For 10 years, Dr Rachna Pande has made Rwanda her home. Working as the Head of Department, Internal Medicine in Ruhengeri hospital, she is part of a team that provides care for sick people in the area. Having moved to Rwanda to join her husband who was working in Rwanda, she is now involved in helping trainee doctors to improve their skills and in disseminating health education to the public, and is a contributor in this paper’s Health Magazine.
Briefly tell us about your childhood; where and when were you born and what was it like growing up?
I was born in Jabalpur, Madhya Pradesh in central India in May 1960. I have two brothers. My father was a governmental official and because of this, he was posted to different places. Therefore, we stayed in several places while growing up. I had a very enjoyable childhood. There were lots of children in the neighbourhood so we had a lot of fun playing and studying.
How was it like growing up as a girl in India?
Well, the society in which I grew up was pretty conservative. On my part, I was lucky to have parents who were relatively liberal. Still, I couldn’t escape the usual strict rules such as leaving or returning home after dark or even going to public places unescorted.
In your time as a doctor, what are some of your observations concerning health?
I work at the hospital but during my leisure time, I work within the communities. In treating patients both in and out of the hospital, I have come to realise that many health related problems are simply related to nutrition and other life style related factors which can be corrected. I have also realised that medicine though fairly well advanced does not provide cure for many chronic diseases. Hence stress should be on life style factors.
What has been the scariest moment in your career?
In 1984, I was a resident doctor at Bhopal Memorial Hospital in central India. A storage tank containing methyl isocyanate (MIC) at the Union Carbide pesticide plan leaked gas into the densely populated city of Bhopal, India. People in hundreds thronged the hospital sick and dying. It was scary to see people dying at such a fast rate.
Is there anything that you miss about India that we don’t have here in Rwanda?
I miss the festivals of India. We have a very colourful culture with some festival practically every month from January to November. Here in Rwanda, there are some festivals celebrated by the Indian community in Kigali. But they are on a small scale and I being far am not able to attend them regularly.
When you leave Rwanda, what lessons will you take with you?
First of all, I will miss the good climate and the warmness and gentleness of people here. But the biggest lesson I shall take when I leave is, regarding patience. I have seen people being so patient and calm in the most difficult situations, and that for me, is worth adopting.
The journey from first using cannabis through to developing mental health problems is very different for men and women. Men outnumber women at every point along the way. Despite these marked gender differences, little attention has been paid to such a basic demographic factor in cannabis psychosis and the underlying reasons for why men fare so poorly.
The first clue might be found in who uses cannabis. The most comprehensive survey of drug use in the UK shows a consistent trend of twice as many men than women reporting that they have used cannabis. But no one really knows why there is a marked variation between the genders when it comes to using cannabis. Some have suggested that drug use carries more social stigma for women than men, and that younger men are also more likely than women to engage in risk-taking behaviour including illicit drug use. Others have said that men are more likely to use drugs and alcohol as a coping mechanism, while women tend to cope with stress by using social support. Differences in the rates of psychosis unrelated to cannabis also mirror the gender differences evident in cannabis users, with males outnumbering females by a ratio of 2:1.
Cannabis has been linked to psychosis for some time and although the debate continues as to the exact nature of the relationship, many people require health and social care for the problems they experience. However, it is interesting that despite the widespread attention that researchers have paid to cannabis psychosis there has yet to be a large scale analysis of the role gender in the condition. To date, seminal research on this issue has focused disproportionately on men or on small samples.
We analysed admissions to hospital in England and found that men are four times more likely than women to be diagnosed with cannabis psychosis. These elevated rates were consistent over the 11 years of the study period.
Bias in treatment
So what might account for this widening of the gender ratio? There are a number of plausible explanations. It could be the result of a bias in treatment services which tend to be dominated by male patients. This is in some ways also linked to the long-standing bias in research involving samples of men because research samples are often drawn from treatment settings out of convenience.
Staff working in mental health services may have also become more attentive to problems associated with cannabis use, and the greater number of men diagnosed and treated for cannabis psychosis may therefore reflect the disproportionate number of men who currently receive treatment for mental health problems. Paradoxically, the excessive number of male patients in services can act as a barrier to women who need treatment, as they frequently have a history of trauma and exploitation perpetrated by men.
It is also likely that women with children will avoid seeking specialist treatment when they develop mental health problems as a result of cannabis use due to the fear that their children may be taken into care, particularly if they have no family support. Likewise, services may be treating such women differently knowing that they have a duty to safeguard these children. Consequently, health and social care services might be offering alternatives to hospital treatment such as community services as a way of maintaining continued contact between mother and child.
And then there is biology, which may also have a role to play. Research has suggested that the female hormone oestrogen may have a protective effect for women in relation to psychosis.
Despite all the unknowns when it comes to cannabis psychosis, gender clearly matters. As well as treating men and reducing the number of people with psychosis, what we now need to work out is whether there are women we need to reach and how best to do it.
People who suffer from neuroticism – a condition characterised by anxiety, fear and negative thoughts – are extremely tuned in to looking for threats. For that reason, you may expect them to perform well in jobs requiring vigilance: stunt pilots, aviators and bomb defusement. Yet, the evidence suggests they are actually more suited to creative jobs.
Exactly what drives neuroticism and the creativity it is associated with is not known. But researchers have now come up with a theory which suggests that it could be down to the fact that people who score highly on neuroticism tests, meaning they are prone to anxiety or depression, tend to do a lot of thinking – often at the expense of concentrating at the task at hand.
Past, present and future
The hypothesis, which is yet to be experimentally verified, is an extension of what we already know. People who have neurotic traits typically look for things to worry about (a mechanism dubbed “self-generated thinking”). For example, people who get depressed are consumed by such self-generated negative thoughts that they forget what they are supposed to be doing. In other words, they are not very tuned in to the ”here and now”, which is pretty important if you need somebody to concentrate on defusing a bomb.
What the new research helps to do is explain the underlying brain mechanisms that interfere with “on the job thinking”. A certain amount of brain arousal is great for concentration but too much interferes with clear thinking and that’s what you want when performing stunts, flying planes, and disposing of bombs.
So where does the creativity come in? The authors argue that people who engage in self-generated thinking are creative because they are not rooted in reality – they are away with the fairies. Indeed, they may resist attempts to get them to concentrate on reality whilst they focus on their own thoughts. It is hardly a surprise, then, that their ideas can be new, whacky and original.
So while people scoring high on neuroticism may struggle with a lot of stress, they can still have a successful working life. They may actually be able to find creative solutions to problems that didn’t exist in the first place, and in the process come with some pretty useful and imaginative stuff. Rather like Billy Liar, in his escape from his tedious existence conjuring up some fairly exciting daydreams.
