How Should Health Research Be Conducted in Low-Income Countries?
One of the results of the Global Maternal Health Conference of 2013 in Tanzania was a code of conduct for health research in low-income countries. It was proposed by Richard Horton, the chairperson of the discussion, and published in The Lancet. Generally, codes of conduct are boring and not meant to be read fully, only agreed upon, but the assertions made in this new and shiny proposal are quite awesome:
1. No ethics committee, funder of research, or medical journal should approve, support, or publish research about a low-income country without joint authorship from that country.
2. In any research project in a low-income setting, local scientists must be included as co-principal investigators.
These two principles at first sound extremely limiting. If these principles were implemented, more effort would be needed to put together a research team. It would also mean ever-increasing numbers of hoops you’d have to jump through in order to proceed with your study.
However, this principle puts researchers in a position to literally examine the place they’re coming from. It ensures that research about a low-income country occurs from a collaborative perspective, rather than from the viewpoint of an outsider looking in. This may be a more philosophical consideration rather than one of whether or not the study is scientifically valid, but principle investigators that are local scientists will be more likely to further safeguard the culturally appropriate, and actually appropriate, health needs of the host country.
The people who take part in the studies are protected by guidelines from the Council for International Organisation of Medical Sciences. There must be a prior agreement to actually apply the treatment in question to people in the trials if it is found to be beneficial. However, this is only relevant to a few studies in the human-testing stage of drug trials, and can be ignored if the researchers do have a strong enough reason not to offer the treatment. Other research, whether it is qualitative or epidemiological, have no such guidelines to ensure benefit to the people in question. If the local community represented in the study doesn’t benefit from the study, at least the local knowledge and work of the scientists in the community is published and acknowledged.
Moving onto the last few principles:
3. Before starting research in a low-income country, western authors and institutions must define a clear plan for how they will transfer research skills back to that country.
4. Medical journals and their publishers must ensure that all global health research is free at the point of use in countries.
5. Western journals must facilitate language translation of research, either themselves or by enabling local journals to republish freely.
These aim to create a more equitable balance of skill and resources between countries with large differences in economic power. Conducting studies about lower income countries without input from their own scientists can be seen as unethical. An excuse to do so anyway would be if a community is under-equipped with scientists, or if the local institutions do not have the capacity to conduct the research. But if no move was made to address this imbalance of skills and capacity and leave such a inequality in place, and also benefitting from it by receiving credit for the work but sharing none of the benefit, this would be unquestionably unethical. These principles are more strategies to create a more equal sharing of knowledge, particularly as any person has the right to their own health information.
This proposal by Richard Horton still doesn’t address the whole picture, ethical or otherwise, and neither have I. It doesn’t address how informed consent can be ensured if the people in the health study may have lower health literacy levels, or if gaining access to healthcare benefits may not make their participation in a study wholly voluntary. There isn’t any information yet about the difficulties and barriers in implementing the code or ensuring such guidelines will be followed. But this doesn’t mean it can’t be a good idea to hopefully follow through.
For more perspectives on the ethics of international health research, check out these articles (PDFs):
- Bhutta ZA. Ethics in international health reseach: a perspective from the developing world. Bull World Health Org 2002;80:114 – 20.
- Lansang MA, Crawley FP. The ethics of international biomedical research. BMJ 2000;321:777 – 8.
[Creative Commons licensed Flickr photo by gatesfoundation]