Clinical Trials Offshored: On Private Sector Science and Public Health

Generative Hanging Out: Developing Engaged Practices for Health-Related Research1

"Hanging out" with one's interlocutors generates ethnographic ways to creatively involve people in health care research. This special issue focusses on people who are difficult to engage in conventional research because they are not verbally fluent, such as people with dementia or learning disabilities, or who speak a language that the researcher does not understand. In this introduction I discuss how "Hanging out" shifts the goal-orientation of research practices toward relationships and settings. Hierarchies may be shifted to provide attractive possibilities for interlocutors to participate by doing things together with the researcher. The research practice itself becomes the object of analysis.

[Everyday transgressions of borderlines: the scandalization of clinical drug trials of the psychiatrist Roland Kuhn]

"Experimental case Münsterlingen: clinical trials in psychiatry, 1940-1980" is the name of the report of a control commission established by the government of the Swiss Canton Thurgau in 2016, after several articles in the press after 2012 had criticized the drug tests carried out by Roland Kuhn, the former clinical director of the cantonal mental hospital in Münsterlingen. The report discusses "fine discrepancies in everyday borderline transgressions" "from today's viewpoint". These borderline transgressions were seen especially in the missing, inadequate or undocumented informed consent of patients and in the usage of test substances, which varied between the (mostly) accepted or not refused intake and the camouflaged or (seldom) threatened application via injection. Thus, the report shows on the one hand, the considerable development of the normative context of treatment of mentally ill patients in the past 70 years and on the other hand, with its detailed descriptions, it can sensitize today's therapists to the pertinent context. But most of all this is the story of Roland Kuhn, the responsible psychiatrist and the drug testing discoverer of the antidepressive effect of imipramine. This story of the discovery is judged from very differing perspectives and is thus relativized, all the way from observations of a "provincial psychiatrist" to consideration for the Nobel Prize. At the same time critically evaluated traits of Kuhn's personality seem to have influenced the occasionally negative comments of the commission report. We should recognize, however, that with his qualitative and psychopathological individual case observations, Kuhn discovered the antidepressive effect of a test substance that as a hypothesis was verified by subsequent quantitative and statistical methods.

'Working relationships' across difference - a realist review of community engagement with malaria research

Background: Community engagement (CE) is increasingly accepted as a critical aspect of health research, because of its potential to make research more ethical, relevant and well implemented. While CE activities linked to health research have proliferated in Low and Middle Income Countries (LMICs), and are increasingly described in published literature, there is a lack of conceptual clarity around how engagement is understood to 'work', and the aims and purposes of engagement are varied and often not made explicit. Ultimately, the evidence base for engagement remains underdeveloped. Methods: To develop explanations for how and why CE with health research contributes to the pattern of outcomes observed in published literature , we conducted a realist review of CE with malaria research - a theory driven approach to evidence synthesis. Results: We found that community engagement relies on the development of provisional 'working relationships' across differences, primarily of wealth, power and culture. These relationships are rooted in interactions that are experienced as relatively responsive and respectful, and that bring tangible research related benefits. Contextual factors affecting development of working relationships include the facilitating influence of research organisation commitment to and resources for engagement, and constraining factors linked to the prevailing 'dominant health research paradigm context', such as: differences of wealth and power between research centres and local populations and health systems; histories of colonialism and vertical health interventions; and external funding and control of health research. Conclusions: The development of working relationships contributes to greater acceptance and participation in research by local stakeholders, who are particularly interested in research related access to health care and other benefits. At the same time, such relationships may involve an accommodation of some ethically problematic characteristics of the dominant health research paradigm, and thereby reproduce this paradigm rather than challenge it with a different logic of collaborative partnership.