Remaining questions
We know that people who are clinically depressed spend an extraordinary amount of time living in the past. We know that people diagnosed with chronic worry (Generalised Anxiety Disorder) spend an extraordinary amount of time living in the future. The strength of the study is that it pulls together what is already known about people who spend a lot of time engaged in distorted thinking, some of which can be labelled as creative.
The authors argue that this creative flair applies specifically to problem solving, as they believe rumination and worry improve such skills. However, this is questionable as there is actually evidence that people who are depressed or worry are not very good at problem solving at all. Indeed, one of the interventions recommended for both conditions is Problem Solving Therapy. To adequately solve problems you need to be approaching reality and its problems, not avoiding them through aimless thinking. The new study falls short by not discussing this.
Anxiety and depression can be a lonely place. hikrcn
The authors also argue that psychological interventions such as meditation and mindfulness – which are thought to dampen some of these heightened responses by grounding people in the “here and now” – may do more harm than good. The jury is still out, but there is enough evidence available suggesting the benefits of mindfulness for people who are depressed and anxious with limited side effects.
Neuroticism, by its very nature, alerts you to past and future danger and some individuals can make good use of that. And that can be good. Our caveman ancestors came equipped with primitive brain parts allowing them to engage in predicting threat. But even if anxious or depressed people are able to come up with some great ideas, they are surely far more likely to contribute to society in the long run if they can find relief from their suffering.
Despite the near-universal acceptance of the benefits of vaccination, some people still worry about risks associated with their use. Luckily, scientists are vigilant about identifying possible risks, so they can be addressed before problems emerge.
Still, people sometimes forget that science is the process by which we arrive at solutions. And they worry about incremental scientific steps that often expose weakness in these solutions.
A recent study published in the journal PLOS Biology, for instance, was presented by some media as claiming that certain vaccines make viruses more dangerous. The research showed chickens treated with its vaccine are more likely to spread a highly virulent strain of Marek’s disease virus, a condition that affects poultry.
The reason was simple: the vaccine used in the study targets Marek’s disease, not the virus that causes it. These types of vaccines are known as “leaky vaccines” because they don’t affect the ability of the virus to reproduce and spread to others; they simply prevent the virus from causing disease.
Marek’s disease vaccines use a non-disease-causing virus to infect cells. This preventive infection stops tumour formation and death when those cells are infected by the Marek’s disease virus.
But the virus can replicate and still produce more virus particle, which can infect other chickens. All Marek’s disease vaccines, since their introduction in the 1970s, have been leaky; they allow chickens to carry and spread the virus without getting the disease.
‘Imperfect-vaccine hypothesis’
The effect of leaky vaccines on how disease spreads is explained by the “imperfect-vaccine hypothesis”. It holds that, without vaccination, a very virulent virus can get into a population and kill infected hosts (people or animals) very quickly – before they have a chance to spread it. This means that the virus will die out very quickly too, as all potential hosts will be dead or immune to it.
A leaky vaccine can prevent the very virulent virus from killing the host, but doesn’t stop that host from spreading the virus to others. This means that a very virulent virus can survive for long periods in the vaccinated hosts. And it can continue to spread in this time, making it less likely to die out.
The PLOS Biology study showed chickens vaccinated against Marek’s disease were more likely to spread the disease to other chickens, than unvaccinated chickens were. The unvaccinated chickens all died in less than ten days – before they could spread the virus.
The vaccinated chickens, on the other hand, were protected from the disease so were able to spread the virus to other (unvaccinated) chickens for weeks and weeks. The unvaccinated but infected chickens became ill with Marek’s Disease which in turn killed most of them.
One of the reasons the researchers looked at Marek’s disease in chickens is because it has been getting progressively deadlier. Originally, the disease occurred mainly in older chickens and caused paralysis. But an acute form of the disease emerged in the 1950s and has since become the dominant form. This rather virulent version can kill up to 100% of unvaccinated birds.
Leaky but not sinking
But what does all this mean for the future of vaccination?
Well, the first thing to note is that in this study the vaccinated chickens always had the best outcome. In one experiment, only three out of 50 unvaccinated chickens survived the disease, while vaccination protected the majority of chickens (46 out of 50 survived).
The authors also noted that vaccination has been very effective in preventing deaths in chickens due to Marek’s disease. They said their study didn’t indicate whether vaccination played any role in the development of the serious form of Marek’s disease.
Vaccines prevent disease, even if they’re leaky. But it’s important to note there are currently no vaccines against viruses that infect humans that are leaky. Current human vaccines mimic the body’s own response to viruses.
But yet-to-be-developed vaccines for diseases such as HIV, Ebola or malaria, where humans have been unable to mount an effective natural defence, are likely to be leaky. And even imperfect vaccines for these illnesses would be an enormous step forward.
The possible effect of “leaky vaccines” on how viruses spread is an interesting new observation. But there are a number of other ways by which viruses can change in response to vaccination.
An arms race
One response of viruses to vaccines involves the evolution of viral proteins that allow them to escape the vaccine. This is known as “epitope evolution” and it’s the reason flu vaccines change each year.
Even if a vaccine is effective in preventing a particular strain of virus, other strains may take its place. This was a concern when the human papillomavirus (HPV) vaccine was introduced nearly ten years ago. But researchers have investigated whether any HPV types not in the vaccine have become more common since the vaccine was introduced and there’s no evidence this is happening.
The interaction between viruses and their targets can change over time. In the case of Marek’s disease, the infection has become progressively deadlier. Increased use of broiler chickens, lack of genetic diversity in flocks and high-density rearing may all have played a role in the changes seen in the disease.
The benefits of vaccination far outweigh its risks. And it is research like this that helps medical researchers actively identify possible dangers so we can safely continue to avoid the diseases that terrified our parents’ generation.
Correction – this article has been amended to correct an error in paragraph starting “The vaccinated chickens, on the other hand..” The previous version said those chickens spread the disease to unvaccinated chickens and made them immune. The error was added during edited and has now been corrected.
People can prevent unwanted pregnancies in many different ways. They can use condoms, oral contraceptives, injected contraceptives, IUDs, sponges and more. All of these methods can significantly reduce the chance of pregnancy. For example, condoms, when used properly, reduce the chances of pregnancy by 90 to 95 percent.
But if a couple has sex without using a contraceptive, or if the contraceptive fails (for example, a condom breaks), and the woman has no desire to become pregnant, what can she do?
The generic name for this contraceptive is levonorgestrel. It’s also known by the name morning after pill.
If you take it within 72 hours after you’ve had unprotected sex, the morning after pill can reduce the risk of pregnancy by up to 89%. If you take the morning after pill within 24 hours, it is about 95% effective.
But you should know that the morning after pill is not as effective as regular contraception. So don’t take it as your main form of birth control. And, it does not protect you against sexually transmitted diseases. Think of it as a backup — not for routine use. That’s why it’s called morning after pill.
