Topic: Global

Perilous Medicine: The Quest to Restore Protections for Health Workers

Pervasive violence against hospitals, patients, doctors, and other health workers has become a horrifically common feature of modern war. These relentless attacks destroy lives and the capacity of health systems to tend to those in need. Inaction to stop this violence undermines long-standing values and laws designed to ensure that sick and wounded people receive care.

In his new book Leonard Rubenstein—a human rights lawyer who has investigated atrocities against health workers around the world and core faculty member at the Berman Institute of Bieoethics —offers a gripping and powerful account of the dangers health workers face during conflict and the legal, political, and moral struggle to protect them. In a dozen case studies, he shares the stories of people who have been attacked while seeking to serve patients under dire circumstances including health workers hiding from soldiers in the forests of eastern Myanmar as they seek to serve oppressed ethnic communities, surgeons in Syria operating as their hospitals are bombed, and Afghan hospital staff attacked by the Taliban as well as government and foreign forces. Rubenstein reveals how political and military leaders evade their legal obligations to protect health care in war, punish doctors and nurses for adhering to their responsibilities to provide care to all in need, and fail to hold perpetrators to account.

Bringing together extensive research, firsthand experience, and compelling personal stories, Perilous Medicine also offers a path forward, detailing the lessons the international community needs to learn to protect people already suffering in war and those on the front lines of health care in conflict-ridden places around the world.

In an interview with Global Health Now, Rubenstein explained why he wrote the book:

“I wrote it, first and foremost, for those who take enormous risks to provide care in the midst of war, so that their commitment to health can be matched by a commitment to rights to their protection. At the same time, I wanted to enhance understanding of the pervasiveness of the violence, the logics animating it, and its devastating impacts for millions of people already suffering in war. Another goal was to seek to engage the public health, nursing, and foreign policy communities—and the wider public—in stopping it.”

Read the full Q&A.
Listen to Rubenstein’s appearance on the “Public Health On Call” podcast.
Attend (via Zoom) his Oct. 11 Berman Institute Seminar Series talk, “The Paradoxical Fragility of the Norms of Protection of Health Care in War.”

Rubenstein has spent his career, spanning four decades, devoted to health and human rights. A graduate of Harvard Law School he is now Professor of the Practice at the Johns Hopkins Bloomberg School of Public Health, and Director of the Program in Human Rights, Health and Conflict at its Center for Public Health and Human Rights. At Johns Hopkins, he is also a core faculty member of the Berman Institute of Bioethics and the Center for Humanitarian Health.

Overview: Ethical Concerns in Responding to Coronavirus

For comprehensive Covid-19 Ethics and Policy Resources, visit our dedicated webpage, bioethics.jhu.edu/coronavirus.

The ongoing coronavirus outbreak vividly demonstrates the important role of bioethicists in leading the charge for equitable and effective public health policies.

“Through years of experience and scholarship, and tested through multiple threatened and actual epidemics, there now exists a rough consensus about the ethical principles that should guide responses to this latest threat,” said Jeffrey Kahn, Andreas C. Dracopoulos Director of the Berman Institute of Bioethics. “Bioethicists from the Berman Institute have been leaders in shaping this framework.”

The Berman Institute is working to disseminate these ideas through social media, appearances in traditional news media, and through other means, as widely as possible on an ever-expanding range of issues, including:

Human Research
“For reasons of safety, efficacy, and ethics, it’s usually better to test vaccines on animals before humans. You have to have good reason to say, ‘We need to go straight to humans or go to humans at this particular point.'”

“Kahn worries about people signing up to be in the trial because they think the vaccine could give them immunity before it becomes available to everyone else. In reality, this kind of early trial is just to make sure that the vaccine is not toxic and does indeed provoke some kind of immune response in people. Participants are very unlikely to be fully immunized to the virus over the course of their participation.”