More than sample providers: how genetic researchers in Pakistan mobilized a prenatal diagnostic service for thalassemia

While unequally resourced partners from the so-called global South are often considered ‘mere sample providers’ in larger international genomics collaborations, in this paper, we show how they strategically work to mobilize their role in a global system of tissue exchange to deliver services for local communities. We unpack how a prenatal diagnostic service for thalassemia in Pakistan emerged out of the maneuvering efforts of internationally connected Pakistani researchers. By tracing the distributed capacities that emerged and circulated as they set about improving medical genetics in Pakistan, we outline some key conditions that led to the establishment of the service: first, the scale of unmet needs that geneticists faced when collecting data as part of their research that made medical genomics a relevant field; secondly, joint efforts between researchers and physicians that were engaged with the challenge of decreasing disease prevalence through diagnostics and abortion; and finally, the ways in which international research collaborations helped generate resources to improve medical genetics in Pakistan. To understand how genetic research and medicine is currently being developed in Pakistan, we need to ethnographically re-center our analyses in ways that allow us to identify the resourceful ways in which researchers maneuvre to secure locally relevant outcomes.

Comparative ethnographies of medical research: materiality, social relations, citizenship and hope in Tanzania and Sierra Leone

In this paper we bring together ethnographic research carried out during two clinical prevention trials to explore identities, relations and political imaginations that were brought to life by these different technologies. We highlight the ways in which critical anthropological engagement in clinical trials can help us radically reconsider the parameters and standards of medical research. In the paper we analyse the very different circumstances that made these two trials possible, highlighting the different temporalities and politics of HIV and Ebola as epidemics. We then describe four themes revealed by ethnographic research with participants and their communities but mediated by the specific sociopolitical contexts in which the trials were taking place. In both countries we found materiality and notions of exchange to be important to participants’ understanding of the value of medical research and their role within it. These dynamics were governed through social relations and moral economies that also underpinned challenges to Western notions of research ethics. The clinical trials offered a language to express both disaffection and disillusionment with the political status quo (often through rumours and anxieties) while at the same time setting the foundations for alternative visions of citizenship. Attached to these were expressions of ‘uncertainty and hope’ steeped in locally distinctive notions of destiny and expectations of the future.

Informal professionalization of healthy participants in phase I clinical trials in Russia

Background:

Previous social science research has shown how some healthy phase I trial participants identify themselves as workers and rely on trials as a major source of income. The term “professionalization” has been used to denote this phenomenon.

Purpose:

We aim to examine a component of healthy trial participants’ professionalization that has not yet been systematically studied: how repeat phase I trial participants develop and claim expertise that distinguishes them from others and makes them uniquely positioned to perform high-quality clinical trial labor. We also aim to explain the significance of these research results for protection of healthy participants in phase I trials.

Methods:

This qualitative exploratory study was conducted in Russia, in two phase I trial units. It involved semi-structured interviews with 28 healthy trial participants with varying lengths of experience in trials, observations of work done in trial units, and interpretive conversations with investigative staff.

Results:

Interviewed healthy individuals who repeatedly participate in phase I trials describe developing knowledge and skills that involve appreciating the meaning of trial procedures, coming up with techniques to efficiently follow them, organizing themselves and others in the course of a trial, and sharing tacit ways of doing trial work well with other less experienced participants. Our results suggest that a prerequisite for such expertise-centered professionalization is the emergence of a positive identity linked to seeing value in trial participation work. A crucial component of professionalization thus understood is the development of a work ethic that entails caring about results and being reliable partners for investigators.

Limitations:

The attitudes and behaviors presented in this article are not suggested to be universally shared among healthy trial participants, but rather represent a particular instance of professionalization that coexists with other views and tactics.

Conclusions:

A way of better protecting healthy trial participants begins with recognizing their skills, knowledge, and the centrality of the contribution they are making to pharmaceutical research. Currently, the expertise of experienced trial participants is recognized on the work floor only; therefore, the professionalization we described is informal. Yet, the informal professionalization process is inherently risky as it does not involve any change in the formal conditions of trial participants’ work. Instituting formal measures for protecting healthy trial participants as skilled workers combined with recognition of their expertise is essential.

Traveling health-promoting infrastructures: A meta-ethnographic analysis

In recent years, it has become increasingly important to understand the global circulation of healthcare innovations in nations' attempts to solve contemporary health challenges. This article is a systematic review and meta-ethnography-inspired analysis that explores the global circulation of health-related standards, protocols, procedures, and regulations, or what we term health-promoting infrastructures (HPIs). The notion of HPIs is defined as built networks that allow for the circulation of health expertise with the intention of promoting solutions that address global health problems. We conducted systematic searches in six relevant electronic databases and ended up with a set of 13 studies. The review shows that it takes arduous work to prepare and facilitate the travel of HPIs and to mold them into meaningful local forms. In conclusion, we argue that HPIs can helpfully be thought of as scripted forms, which are globally available in always sited efforts to address specific problems.

