The distribution of biomedical research resources and international justice

A decade of Ecuador´s efforts to raise its health research output: a bibliometric analysis

Background: Over the past decade, the political movement called ‘Revolución Ciudadana’ implemented a variety of policies and interventions (P&I) in Ecuador to improve higher education and strengthen local research capacity. We refer specifically to the ‘Mandato 14’ and the Higher Education Law (LOES, Spanish acronym) launched in 2008 and 2010, respectively.

Objective: To assess the impact of these P&I (Mandato 14/LOES) on the production of health sciences-related articles (HSRA), and the relationship of these HSRA with the country’s health priorities.

Methods: A Scopus search was performed to retrieve HSRA published from 1999 to 2017. Bivariate analysis was used to assess variation between the period I (1999–2008) and period II (2009–2017). Further, we examined the association between the top 10 causes of mortality and the total HSRA output.

Results: The final study sample consisted of 2784 articles. After 2008, Ecuadorian production of HSRA increased steadily from 671 to 2133 publications (p<.001). Overall (1999–2017), the most common study design was cross-sectional (32.3%), the primary research focus was in the clinical-surgical area (49.3%), and the academic institutions were the primary drivers of scientific production during period II (56.9% vs. 29.5%, p<.001). Further, we found a decrease in the production of randomized controlled trials (6.7% vs. 1.8%, p<.001). Only 9% of research production involved the primary causes of mortality, and the proportion has remained unchanged over time (8.2% vs. 9.3%, p>.05).

Conclusions: Ecuadorian HSRA output increased significantly after 2008. This larger volume of scientific output could be the result to the Mandato 14/LOES implemented in the last decade. However, a low percentage of HSRA are dedicated to addressing the country’s health priorities. Proper planning, execution and monitoring of national health research agendas would reduce the mismatch between health burden and the HSRA output in Ecuador and other low-and middle-income countries.

What Do the Various Principles of Justice Mean Within the Concept of Benefit Sharing?

The concept of benefit sharing pertains to the act of giving something in return to the participants, communities, and the country that have participated in global health research or bioprospecting activities. One of the key concerns of benefit sharing is the ethical justifications or reasons to support the practice of the concept in global health research and bioprospecting. This article evaluates one of such ethical justifications and its meaning to benefit sharing, namely justice. We conducted a systematic review to map the various principles of justice that are linked to benefit sharing and analysed their meaning to the concept of benefit sharing. Five principles of justice (commutative, distributive, global, procedural, and compensatory) have been shown to be relevant in the nuances of benefit sharing in both global health research and bioprospecting. The review findings indicate that each of these principles of justice provides a different perspective for a different benefit sharing rationale. For example, commutative justice provides a benefit sharing rationale that is focused on fair exchange of benefits between research sponsors and communities. Distributive justice produces a benefit sharing rationale that is focused on improving the health needs of the vulnerable research communities. We have suggested that a good benefit sharing framework particularly in global health research would be more beneficial if it combines all the principles of justice in its formulation. Nonetheless, there is a need for empirical studies to examine the various principles of justice and their nuances in benefit sharing among stakeholders in global health research.

Forms of benefit sharing in global health research undertaken in resource poor settings: a qualitative study of stakeholders' views in Kenya

BACKGROUND

Increase in global health research undertaken in resource poor settings in the last decade though a positive development has raised ethical concerns relating to potential for exploitation. Some of the suggested strategies to address these concerns include calls for providing universal standards of care, reasonable availability of proven interventions and more recently, promoting the overall social value of research especially in clinical research. Promoting the social value of research has been closely associated with providing fair benefits to various stakeholders involved in research. The debate over what constitutes fair benefits; whether those that addresses micro level issues of justice or those focusing on the key determinants of health at the macro level has continued. This debate has however not benefited from empirical work on what stakeholders consider fair benefits. This study explores practical experiences of stakeholders involved in global health research in Kenya, over what benefits are fair within a developing world context.

METHODS AND RESULTS

We conducted in-depth interviews with key informants drawn from within the broader health research system in Kenya including researchers from the mainstream health research institutions, networks and universities, teaching hospitals, policy makers, institutional review boards, civil society organisations and community representative groups.The range of benefits articulated by stakeholders addresses both micro and macro level concerns for justice by for instance, seeking to engage with interests of those facilitating research, and the broader systemic issues that make resource poor settings vulnerable to exploitation. We interpret these views to suggest a need for global health research to engage with current crises that face people in these settings as well as the broader systemic issues that produce them.

CONCLUSION

Global health research should provide benefits that address both the micro and macro level issues of justice in order to forestall exploitation. Embracing the two is however challenging in terms of how the various competing interests/needs should be balanced ethically, especially in the absence of structures to guide the process. This challenge should point to the need for greater dialogue to facilitate value clarification among stakeholders.

Pandemic preparedness in Asia: a role for law and ethics?

