugees in South Africa are not really an indication that Bob Madhat Gabrielle Mugabe stuffed it up. Not at all, according to Thabo and his lover Robert Madhat Gabrielle Mugabe. That much is clear. Reassuringly the leadership void that is Thabo Mbeki has been filled by many African leaders who have condemned the rapidly escalating genocide in Zimbabwe.

Comes Paddy Ashdown. He suggests in today's TIMES that may be the time has come for a military intervention in Zimbabwe, to stop the thugs governing the country from destroying what's left of it, and to stop them from killing more brave Zimbabweans. Sadly, however, Zimbabwe has no oil to speak of, hence this almost certainly is not going to happen any time soon. All we've got is black-on-black violence, and as anyone knows, that doesn't really count. If there is no other reason than to preserve their lives, we can almost be certain that no truly international intervention will be forthcoming. To be fair, SADC or the AU could send their own troops, but they're probably equally unwilling to interfere with this Zim home-made problem.

Going Canada - (South) Africans on the move

This has been an interesting week for me. You know, I have worked in South Africa for some five years or so. To be honest, in intellectual terms, I had the best time of my career there, as the work I undertook was - on my books anyway - truly meaningful. Made some great friends there, too. Eventually I left, for all sorts of reasons, chief among them the unpleasantly low salary that made me wonder about my pension (or lack thereof), lack of personal security (living in Jozi probably didn't help), the deteriorating administrative infrastructure at my university, continuing electricity failures in my suburb, and most importantly nagging doubts about the country's future (I had seen what happened to Zimbabwe next door).

Anyone who has been following this blog knows that I am continuously railing about the dangers to democracy the ANC poses in the country. Large sections of its senior leadership are convicted fraudsters and thieves who have decided to use the public purse as their private piggy-bank. The organisation has long ago begun to use the public broadcaster as a propaganda instrument. The lack of any serious opposition in effect renders the country a one-party state akin to Mexico during its decades under the PRI. Well, there is one-party states and one-party states. Singapore is also more or less run by one party, but it's well-run, something one cannot reasonably claim for South Africa. Its current President presided over a preventable genocide-equivalent tragedy due to his crazy handling of the AIDS crisis in the country. Nobody has as yet held him accountable for the crimes he and his health minister committed against the South African people (aided and abetted by the ANC). Here is evidence demonstrating that the President was pro-actively involved in protecting corrupt underlings of his, in this case the country's former Police Commissioner. His most significant rival (the party's current President) is a bone head of sorts. Aged 65 he just married his fifth wive, a 33 year old woman. Him becoming the next President of the country would be akin to Homer Simpson becoming President of the USA ... well, come to think of it, someone akin to Homer Simpson is currently President of the USA. In South Africa, the separation of state organs and party organs is weakening.

The only hope I have for the country rests with its young people. Many of them don't have the near-pathological hang-up's about race/ethnicity/skin-color that frequently prevent the current ruling class from instituting prudent policies. Thinking back of many of my students, and reading what's currently going on in the country, you'd think they were already a different kind of person. They seem to have been spared the crippling effects of apartheid South Africa on their personalities, very much unlike many members of the current ruling class who have undoubtedly sustained very serious psychological damage. Given a decent education (I won't even go into years of failing education policies that the ANC can also take credit for), they are the last best hope for the country. Thing is, they got to get rid of the current ruling elites altogether, as well as their hand-groomed 'youth' successors in the ANCYL (the party's youth league). Oh well, there's wishful thinking.

So, bad news all around. Let me get to what triggered this commentary: I got three different email messages independently of each other from South African friends/former colleagues during the last week. One from an Afrikaner who has decided to leave the country for good. One from an Indian student of mine who has just graduated as a medical doctor, and will move to Canada. One from a Nigerian medical professional who is in the middle of sorting out his immigration documents so that he can also move to Canada. He told me that he holds little hope for the future of the country and that he's getting out. This, while completely anecdotal, is quite significant. All three of them are very highly trained - and badly needed - professionals, yet they all have decided to get on with life, having lived in Africa for many years. Just today the Mail and Guardian reports that Gauteng's (the country's - and continent's - industrial and commercial powerhouse) pathology services are 'bleeding pathologists dry', meaning that they're in danger of collapsing due to too many of these specialists leaving the country. A brand new survey in Human Resources for Health reports that about 1 out of every five Africa born doctors now works in a developed country.