'Hold on' (Bambelela)! Lyrical interpretations of participation in an HIV prevention clinical trial

During a five-day workshop, former clinical trial participants and local musicians wrote the lyrics and recorded a song about an HIV prevention trial. Born of concerns about misconceptions regarding experimental drug trials, the aim was to engender engagement with medical researchers and open dialogue about the risks and benefits of trial participation. Composing lyrics that highlighted their credibility as communicators of medical scientific knowledge and their selfless sacrifice to stem the transmission of HIV, women performed their social positioning and cultural authority in contrast to men as well as other women not part of the trial. While involvement in HIV prevention initiatives often attracts stigma, scorn and criticism, the song's lyrics highlighted women's new-found identities as heroines searching for a solution to the spread of HIV, challenging these stereotypes. Methodologically, the paper describes a novel approach that uses artistic expression for public engagement with biomedical research.

The biopolitics of CFS/ME

This paper argues that Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) constitutes a biopolitical problem, a scientific object which needs to be studied, classified and regulated. Assemblages of authorities, knowledges and techniques make CFS/ME subjects and shape their everyday conduct in an attempt to increase their supposed autonomy, wellbeing and health. CFS and CFS/ME identities are however made not only through government, scientific, and medical interventions but also by the patients themselves, a biosocial community who collaborates with scientists, educates itself about the intricacies of biomedicine, and contests psychiatric truth claims. CFS/ME is an illness trapped between medicine and psychology, an illness that is open to debate and therefore difficult to manage and standardise. The paper delineates different interventions by medicine, science, the state and the patients themselves and concludes that CFS/ME remains elusive, only partially standardised, in an on-going battle between all the different actors that want to define it for their own situated interests.

Good collaborative practice: reforming capacity building governance of international health research partnerships

In line with the policy objectives of the United Nations Sustainable Development Goals, this commentary seeks to examine the extent to which provisions of international health research guidance promote capacity building and equitable partnerships in global health research. Our evaluation finds that governance of collaborative research partnerships, and in particular capacity building, in resource-constrained settings is limited but has improved with the implementation guidance of the International Ethical Guidelines for Health-related Research Involving Humans by The Council for International Organizations of Medical Sciences (CIOMS) (2016). However, more clarity is needed in national legislation, industry and ethics guidelines, and regulatory provisions to address the structural inequities and power imbalances inherent in international health research partnerships. Most notably, ethical partnership governance is not supported by the principal industry ethics guidelines - the International Conference on Harmonization Technical Requirements for Registration of Pharmaceutical for Human Use (ICH) Good Clinical Practice (ICH-GCP). Given the strategic value of ICH-GCP guidelines in defining the role and responsibility of global health research partners, we conclude that such governance should stipulate the minimal requirements for creating an equitable environment of inclusion, mutual learning, transparency and accountability. Procedurally, this can be supported by i) shared research agenda setting with local leadership, ii) capacity assessments, and iii) construction of a memorandum of understanding (MoU). Moreover, the requirement of capacity building needs to be coordinated amongst partners to support good collaborative practice and deliver on the public health goals of the research enterprise; improving local conditions of health and reducing global health inequality. In this respect, and in order to develop consistency between sources of research governance, ICH-GCP should reference CIOMS ethical guidelines as the established standard for collaborative partnership. Moreover, greater commitment and support should be given to co-ordinate, strengthen and enforce local laws requiring equitable research partnerships and health system strengthening.

