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U N I V E R S I T Y

O F

B E R G E N

Inequalities in health care between rich and poor


countries

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Debate
In our view, an experimental intervention should normally be compared with
an established, effective treatment . . . whether or not that treatment is
available in the host [developing] country. (Shapiro & Meslin, 2001)
Clinical trials should not exploit the subjects who agree to participate in them.
(Shapiro & Meslin, 2001)

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WHY is it happening?
Clinical research is moving to countries where the
research industry gets the best value for money while
gathering data acceptable for submission to regulatory
agencies.
Reasonable availability of interventions that are proven
to be useful during the course of research trials.
Developed countries society funds research to improve
own health.
Research in developing countries creates a greater risk
of exploitation: individuals or communities in developing
countries assume the risks of research, but most of the
benefits may accrue to people in developed countries.
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WHY is it happening?

Limited understanding of the nature of scientific


research neither cause nor are necessary for
exploitation, they increase the possibility of such
exploitation.
The regulatory infrastructures and independent
oversight processes that might minimize the risk of
exploitation may be less well established, less supported
financially, and less effective in developing countries.
Research findings from a higher-income country may be
costly or hard to implement in a lower-income country.
May not be culturally appropriate.
few political and institutional conditions in place in many
poor countries to deal effectively with the regulation of
research activities
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Example (Exploitation)
Unethical research is the Tuskegee Study of Untreated
Syphilis. In that study, which was sponsored by the U.S.
Public Health Service and lasted from 1932 to 1972, 412
poor African-American men with untreated syphilis were
followed and compared with 204 men free of the disease
to determine the natural history of syphilis. Although
there was no very good treatment available at the time
the study began (heavy metals were the standard
treatment), the research continued even after penicillin
became widely available and was known to be highly
effective against syphilis.

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Example (Positive result)


Standard short-course antituberculous therapy was first
shown to be effective in clinical trials conducted by the
UK Medical Research Council (MRC) in East Africa.
(Mabey, 1996)
Single-agent therapy for bacterial meningitis was
shown to be effective by another MRC-supported group
in northern Nigeria at a time when combination therapy
was the norm in many industrialised countries. (Mabey,
1996)

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References
Shapiro, Harold T., & Meslin, Eric M. (2001). Ethical
Issues in the Design and Conduct of Clinical Trials in
Developing Countries. New England Journal of
Medicine, 345(2), 139-142. doi:
doi:10.1056/NEJM200107123450212
Mabey, David. (1996). Importance of clinical trials in
developing countries. The Lancet, 348(9035), 11131114. doi: http://dx.doi.org/10.1016/S01406736(05)65268-3

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