AAMC Reporter: February 2005

Leonard S. Rubenstein, Executive Director, Physicians for Human Rights

Viewpoint: "Maintaining Professional Independence in the Age of HIV/AIDS"

Since the beginning of the HIV/AIDS pandemic, physicians and other clinicians have had to confront the searing politics of the disease. From fights in the United States over appropriate means of preventing the spread of the virus among gay men in the 1980's to limitations on prevention and treatment strategies in many AIDS-affected developing countries, politics intruded not only on policy and funding but also on clinical practice. Paradoxically, increased knowledge about transmission, prevention and treatment has not lessened interference with professional judgments and ethical responsibilities.

Denial by government of the nature, consequences or means of transmission of HIV has had a devastating impact on health providers and their patients throughout the world. In China, for example, Ma Shiwen, a leading health official in China's AIDS-stricken Henan province, was arrested in August 2003 for leaking documents to the public about a government-sponsored blood-selling program in which tens of thousands of villagers became HIV-positive through blood transfusions.

Worse yet, in Libya, doctors and nurses became scapegoats for the lack of an effective AIDS policy. In 1999 about 400 children in a Tripoli hospital tested positive for HIV. The government accused 16 health professionals, including five Bulgarian nurses and a Palestinian physician, of deliberately infecting the children. The Libyan health professionals were charged only with negligence, and all were eventually acquitted. The foreign health workers were accused of "attacking the security of the state," as well as intentionally killing the youths. The six were imprisoned, denied access to anyone from the outside world for over 10 months, tortured, forced to give false confessions and in some cases raped. They met with lawyers for the first time only after the trial began.

After five years of incarceration, the doctor and nurses working in Libya finally had a chance to defend themselves and demonstrated that the virus was transmitted by the lack of sound infection controls in the hospital. Professor Luc Montagnier, the co-discoverer of HIV, testified that infections at the hospital likely began before the defendants arrived at the hospital and also continued to spread after they were arrested. He also found practices that would increase transmission, including the re-use of unsterilized needles. Despite the expert testimony, the doctor and nurses were nevertheless convicted and sentenced to death in May 2004.

Appeals from physicians around the world, organized by Physicians for Human Rights and others, protested the fairness of the trial, the verdict and the death sentences. In December 2004, the Libyan government announced that the six health professionals would not be executed but demanded that Bulgaria compensate the families of the victims for their losses and reimburse the hospital for the cost of treatment. Bulgaria has refused, and the six remain imprisoned.

Consider, too, the case of Dr. Matthys Johannes van Mollendorff, former superintendent of the Rob Fereira Hospital in South Africa. Responding to the vulnerability of women to HIV through rape, in 2002 he joined forces with the Greater Nelspruit Rape Intervention Project (GRIP), the first charity in South Africa to give free anti-retrovirals to rape survivors and their newborns. At the time, the South African government was in denial about the relationship of HIV to AIDS. Anti-retroviral drugs were licensed and available to patients with health insurance, but government policy forbade the use of these drugs in the public sector.

Despite the fact that GRIP was providing the medications for free, the provincial ministry of health removed Dr. van Mollendorff from his position for insubordination. By April 2002, the government reversed its policy on HIV, but refused to reinstate Dr. van Mollendorff. His administrative appeal was denied, and it was not until a year later that a court upheld his claim and reinstated him.

Denial also affects HIV/AIDS policy in the United States. Grant applications for AIDS research focusing on some forms of sexual activity have been subject to special scrutiny irrespective of their scientific soundness. The Centers for Disease Control and Prevention has proposed a new set of requirements stipulating that state or local health officials must review AIDS-related education materials to determine whether they are obscene.

The lesson here is that professional independence is a more fragile commodity than many physicians assume, especially when it collides with policies based on denial or ones laced with ideology. And of course threats to physicians and nurses extend well beyond HIV/AIDS practices. But the response should be clear enough as well: professional solidarity and insistence on policy consistent with science and medicine are essential. That means that both medical associations and individuals need to speak out against political, non-scientific-based interference with clinicians and researchers whenever and wherever it occurs. One vehicle for doing that is through the Physicians for Human Rights' Colleagues at Risk program, which provides information on cases and guidance on how to respond.

Speaking up can both rescue fellow doctors and promote a global culture of improved health and human rights for all.

For information: www.phrusa.org

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