Une santé mondiale repensée : la perspective de futures chercheuses-praticiennes

 L'étude des conséquences de la mondialisation sur la santé des populations est au coeur de la santé mondiale. Ce faisant, la mondialisation conditionne également la mise en oeuvre des projets de recherche et des interventions en santé mondiale, et les rapports sociaux inégalitaires qui s'y perpétuent. Le présent commentaire propose des réflexions sur des défis épistémologiques et politiques auxquels se confronte la santé mondiale. Celles-ci sont issues d'observations et de discussions pendant et après la Conférence canadienne sur la santé mondiale, tenue en novembre 2015. Durant cet événement, une volonté affirmée par la communauté internationale de promouvoir l'équité en santé pour tous et un meilleur partage des savoirs et des ressources au sein des partenariats s'est clairement exprimée. Ainsi, nous envisageons un avenir différent, plus intersectionnel et porteur d'espoir, en proposant une déconstruction de la biopolitique hégémonique des institutions du Nord, tout en mettant au coeur de nos actions les communautés et des partenariats francs, solides et susceptibles de perdurer. Pour ce faire, des pistes sont proposées. Celles-ci nous semblent essentielles à considérer, si l'on prône l'équité et la justice sociale et ce, en commençant par nos propres actions. Notre propos s'ancre dans les pratiques et les réflexions d'un groupe de candidates au PhD en santé publique, dans l'option en santé mondiale.

Current and emerging global themes in the bioethics of regenerative medicine: the tangled web of stem cell translation

Probably the most serious problem facing the field of regenerative medicine today is the challenge of effective translation and development of viable stem cell-based therapies. Particular concerns have been raised over the growing market in unproven cell therapies. In this article, I explore recent developments in the stem cell therapy landscape and argue that while the sale of unproven therapies undoubtedly poses ethical concerns, it must be understood as part of a larger problem at the interface between biomedicine, healthcare, publics, policy and the market. Addressing this will require a broader perspective incorporating the shifting relationships between different stakeholder groups, the global politics of research and innovation, and the evolving role of publics and patients with respect to science.

Austerity and the embodiment of neoliberalism as ill-health: Towards a theory of biological sub-citizenship

This article charts the diverse pathways through which austerity and other policy shifts associated with neoliberalism have come to be embodied globally in ill-health. It combines a review of research on these processes of embodiment with the development of a theory of the resulting forms of biological sub-citizenship. This theory builds on other studies that have already sought to complement and complicate the concept of biological citizenship with attention to the globally uneven experience and embodiment of bioinequalities. Focused on the unevenly embodied sequelae of austerity, the proceeding theorization of biological sub-citizenship is developed in three stages of review and conceptualization: 1) Biological sub-citizenship through exclusion and conditionalization; 2) Biological sub-citizenship through extraction and exploitation; and 3) Biological sub-citizenship through financialized experimentation. In conclusion the paper argues that the analysis of biological sub-citizenship needs to remain open-ended and relational in order to contribute to socially-searching work on the social determinants of health.

Justification for conducting neurological clinical trials as part of patient care within private practice

The aim of this review was to assess the benefits and drawbacks of conducting neurological clinical trials and research in private practice for the patients, clinician, Practice Manager, sponsors/Clinical Research Organisations (CROs) and Clinical Trial Coordinator (CTC) to determine if this is justified for all involved. A combination of literature reviews, original research articles and books were selected from 2005 to 2015. Provided that the practice has sufficient number of active trials to prevent financial loss, support staff, adequate facilities and equipment and time, the benefits outweigh the drawbacks. Clinical trials provide patients with more thorough monitoring, re-imbursement of trial-related expenses and the opportunity to try an innovative treatment at no charge when other options have failed. For the clinician, clinical trials provide more information to ensure better care for their patients and improved treatment methods, technical experience and global recognition. Trials collect detailed and up-to-date information on the benefits and risks of drugs, improving society's confidence in clinical research and pharmaceuticals, allow trial sponsors to explore new scientific questions and accelerate innovation. For the CTC, industry-sponsored clinical trials allow potential entry for a career in clinical research giving CTCs the opportunity to become Clinical Research Associates (CRAs), Study Start-Up Managers or Drug Safety Associates.