The morning after pill can be purchased over the counter at drugstores without a prescription or proof of age. Because it is most effective when taken as soon as possible (up to 72 hours after sex), consider having a ready supply in your medicine cabinet.
You can take the morning after pill if:
• The condom came off or broke.
• The diaphragm slipped out of place.
• You didn’t use any birth control.
• You missed at least two or three active birth control pills in a row.
• You forgot to insert your ring or apply your patch.
• Your partner didn’t pull out in time.
• You have another reason to think your birth control might not have worked.
• You were forced to have sex.
Remember: the morning after pill will not protect you from getting pregnant if you have sex after taking the pills. Instead, you need to take it right after you have unprotected sex.
Do not take the morning after pill if:
• You know you are pregnant or suspect you might be.
• You have a history of allergy or hypersensitivity to its ingredients.
• You have a history of recent abnormal vaginal bleeding that your doctor has not yet evaluated.
Some Side Effects of the morning after pill
Many women have taken emergency contraception without serious complications. But it’s a good idea to ask your doctor about possible interactions with other medications.
The morning after pill is considered safe for most women. You should not take it if you are pregnant because it will not end the pregnancy.
Potential side effects of the morning after pill include:
• nausea
• abdominal pain
• fatigue
• headache
• menstrual changes
• dizziness
• breast tenderness
• vomiting
If you vomit within two hours after taking the drug, call a healthcare professional to find out if you should repeat the dose.
With the morning after pill , you may also have some unexpected bleeding. It should go away by the time of your next period. However, it is possible that the pill may cause your next period to be heavier or lighter than usual. It may also come earlier or later than is normal for you. If you don’t get your period within three weeks, get a pregnancy test to make sure you’re not pregnant.
This article is part of a series The Conversation Africa is running on issues related to LGBTI in Africa. You can read the rest of the series here.
People who are attracted to others of the same sex develop their orientation before they are born. This is not a choice. And scientific evidence shows their parents cannot be blamed.
Research proving that there is biological evidence for sexual orientation has been available since the 1980s. The links have been emphasised by new scientific research.
In 2014, researchers confirmed the association between same-sex orientation in men and a specific chromosomal region. This is similar to findings originally published in the 1990s, which, at that time, gave rise to the idea that a “gay gene” must exist. But this argument has never been substantiated, despite the fact that studies have shown that homosexuality is a heritable trait.
Evidence points towards the existence of a complex interaction between genes and environment, which are responsible for the heritable nature of sexual orientation.
These findings are part of a report released by the Academy of Science South Africa. The report is the outcome of work conducted by a panel put together in 2014 to evaluate all research on the subject of sexual orientation done over the last 50 years.
It did this against the backdrop of a growing number of new laws in Africa which discriminate against people attracted to others of the same sex. The work was conducted in conjunction with the Ugandan Academy of Science.
Existing research
The academy looked at several scientific studies with different focus areas that have all provided converging findings. These include family and twin studies. The studies have shown that homosexuality has both a heritable and an environmental component.
Family studies have shown that homosexual men have more older brothers than heterosexual men. Homosexual men are also more likely to have brothers that are also homosexual. Similarly, family studies show that lesbian women have more lesbian sisters than heterosexual women.
Studies on identical twins are important as identical twins inherit the same genes. This can shed light on a possible genetic cause. Studies on twins have established that homosexuality is more common in identical (monozygotic) twins than in non-identical (dizygotic) twins. This proves that homosexuality can be inherited.
However, the extent of the inheritance between twins was lower than expected. These findings contribute to the notion that although homosexuality can be inherited, this does not occur according to the rules of classical genetics. Rather, it occurs through another mechanism, known as epigenetics.
Epigenetics likely to be an important factor
Epigenetics relates to the influence of environmental factors on genes, either in the uterus or after birth. The field of epigenetics was developed after new methods were found that identify the molecular mechanisms (epi-marks) that mediate the effect of the environment on gene expression.
Epi-marks are usually erased from generation to generation. But under certain circumstances, they may be passed on to the next generation.
Normally all females have two X-chromosomes, one of which is inactive or “switched off” in a random manner. Researchers have observed that in some mothers who have homosexual sons there is an extreme “skewing” of inactivation of these X-chromosomes. The process is no longer random and the same X-chromosome is inactivated in these mothers.
This suggests that a region on the X-chromosome may be implicated in determining sexual orientation. The epigenetics hypothesis suggests that one develops a predisposition to homosexuality by inheriting these epi-marks across generations.
External environmental factors such as medicinal drugs, chemicals, toxic compounds, pesticides and substances such as plasticisers can also have an impact on DNA by creating epi-marks.
These environmental factors can also interfere with a pregnant woman’s hormonal system. This affects the levels of sex hormones in the developing foetus and may influence the activity of these hormones.
Future studies will determine whether these factors may have a direct impact on areas of the developing brain associated with the establishment of sexual orientation.
Looking to evolution
From an evolutionary perspective, same-sex relationships are said to constitute a “Darwinian paradox” because they do not contribute to human reproduction. This argument posits that because same-sex relationships do not contribute to the continuation of the species, they would be selected against.
If this suggestion were correct same-sex orientations would decrease and disappear with time. Yet non-heterosexual orientations are consistently maintained in most human populations and in the animal kingdom over time.
There also appear to be compensating factors in what is known as the “balancing selection hypothesis”, which accounts for reproduction and survival of the species. In this context, it has been demonstrated that the female relatives of homosexual men have more children on average than women who do not have homosexual relatives.
Future studies
The academy found that a multitude of scientific studies have shown sexual orientation is biologically determined. There is not a single gene or environmental factor that is responsible for this – but rather a set of complex interactions between the two that determines one’s sexual orientation.
However, more evidence is leading investigators to a specific region on the X-chromosome, and possibly a region on another chromosome.
The identification of these chromosomal regions does not imply that homosexuality is a disorder – nor does it imply that there are mutations in the genes in these regions, which still remain to be identified. Rather, for the first time, it suggests that there is a specific region on a chromosome that determines sexual orientation.
Although research has not yet found what the precise mechanisms are that determine sexual orientation – which may be heterosexual, homosexual, bisexual or asexual – the answers are likely to come to the fore through continued research. These findings will be important for the field of genetics and, more importantly, for those attracted to others of the same sex and society as a whole.
Pleasure, excitement and intimacy are powerful drivers in young people’s sexual decision making. But they are rarely considered when it comes to strategies for reducing the risk of sexually transmitted infections (STIs) or promoting condom use.
Stubbornly high rates of STIs in the UK, particularly among under-25s, demonstrate that the plethora of messages and campaigns focused on risk of infection as the driver for condom use have failed to resonate with young people. Or more accurately, with all young people, all the time. It is time to move away from building messages around sex as a risk of infection or pregnancy, and instead to develop campaigns around sex as pleasure, intimacy and excitement.