Management of pandemic influenza relies on complex coordination of many different dimensions of the health and social care systems, emergency services, levels of national and local government, civil society, communications and media, and cultural expectations. Law is one small but important component of those arrangements, which touch on fundamental ethical debates. This review demonstrates that the Asian region is actively engaging those issues in diverse ways in light of their varied socioeconomic and cultural backgrounds, but scope remains for prioritising further research into these relationships.

Ethical issues in human genomics research in developing countries

BACKGROUND

Genome-wide association studies (GWAS) provide a powerful means of identifying genetic variants that play a role in common diseases. Such studies present important ethical challenges. An increasing number of GWAS is taking place in lower income countries and there is a pressing need to identify the particular ethical challenges arising in such contexts. In this paper, we draw upon the experiences of the MalariaGEN Consortium to identify specific ethical issues raised by such research in Africa, Asia and Oceania.

DISCUSSION

We explore ethical issues in three key areas: protecting the interests of research participants, regulation of international collaborative genomics research and protecting the interests of scientists in low income countries. With regard to participants, important challenges are raised about community consultation and consent. Genomics research raises ethical and governance issues about sample export and ownership, about the use of archived samples and about the complexity of reviewing such large international projects. In the context of protecting the interests of researchers in low income countries, we discuss aspects of data sharing and capacity building that need to be considered for sustainable and mutually beneficial collaborations.

SUMMARY

Many ethical issues are raised when genomics research is conducted on populations that are characterised by lower average income and literacy levels, such as the populations included in MalariaGEN. It is important that such issues are appropriately addressed in such research. Our experience suggests that the ethical issues in genomics research can best be identified, analysed and addressed where ethics is embedded in the design and implementation of such research projects.

Disparities in the contribution of low- and middle-income countries to palliative care research

CONTEXT

Important aspects of the palliative care needs of patients from low- and middle-income countries (LMIC) are largely unexplored. About 44 million of the 56 million annual deaths worldwide occur in developing countries, and it is estimated that more than 33 million of those concerned would benefit from palliative care. In this context, the understanding of specific social and cultural needs is fundamental to the development of appropriate health policy and clinical practice concerning palliative and end-of-life care.

OBJECTIVES

This study aims to answer the question: what are the contributions, in terms of generation of knowledge, of LMIC to the published palliative care literature?

METHODS

A bibliometric analysis was conducted in Medline and EMBASE (to June 2008). Articles were included when either the first author (institutional affiliation or contact address) or the data collection was derived from LMIC, as defined by criteria of the World Bank. Excluded were articles done in migrant and non-palliative care populations.

RESULTS

The literature search resulted in 845 references. In total, 245 articles coming from LMIC were identified, being published by 34 LMIC (27.3% of LMIC). The first publications appeared in 1982. The study shows a rather modest contribution of publications from LMIC. However, the volume of publications within LMIC is distributed unequally: upper-middle-income countries published almost half of the articles (46.9%), whereas only 11% of the publications came from low-income countries. In contrast, 104 LMIC (72.7% of LMIC) do not have any registered publications. Surprisingly, 25% of the articles with data from LMIC have been done and published by high-income countries. Reasons for the underrepresentation, as well a possible correction of this imbalance, are discussed.

CONCLUSION

Palliative care research should be a priority in LMIC, where many patients could benefit tremendously from it, and publication of findings in these countries should be encouraged.

Mapping chronic illness in the age of globalization: reclaiming the good for the chronically ill

Until recently, infectious diseases were the main cause of death worldwide. New medical discoveries and the evolution of public health improved life expectancy and the ability to survive acute threats, thus changing the course of diseases from acute to chronic. Today, chronic illness is the most important health concern worldwide. Chronic illness increases existing poverty and pushes other people into it. As nurses, members of the healthcare system and members of this world, we cannot forget that our response toward globalization and chronic disease has to be centered in leadership through reorienting local and national healthcare systems. All actions must be grounded in the ethical treatment of the ill; we cannot close our eyes in hospitals or communities to what is happening now worldwide because our responsibility is to promote health, prevent disease, and care for human beings.

Thinking the post-colonial in medical education

CONTEXT

Western medicine and medical techniques are being exported to all corners of the world at an increasing rate. In a parallel wave of globalisation, Western medical education is also making inroads into medical schools, hospitals and clinics across the world. Despite this rapidly expanding field of activity, there is no body of literature discussing the relationship between post-colonial theory and medical education.

DISCUSSION

Although the potential benefits of international partnerships and collaborations in education are incontrovertible, many medical educators are sometimes too unreflecting about what they are doing when they advocate the export of Western curricula, educational approaches and teaching technologies. The Western medical curriculum is steeped in a particular set of cultural attitudes that are rarely questioned. We argue that, from a critical theoretical perspective, the unconsidered enterprise of globalising the medical curriculum risks coming to represent a 'new wave' of imperialism. Using examples from Japan, India and Southeast Asia, we show how medical schools in non-Western countries struggle with the ingrained cultural assumptions of some curricular innovations such as the objective structured clinical examination, problem-based learning and the teaching of clinical skills.

CONCLUSIONS

We need to develop greater understanding of the relationship between post-colonial studies and medical education if we are to prevent a new wave of imperialism through the unreflecting dissemination of conceptual frameworks and practices which assume that 'metropolitan West is best'.