Gaining control over breast cancer risk: Transforming vulnerability, uncertainty, and the future through clinical trial participation - a qualitative study

Concepts of disease risk and its management are central to processes of medicalisation and pharmaceuticalisation. Through a narrative perspective, this paper aims to understand how such macro-level developments may (or may not) be experienced individually, and how an algorithm that is used for recruitment into a clinical trial may structure individual notions of being 'at risk' and 'in need of treatment'. We interviewed 31 women participating in the Study of Tamoxifen and Raloxifene (STAR), a chemoprevention trial conducted in the US between 1999 and 2006. Interviews were thematically analysed. Women in the study had experienced the threat of breast cancer and felt vulnerable to developing the disease prior to STAR participation. The diagnosis of 'being at risk' for cancer through an algorithm that determined risk-eligibility for STAR, opened up the possibility for the women to heal. The trial became a means to recognise and collectivise the women's experiences of vulnerability. Through medication intake, being cared for by study coordinators, and the sense of community with other STAR participants, trial participation worked to transform women's lives. Such transformative experiences may nevertheless have been temporary, enduring only as long as the close links to the medical institution through trial participation lasted.

Feeding and Bleeding: The Institutional Banalization of Risk to Healthy Volunteers in Phase I Pharmaceutical Clinical Trials

Phase I clinical trials are the first stage of testing new pharmaceuticals in humans. The majority of these studies are conducted under controlled, inpatient conditions using healthy volunteers who are paid for their participation. This article draws on an ethnographic study of six phase I clinics in the United States, including 268 semistructured interviews with research staff and healthy volunteers. In it, I argue that an institutional banalization of risk structures the perceptions of research staff and healthy volunteers participating in the studies. For research staff, there are three mechanisms by which risk becomes banal: a perceived homogeneity of studies, Fordist work regimes, and data-centric discourse. For healthy volunteers, repeat study participation contributes to the institutional banalization of risk both through the process of desensitization to risk and the formation of trust in the clinics. I argue that the institutional banalization of risk also renders invisible ethical concerns about exploitation of underprivileged groups in pharmaceutical research.

What is it to do good medical ethics? On the concepts of 'good' and 'goodness' in medical ethics

In his book The Varieties of Goodness Georg Henrik von Wright advocates that a useful preliminary to the study of the word 'good' is to compile a list of familiar uses and try to group them under some main headings. The present paper aims at exploring the question, 'What is it to do good medical ethics?', and notably from the vantage point of everyday expressions of the word 'good' and von Wright's grouping of them into six different types of goodness.

Informed Consent: The Politics of Intent and Practice in Medical Research Ethics

Informed consent is a key feature of risk management in medical research. This review outlines the history of the consent requirement and describes its diverse forms through a review of anthropological studies of consent practices. We make a distinction between the politics of intent and the politics of practice to show how the consent requirement has become entrenched in practices through insistence on particular morally sanctioned intentions regardless of whether these intentions are ever realized. We draw attention to the importance of socioeconomic contexts, material practices, and the ethicopolitical dynamics that undergird the resilience of informed consent. We conclude that informed consent has become so ubiquitous thanks to an ability to conjure a stable image of a recognizable and manageable procedure with a particular moral appeal, while simultaneously serving as an empty signifier: an image onto which people can project very different hopes, concerns, and expectations.

A comparison of neuropsychological performance between US and Russia: preparing for a global clinical trial

BACKGROUND

Understanding regional differences in cognitive performance is important for interpretation of data from large multinational clinical trials.

METHODS

Data from Durham and Cabarrus Counties in North Carolina, USA and Tomsk, Russia (n = 2972) were evaluated. The Montreal Cognitive Assessment (MoCA), Trail Making Test Part B (Trails B), Consortium to Establish a Registry for Alzheimer's Disease Word List Memory Test (WLM) delayed recall, and self-report Alzheimer's Disease Cooperative Studies Mail-In Cognitive Function Screening Instrument (MCFSI) were administered at each site. Multilevel modeling measured the variance explained by site and predictors of cognitive performance.

RESULTS

Site differences accounted for 11% of the variation in the MoCA, 1.6% in Trails B, 1.7% in WLM, and 0.8% in MCFSI scores. Prior memory testing was significantly associated with WLM. Diabetes and stroke were significantly associated with Trails B and MCFSI.

CONCLUSIONS

Sources of variation include cultural differences, health conditions, and exposure to test stimuli. Findings highlight the importance of local norms to interpret test performance.