Some recent practiceand research is starting to put the pleasure agenda in the foreground of sexual health. For example, recent empirical research in the United States has highlighted how young people’s motivation to seek pleasure was the most important factor behind their lack of condom use. This priority means pleasure is a factor we can’t afford to neglect.
For young men, sex is also pivotal in the construction of their sense of masculinity. Pressures on young men to be good at sex, to take the lead and to maintain and sustain an erection are high. Condom use can threaten or undermine these imperatives by placing this performance at risk. Young men fear that the interruption to apply a condom may cause them to lose their erection and make them appear fumbling and unsure. It requires a level of negotiation and discussion which they can find difficult and embarrassing and it does not fit their conception of sex as spontaneous and exciting.
This combination means that, despite having the knowledge about its importance, condom use in itself constitutes a more immediate and significant risk to young men than that of infection, which is often seen as trivial and treatable.
That’s one way to get over the awkwardness Shutterstock
Embracing and seeking to control risk is a valued masculine attribute. Consequently, being seen as sexually risky and adventurous by rejecting social conformities relating to safe sex can also enhance masculine status.
However, it is not only young men who are resistant to condom use. Research shows that young women also have preferences for condom-less heterosexual sex, often citing condoms’ impact on feelings of intimacy and trust as important factors. And while gender stereotypes and masculine expectations mean that this “romantic” rationale is not typically associated with or acknowledged by young men, it doesn’t mean that, in the privacy of an encounter with their partner, the desire to be intimate and the pleasure of this closeness is not also privileged by young men.
Talking more about pleasure would enable us to better promote condom use among young men. It would enable us to explore alternatives to penetrative sex, discuss the nitty gritty (such as how to manage condom use without fumbling and embarrassment) and challenge the preoccupation with sex as a performance to be mastered.
Putting pleasure and excitement at the heart of our discussions with young men provides us with a coherent, inclusive and meaningful starting point from which to talk about sex. It brings policy and interventions alongside the interests of young men rather than in opposition to them and offers a space in which to address the concerns relating to masculinities that trouble them.
Globally, there has been an increase in the amount of alcohol being consumed. Research suggests that this trend is driven by an increase in drinking in India and China. In Africa, the alcohol consumption trend has not increased since 2006.
South Africa, however, has some of the worst drinking habits in the world. While only 60% of South Africans drink alcohol – higher than the worldwide average of 52% – the level of alcohol consumed amounts to each citizen drinking between ten and 12.4 litres of pure alcohol a year. Worldwide consumption is, on average, 6.2 litres.
Alcohol is estimated to cost South Africa R37.9 billion annually. This includes costs around health care, crime and social welfare, alcohol treatment and prevention and road traffic accidents. And this does not include intangible costs such as premature morbidity, morality and absenteeism from work.
South Africa’s new liquor laws
Alcohol is a legal substance, used in a reasonably safe manner by some South Africans. It is also an industry that creates employment along the value chain. The question the country faces is: how can the harm associated with alcohol be mitigated?
In May, Trade and Industry Minister Rob Davies gazetted a new policy for public comment. The policy recommends:
increasing the drinking age from 18 to 21;
stipulating that premises selling alcohol have to be 500m away from schools, churches, recreational and rehabilitation facilities; and
restricting alcohol advertising as well as prohibiting sponsorship and promotions associated with alcohol.
According to minister’s discussion paper there are more than 230,000 liquor outlets across the country and South Africans consume more than five billion litres of alcohol each year. Foetal alcohol syndrome cases in South Africa increased from between 41 and 46 for ever 1000 children in 1997 to between 75 and 74 for every 1000 children in 1999. 46% of people who died in accidents had alcohol in their bloodstream, equal or above the legal drinking limit.
Global interventions that work
Globally, there are a basket of interventions that have shown to decrease the harmful use of alcohol. These include:
increasing the price which particularly affects young people who are price sensitive;
banning advertising and sponsorship of alcohol; and
restricting trading by imposing limits on when and where alcohol is sold.
According to the World Health Organisation, these three intervention are considered “best buys” as they are highly cost-effective in reducing alcohol-attributable deaths and disabilities.
In addition, changing how alcohol is sold can also mitigate harm. For example, selling food where alcohol is sold, serving soft drinks and water in addition to alcohol and ensuring adequate lighting, space and security all decrease incidents of violence. Refusing to serve drunk people has also been found to mitigate the harm of alcohol.
What would work in South Africa
In South Africa, similar interventions could be beneficial on many fronts, especially as the interventions are aimed at decreasing alcohol consumption and changing drinking behaviour.
The challenge for South Africa is that there are both regulated and unregulated alcohol outlets on every corner, and often near every school. The drunkenness spills out into the street, with violence hovering over ordinary people’s lives. Drinking places are unsuitable for children to live near, but that is exactly where they live and go to school.
Many argue that given the high number of unregulated outlets it would be impossible to police safer drinking places. Many argue that given the high number of unregulated outlets it would be impossible to police safer drinking places. Raising the cost of alcohol, which is also a very effective way to decrease adolescent drinking, and earmarking that money for alcohol control could be a way this to solve this.
Increasing the age at which a person can legally drink is an excellent option in a country where there is such a high road accident morbidity and mortality of drivers and pedestrians. The lethal combination of getting a driver’s licence and drinking alcohol is best delayed until the brain is a bit more mature.
And restrictions on advertising and sponsorship would go a long way to contributing to the denormalisation of drunkenness in our society – something that has to be done to create a society in which alcohol doesn’t wreak the havoc it does in South Africa.
The power of the industry
Many of the national sports teams are sponsored by alcohol brands, such as Castle Lager. Anthony Phelps/Reuters
The alcohol industry has a direct interest in increasing the amount of alcohol consumed. It argues that it is each person’s responsibility to decrease harm around alcohol.
The industry is also behind a number of campaigns aimed at reducing the harmful effects of alcohol consumption. But some are directed at the wrong problem while others are misplaced.
For example, its contribution to educating people around the harmful effects of alcohol takes the form of promoting the dangers of underage drinking, foetal alcohol syndrome and drinking and driving. But these interventions account for less than 25% of alcohol-attributable harm in South Africa – and will not affect their bottom lines.
The industry focuses on foetal alcohol syndrome by promoting messages that pregnant women should not drink. But it is missing the point. The greatest harm that alcohol does to the foetus is in the first eight weeks of a pregnancy when most women are not aware that they are pregnant. To address foetal alcohol syndrome, binge drinking among young girls and women needs to decrease. And the use of contraception should be promoted.
While the focus on drinking and driving will mitigate harm, the “designated driver approach” suggests that drinking too much is accepted as long as you do not get behind the wheel. Many advertisements normalise this behaviour.