Travel Restrictions
“A critical principle in outbreak response is that governments should implement the least restrictive measure that can still achieve the public health objective. The goal is to balance the freedom of individuals against the restrictions on freedom required to achieve legitimate protections of the public’s health, with public and transparent justification of policy decisions. Quarantine is considered a measure of last resort given the severe restrictions it imposes on individual liberty.”

Inequitable Impact of School Closings
“As in all public health emergencies, poor children and poor families will suffer the most. An ethically defensible policy of school closures needs not only to meet the bar of public health necessity. Government agencies and community organizations in education, nutrition assistance and housing, as well as public health, must also be planning to take active measures to mitigate the disproportionate burden that will fall on our most vulnerable children.”

Dr. Faden’s prescient Education Week piece helped prompt discussion among K-12 educators nationwide. Officials in numerous states have sought USDA waivers that will enable them to continue providing free meals during school closures.

Allocation of Scarce Resources
“It is appropriate and accurate to reassure the public that most people who contract Covid-19 will recover fully on their own. At the same time, the public needs to be prepared for the possibility of more dire scenarios. Participants in our study were adamant that politicians, and health officials, be transparent and honest about the prospect of and plans for the rationing of ventilators and other equipment. In health emergencies, experts often ask the public to heed the advice of public health professionals; in the case of planning for situations involving scarcity, it is equally important that the experts heed the advice of the public.”

Inequitable Impact of Social Distancing
“The implications of some of these public health measures are so wildly different for people who are differently situated in the United States that the social distancing [decision] is not our only decision. It’s our first one, and then there’s a very different set of ethical dominos that follow from that.”

Kass listed a number of ethical considerations she’s concerned about, like making sure there’s adequate income replacement for workers unable to earn a living, making sure grocery stores stay open and accessible, and even making sure people have access to the creature comforts that make social distancing bearable.

Inequity of Work Requirements During Pandemic
“Income replacement for people whose employment has been curtailed by the government isn’t just an economic issue, it’s an ethical one. Likewise, we need to consider what to do for workers in jobs where sufficient protection from infection cannot be provided. While we have expectations of certain healthcare professionals, like doctors and nurses, who have taken oaths to continue working even when it puts them at personal risk, the same isn’t true for hospital support staff or grocery store checkers. We can’t simply expect those workers to continue facing risks that others can avoid.”

Equity in Vaccine Development
“Historically, the interests of pregnant women have not been adequately included in global responses to outbreaks and epidemics. As the world rushes to develop new vaccines against Covid-19, we must ensure that, this time, pregnant women and their babies will not be left behind. Developing a coronavirus vaccine that they are unable to use would be not only a tragedy but a grave injustice.

The article was included as required reading for the 38th Annual Congressional Leadership Conference of the American College of Obstetricians and Gynecologists, as physicians came to Washington from across the country to meet legislators and help shape public policy. Faden and Krubiner’s co-author of the STAT and Boston Globe article and collaborator in the PREVENT project, Ruth Karron of the Johns Hopkins Vaccine Initiative, was quoted in a March 3 New York Times article, “What Pregnant Women Should Know About Coronavirus.”

Patient Privacy and Contact Tracing
“Doctors don’t out people. Whether it’s HIV, syphilis, coronavirus or anything else, people simply won’t show up to their doctor if they feel they might be outed for a condition.”

Impact on Incarcerated Individuals
Detention and correctional spaces are the “perfect environment for the spread of COVID-19. So when we talk about social distancing, it’s almost impossible in prisons unless you have complete lockdown – basically, put everybody in solitary confinement.”

The Berman Institute continue to offer insights and expertise to aid in the response to the monumental challenges posed by the outbreak.

Related Berman Institute Resources

Mario Macis, PhD

  • National Institutes of Health (NIH) “Creative and Novel Ideas in HIV Research (CNIHR) grant for “Behavioral nudges, information and incentives for HIV testing: A field experiment in Ecuador”, 2016-18.
  • Johns Hopkins University Discovery Award, 2016.
  • Johns Hopkins University early-career Catalyst Award, 2015.
  • Johns Hopkins University Alumni Association Excellence in Teaching Award, 2013.
  • National Science Foundation (NSF) Grant for “Field Experiments on Incentives and Blood Donations”, 2009-12.

