Medical Double Standards in the Third World
When it comes to third world medicine we almost invariably hear from the WHO about the successes of massive vaccination programs. If you look into the recent agenda for the World Health Assembly  you will find pandemic influenza vaccines at the top of the technical matters, and in the status section, the eradication of Poliomyelitis is at the top of that section. What is glaringly absent is a discussion of the pervasive double standards in research ethics, health-care safety and professional rigor that exist in the developing world. The WHO and its medical partners won’t talk about it publicly because when you look at the numbers, it is directly implicated in the suffering and ultimate death of millions of people in the developing world. That is what we’ll cover in this piece.
It is well known that needle re-use can be a major cause of virus transmission. In 2000, a WHO press release states:
Unsafe Injection practices have serious large-scale consequences…”unsafe injection practices throughout the world result in millions of infections which may lead to serious disease and death. Each year over-use of injections and re-use of dirty syringes and needles combine to cause an estimated 8 – 18 million hepatitis B virus infections, 2.3-4.7 million hepatitis C virus infections and 80,000 – 160,000 infections with HIV/AIDS worldwide. 
That same press release uses an epidemic of Hepatitis C that occurred from Schistosomiasis treatment in Egypt. Notably absent is any discussion of the massive immunization campaigns waged throughout the third world coincident with the massive epidemics of HIV and other infectious diseases. However, someone there must be aware of the potential problem because the press release states the following at the end:
In addition, to ensure the safety of immunization injections, WHO, the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the International Federation of the Red Cross and Red Crescent Societies (IFRC) have recently called for the exclusive use of auto-disable (AD) syringes for immunization by the end of 2003.
We know quite reliably that the WHO knew years prior to this press release (2003) that medical practices in the developing world were problematic. As Gisselquist outlines in his 2009 article  the WHO was quietly giving UN employees the following advice in 1991.
take special precautions to avoid HIV transmission via blood . . . If you are not carrying your own needles and syringes, avoid having injections unless they are absolutely necessary . . . Avoid tattooing and ear-piercing. Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary. Before submitting to any treatment that may give an entry point to HIV, ask whether the instruments to be used have been properly sterilized.
The WHO never made any public statements to the population living in these countries of these dangers. That is clearly unethical and continues today. In 2001, Dr. Keith Sabin with the CDC is quoted in the Times of India Online article about the problems surrounding unsafe injections.
In many parts of the world, these injections are very unsafe. ”Equipment is being reused without particularly being sterilised,” Sabin pointed out.
”In Southeast Asia, nearly 80 per cent of injections that are given are with nonsterilised equipment. The next highest rate is found in Africa, which is a shade under 80 per cent and then Eastern Europe with nearly 70 per cent injections with unsafe equipment,” he said.
In his paper, Hunsmann highlights this behaviour. 
The dominant epidemiological interpretation is accompanied by a largely silent political context. If, as the dominant explanation suggests, the spread of HIV in SSA is principally due to individual behaviour, any protest leveled at the authorities related to AIDS would be viewed as superfluous, if not absurd. While it seems somewhat understandable that African governments subscribe to this explanation, it is more troubling that most international agencies and many social scientists also sing the same tune. Indeed, many AIDS researchers have become party to this nearly complete sexualization of the HIV epidemics in SSA.
The focus on spending the scarce resources on vaccination – an extremely narrow focus – ignores the reality that living conditions and access to health care have a large impact on the transmission of all infectious disease and their relative mortality rates. Hunsmann outlines how individual health directly affects the transmissibility of AIDS through sexual contact, likely accounting for the vast differences we see in endemic transmission between the developing and developed world.
If the blind eye to abhorrent medical practice, and the political focus on personal sexual practice is not disturbing, the ethical research practices in the developing world should at least raise some eyebrows. In his paper, Gisselquist relates a disturbing example of a study seemingly absent of ethical guidance. 
In one important respect, what happened in Masaka compares unfavourably to the Tuskegee study. In Tuskegee, doctors followed men with tertiary syphilis, who were not at risk to infect others. In Masaka, researchers monitored HIV transmission from HIV-positive adults who did not know they were infected to unsuspecting spouses and to children. The Masaka team invited spouses of HIV-positive NHC participants to join the NHC, and recorded 22 seroconversions among them.
In another example, he relates a study about women and their babies.
During 1997–2000, the Zimbabwe Vitamin A for Mothers and Babies (ZVITAMBO) study tested and followed over 4400 HIV-positive women and their newborn children, observing HIV infections and deaths in the children. ‘Mothers could learn their [HIV test] results at any time . . . but they were not required to do so. This feature makes ZVITAMBO unique. All other studies of infant feeding and HIV have been conducted among mothers who knew their HIV status’.
Less than 20% of HIV-positive women chose to learn their HIV status, and 92% of HIV-positive mothers were still breastfeeding at one year. With prolonged breastfeeding, the project observed 64 incident infections in children aged 12–24 months. Governments and other organizations in the USA, Canada and Europe funded the studies mentioned in previous paragraphs, and ethical review boards in rich countries approved and monitored the studies. Acceptance of unethical HIV research in Africa is deeply rooted in the international health aid industry.
This type of behaviour is clearly unethical by modern medical standards. Gisselquist relates the history of the US study in Tuskegee which generated public outrage and forced the medical community to change their ethical guidelines in these types of situations.  The evidence here suggests that the medical community weakens these guidelines based on the population in question.
I doubt many people believe that the WHO and developing world governments want huge segments of their population to suffer from ravaging disease and death. The WHO is investing significant effort in attempts to help these developing world populations improve their quality of life. So what is going wrong? Some of these ethical discrepancies might be rooted in what some consider a pragmatic approach, or possibly justified through some warped view of the greater good. However, when one objectively looks at the current situation, it becomes pretty clear that despite good intentions the outcome has been devastating for the affected populations.
It appears that yet again, the international medical community insists on re-learning old lessons the hard way. Ethical double standards are unacceptable regardless of the population, and simple solutions to complex problems never work.
 Provisional agenda for the Sixty-third World Health Assembly http://apps.who.int/gb/ebwha/pdf_files/EB126/B126_27-en.pdf
 Gisselquist D. “Double standards in research ethics, health-care safety, and scientific rigour allowed Africa’s HIV/AIDS epidemic disasters” International Journal of STD & AIDS, Volume 20, 2009
 Hunsmann M, “Political determinants of variable aetiology resonance” International Journal of STD & AIDS, Volume 20, 2009