Saturday, October 10, 2009

Drug-resistant TB, and human rights: a response to a reply

The forthcoming issues of Health and Human Rights (Vol.11, no.2) will feature the paper by Limitations on human rights in the context of drug-resistant tuberculosis: A reply to Boggio et al. by Joseph J. Amon, Fran├žoise Girard, and Salmaan Keshavjee. The paper is a “reply” to a paper I had co-authored with Matteo Zignol, Ernesto Jaramillo, Paul Nunn, Genevieve Pinet, and Mario Raviglione on treatment supervision for basic TB control, management of drug-resistant TB, and human rights. After reading the paper, some of my co-authors and I felt compelled to write a letter to Health and Human Rights’ editors to raise a number of issues. The letter, which is published on-line after the paper, is the following:

Dear Editors:

We read with interest the paper “Limitations on human rights in the context of drug-resistant tuberculosis: A reply to Boggio et al.” co-authored by Drs. Amon, Girard, and Keshavjee. While we welcome the effort to expand our framework[1] and we applaud the Authors for continuing the discussion on this extremely important topic, we believe that the paper by Amon and colleagues may be misleading to your Journal’s readership.

First, Amon and colleagues do not technically “reply” to our argument. They do not challenge any of our assumptions. To the contrary, they explicitly agree with all of them. In the abstract, they state “there is little international disagreement with [our] position.” A similar claim is made on page 2 (“Boggio et al., like others previously, argue that involuntary detention may legitimately be used in a limited number of cases. . . . In theory, few would disagree”), page 6 (“Boggio et al. fairly describe the relationship of rights and health in theory”), and eventually offer conclusions that mirror precisely our own conclusions: “Only in exceptional cases, where patients resist treatment after all feasible programmatic solutions have been exhausted, should detention with proper checks, balances, and safeguards, be considered” (p. 6; citation pages here refer to the pdf version of Amon et al.). These considerations undermine the idea that Amon and colleagues’ paper is in reply to ours. If anything, it expands our arguments.

Second, Amon and colleagues criticize our paper as it is allegedly not “informed by practice” (p 6). The claim is without merit, as our paper was intended to articulate the foundations of WHO’s recommendations for practice in the area of drug-resistant TB, drawing on the field experience of the co-authors and many others,[2] rather than providing a tool to be directly translated into practice. WHO’s involvement with control of drug-resistant TB is much broader than our paper, as Amon et al., know well; thus, characterizing it as not “informed by practice” does a disservice to the readership.

Third, Amon and colleagues claim that policies adopted by the South African government are in violations of international human rights law and that this may be caused by a “a narrow reading of [our] argument, coupled with [our] lack of explicit reference of what constitutes a ‘last resort’” (p. 6). After this statement, Amon and colleagues fail to provide any evidence — empirical or logical — of why our paper, if narrowly read, would be the cause of certain practices. We certainly did and do not endorse a lighthearted approach to coercive measures.

Finally, Amon and colleagues claim, in the abstract, that our paper raises a “false” dilemma. The authors’ explanation of why it is a false dilemma is that there is no need to breach individual rights for the sake of containing TB because, “given the early indications of success of Lesotho’s community-based treatment program, and the documented evidence of successful community-based models in other urban and rural settings, any assumption that isolation and other compulsory measures are necessary and effective for the treatment of drug-resistant TB must be reconsidered.” (p. 6). In other words, “early indications” suggest that there is not (nor will be) need for coercive measures. A few comments are needed on this characterization of our paper as presenting a “false” dilemma. First, without need to delve a complex philosophical debate on dilemmas,[3] it suffices to say that a dilemma is “true” if it can genuinely arise from practice (in our case, the tension between individual rights and public health considerations). A “true” dilemma can then be resolved and that does not turn it into a “false” dilemma: it simply becomes a “resolved” dilemma. Second, Amon and colleagues’ language itself suggests that evidence that coercive measures are never warranted is not robust enough. Therefore, they implicitly concede that the dilemma raised in our paper may in fact arise. As a matter of fact, sound and resourceful TB control programs sometimes deal with TB patients in which all measures have failed to promote adherence to treatment.[4] Furthermore, they also concede that it is unlikely to be resolved unless one resorts to coercive measures — once again under exceptional circumstances. Finally, Amon and colleagues advocate a course of action that is precisely what WHO has recommended for a long time: community-based measures and the DOTS strategy.

Andrea Boggio, Matteo Zignol, Ernesto Jaramillo, and Mario Raviglione

References:
1. A. Boggio, M. Zignol, E. Jaramillo, et al. “Limitations on human rights: are they justifiable to reduce the burden of tuberculosis in the era of MDR- and XDR-TB?” Health and Human Rights: An International Journal 10/2 (2008), pp. 121-126. Available at http://www.hhrjournal.org/index.php/hhr/article/view/85/169 (html) and at http://www.hhrjournal.org/index.php/hhr/article/view/85/158 (pdf).
2. B. H. Lerner, “Catching Patients: Tuberculosis and Detention in 1990s,” Chest 1115/1 (1999), pp. 236-241; “How Israel Manages Noncompliant TB Patients” Biot Report #437 (July 05, 2007). Available at http://www.semp.us/publications/biot_printview.php?BiotID=437.
3. T. McConnell, “Moral Dilemmas,” The Stanford Encyclopedia of Philosophy (Winter 2003 Edition), E. N. Zalta (ed). http://plato.stanford.edu/entries/moral-dilemmas/
4. See, references cited in footnote 2.

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