Access to thalidomide for the treatment of multiple myeloma in Canada: physician behaviours and ethical implications

Comparative analysis of the use and control of thalidomide in Brazil and different countries: is it possible to say there is safety?

INTRODUCTION

One of the biggest drug disasters in history has not prevented thalidomide from being used to treat various clinical conditions. Currently, Brazil has a worrying scenario: high consumption of the drug and, cases of pregnant women using thalidomide, even after adopting restrictive legislation.

AREAS COVERED

This review of the literature and legislation sought to comparatively analyze the monitoring of thalidomide use in Brazil and other countries that use this drug. Finally, we discuss the differences between the countries.

EXPERT OPINION

This analysis allows us to think beyond the safe use of thalidomide, but the safety provided by any type of monitoring system. It seems that out-patients that use unsafe drugs are exposed to some degree of risk. To improve safety, more extensive improvements are needed than monitoring systems related to the use of thalidomide. Its safe use depends on a drastic reduction in the incidence of leprosy and Erythema Nodosum Leprosum in the world; investment in research and development of safe and effective therapeutic alternatives to thalidomide; improvement of health systems and their health surveillance systems, particularly in primary health care; awareness of health professionals and patients for greater responsibility in the use of medicines, especially thalidomide.

Science at the Crossroads: Fact or Fiction?

Modern Academic Science is largely based on the formulation of hypotheses that are then confirmed through observations and experiments. There is little scope forcuriositythat played an important role in early Science. Results carrying negative implications are not easy to publish, and hypotheses have a tendency to take on the mantra of religious beliefs. Academic Science is facing on many fronts pressures that hardly existed in the past. Financial rewards apart from salary can be very high, in the form of fees for consultants, expert legal witnesses, patent development, and even the establishment of private companies. Commercial funding forms a significant percentage of the Total Research Budgets in Science and Medicine, but this often leads to loss of control over research protocols and freedom to communicate the results. Media attention confers fame and prestige that is assiduously sought out by some individual scientists, often supported by University resources, and Press Conferences prior to or synchronous with actual publication. Scientists have long been employed full-time by Government Departments, but research contracts are being increasingly offered by the latter to academic staff on a part-time basis. These pressures and opportunities, together with the priority given to research by most University Tenure and Promotion Committees, are tending to diminish the appetite of scientists for other important responsibilities such as teaching and administration. In a few decades, University scientists have moved from the »Ivory Tower« to the High Street, and many are serving more than one master. The above scenario may bring increased remuneration and the pursuit of research that would be too expensive without these external sources, but adverse consequences have also occurred. They may lead to the complicity of scientists, through no fault of their own, in the introduction of drugs and supplements that: a) fail to deliver the benefits claimed; b) increase the risk of some unrelated illness; c) possess dangerous side effects not known or reported at the time of introduction. Examples include hormone replacement therapy and antioxidant vitamins (A and E) to protect against Coronary Heart Disease; dietary fibre to prevent colon cancer; and arguably calcium supplements to treat osteoporosis. On occasions, academic scientists have served as fronts for the publication by the manufacturers of falsified reports minimizing the risk of serious drug side-effects to ensure Regulatory Approval, as occurred with Vioxx in the treatment of arthritis, and Seroquel for schizophrenia and bipolar depression. Individual fraud or misconduct is more frequent than suspected, because most incidents are without major impact and are suppressed by Universities and Funding Agencies. Major scandals are rare, but may have serious repercussions for the general public and bring science into disrepute. Recent examples include: the Cold Fusion controversy (Low Energy Nuclear Reaction); the link age by Andrew Wakefield of autism with Rubella vaccination; the infamous creation of stem cells by somatic cell nuclear transfer falsely reported by Hwang Woo-Suk. Fraud by commercial companies is subject to the full force of the law, but Science is treated as a self-regulating profession, and as such the punishments handed out are relatively trivial. In essence, Science prior to 1950, except in North America, proceeded along a highway that segregated the traffic into Commercial, Government and Academic streams, and passed through inspiring landscapes and green pastures. It later came to a crossroads from which the alternative road led to the Marketplace, and on which segregation into the above three streams was not enforced. It has now become the main thoroughfare for Science world-wide, but there are reasons to believe that this has increased the incidence of dangerous driving and traffic accidents in the form of conflicts of interest, unethical behaviour, misconduct and even fraud. It may be too late to return to the crossroads and continue along the original highway, but there could be considerable merit in restoring the original segregation between the three streams of Science and in developing, as well as enforcing, a stricter code of behaviour, for which some elements are proposed.