Critical perspectives on nursing as bodywork

Nursing is grounded in care of the body. This article examines nursing as bodywork, as experienced intersubjectively by nurses together with patients and collectively as a body within the health care labor force. The relation of nurses to the body generates conflicting and contradictory social meanings from intimate and sacred work to dirty work. Such meanings have contributed to stigmatizing the work and the worker within the labor force as well contributing to an ongoing stratification in the labor force as nurses have shifted bodywork "to lower level" or ancillary workers.

Benefit sharing: an exploration on the contextual discourse of a changing concept

Background

The concept of benefit sharing has been a topical issue on the international stage for more than two decades, gaining prominence in international law, research ethics and political philosophy. In spite of this prominence, the concept of benefit sharing is not devoid of controversies related to its definition and justification. This article examines the discourses and justifications of benefit sharing concept.

Discussion

We examine the discourse on benefit sharing within three main spheres; namely: common heritage of humankind, access and use of genetic resources according to the Convention on Biological Diversity (CBD), and international clinical research. Benefit sharing has change from a concept that is enshrined in a legally binding regulation in the contexts of common heritage of humankind and CBD to a non-binding regulation in international clinical research. Nonetheless, there are more ethical justifications that accentuate benefit sharing in international clinical research than in the contexts of common heritage of humankind and the CBD.

Summary

There is a need to develop a legal framework in order to strengthen the advocacy and decisiveness of benefit sharing practice in international health research. Based on this legal framework, research sponsors would be required to provide a minimum set of possible benefits to participants and communities in research. Such legal framework on benefit sharing will encourage research collaboration with local communities; and dispel mistrust between research sponsors and host communities. However, more research is needed—drawing from other international legal frameworks, to understand how such a legal framework on benefit sharing can be successfully formulated in international health research.

From global bioethics to ethical governance of biomedical research collaborations

One of the features of advanced life sciences research in recent years has been its internationalisation, with countries such as China and South Korea considered 'emerging biotech' locations. As a result, cross-continental collaborations are becoming common generating moves towards ethical and legal standardisation under the rubric of 'global bioethics'. Such a 'global', 'Western' or 'universal' bioethics has in turn been critiqued as an imposition upon resource-poor, non-Western or local medical settings. In this article, we propose that a different tack is necessary if we are to come to grips with the ethical challenges that inter-continental biomedical research collaborations generate. In particular we ask how national systems of ethical governance of life science research might cope with increasingly global research collaborations with a focus on Sino-European collaboration. We propose four 'spheres' - deliberation, regulation, oversight and interaction - as a helpful way to conceptualise national systems of ethical governance. Using a workshop-based mapping methodology (workshops held in Beijing, Shanghai, Changsha, Xian, Shenzen and London) we identified three specific ethical challenges arising from cross-continental research collaborations: (1) ambiguity as to which regulations are applicable; (2) lack of ethical review capacity not only among ethical review board members but also collaborating scientists; (3) already complex, researcher-research subject interaction is further complicated when many nationalities are involved.

Recruitment practices and the politics of inclusion in cancer clinical trials

Since the U.S. National Institutes of Health (NIH) Revitalization Act of 1993, researchers with federal funding have been required to include "minorities and women" in their clinical trials, and inclusion in research has come to be seen as an important strategy for reducing health disparities. On the basis of ethnographic research in oncology clinics in an academic medical center and a public hospital over a period of two years, this article examines how the NIH inclusion mandate is playing out in the context of oncology clinical trials. We argue that although individual patients are recruited to particular trials by individual providers, recruitment processes are shaped by the structural inequities in the U.S. health care system that create differential access to medical facilities with different and unequal research infrastructures. Given the heterogeneity of clinical trials, research infrastructures, and the U.S. health care system, the meanings of inclusion in research are multiple, and inclusion by itself does not ensure equity.

The logic of strategic ignorance

Ignorance and knowledge are often thought of as opposite phenomena. Knowledge is seen as a source of power, and ignorance as a barrier to consolidating authority in political and corporate arenas. This article disputes this, exploring the ways that ignorance serves as a productive asset, helping individuals and institutions to command resources, deny liability in the aftermath of crises, and to assert expertise in the face of unpredictable outcomes. Through a focus on the Food and Drug Administration's licensing of Ketek, an antibiotic drug manufactured by Sanofi-Aventis and linked to liver failure, I suggest that in drug regulation, different actors, from physicians to regulators to manufacturers, often battle over who can attest to the least knowledge of the efficacy and safety of different drugs - a finding that raises new insights about the value of ignorance as an organizational resource.