Some drunk driving adverts promote drinking as long as you have a designated driver.
Despite these campaigns, the industry pours huge amounts of money into sports sponsorship through rugby, soccer and cricket. Various teams are sponsored by South African breweries. It has also invented alcopops to persuade young people – particularly boys – that alcohol is desirable.
The reality is that South Africa must take steps to address alcohol-related harm. This can improve safety at the population level as well as redirect much needed resources to the fiscus.
Thanks to IVF and donor conception, infertile couples, single women and lesbian couples now have a better chance of starting families. But while you might know someone who has gone through the process, it’s rarely openly discussed.
Last month, you submitted your questions about donor conception and IVF and we put them – and some of our own – to The Conversation’s experts in law, embryology, sociology, psychology and donor conception.
Here are your questions answered (scroll down or click on the links below):
Q1. How much are men compensated for donating sperm and women for donating eggs?
A. Deborah Dempsey, sociologist:
In Australia, human eggs and sperm cannot be treated as goods that are bought or sold. It’s permissible to pay egg and sperm donors “reasonable expenses” (such as travel and parking) and medical costs incurred in the process of making their donation. Although the actual sum paid varies, for sperm donors it is generally around A$250 per donation.
For egg donors, it is substantially more as it’s a much more invasive medical procedure. Women are required to self-inject drugs for several days to hyper-stimulate their ovaries and need to be monitored to ensure there are no serious side effects. Eggs must be extracted by a medical practitioner, and this usually requires an anaesthetic and a half-day stay in hospital.
If there is too great a financial gain attached to providing eggs and sperm, one concern is that people will be motivated by money rather than a desire to help infertile men or women, and this could cause harm. Potential donors, for instance, may be more likely to conceal a health condition that could be passed on to intended parents or children because they wanted to receive the fee.
The issue of compensation is currently a hot topic due to a national shortage of both egg and sperm donors in Australia. In April, one group of fertility clinics made headlines for offering A$5,000 payments to cover egg donors’ expenses. Debate centred around whether this flat fee could be considered an “inducement” to participate, just as it did several years ago when a different clinic offered A$7,000 to Canadian students willing to come to Australia for a working holiday and to donate sperm.
I agree with a number of other scholars who argue it’s time we looked seriously at whether the principle of “reasonable expenses” is useful in taking into account the actual risks, costs and inconveniences incurred by egg and sperm donors, and the interests of children born from such donation.
Clinic-recruited donation is probably the most well-known method of donation.
Because of the critical shortage of donor eggs and sperm in Australia, some clinics are now recruiting from overseas. This is generally permitted if it complies with local laws.
Patients can also ask someone they know to donate to them. This is commonly a friend or family member, however, some people may find their donor through online forums as well. Advertising online is subject to many legal restrictions, so be careful if you go down this route.
Sperm donation can also occur outside the clinic environment. Private insemination with donor sperm is not necessarily illegal, but potential medical and legal issues can arise from these arrangements. Unlike clinic-recruited donors, private donors are not screened for infectious diseases and donors often advertise online without their true identities being confirmed.
The local shortage of donor sperm and eggs has promoted some clinics to recruit from overseas. Gotzila Freedom/Shutterstock
There are also no restrictions on the number of children that can be fathered from a single donor in a private donation scenario. One Sydney “freelance sperm donor” claims to have fathered 18 children. In contrast, clinic-recruited donors are only allowed to produce a limited number of families. They can also be removed from use if abnormalities are detected in the offspring.
There are pros and cons to both clinic and private donation, however, patients should seek medical and legal advice if they choose the latter.
Q3. What sort of identifying information is filed about open donors on the information register?
A. Fiona Kelly, legal scholar:
Under Australian guidelines, all donors in Australia are required to be “open donors”. Anonymous donors ceased to be available across the country in 2005, though some states abolished anonymity earlier.
The guidelines require fertility clinics in Australia to collect the following information from sperm and egg donors:
name, any previous name, date of birth and most recent address
details of medical history, family history, and any genetic test results that are relevant to the future health of the person conceived by egg or sperm donation (or any subsequent offspring of that person) or the recipient of the donation
details of physical characteristics.
Clinics are also obliged to tell egg and sperm donors that it is their ethical responsibility to keep the clinic informed about any changes to their health that may be relevant to the persons born or the recipients of their donation, and about changes to their contact details.
Clinics are not required to proactively gather additional health information or change of address details. So it’s possible that the information a donor-conceived person receives when they turn 18 is not up to date.
In some states and territories, such as Victoria and New South Wales, donor information is held in a central register, while other states and territories require the clinics to maintain the data.
Q4. When and how should you tell children they’re donor-conceived?
A. Damian Adams, donor conception researcher:
Discovering you’re donor-conceived later in life can potentially lead to confusion, anger and distrust of the family members who kept the secret from you.
Some researchers argue that telling children earlier in life causes less harm. Associate Professor Ken Daniels, a sociological researcher into donor conception, writes that “a child should never be able to remember a time when he/she did not know”. Others suggest it should at least occur before the identity construct window of adolescence occurs.
As there is currently no evidence that more problems arise by telling early, doing so while young has the least potential to create problems.
There are numerous books on the market that can assist parents in how to tell, as well as numerous online resources. One of the better ones is run by the Victorian Assisted Reproductive Treatment Authority (VARTA) which has been running very successful “Time to Tell” campaigns for many years and has numerous informative pages on their website dealing with this.
Q5. What kind of contact can donors expect when their offspring are adults?
A. Roger Cook, psychology scholar:
When offspring reach adulthood it’s possible for them to initiate contact with their donor, the outcome of which is varied. Some offspring reach strong relationships with their donor parent and some do not. There are, of course, some offspring who do not want to make contact.
Typically, however, if both the donor and the offspring are enthusiastic and prepared for contact, an on-going relationship can emerge but it’s not usually a parenting relationship. Often, the young adult can develop and maintain positive relationships with his or her biological father or mother but retain affection for the parents who raised them.
Q6. What are the options for gay men to start a family?
A. Deborah Dempsey, sociologist:
Australian gay men’s pathways to creating families with children are diverse, although relatively limited compared to men in the United States.
Australian gay men’s history of involvement in known sperm donation for lesbian and single heterosexual friends and acquaintances dates from at least the 1980s. Some men are able to negotiate “donor dad” or parental relationships with children conceived in this way.
Gay dads in Australia have fewer pathways to fatherhood than in the US. Dubova/Shutterstock
Since the early 2000s, it has become popular for Australian gay men to form families through surrogacy, particularly commercial surrogacy arrangements abroad.
For gay men who are US residents, adoption is a well-documented path to parenthood. Though laws in some Australian states do not permit gay men or lesbians to adopt. And relatively few children are available for adoption in Australia.
