November HIV/AIDS Public Health Journal Club

The theme of the November Journal Club meeting at the Nelson R Mandela School of Medicine focused on "Research Ethics", featuring presenters Dr Ames Dhai (of the Department of Obstetrics & Gynaecology and Chair of the Bio-ethics Reference Group), and Dr Rob Pawinski (of Department of Community Health and the Enhancing Care Initiative).

Dr Dhai's chosen journal article "Human Rights, Politics and Review of Research Ethics" was authored by Chris Beyrer and Nancy E Klass and appeared in The Lancet 2002; 360 : 246-51. Her choice was based on the study in question reflecting numerous similarities with the South African experience of ethical issues, and highlighting the importance of the surrounding social context and political frameworks that might affect ethical research.

Some significant points emerging from the study included:

• a tendency to focus on the protection of individuals which can obscure the potential risks for groups and communities;


• researchers having to apply for ethics clearance to the very governments which perpetuate human rights violations;


• the fact that human rights violations can have fatal consequences for participants in research studies;


• implementation of findings might not be validated;


• acquiring government approval might intensify coercion by corrupt officials.


The article refers to a case in Rwanda where the findings of a particular study, albeit seemingly unrelated, (i.e. the health conditions of mobile refugees) actually enabled the perpetuation of human rights violations. Dr Dhai noted that in KwaZulu-Natal, participants of programmes conducted at Hlabisa tend to be labelled as "vectors of HIV/AIDS", and the area is perceived in some quarters as a "hotbed" of HIV, largely as a result of the mainstream media's focus on the extensive research being done in there. This comment generated discussion around the need to survey the effects of research on this particular community, and in particular to address the problem of the stereotyping of its members through "excessive publication", both academic and journalistic.

Dr Dhai concluded by emphasising that a weighing up of potential risks and benefits for participants of research projects should result in an equilibrium of justice. She also noted that the journal article does not factor in positive examples of research supportingrights-based social change, as in the case in South Africa, where the results of ARV research have strengthened the lobby movement for access to treatment for all, not only by giving individual participants hope for sustained and healthier life, but also through the provision of scientific data as evidence of the benefits of ARV treatment.

Dr Pawinski's presentation focused on "Ethical Analysis in Public Health" by M Roberts and M Reich (The Lancet 2002; 359 : 1055-59). Emphasising the need for more in-depth training on research ethics for medical practitioners, he gave an overview of the various philosophical approaches to ethics, and explained that these made up a guiding framework for what is an ongoing process.

He and Dr Dhai then led the gathering in a stimulating debate on ethical approaches to MDR (multi-drug resistant) Tuberculosis, which, being airborne, is highly contagious and currently results in an 80% mortality rate in South Africa. They explained that healthcare workers feel deeply anxious about their vulnerability to infection, and that new policy needs to be put in place to address this problem.

The question posed was: Given that TB is a notifiable disease, should patients be quarantined while under treatment in order to ensure adherence?
The ensuing debate revolved around where "patient privileges end and public peril begins". While a member of the Treatment Action Campaign felt that quarantine should not be supported, and others noted that patients suffering from ebola (haemorraghic fever) were isolated immediately, another mentioned that so far, evidence suggests that only 50% of those quarantined for treatment would respond. Those in favour of quarantine for MDR TB patients felt that even if few resources are available, action should be positioned in order to prevent an epidemic.

It was recognised that the development of policy in this regard could have far-reaching implications for decisions pertaining to HIV/AIDS as a notifiable disease, as well as other repercussions for public health services.

To download the presentations, click on the links in the righthand column.

The monthly HIV/AIDS Public Health Journal Club is a joint venture incorporating the Department of Community Health's HIV/AIDS Public Health Programme, the Enhancing Care Initiative KwaZulu-Natal (ECI), and the Centre for HIV/AIDS Networking (HIVAN). The Enhancing Care Initiative is collaboration between the University of KwaZulu-Natal, the Harvard AIDS Institute and the KZN Department of Health.