In the ruins of Babel: pitfalls on the way toward a universal language for research ethics and benefit sharing

At the end of a paper on international research ethics published in the July-August 2010 issue of the Hastings Center Report, London and Zollman argue the need for grounding our duties in international medical and health-related research within a broader normative framework of social, distributive, and rectificatory justice. The same goes for Thomas Pogge, who, in a whole range of publications during the past years, has argued for a human-rights-based approach to international research. In a thought-provoking paper in the June 2010 issue of the American Journal of Bioethics, Angela J. Ballantyne argues that “the global bioethics priority” in medical and health-related research ethics today is how to do research fairly in an unjust world.

Adverse events and placebo effects: African scientists, HIV, and ethics in the 'global health sciences'

This paper builds on the growing literature in 'postcolonial technoscience' by examining how science and ethics travel in transnational HIV research. I use examples of two controversial US-funded studies of mother-to-child transmission in Africa as case studies through which to explore quandaries of difference and inequality in global health research. My aim is not to adjudicate the debates over these studies, but rather to raise some questions about transnational research, science, and ethics that often get lost in public controversies over the moral status of such trials. Using interviews conducted with American and Ugandan HIV researchers as well as relevant material published in the popular and medical press, I argue that debates over research practice and the conditions under which practices are deemed ethically legitimate or questionable reflect the challenges faced by African researchers seeking to participate in global health science. In doing so, I show how questions of scientific legitimacy and authority are played out in debates over who decides what constitutes 'the normal' in human biological research and who can legitimately 'speak for Africa' regarding the ethics of research design and practice. I conclude that researchers from'resource-poor settings' must often walk a tightrope between claims of difference from the global North and assertions of sameness, in which a claim too forceful in either direction can undermine the ethical--and thus scientific--legitimacy of their research.

One step forward, one step sideways? Expanding research capacity for neglected diseases

BACKGROUND

There is general agreement, including from the pharmaceutical industry, that current market based methods of generating research into the development of pharmaceutical products that are relevant for developing countries do not work. This conclusion is relevant not just for the most neglected diseases such as leishmaniasis but even for global diseases such as cancer and cardiovascular disease.

DISCUSSION

Stimulating research will mean overcoming barriers such as patent thickets, poor coordination of research activities, exclusive licensing of new technologies by universities and the structural problems that inhibit conducting appropriate clinical trials in developing countries. In addition, it is necessary to ensure that the priorities for research reflect the needs of developing countries and not just donors. This article will explore each of these issues and then look at three emerging approaches to stimulating research -paying for innovation, priority review sales or vouchers and public-private partnerships, - and evaluate their strengths and weaknesses.

SUMMARY

All of the stakeholders agree that there is a pressing need for a major expansion in the level of R&D. Whatever that new model turns out to be, it will have to deal with the 5 barriers outlined in this paper. Finally, none of the three proposals considered here for expanding research is free from major limitations.

How to do research fairly in an unjust world

International research, sponsored by for-profit companies, is regularly criticised as unethical on the grounds that it exploits research subjects in developing countries. Many commentators agree that exploitation occurs when the benefits of cooperative activity are unfairly distributed between the parties. To determine whether international research is exploitative we therefore need an account of fair distribution. Procedural accounts of fair bargaining have been popular solutions to this problem, but I argue that they are insufficient to protect against exploitation. I argue instead that a maximin principle of fair distribution provides a more compelling normative account of fairness in relationships characterised by extreme vulnerability and inequality of bargaining potential between the parties. A global tax on international research would provide a mechanism for implementing the maximin account of fair benefits. This model has the capacity to ensure fair benefits and thereby prevent exploitation in international research.