La Trobe University researcher Jennifer Power and her colleagues investigated family make up in the 2012 Work, Love and Play study. Of the 88 gay and bisexual men who described themselves as “actively involved” in parenting a child:
39% had become parents in a previous heterosexual relationship
23% were parenting children conceived through surrogacy
19% had become parents through known sperm donation to lesbian couples or single women
Q7. What logistical barriers do lesbian couples face when starting a family?
A. Deborah Dempsey, sociologist:
Lesbian couples using clinical donor insemination, known donor insemination or IVF to form families with children must navigate a complex range of logistical, social and emotional issues.
Finding a suitable known donor can be difficult because of the need for compatible expectations about parenthood. Men may want more or less involvement than the lesbian parents feel comfortable with; they may feel awkward or uncertain about the responsibilities attached to giving sperm; or their partners may not approve of the idea.
For some lesbian couples, deciding who will become pregnant and whose eggs will be used will be straightforward and for others, it will be emotionally difficult. It really depends on how the women view the issue of being genetically related to the child, and their feelings about how important it is to become pregnant and give birth.
In some US states, a procedure called “reciprocal IVF” is offered so both women can have a biological relationship to the child. One woman provides the egg, while the other becomes pregnant and gives birth. However this procedure is currently only possible in Australia if the couple has fertility problems.
Q8. Who goes on the birth certificate when using a sperm or egg donor? And what about if the couple is same-sex?
A. Fiona Kelly, legal scholar:
Where a couple or single woman has used assisted reproduction (ART) to conceive, the donor is not named on the birth certificate. Rather, the recipient parent(s), who are the legal parents of the child, are named, provided they were married or in a de facto relationship at the time of conception.
In all states and territories, the woman who gives birth to a child born as a result of ART is the “mother” of that child. When a married woman or a woman in a de facto relationship with a man becomes pregnant as a result of assisted reproduction her partner is presumed to be the father, provided he consented to the procedure.
All Australian jurisdictions also presume the same-sex partner of a birth mother who has used ART to conceive is a legal parent of a child born. In other words, same sex couples and opposite sex couples are treated identically.
The language that is used on birth certificates may vary. For example, in Western Australia, the partners may register as “mother” and “parent”; “mother” and “mother”; or “parent” and “parent”. In the ACT, a person may be registered as “mother”, “father” or “parent”.
Several states make a notation on the child’s birth certificate, indicating that further information is available about the child’s birth. The notation ensures the child can determine that he or she is donor conceived, particularly in the event of the child not having been informed by their parents of the nature of their conception.
Back in 1987, the cost of IVF treatment was about A$3,500 to A$4,500 and the pregnancy rate was around 40-50% after three attempts. At the time, Professor Carl Wood, one of the pioneers of Australian fertility treatment, said:
as the test-tube procedure has been developed only recently, it is reasonable to assume that with further improvements the cost may be reduced and the success rate increased.
Arguably, the reverse has occurred with live birth rates reported to be as low as 4% at one IVF clinic. Further, despite a large proportion of IVF now being subsided by Medicare, the going rate for a fresh IVF cycle is around A$10,000, with out-of-pocket expenses commonly over A$4,000 before private health insurance rebates.
Using donor sperm or eggs costs more again, with clinic-recruited donor sperm usually costing around A$1,000 per treatment. Although, actually paying a donor for their eggs or sperm remains illegal.
Fitness guru Michelle Bridges recently caused a stir when she suggested her ability to conceive naturally at 44 was because of her and her partner’s healthy lifestyle.
While lifestyle factors such a smoking and weight will play a role, the biggest contributing factor to infertility is the woman’s age. So while Michelle Bridges’ 12-week body challenge may reduce your body mass index, drinking protein shakes and running on the treadmill cannot turn back the clock.
Michelle Bridges was lucky; most women her age would need donor eggs. AAP/Tracey Nearmy
The highest success rates are reported in women under 30 who have around a 26% chance of having a baby with IVF. Women over 40 have around a 6% chance, and as for women 44 or older such as Michelle, the chance of going home with a baby is less than 1%. Michelle was lucky. Most women her age would need donor eggs.
There is also a wide discrepancy between the success rates of IVF providers. The last report showed overall results ranged from 4% at one clinic to 30.9% at another.
There is also evidence to suggest having a younger male partner may improve IVF outcomes in women. This doesn’t necessarily mean women should go out looking for a young male sperm donor, it just shows there are many factors at play, many of which are out of patients’ control.
Q11. Is sex selection legal in Australia? Should it be?
A. Deborah Dempsey, sociologist:
Sex selection using assisted reproductive technology is only legal in Australia to reduce the risk of transmission of a serious genetic conditions, such as duchenne muscular dystrophy.
Sex selection of embryos created through IVF is done using a technique called pre-implantation genetic diagnosis (PGD). This technique enables the removal of one or more cells from an embryo so it can be tested for genetic abnormalities prior to implantation.
Some Australians would like to use PGD for “family balancing” reasons. Australians often consider it ideal to have at least “one of each” in their family, although in many parts of the world there is a cultural preference for sons. Australians are known to travel overseas to obtain sex selection services in countries where clinicians will perform PGD for non-medical reasons.
While I understand that some parents have a very strong desire to have children of both sexes, my personal view is the practice is undesirable and discriminatory. If we take the “family balancing” idea seriously enough to legally facilitate it, we are perpetuating the view that boys and girls are so different from each other that families with children of one sex are “unbalanced” and somehow deficient.
There would also be no impediment to using the procedure to support more extreme forms of gender discrimination, for example, in cases where families favour having sons.
Q12. How long can donor eggs and sperm stay in the freezer?
A. Loretta Houlahan, embryology lecturer:
Donor eggs and sperm are often frozen before they’re given to recipients. This allows donors to be tested for infectious diseases and genetic abnormalities, transported interstate or overseas, if needed, and to be readily available for patients who need them.
Some people express concerns about the survival rates of donor eggs or sperm that were frozen many years ago. But as long as they’re stored correctly, there is no biological limit on the amount of time eggs or sperm can remain in frozen. Just like Elsa in the movie Frozen, the cold never bothered them anyway, and staying frozen doesn’t reduce their thaw survival rates.
There’s no limit to how long donor eggs and sperm can be frozen. nevodka/Shutterstock
The main problem with eggs and sperm that were frozen many years ago is that the older freezing methods were not as good as the new ones. Eggs frozen using the now-outdated “slow frozen” method have poorer survival rates than those that have been vitrified (“snap frozen”).
There is also limited information about the success of egg freezing in general. So while we know eggs can survive the thaw process, we don’t know the how many babies are being born from this process.
Sperm isn’t usually vitrified like eggs are, but advances in sperm freezing technology have also improved success rates over time.
