Does the Third World Deserve Second-Class AIDS Treatment?

Health and medicine explained.
Nov. 8 1997 3:30 AM

Does the Third World Deserve Second-Class AIDS Treatment?

Yes; some help is better than no help.

This September, the New England Journal of Medicine created a firestorm when it accused researchers of conducting unethical experiments to reduce HIV in newborns in Third World countries. The charges, comparing the work to the infamous Tuskegee experiment, have since halted at least one HIV study. But a closer look suggests that the critics suffer from an ethical blindness of their own.

Advertisement

The studies in question are seeking low-cost ways to prevent HIV-positive pregnant mothers from transmitting the virus to their newborns. A breakthrough 1994 study found a drug regimen that dramatically reduced HIV-transmission rates--from 26 percent of births to 8 percent. Doctors in industrialized nations rapidly adopted the strategy as the standard of care. At $800 a pop, however, poor countries can't afford the full regimen. It's also too complex. Mothers must take AZT, an antiviral, five times a day during pregnancy; receive intravenous AZT during labor; forgo breastfeeding to prevent transmission in milk; and give their babies liquid AZT four times daily for six weeks.

Sixteen studies to find simpler, cheaper methods are now testing everything from vitamin A to a shorter course of oral AZT. The U.S. Centers for Disease Control and Prevention and the National Institutes of Health fund nine of these, involving 12,211 women in Uganda, Thailand, Tanzania, and elsewhere. In every study, some mothers must serve as a comparison group, and that's where the trouble begins. For two years researchers debated whether to compare new therapies to the full AZT regimen or to no treatment at all. In the end, 15 of the 16 trials gave the comparison group a placebo.

In their article reopening the debate, Peter Lurie and Sidney Wolfe, doctors with Ralph Nader's Public Citizen Health Research Group, condemned these 15 trials. Researchers giving placebos, they said, were knowingly killing children. They quoted the Helsinki Declaration of the World Health Organization: "In any medical study, every patient--including those of a control group, if any--should be assured of the best proven diagnostic and therapeutic methods." To them, the only valid question is how new treatments compare to the complex AZT treatment.

42000_42970_neubecker_placebospot

T he Journal's editorial was even more pointed. It accused HIV researchers of "self-serving justification," and likened their studies to the Tuskegee experiment. Conducted by the U.S. Public Health Service from 1932 to 1972, that study left 412 black syphilitic men untreated--even after penicillin became widely available--in an attempt to determine the natural history of syphilis. The experiment, halted only after exposure by journalists, remains a textbook example of unethical, racist research.

The Journal's charges made front-page news. Only a pre-publication leak allowed NIH director Harold Varmus and CDC director David Satcher to publish their indignant defense the next week. In an unlikely spectacle, Republican Sen. Dan Coats stood up for poor Africans to oppose Satcher's nomination for surgeon general. (Ultimately, the Senate Labor Committee approved Satcher 12 to 5.) Johns Hopkins researchers suspended an Ethiopian study with placebos. Other suspensions may follow.

Ethics, the critics insist, demand that U.S. researchers provide the American standard of care to Third World subjects to avoid exploitation. But they don't. The critics' arguments seem reasonable only if they ignore the facts:

This isn't Tuskegee. In Tuskegee, doctors sought no public review, had no clearly beneficial aim, and deceived patients into getting no treatment. By comparison, the HIV trials were reviewed extensively and approved by local governments and the World Health Organization. The experimental therapies may offer great benefit. And some subjects receive placebos because, unlike penicillin for Alabama, the full AZT regimen is out of reach for poor countries.

The complete AZT regimen isn't coming. By 2000, 6 million pregnant women in developing nations will carry HIV. Critics are right that a complex AZT regimen would be best for them. It is the standard of care. So are CAT scanners and heart-bypass surgery. But poor countries aren't going to get any of these. Cost is a big reason--these countries typically spend under $20 per person on health care annually. But even if Glaxo Wellcome gave away the drugs, the complete regimen is still infeasible in much of Africa and south Asia. There, tubing and skills for intravenous AZT are scarce. The governments can't afford to give moms formula to stop them from breast-feeding. Mothers also live too far from doctors to get therapy early in pregnancy and to keep up with necessary monitoring.

Something may be better than nothing. If trials compared low-cost therapy to the complete AZT regimen it's likely that the new regimens will prove less effective. But such results are useless, since the full treatment is not an option. Without a placebo group, we still won't know if any of the treatments are better than nothing and therefore worth giving.

TODAY IN SLATE

Politics

Talking White

Black people’s disdain for “proper English” and academic achievement is a myth.

Hong Kong’s Protesters Are Ridiculously Polite. That’s What Scares Beijing So Much.

The One Fact About Ebola That Should Calm You: It Spreads Slowly

Operation Backbone

How White Boy Rick, a legendary Detroit cocaine dealer, helped the FBI uncover brazen police corruption.

A Jaw-Dropping Political Ad Aimed at Young Women, Apparently

The XX Factor
Oct. 1 2014 4:05 PM Today in GOP Outreach to Women: You Broads Like Wedding Dresses, Right?
Music

How Even an Old Hipster Can Age Gracefully

On their new albums, Leonard Cohen, Robert Plant, and Loudon Wainwright III show three ways.

How Tattoo Parlors Became the Barber Shops of Hipster Neighborhoods

This Gargantuan Wind Farm in Wyoming Would Be the Hoover Dam of the 21st Century

Moneybox
Oct. 1 2014 8:34 AM This Gargantuan Wind Farm in Wyoming Would Be the Hoover Dam of the 21st Century To undertake a massively ambitious energy project, you don’t need the government anymore.
  News & Politics
Politics
Oct. 1 2014 7:26 PM Talking White Black people’s disdain for “proper English” and academic achievement is a myth.
  Business
Moneybox
Oct. 2 2014 9:19 AM Alibaba’s Founder on Why His Company Is Killing It in China
  Life
Quora
Oct. 2 2014 8:27 AM How Do Teachers Kill the Joy of Reading for Students?
  Double X
The XX Factor
Oct. 1 2014 5:11 PM Celebrity Feminist Identification Has Reached Peak Meaninglessness
  Slate Plus
Behind the Scenes
Oct. 1 2014 3:24 PM Revelry (and Business) at Mohonk Photos and highlights from Slate’s annual retreat.
  Arts
Culturebox
Oct. 2 2014 9:08 AM Demons Are Real A horror movie goes behind the scenes on an Intervention-like reality show.
  Technology
Future Tense
Oct. 1 2014 6:59 PM EU’s Next Digital Commissioner Thinks Keeping Nude Celeb Photos in the Cloud Is “Stupid”
  Health & Science
Bad Astronomy
Oct. 2 2014 7:30 AM What Put the Man in the Moon in the Moon?
  Sports
Sports Nut
Oct. 1 2014 5:19 PM Bunt-a-Palooza! How bad was the Kansas City Royals’ bunt-all-the-time strategy in the American League wild-card game?