Berman Featured at “Hopkins on the Hill”

To underscore the role and subsequent results of federally-funded research, Johns Hopkins hosted a showcase of 21 project teams from all corners of the institution, including three Berman Institute faculty, at a special June 12, event in the House of Representatives, called Hopkins on the Hill.

Berman Institute Associate Director for Global Programs Joe Ali was selected to present the Berman Institute’s training programs for scholars in sub-Saharan Africa.

“Debates about ethical controversies in global health research are often dominated by voices from the global ‘North,’” said Ali. “Federally-funded global bioethics initiatives empower sub-Saharan African researchers and institutions to meaningfully engage in local and international research and deliberations about the ethics of such research.”

Ali was joined by Berman Institute associate faculty member Megan Collins, whose presentation was titled “A Vision for Success: How Providing Glasses is Helping Baltimore’s Youth.”

Also presenting was Carey Business School professor Mario Macis, who recently became an affiliate member of the Berman Institute faculty. Macis presented about “Motivating HIV Testing with Incentives and Behavioral Nudges.”

“We are thrilled to highlight these early career researchers whose scientific investigations and innovations represent a fraction of the remarkable, publicly funded research underway at Johns Hopkins,” says JHU President Ronald J. Daniels. “Their work is not only advancing scientific understanding, but also creating products and therapies that improve the quality of life in America.”

Daniels has long been an advocate for the importance of federal support for research, especially for young researchers. Johns Hopkins has led U.S. universities in research and development spending for 39 consecutive years, putting a record $2.562 billion in FY2017 into projects to cure disease, promote human health, advance technology, and expand knowledge of the universe and ourselves.

“The wide breadth of research at Johns Hopkins, from engineering to the life sciences, from the social sciences to the humanities, continues to be funded at record levels,” says Denis Wirtz, the university’s vice provost for research. “This support allows the institution to uphold its critical mission of fostering independent and original research, and bringing the benefits of discovery to the world.”

Berman Institute Launches SNF Bioethics Academy

The Johns Hopkins Berman Institute of Bioethics (JHU) in conjunction with the Bioethics Chair at the Swiss Federal Institute of Technology (ETH) have launched a new initiative called the Stavros Niarchos Foundation Bioethics Academy (SNFBA). The SNFBA is exclusively supported by the Stavros Niarchos Foundation (SNF) and was created with the intent to support and enhance knowledge and awareness for bioethics in Greece.

Visit the SNF Bioethics Academy for full information.

The three main components of the SNFBA are:

  1. An intensive bioethics summer course offered every June, beginning in 2019, in Athens, Greece;
  2. Annual in-depth workshops alternating between Zurich, Switzerland (hosted at ETH) and Baltimore, USA (hosted by JHU), beginning winter 2021;
  3. An alumni network that provides ongoing connections with other Greek bioethics professionals, resources and information through a dedicated website, and virtual discussions via webinar.

Summer Bioethics Course

June 20-22, 2019
Stavros Niarchos Foundation Cultural Center

The SNFBA is co-directed by Prof. Jeffrey Kahn, the Andreas C. Dracopoulos Director of the Johns Hopkins Berman Institute of Bioethics (JHU), and Prof. Effy Vayena, Head of the Health Ethics and Policy Lab at the Swiss Federal Institute of Technology in Zurich (ETH).

The inaugural Bioethics Summer Course in 2019 is a three-day course including lectures by international faculty followed by small group discussions facilitated by JHU and ETH faculty and Greek bioethics experts.

IN-DEPTH WINTER TWO-DAY WORKSHOPS

These workshops will alternate between Zurich, Switzerland (hosted at ETH) and Baltimore,  U.S.A. (hosted at JHU) and will include faculty from the Summer Course along with additional visiting faculty. Approximately 20 attendees will be invited per workshop, based on their interest in further training and education in bioethics and their aptitude for bioethics.