So, to sum it up, donor eggs and sperm can theoretically remain frozen indefinitely – although there are legal restrictions on this.
Q13. How difficult is it to obtain information about overseas donors/surrogates?
A. Damian Adams, donor conception researcher:
Australian clinics are mandated to follow National Health and Medical Research Council’s guidelines which stipulate that all donor-conceived people (since the guidelines came into effect in 2005) are entitled to know identifying information on the donor once they reach 18 years of age. Subsequently, if clinics are sourcing eggs or sperm from overseas, the information available must meet our guidelines.
We are yet to see whether any donor-conceived people have trouble accessing this information as those conceived under these guidelines as they’re yet to turn 18. Those conceived prior to this will be at the mercy of whatever agreement the Australian clinic and the overseas clinic had in the supply of those gametes and associated information. The donor-conceived are then also reliant on a foreign business maintaining and looking after those records.
Anecdotal evidence from older donor-conceived people overseas does not paint a rosy picture of possible outcomes from seeking information, although it is hoped that their practices have also changed for the better as has been the case in Australia.
Q14. How are donor eggs and sperm transported interstate and overseas?
A. Loretta Houlahan, embryology lecturer:
After eggs and sperm are frozen, they need to be kept in liquid nitrogen, which is about minus 196 degrees Celsius. This can make transportation tricky, as liquid nitrogen is really dangerous, and if it was to leak it could easily kill the courier or the any one else around at the time.
Luckily, scientists have come up with a special device called a “dry shipper” which allows frozen embryos, eggs and sperm to be transported safely while keeping everyone safe. Dry shippers absorb the liquid nitrogen in the walls so it doesn’t leak, but it still keeps everything cold.
Very occasionally, this process can fail, but most transportation occurs successfully without any damage to patient material.
Q15. What barriers do donor-conceived people face in obtaining information about their biological mother or father?
A. Damian Adams, donor conception researcher:
This is highly dependent on when the person was born and which state they were born in. Those conceived from 2005 onwards around Australia, and 1998 onwards in Victoria, are entitled to access identifying information. Prior to those dates, donations were primarily anonymous.
For those conceived under anonymous conditions there are, however, voluntary registers in Victoria, Western Australia and New South Wales which offspring can put their details on in the hope that the donor will also place their details on the register. If the donor is not on the register – or if they were conceived in another state – the offspring will be reliant on assistance from the clinic.
Research my colleagues and I published in 2012 on accessing information in Australia showed some people found dealing with the clinics quite difficult (others have found them helpful), and if information was available that there was no national consistency on what information was recorded.
In some instances, records had been destroyed or redacted. We have also seen instances of registers failing to match people who were later matched through DNA testing.
So, some younger offspring may find it easy, while older offspring may find it difficult or even impossible.
Q16. Can donor-conceived people access information about their donor if they were conceived before anonymity was abolished?
A. Fiona Kelly, legal scholar:
The only state in which donor records have been opened retrospectively is Victoria. As of June 2015, all donor-conceived people who were conceived in Victoria may apply for access to their donor’s identifying information, with the donor’s consent.
In other states, there is no right of retrospective access. However, in a number of states, such as NSW and WA, donor-conceived people may place their names on a voluntary registry. If both the donor-conceived person and the donor register, access is permitted by mutual consent.
Q17. Will using donor eggs from a younger woman increase my chances?
A. Loretta Houlahan, embryology lecturer:
Women over 40 are the main recipients of donor eggs. Using donor eggs from a younger woman significantly increases the chances of success.
However, using donor eggs doesn’t eliminate all complications. Women who use donated eggs have a higher risk of developing serious complications, specifically high blood pressure and pre-eclampsia. Although it was thought these dangers may have been linked to the age of the birth mother and not the egg donor, the real reason remains unknown.
There is also a difference between fresh and frozen eggs to consider. Fresh is best because the success rate with thawed eggs remains unclear. However, this option is not always available where donor eggs are involved. Until only recently, egg freezing was considered experimental so we are still learning a lot about this process.
Q18. What motivates men to donate sperm, and women to donate eggs?
A. Roger Cook, psychology scholar:
Both sexes are motivated, at least in part, by a sense of altruism.
In the past, some men were enticed to donate by payments, albeit very low amounts. This became less common through the 1980s and now some clinics provide some reimbursement but no inducement payments. The Human Tissue Act of 1982 prohibits commercial profiting from semen donation. Financial reward is not a current motivation.
The motivation for men to donate sperm changed somewhat after laws were introduced prohibiting anonymous donation. Donors must now be prepared to be identified and allow contact with their donor children. This has reduced the number of men donating, as the necessity of identification is incompatible with their sense of privacy.
Another motivation for some men is a desire to be biological fathers, particularly when they’re unlikely to form a parenting relationship with a woman.
Women are usually more reluctant than men to give away their DNA, except when they have had their own experience of IVF. This is likely related to the significance of pregnancy and child birth experience, which men experience in a different way.
Women who donate their eggs are have been through infertility treatments such as IVF, and therefore have some understanding of the distress that follows such circumstances. Their motivation is to help other women who are not able to produce their own viable eggs.
Q19. Why do I need ICSI (sperm injections) if I use donor sperm?
A. Loretta Houlahan, embryology lecturer:
A common source of confusion for patients is why they need to use intra-cytoplasmic sperm injection (ICSI) when using donor sperm. ICSI is usually preserved for treatment where the male partner has a low sperm count and costs a lot more than a standard IVF treatment.
The main reason ICSI is used is because of the critical shortage of donor sperm. To enable supply to meet demand, the donor sperm sample may be diluted. This way it can be used in more patient treatments. The downside to this is that because diluted samples contain such a low volume of sperm, ICSI is required for the insemination procedure.
ICSI is also required to inseminate frozen-thawed eggs. In order to freeze eggs, the “cumulus cells” that surround them need to be removed. In natural conception, as well as standard IVF, the cumulus cells act like a maze and the sperm are required find their way through these cells to get to the egg.
It also acts like a barrier to limit the number of sperm that reach the end point. Without the cumulus cells in-tact, the risk of more than one sperm fertilising the egg is too high, so ICSI is used to avoid an abnormal fertilisation. With ICSI, the embryologist can ensure only one sperm enters the egg.
In response, global health authorities are starting to sound a little giddy. “We believe that the world is on the verge of an efficacious Ebola vaccine,” said Marie Paule Kieny, the World Health Organization’s (WHO) assistant director-general for health systems and innovation (and an author on the study). “It could be a game changer.”
She’s right: this is wonderful news, and a great testament to human ingenuity. A genetically engineered hybrid of the benign vesicular stomatitis virus and the Zaire strain of Ebola, together called rVSV-ZEBOV, was tested in a multi-site clinical trial conducted amid a massive aid response in Guinea, one of the poorest countries in Africa. The scientific and logistical acrobatics required to pull this off boggle the mind.