Health, justice, and the environment

In this article, we argue that the scope of bioethical debate concerning justice in health should expand beyond the topic of access to health care and cover such issues as occupational hazards, safe housing, air pollution, water quality, food and drug safety, pest control, public health, childhood nutrition, disaster preparedness, literacy, and many other environmental factors that can cause differences in health. Since society does not have sufficient resources to address all of these environmental factors at one time, it is important to set priorities for bioethical theorizing and policy formation. Two considerations should be used to set these priorities: (1) the impact of the environmental factor on health inequality, and (2) the practicality of addressing the factor.

Ethics and drug resistance

This paper reviews the dynamics behind, and ethical issues associated with, the phenomenon of drug resistance. Drug resistance is an important ethical issue partly because of the severe consequences likely to result from the increase in drug resistant pathogens if more is not done to control them. Drug resistance is also an ethical issue because, rather than being a mere quirk of nature, the problem is largely a product of drug distribution. Drug resistance results from the over-consumption of antibiotics by the wealthy; and it, ironically, results from the under-consumption of antibiotics, usually by the poor or otherwise marginalized. In both kinds of cases the phenomenon of drug resistance illustrates why health (care)--at least in the context of infectious disease--should be treated as a (global) public good. The point is that drug resistance involves 'externalities' affecting third parties. When one patient develops a resistant strain of disease because of her over- or under-consumption of medication, this more dangerous malady poses increased risk to others. The propriety of free-market distribution of goods subject to externalities is famously dubious--given that the 'efficiency' rationale behind markets assumes an absence of externalities. Market failure in the context of drug resistance is partly revealed by the fact that no new classes of antibiotics have been developed since 1970. I conclude by arguing that the case of drug resistance reveals additional reasons--to those traditionally appealed to by bioethicists--for treating health care as something special when making policy decisions about its distribution.

Solidarity: a (new) ethic for global health policy

This article explores solidarity as an ethical concept underpinning rules in the global health context. First, it considers the theoretical conceptualisation of the value and some specific duties it supports (ie: its expression in the broadest sense and its derivative action-guiding duties). Second, it considers the manifestation of solidarity in two international regulatory instruments. It concludes that, although solidarity is represented in these instruments, it is often incidental. This fact, their emphasis on other values and their internal weaknesses diminishes the action-guiding impact of the solidarity rules. The global health and human subject research scene needs a completely new instrument specifically directed at means by which solidarity can be achieved, and a reformed infrastructure dedicated to realising that value.

Eighteen years of research on AIDS: contribution of and collaborations between different world regions

The scientific community invests significant resources on HIV/AIDS research to confront the current epidemic. We reviewed the medical literature in order to evaluate the contribution of different world regions on HIV/AIDS research during the past 18 years. We retrieved articles, using an elaborate methodology, from three journals focusing on HIV/AIDS between 1986 and 2003, indexed in the Journal Citation Reports (JCR) and the Web of Science databases of the Institute for Scientific Information (ISI). Comparisons were made by dividing the world into nine geographic regions, and by using the human development index (HDI) categorization. A total of 9502 articles on HIV/AIDS were retrieved from three AIDS journals over an 18-year study period. The United States and Western Europe together and five developed out of nine world regions made up a striking 83% and 92% of the world's research production on HIV/AIDS, respectively. Scientists from the developing world participated in 10.4% of the articles published during 1986-1991, 14.7% during 1992-1997, and 21.3% during 1998-2003. Researchers from countries included in the high, medium, and low HDI category produced 2240, 9, and 15 articles per billion population, respectively. About half of articles originating in Latin America and the Caribbean and half in Asia were produced in collaboration with the United States. However, 40% of articles from Africa and 58% from Eastern Europe were produced in cooperation with Western Europe. Collaboration between researchers within developing regions was negligible. The vast majority of the world's research on AIDS is produced in the developed world. Although research production was minimal in the developing world, we found that regions included in the low and medium HDI categories showed a higher proportion of increase in research productivity than the developed countries. International collaborations should significantly increase and expand beyond the traditional cultural and political lines of international relationships.

Ethics, biotechnology, and global health: the development of vaccines in transgenic plants

As compared with conventional vaccine production systems, plant-made vaccines (PMVs) are said to enjoy a range of advantages including cost of production and ease of storage for distribution in developing countries. In this article, we introduce the science of PMV production, and address ethical issues associated with development and clinical testing of PMVs within three interrelated domains: PMVs as transgenic plants; PMVs as clinical research materials; and PMVs as agents of global health. We present three conclusions: first, while many of the ethical issues raised by PMVs are familiar, PMVs add a new dimension to old issues, and raise some novel issues for ethicists and policy-makers; secondly, it is premature to promise broad applicability of PMVs across the developing world without having demonstrated their feasibility; thirdly, in particular, proponents of PMVs as a solution to global health problems must, as a condition of the ethical conduct of their research, define the commercial feasibility of PMVs for distribution in the developing world.