Public Health Ethics and Malaria Research

Wen Kilama of the African Malaria Network Trust brought a challenging idea to the malaria researchers gathered at MIM’s 5th Pan-African Malaria Conference on Tuesday. He explained that while we have a strong tradition of biomedical ethics that protect the individual from harm in research trials, we do not have a clear code of ethical processes, not the mechanism to oversee and regulate these for public or population health research.

atiamkpat-community-1-nets-sm.jpgHis thoughts are also expounded in a current article in a supplement to Acta Tropica and ask us to consider difficult questions such as weighing individual protection and public benefit of an intervention beijng tested.  Examples of these have included immunization regimens, water fluoridation and iodization of salt. In malaria research we also must consider individual freedoms and choices balanced against the community protective effects of indoor residual spraying or wide coverage long lasting insecticide treated net (LLIN) campaigns.

Dr Kilama raised an interesting ethics about the distribution of two different types of LLINs.  One is a polyester multifiber net with insecticide coated yarn has received only Phase 2 approval from WHOPES, which approves insecticides for human safety. The other is a polyethylene monofilament net with insecticide incorporated into the yard. This has received Phase 3 WHOPES approval.  Ironically three times as many of the former were made available to the public than the later in recent years. Is this ethical?

Dr Kilama also raised an equity issue – how can we justify testing health interventions like LLINs on rural poor people who bear the greatest malaria burden when at the start of most programs, it is better off urban people who can afford the nets?

Corporate social responsibility also plays a role after research and testing for regulatory approval have been done. The manufacturers of the monofilament polyethylene nets have made provision for royalty free transfer and have already set up operations in one African country and are ready to move into others.  Their first African factory employs 6,000 people locally and has a positive economic impact on at least 30,000 in the community.

Ethical considerations in a population/public based research like vector control is complex. Community awareness and consent processes come at the start, but then effort must be made to enlist the informed participation of households and individuals.  Ghana’s Navrongo community research facility was mentioned as an example of an institution that has a codified community ethics process.

Dr Kilama called on the public health research community, and especially community malaria researchers, to develop consensus ethical procedures for community studies.

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