Yet, for three reasons, we cannot know if the vaccine really worked, or how well. Those reasons are the lack of placebo comparison, the way the investigators diagnosed vaccine failure and the possibility of statistical flukes.
Reason #1: There was no placebo to test the vaccine against
In response to the challenging ethics of Ebola vaccine research, investigators studying rVSV-ZEBOV opted not for the standard placebo-controlled trial with which most vaccines are tested but instead for an innovative approach called “ring-vaccination.”
In the clinical trial, the investigators drew a “ring” of vaccination around people with known exposures to Ebola. Groups of people who were exposed to a person with Ebola virus disease, or to someone who had been in contact with someone else with Ebola virus disease, were invited to participate in the study. Researchers recruited 7,651 people who fit that profile and randomized them to receive immediate vaccination with rVSV-ZEBOV or vaccination that was delayed by 21 days.
Afterwards, investigators followed all study participants for several weeks to see if they developed Ebola virus disease. In the immediate vaccination groups, no one developed Ebola virus disease more than 10 days after vaccination, whereas 16 patients in the delayed vaccination group did. Because the number of cases of Ebola virus disease was so much lower (ie, zero) in the immediate vaccination group, the investigators concluded the vaccine was 100% effective.
This conclusion was reasonable, but it also could be wrong. Without a placebo comparison, it’s easy to get fooled. Perhaps people with deferred vaccination were more likely to engage in risky Ebola exposures, or those who developed Ebola virus disease in the immediate vaccination group were less likely to stay in study follow-up. The investigators did as good a job as possible to avoid these problems, but without a placebo arm in the study, we just cannot be sure.
Reason #2: The definition of vaccine failure isn’t failsafe
No cases of Ebola developed in the immediate vaccination group 10 days after vaccine was given. But nine cases of Ebola developed in the immediate vaccination group within 10 days of vaccination. Since the incubation period for Ebola virus disease is typically longer than 10 days, the investigators concluded that the nine cases of Ebola virus disease that developed within 10 days of getting the vaccine resulted from pre-vaccine exposure.
Again, this was a defensible conclusion, but it could also be wrong. Sometimes Ebola develops in less than 10 days, which means some or all of the nine people in the immediate vaccination group could have been infected with Ebola after being vaccinated. That means sometimes the vaccine may have failed to provide protection against Ebola, and we do not know exactly how often.
On the decline. New confirmed Ebola cases reported by WHO in 2015. Reuters
Reason #3: The possibility of statistical flukes
When investigators were following study participants to see if the vaccine prevented Ebola, the total number of Ebola cases was shrinking rapidly. That is good news for people living in West Africa but problematic for the study. With such a small number of total cases, comparisons between immediate and delayed vaccinees become harder to make with confidence, because statistical flukes can occur.
How easily could a fluke event have thrown off the results?
Let’s go back to those nine cases of Ebola in the immediate vaccination group. Imagine if just a few of them were cases of vaccine failure, and in fact, were cases where Ebola virus disease developed after vaccination. Further, what if a few immediate vaccinees lived in communities where infection control measures were better, coincidentally, than in communities where vaccination was delayed? Perhaps immediate vaccinees were less likely to encounter Ebola because burial practices were less risky in their communities, by chance, or there was a better supply of gloves and other protective equipment. If both easily imaginable circumstances occurred in just a few cases, vaccine efficacy could be much lower than 100% and our public health messaging would be considerably more muted.
The study investigators took meticulous steps to prevent each of these problems, and they argue persuasively that it is unlikely the protection they saw from rVSV-ZEBOV was entirely due to chance. I agree. The point is that it is easy to imagine ways the vaccine is far less than 100% effective, and even possible (if unlikely) the vaccine provided no protection whatsoever. The reasonable doubt that remains is why most vaccines are tested and then retested in placebo-controlled clinical trials so that the public can trust us when we say vaccines work.
Scientists at the National Microbiology Lab in Winnipeg, Manitoba, prepare an experimental Ebola vaccine for shipment to the World Health Organization in Geneva. Reuters/Public Health Agency of Canada/Handout
Despite need for more info, we aren’t likely to get it
In response to this uncertainty, Lancet editorialists were properly guarded about the vaccine. They wrote, “More data on efficacy are needed before it can be widely deployed.”
More data are needed – but we will probably never get more data. Ebola is burning out in western Africa. That means it is becoming increasingly impossible to test the efficacy of any intervention against Ebola. This is one reason that the clinical trial results for the rVSV-ZEBOV vaccine were released earlier than expected: the data safety and monitoring board for the trial recognized that with so few cases of Ebola, the trial could no longer acquire meaningful efficacy data. That means the Guinea rVSV-ZEBOV vaccine trial is likely to remain the best evidence we have for an effective Ebola vaccine for a long time.
Ordinarily, the next step would be to prove vaccine efficacy beyond a shadow of a doubt by comparing the vaccine to placebo in a large randomized clinical trial. To get this done, we would need to wait for the next time Ebola emerges in some remote village in Guinea or a neighboring country, and then mount the mother of all Ebola vaccine trials designed to prove that the magic bullet we seek is really in hand.
We will probably never take this step. Just as many scientists decried placebo-controlled studies amid the present Ebola epidemic, surely any future resurgence of Ebola cases will be accompanied by a similar hew and cry. In fact, the critique will be even more vehement: with a vaccine already touted as “100% effective,” how can we possibly deny it to people at risk of death in days? As a harbinger of this conversation to come, upon release of the rVSV-ZEBOV study results, the study data safety and monitoring board recommended and ultimately Guinean ethics authorities approved of immediate rVSV-ZEBOV vaccination for all people in the study region who were newly exposed to Ebola.
Are we lowering our standards for vaccines in the developing world?
In a time when we benefit from a panoply of effective vaccines, it is easy to assume all vaccines work well. Yet many vaccine candidates have failed. To list a few, there are failed vaccines against herpes simplex virus and Staphylococcus aureus and even two HIV vaccines that seemed to increase the risk of HIV infection. The reason we test vaccines in rigorous placebo-controlled trials is to avoid exposing the public to vaccine duds, or worse.
Does our well-founded fear of Ebola, and our equally legitimate fear of unethical placebo research in Africa, convince us that people in West Africa should be given a vaccine that hasn’t been proven effective using the same standards as vaccines given in the rich countries of the world?
It might be politically easier, and logistically expedient in the short term, to answer “yes.” But, in the long run, I fear saying “yes” will make it harder to deliver to low- and middle-income countries vaccines of the same quality as are used in rich countries.
That is why it is so important to know whether the Ebola vaccine was 100% effective, or 100% lucky. The good money is on a percentage somewhere in between, but in truth, I doubt we will ever know.