I have had the 'brain drain' discussion the other night with a Jamaican acquaintance of mine who pointed out that at the end of the day, people only have one shot at life, so one cannot really blame people for moving to countries that are reasonably stable and guarantee a better life for these professionals and their families. He is right, of course. It is all the more important then that developing countries leaders think more carefully about how to make life and work for such professionals better than it is right now, or else risk losing them to countries like Canada, Australia and the UK.

For some African countries the failure to have done so translates into a loss of 70% of its locally trained medical professionals. The signs are probably on the wall for the powers that are in South Africa, get your acts together or join the rest of the African basket cases. It's your call.

ANC working tirelessly to render South Africa a true banana republic

Quite remarkable, South Africa's elite crime fighting unit, THE SCORPIONS, is going to be disbanded. The reasons are fairly simple, the crime fighters found too may senior ANC politicians with their hands in the till, showed them to be thieves, corrupt or worse. Among those investigate and prosecuted were Jackie Selebie (once the country's ANC appointed police commissioner), Jacob Zuma (currently the ANCs president) and many others.

The people of South Africa might want to read up on the history of Mexico's PRI to see what is going to happen to their society if they permit the ANC to continue down the path it so clearly has chosen.

So far for the 'new South Africa'. A less than convincing move from historically white-corruption to 'new South Africa' black-corruption. The masses remain as poor as they always were, service delivery is collapsing across the place (even the country's electricity supply is unreliable these days). Just think about it, the ANC cadres were given the amazing choice to stick to President Mbeki (a leader whose warped AIDS policies have cost hundreds of thousands of HIV infected South Africans their very lives!), or Jacob Zuma (a politician current prosecuted for corruption, and a guy who has a habit of sleeping around with plenty of women without using condoms, and who tends to have a shower as a means of post-exposure prophylaxis!). - How sad can it get? It surely looks like a second democratic revolution is called for.

The trouble for South Africans, of course, is that the country has no credible opposition party and, for that reason alone, the ANC is free to do pretty much anything it wishes. And so it does! Sad developments indeed.

Jackie Selebi - South Africa's Police Commissioner and friend of the local Mafia

Jackie Selebi, until recent South Africa's Police Commissioner and head of Interpol has been suspended from his day job in South Africa and forced to resign as head of Interpol. The reason for all this? Well, Selebi admitted some time ago to be best friends with a local crime boss (drug trafficer Glen Agliotti), but insisted that this didn't affect his work. At long last, and despite interference by the country's President, Mr Mbeki, the National Prosecuting Authority has decided that it will charge Selebi with corruption and defeating the ends of justice. Even Thabo Mbeki, South Africa's outgoing President, couldn't protect Selebi anylonger. Despite some skirmishing from Selebi's underlings (eg his police arrested a senior member of the team investigating Selebi under drummed up charges that were straight thrown out of court), his day in court is looming - at long last.
I got to be honest, I can't stand Mr Selebi, he's a pompous, clearly inept, deeply overweight civilian with a strong preference for colourful uniforms. I recall like it was yesterday when I sat with him on a panel and he and I started a discussion about corruption in South Africa. His main mode of reasoning was to explain it away by saying that it wouldn't happen if there were not rich white Europeans (Selebi is a racist kinda character who fits well into the new South African dispensation) offering money to corrupt South Africans. I could see that there was actually some truth in this, yet it seemed at the same time plain stupid to suggest that the person who takes the money and allows him or herself to be bought is kind of innocent. It's clear to me now that Selebi might well have had himself in mind when he tried to suggest that it is (as always) the whities fault. Not a big surprise then that his mafia friend turns out to be a white bloke. He very much knew what he was talking about, it seems.
What is remarkable is how long it took to remove this shady character. The same applies to someone less shady but equally incompetent, South Africa's Minister for Health Prevention, Manto Tshabalala-Msimang. All of these shenanigans can only be explained by the fact that the country is well and truly a one-party state and anything but a functioning democracy. Nobody really has the power to hold the South African government accountable for its failings, of which widespread corruption is just one.