Profitable failure: antidepressant drugs and the triumph of flawed experiments

Drawing on an analysis of Irving Kirsch and colleagues' controversial 2008 article in "PLoS [Public Library of Science] Magazine" on the efficacy of SSRI antidepressant drugs such as Prozac, I examine flaws within the methodologies of randomized controlled trials (RCTs) that have made it difficult for regulators, clinicians and patients to determine the therapeutic value of this class of drug. I then argue, drawing analogies to work by Pierre Bourdieu and Michael Power, that it is the very limitations of RCTs -- their inadequacies in producing reliable evidence of clinical effects -- that help to strengthen assumptions of their superiority as methodological tools. Finally, I suggest that the case of RCTs helps to explore the question of why failure is often useful in consolidating the authority of those who have presided over that failure, and why systems widely recognized to be ineffective tend to assume greater authority at the very moment when people speak of their malfunction.

An organizational perspective on ethics as a form of regulation

In this paper we propose a theoretical framework for analysing the history and function of ethics as a form of regulation. Ethics in the form of codes, rules and declarations, constitutes regulatory policies, and we wish to suggest analysing such policies from an organizational perspective. In many instances ethics policies are reactions to particular events involving harm of patients or research participants. As such they seem to come forward as solutions to specific problems. However, not all such events that instigate the making of new policies, and policies often have other effects and are used for other purposes than what we might expect from the events preceding them: when ethics takes on the form of policy making, the relationship between problems and solutions is more complex. We suggest that an organizational perspective on ethics codes, rules and declarations can deliver a relevant framework for future studies of the implications of wanting to address ethical problems through policy making.

Enhancing innovation between scientific and indigenous knowledge: pioneer NGOs in India

BACKGROUND

Until recently, little attention has been paid to local innovation capacity as well as management practices and institutions developed by communities and other local actors based on their traditional knowledge. This paper doesn't focus on the results of scientific research into innovation systems, but rather on how local communities, in a network of supportive partnerships, draw knowledge for others, combine it with their own knowledge and then innovate in their local practices. Innovation, as discussed in this article, is the capacity of local stakeholders to play an active role in innovative knowledge creation in order to enhance local health practices and further environmental conservation. In this article, the innovative processes through which this capacity is created and reinforced will be defined as a process of "ethnomedicine capacity".

METHODS

The field study undertaken by the first author took place in India, in the State of Tamil Nadu, over a period of four months in 2007. The data was collected through individual interviews and focus groups and was complemented by participant observations.

RESULTS

The research highlights the innovation capacity related to ethnomedical knowledge. As seen, the integration of local and scientific knowledge is crucial to ensure the practices anchor themselves in daily practices. The networks created are clearly instrumental to enhancing the innovation capacity that allows the creation, dissemination and utilization of 'traditional' knowledge. However, these networks have evolved in very different forms and have become entities that can fit into global networks. The ways in which the social capital is enhanced at the village and network levels are thus important to understand how traditional knowledge can be used as an instrument for development and innovation.

CONCLUSION

The case study analyzed highlights examples of innovation systems in a developmental context. They demonstrate that networks comprised of several actors from different levels can synergistically forge linkages between local knowledge and formal sciences and generate positive and negative impacts. The positive impact is the revitalization of perceived traditions while the negative impacts pertain to the transformation of these traditions into health commodities controlled by new elites, due to unequal power relations.

Clinical trials as treatment option: bioethics and health care disparities in substance dependency

Bioethicists have warned against the dangers of mixing research with treatment. They are concerned that research priorities may take precedence over individual patient needs and that research subjects tend to misunderstand the purpose of research or overestimate the direct medical benefits of participating in studies. Yet, other work has questioned whether clinical research can always be separated from therapeutic benefit for participants. Using in-depth interviews with participants in two phase III randomized U.S. clinical trials for methamphetamine dependency, we examine the treatment options available to participants, their experiences with participating in the trials, and potential problems of trial participation. We find that while participants have experience with four alternative treatment modalities - quitting alone, support groups, in-patient treatment facilities, and consulting primary care physicians - the randomized clinical trials compare favorably to alternatives because they provide access to evidence-based behavioral treatments, specialized medical professionals, non-judgmental staff, and the possibility of receiving an experimental drug. We conclude that while randomized clinical trials are imperfect substitutes for clinical care, they constitute a fragile and sporadic therapeutic niche in a country with fundamental problems in access to health care, a mixed punitive-therapeutic drug addiction policy, and a profit-driven pharmaceutical development and approval process.