Workshop content will be topical and developed with input from the selected participants.  The program will include presentations by all participants, intensive case analysis and consultation (with at least some actual cases provided by participants), train-the-trainer exercises so that participants can return to their institutions/workplaces to help educate their peers, and additional specialized content.

ALUMNI NETWORK

The third component of the Stavros Niarchos Foundation Bioethics Academy will be an Alumni Network created for summer course participants, all of whom will automatically be members.

In addition to providing news, resources and information via a dedicated SNFBA website, email, and social media channels, the network will be a means for staying in touch with other SNFBA alumni in Greece and bioethics faculty at JHU and ETH. The network will host virtual discussions via webinar and convene in-person reunions and events in conjunction with the timing of the annual summer course and SNF Annual International Conference in Athens.

Prof. Fanzo shapes Lancet food systems report

The average person’s daily diet will need to change drastically during the next three decades to make sure everyone is fed without depleting the planet, a panel of experts including the Berman Institute’s Jessica Fanzo has concluded.

Global consumption of foods such as red meat and sugar will have to decrease by about half to make sure the Earth will be able to feed a growing population of 10 billion people by 2050, according to the EAT-Lancet Commission on healthy diets from sustainable food systems.

Written by 37 scientists from 16 countries and published Wednesday in the medical journal The Lancet, in conjunction with an advocacy group called the EAT Forum, the report was funded by the Wellcome Trust and Stordalen Foundation. In addition to the recommendations on meat, it calls for curbing food waste, a major source of greenhouse gas emissions, and overhauling agriculture so it doesn’t worsen deforestation and the depletion of scarce water.

“It’s not a blanket approach, but when you look at the data there are certain individuals or populations that don’t need that much red meat for their own health,” Fanzo, Bloomberg Distinguished Associate Professor of Global Food & Agricultural Policy and Ethics, said in a New York Times interview. “There’s a real inequity. Some people get too much. Some people get too little.”

Fanzo serves as the Director of the Global Food Ethics and Policy Program at the Berman Insitute, and plays key advisory roles in Johns Hopkins’ Alliance for a Healthier World on the food security and nutrition theme, as well as the Bloomberg American Health Initiative on obesity and food systems.

She is currently serving as the co-Chair for the Global Nutrition Report, and is the Team Leader for the High-Level Panel of Experts for Food Systems and Nutrition for the UN Committee on Food Security.

Fanzo also appeared in a Lancet podcast to discuss the need for a transformation in the way we eat, and was quoted in National Geographic’s coverage of the report.

 

Vaccine Guidance Gains Global Attention

Health and Bioethics Experts: “The treatment of pregnant women in vaccine research
and deployment is unacceptable. Business as usual simply cannot continue.”

New Report Lays out Recommendations for Policymakers, Researchers, and Global Health Organizations on Including Pregnant Women in Epidemic Vaccine Development and Deployment

Even as health care responders valiantly battle the ongoing Ebola outbreak in the Democratic Republic of Congo, one highly vulnerable group is being denied a potentially life-saving vaccine: pregnant and lactating women. This and other recent epidemics of Zika, Lassa Fever, and Hepatitis E have shown how infectious disease outbreaks can severely – and at times uniquely – affect the health of pregnant women and their offspring. Despite a significantly higher risk of serious disease and death, vaccines against these devastating diseases are rarely developed and approved for pregnant women.