African Vaccine Trials Ethics Problems Continue

A few weeks ago much propagated microbicide trials designed to test the efficacy of a microbicide aimed at reducing or preventing HIV transmission during sexual intercourse ended in failure. It turned out that the microbicide actually increased the risk of HIV infection. All sorts of ethical questions arose, of course, including whether an infection acquired during the course of the trial should count as a trial related injury that ought to be subject to compensation.

Well, much better resourced preventive HIV vaccine trials also crashed in a spectacular way today. Again, it turned out that the trials left those who were injected with the vaccine candidate more susceptible to HIV infection than those who were in the placebo arm. In all fairness to those who undertook this trial, the plug was pulled quickly when these results came to light. Equally, how would one ever find out whether a vaccine candidate works other than by means of undertaking such trials. So, the problem with both the microbicide trials, and the preventive vaccine trials isn't that they took place at all. The problem is to do with the question of what is owed to those who became already infected during the course of the prevention trial, and to those who are now at greater risk of catching an infection. There were also clear failings in the informed consent process.

I think these quotes from two of the participants are revealing in important ways. I found them in an article in the Washington Post:

"It's quite shocking," said Nelly Nonoise, 26, who had received three injections of the vaccine in her left shoulder. She added, "I probably wouldn't have joined the study knowing there's a risk." Another participant, Nonhlanhla Nqakala, 22, said she thought the text message urging her to visit the vaccine test site meant she had tested positive for HIV. Her brother and a close friend had the disease and died, she said. Nqakala said she was relieved when a doctor explained that she was not infected, but the news of a possible problem with the vaccine -- she had received three doses, not placebos -- left her distressed. "I thought the trial would help us find a cure for HIV," she said."

Now, here is a problem obviously! Two people are being interviewed by the journalist, and both indicate that they didn't understand properly the nature of the trial. This does not reflect well on the investigators' professed best practice standards in their informed consent process. It seems obvious that they happily accepted participants into their trial who did not actually comprehend the nature of the trial.

Again, the question is what is owed to the trial participants by the trial sponsors and / or the investigators. Surely if you accept people into your trial that end up being worse off when the trial is stopped, you have some responsibility for these folks, particularly so when obviously you took participants into the trial that didn't understand what was going on in the first place.

And yes, this smug ethicist can claim without embarrassment that 'I told you so' prior to the start of the trial. I argued that trial participants' competence and level of information / comprehension needed to be tested in order to rule out that people would end up in the trial that do not understand its nature. This was rejected at the time with arguments such as 'we would never be able to recruit enough participants then'. So the public health and research imperative was prioritised over individual participants' well being.

Lessons to be learned: Well, to be frank, the warnings were there prior to the trial and they were ignored. That one should not do this isn't exactly a new lesson, so, if anything we should probably consider erring on the side of caution on the odd occasion in future.

The Washington Post cites the Principal Investigator with these remarks:

"This is my worst nightmare," said Glenda Gray, the lead South Africa investigator for the vaccine study. "I haven't slept for days. I have a headache. I'm ready to resign from trials for the rest of my life."

Of course, while I have no doubt about Glenda Gray's integrity as a researcher, and while I have no doubt that her current qualms are genuine, much of this could have been avoided if sensible procedures in terms of the informed consent process had been put in place, including knowledge and comprehension evaluation of the prospective participants. The failure to do so puts the moral responsibility for this trial's failure squarely on the shoulders of the trial sponsors and investigators. It's not about resigning from clinical trials, it's about avoiding ethical short cuts (for instance in the informed consent process).

South African government insanity on HIV/AIDS seems to continue

'Mbeki must be investigated'
26/09/2007 17:40 - (SA)

Cape Town - The Treatment Action Campaign (TAC) has called for a judicial investigation into the presidency and the health minister, as well as Christine Qunta.

In a press statement released on Wednesday, the TAC said there was prima facie evidence that illegal and unethical experiments were conducted on people living with HIV/Aids with a toxic and unregistered substance named Virodene.

The experimentation was for commercial benefit.

The statement claimed that the substance Virodene P058 was a derivative of the toxic, potentially lethal industrial solvent N dimethylformamide (DMF), which was never registered with a medicines regulatory authority of any state in the world.

There was evidence that the Office of the Presidency, President Mbeki and Minister of Health Manto Tshabalala-Msimang were involved in these trials after the Medicines Control Council and the University of Pretoria ruled them unethical and in contravention of the law, the TAC said.

President corrupt?

This led the organisation to call for the appointment of a judicial commission of inquiry to determine to what extent the president, health minister, government official had been involved and how much experimentation on people was being conducted.

The TAC also alleged that Christine Qunta, a practising attorney, was an investor and director in a company that profiteers from selling untested and unregistered cures and treatments for Aids.

Qunta was allegedly appointed by the health minister to a presidential task team on traditional medicines.

The TAC alleges that Qunta and her legal firm had earned tens of thousands of rands in fees profiteering from the unethical, unscrupulous and unlawful activities of Matthias Rath, the vitamin salesman.

The organisation believed that "at best it appears someone in the presidency acted unethically in 2000 and 2001. At worst, there is direct involvement of the president himself in corrupt, illegal actions with potentially deadly consequences for patients with HIV."

HIV/AIDS: The ANC facilitated genocide seems to be swinging back into higher gear

Interested observers will know that South Africa is currently run by the ANC's President Thabo Mbeki (who informed interviewers repeatedly that he doesn't know a single person who died on AIDS in his country, and who expressed doubts that HIV is the cause of AIDS).

His Minister for Health Prevention is Manto Tshabalala-Msimang (who offered at one point in her illustrious career beetroot, the African potato and garlic as a means to prevent AIDS). They both continue to conspire against millions of HIV infected South Africans with a wide array of truly idiotic statements and every effort to slow down the roll-out of antiretroviral treatments as good as is feasible (ideally without getting caught).

Eventually they were forced by mostly court decisions to stop the HIV related genocide that they were quietly organising and presiding over. Still, things happen even to truly nasty people like the Pres and his sidekick Manto. Manto, who would fit nicely into Scotland, given her interest in booze, had to be taken out of action to get a new liver (as her old liver truly couldn't handle the amount of alcohol she's guzzling). While she quickly jumped the queue to get a new liver (makes sense, who else would assist so kindly in executing Thabo Mbeki's genocidal activities), her Deputy Minister Nozizwe Madlala-Routledge took over. She is an old hack of the South African communist party and so a member of a party belonging to the triparty alliance making up the government of the country. Being not an ANC cadre she didn't have to insists that the earth is flat, pigs can fly and AIDS is a conspiracy against Black people organised by the CIA and the international pharmaceutical industry bent on selling poisonous AIDS drugs to South African Blacks. There was no need for her to peddle 'African solutions' such as beetroot, African potatos etc etc (as Manto suggested in between a couple of drinks during one of her conference appearances).

Well, Madlala-Routledge worked tirelessly toward getting AIDS ttreatment programs off the ground while Tshabalala-Msimang jumped the liver transplantation queue. It was only a matter of time until she would be cancelled by Thabo and his sidekick, and today she was. The pretext was that she went to (would you believe) an AIDS conference in Spain even though Thabo the Pres explicitly refused her travel. Stupidly Madlala-Routledge seems to have dragged her son and various hangers-on along so this had all the make-up of a junket trip. A good pretext to fire her. Here's a statement on her dismissal from the South African HIV/AIDS Clinicians' Society that I received a few minutes ago. I would normally encourage you to write to the SA High Commission or Embassy in your country and ask that you criticise her dismissal, but what's the point, thhe High Commissioners and ambassadors would report back to Thabo the Pres who is the bloke who fired her in the first place... welcome to the ANC owned rainbow nation in action.