Changing institutional and government practices so that we have vaccines to offer pregnant women in an epidemic is one of 22 long overdue recommendations contained in the new report Pregnant Woman & Vaccines Against Emerging Epidemic Threats: Ethics Guidance for Preparedness, Research and Response, issued in December 2018 by the Pregnancy Research Ethics for Vaccines, Epidemics, and New Technologies (PREVENT) Working Group – a multidisciplinary, international team of 17 experts specializing in bioethics, maternal immunization, maternal-fetal medicine, obstetrics, pediatrics, philosophy, public health, and vaccine research and policy. The report, aiming to ensure that pregnant women are no longer excluded from receiving vaccines against emerging infectious diseases, has received widespread media attention, including:

“The self-perpetuating cycle of excluding pregnant women from research and from the benefits of vaccination must end,” said Carleigh Krubiner, a lead author of the report jointly appointed at the Johns Hopkins Berman Institute of Bioethics and the Center for Global Development. “With global efforts now underway to develop a range of vaccines against devastating epidemic threats, we have to make sure pregnant women are on the agenda, so they will never again be left unprotected in the face of future outbreaks.”

The report lays out concrete steps for equitably addressing the needs of pregnant women in public health preparedness, vaccine research and development, and the deployment of vaccines during epidemics. Its recommendations include:

  • During an epidemic, the default should be to offer vaccines to pregnant women—not the reverse.
  • Vaccines that can be safely given to pregnant women need to be developed. For these vaccines, evaluation in pregnancy needs to occur as early in the clinical development process as possible.
  • During an epidemic, decisions about whether pregnant women will be offered vaccines should consider not only any potential risks of the vaccine but also, and importantly, the risks pregnant women and their babies face if vaccine is denied.
  • All decisions about inclusion or exclusion of pregnant women should be informed by those with the relevant expertise in maternal and neonatal health as well as in vaccinology and virology.
  • The perspectives of pregnant women themselves should inform vaccine research and deployment decisions that may mean life or death for them and/or their babies.

The full recommendations are available at http://vax.pregnancyethics.org/prevent-guidance.

“The way we have treated pregnant women in vaccine research and deployment is utterly unacceptable. Business as usual cannot be permitted to continue,” said Ruth R. Faden, a lead author of the report and founding director of the Johns Hopkins Berman Institute of Bioethics. “Ensuring that pregnant women affected by outbreaks have safe and effective vaccines is not only a matter of justice and health equity, it’s also critical to the public health response.”

That pregnant women affected by the ongoing Ebola crisis in the Democratic Republic of the Congo are not being offered vaccine demonstrates how urgent and serious the consequences are of the status quo exclusions of pregnant women from vaccine research and delivery. In recent UNICEF interviews, pregnant women “clearly articulated that they wanted to choose whether to be vaccinated or not.”  As one woman said, ‘now there is no option, you just send us to death.’”

“As we continue to develop new vaccines against pathogens with serious and often lethal consequences in pregnancy, pregnant women must be on the agenda every step of the way,” said Ruth A. Karron, a lead author of the report and director of the Center for Immunization Research and the Johns Hopkins Vaccine Initiative at Johns Hopkins Bloomberg School of Public Health. “We simply can’t continue to fail pregnant women as we develop new vaccines against emerging threats.  We need to generate an evidence base for safe and effective use of these vaccines during pregnancy.”

To read the full report visit vax.pregnancyethics.org/prevent-guidance. In conjunction with the report release, PREVENT has also released a video that discusses the risks of the status quo, and describes why urgent action is needed. You can watch the video at vax.pregnancyethics.org.

PREVENT is a grant-funded project led by faculty at Johns Hopkins University alongside co-investigators at Georgetown University and the University of North Carolina at Chapel Hill, with external contributions from Working Group Members. The PREVENT Project is funded by the Wellcome Trust (203160/Z/16/Z).

 

Register for the Choose Food Symposium

The CHOOSE FOOD PROJECT aims to help producers and consumers make ethical food choices by giving them access to easy to use, high-quality information about food. It is developing:
  • A Framework for ethical assessment of the food system
  • Educational resources
  • Cutting-edge digital tools
The project aims to guide actors throughout the food value chain to make, market, and choose products more ethically.
To date, our team of experts has articulated 49 Core Ethical Commitments that set parameters for ethical conduct and goals for ethical improvement of food products. These commitments can guide actors along the food chain who have the power to make ethical improvement to production practices. They also provide guidance to consumers who prefer to buy foods that cohere with their ethical values.