'Statement by the Southern African HIV Clinicians Society (9th August 2007)

We are an organisation of over 12 000 health professionals working in HIV care in the Southern Africa region. http://www.sahivsoc.org/ We support the Rural Doctors Association of Southern Africa (RuDaSA) statement issued on 9th August 2007, National Women’s Day. We believe that Deputy Minister Nozizwe Madlala-Routledge has played a fundamental role in bringing civil society and professionals together to support the government’s National Strategic Plan (NSP) for HIV/AIDS, on an unprecedented level. She demonstrated compassion and commitment to South Africa’s population, with a respect for science and public health that made us realise what we should demand from all public servants. The manner of her dismissal (on Women’s Day), when so much positive work has been done in the area of HIV, to provide political and public leadership for the first time, is deeply distressing. Furthermore, it comes when we are seeing alarming signs of a return to the rhetoric and confrontation of the past over HIV. The Society has asked for urgent clarification, as have others, as to why the mother-to-child HIV prevention programme (PMTCT) has not been expanded beyond 30% coverage after 5 years, and why more effective regimens have not been implemented. Yet again, court action is being threatened as the last resort to force action on this issue. Fewer than 20% of adults requiring antiretrovirals are receiving them, after more than 3 years of publicly available ART. Minister Manto Tshabalala-Msimang, since her return from sick leave, has not addressed these worrying problems. Instead she has focused on the (unsubstantiated) high price of future antiretrovirals, claims of good geographical ‘coverage’ for PMTCT and ART access, and continued references to South Africa having the ‘largest and most comprehensive response’, without critical appraisal of those who do not access HIV care. For HIV infected people, their families, and their caregivers, this looks like more of the same – the Minister demonstrating antagonism to the one thing that can save their lives – antiretroviral therapy. It is deeply ironic that price is cited by the Minister as an issue in access to antiretrovirals, when it has taken the bravery of activist groups and professionals, rather than her own department, to fight for current affordable HIV care. Finally, we remain deeply concerned that the targets set for the NSP for 2007 look increasingly unrealisable. Since their publication, no plan has been forthcoming on how to attain the ambitious targets set in the Plan. Our country desperately needs trusted and brave leadership in the area of HIV. The deputy minister gave us hope that this was possible. We wish her well, and thank her for giving us hope and leadership. We recommit ourselves to ensuring that government, the elected steward of our health system, is held accountable for decisions regarding health care for HIV-infected people. On behalf of the Executive, SAHCS.'

My darling Manto Tshabalala-Msimang, South Africa's Minister for Health Prevention

OK, folks, in line with my 'tradition' of sending a funny weekend type story, here's one sent by a South Africa based correspondent on the latest from South Africa's Ministry for Health Prevention!

Buy Our New Book and Help AIDS orphans in South Africa

Sounds like a pathetic excuse to flog a book, no doubt, but if you've any interest at all in bioethics, consider buying this book. It's a pretty cool volume offering reprints of the best papers published in the journals BIOETHICS and DEVELOPING WORLD BIOETHICS. It's a lot of book for a truly low price. The editors support with their royalties phedisang, a South Africa based charity supporting AIDS orphans.

Language, Reality and Political Correctness

I got to be honest. I am not a linguist and this posting might well be out of my intellectual / professional depth. I take the idea of political correctness not as a swear word but as something desireable. Political correctness, as I understand it, simply means in the context of language that I should (must?) not denigrate usual suspect types folks (ethnic minorities, sexual minorities, women, and so on and so forth) by means of language. So, I wouldn't call a black person a 'nigger' or a gay person a 'faggot' because these terms are rightly considered offensive. In a civilised society we should not call each other names like that. One thing that always puzzled me about this is, where one should reasonably draw the line on this. Is it acceptable to call heterosexual folks 'breeders' or 'potential breeders'? Or is that just as unacceptable as calling gay folks 'perverts'?
Here's an interesting piece from South Africa. Lupi Ngcayisa, a black radio DJ referred to blacks in some context as 'kaffirs'. Well, 'kaffir' is a racist slur used (so wiki sez) most often by white South Africans to describe black people or people with darker skin colour. Kaffir is also used by Jamaican Indians to describe African Caribbeans in a derogatory manner. It's clear then that 'kaffir' is historically a racist swear word. This probably is a good reason for not using such terminology. South Africa's Human Rights Commission, if the just mentioned article is to be believed, has issued a list of words that are unacceptable in post-apartheid South Africa.
So far so good. Here's the twist. I'm sure most of us, at one point or other, will have heard African Americans referring to other black people as 'niggers'. Similarly, gay people have chosen a long time ago to use swear words deployed against them and change their meanings by giving positive connotations to them. So, you'd find in Germany gay folks referring to each other as 'schwul' or 'warmer bruder'. This terminology until just a few decades ago would have been considered derogatory and people described as 'schwul' would have taken offense. This is not so any longer. German gay people have succeeded in transforming the meaning of 'schwul' into something positive, into something affirmative. In fact, it is politically correct these days in Germany to refer to gay people (well, certainly gay men) as 'schwul'.
There's interesting questions arising from this: If particular terminology is considered derogatory, and racist, should we really deploy legislation to outlaw the use of such language? If we do, should we make exceptions for people from designated groups who might wish to refer to themselves in such language (probably with a view toward changing the meanings of the terminology in question). If we did that, should we review the utilisation of particular terminology in regular intervals so that we're able to accommodate changes in the meanings of such words? Who is 'we? And how should such changes of meaning come about if we may not to use such words to begin with? Aren't we putting an artificial hold on how certain terms of popular language are allowed to evolve?
In any case, this is what happened recently in South Africa. A black guy was censored for using racist terminology to describe people of his ethnic group. If a gay person like myself referred to himself as a 'pervert' (as I have done, jokingly, often) should he/she be equally censored?

Some good news from South Africa - at long last

Here's good news from today's BRITISH MEDICAL JOURNAL. It's a copy-paste job really. I am tempted to go on raving again about human lives lost due to the unimaginable incompetence of the current South African minister for health prevention, Dr (Beetroot) Manto Tshabalala-Msimang, and, of course, the country's slightly paranoid President Thabo Mbeki, but what's the point... readers of this blog will know. So, here's the BMJ item:

South Africans to get AIDS plan

Pat Sidley

Johannesburg

The South African government has finally introduced a full and far reaching plan to deal with its HIV/AIDS epidemic. But it will cost the country some 14bn rand (£970m; 1.4bn; $1.9bn) over the next five years. This amount was not planned for in the present budget for the year ahead.

The plan aims to give antiretroviral treatment to up to 80% of people with AIDS who need the treatment; to halve the new infection rate by 2011; and to ensure that all pregnant women who are HIV positive have access to treatment to prevent transmission to their babies. The plan envisages better spending of the large donations that pour into the country, with the intention of strengthening the health system and using health staff more efficiently. The whole process will be properly evaluated and monitored.

Less than a year ago, Mr Mbeki's government followed the president's view that AIDS was a syndrome and that "a virus could not cause a syndrome." Mr Mbeki thought that the extent of disease in the country could be attributed to poverty. He voiced misgivings about white Western experts who claimed that AIDS originated in Africa as though Africans were dirty and immoral. And he presided over a cabinet which approved a product as a cure for AIDS that was later found to contain an industrial solvent (BMJ 1997; 314:450).

The health minister Manto Tshabalala-Msimang, who had a liver transplant earlier this month (15 March), has previously advocated the virtues of beetroot and garlic over antiretrovirals and appealed against court decisions fought for and won by the Treatment Action Campaign to compel the government to provide treatment (BMJ 2006,333:167)