In sickness and health: Professor explores the intersection of ethics and disease
As a child in Colorado, Nicole Hassoun came across an abandoned building in a local park. A plaque on the door gave its history as a tuberculosis sanitarium, a concept she didn’t yet understand.
Her grandmother, however, would have known exactly what that meant — and feared it. Once the scourge of North America and Europe alike, tuberculosis is still one of the top 10 causes of death worldwide. But since it particularly strikes poor nations — currently, the greatest number of cases are found in Asia and Africa — the highly contagious disease has attracted little in the way of drug development.
The same can be said for other maladies, such as malaria, AIDS and a range of tropical diseases. With coronavirus diverting funding away from these illnesses, the lack of research and development is likely to worsen.
The coronavirus pandemic is exacerbating global health inequality, noted Hassoun, a Binghamton University philosophy professor, ethicist and co-director of the Institute for Justice and Well-Being.
“It’s exacerbating all kinds of inequality,” she said. “It’s exposing the structural injustices, the foundational inequality in societies, and really making them worse. It’s terrible for women. It’s terrible for children. It’s just terrible.”
She has written extensively on coronavirus in recent months, and is currently exploring the equitable distribution of vaccines and future pandemic preparedness with the aid of a World Health Organization grant. Her work has appeared in The Conversation and newspapers around the country on topics ranging from mask-wearing to vaccines and the need to put ethics ahead of profit when it comes to pandemic response.
In July, she published her second book, Global Health Impact: Extending Access to Essential Medicines, which considers the global health responsibilities of pharmaceutical companies, and makes the case for a new kind of ethical investment in public health. Her recent pieces draw on ideas that she first laid out in the book, written long before the coronavirus pandemic.
“The idea is, can we better align research and development with health impact rather than sales volume?” she asked.
The human right to health
While tuberculosis, AIDS and malaria remain stark realities in the developing world, the medications that treat them are scarce, costly and increasingly obsolete as resistance rates rise. Coronavirus also has a harsh outlook in poorer nations, where ventilators and hospital critical-care facilities are in short supply.
Driven by market pressures, pharmaceutical companies are more likely to invest in commercially lucrative products — typically those that treat chronic conditions in more affluent customers — than those that treat public health threats in poorer nations. Along a similar vein, it’s likely that lifesaving treatments and vaccines under development for coronavirus will only be made available to poorer countries much later, if at all.
In her work, Hassoun argues for the human right to health and access to essential medicines. It’s not without controversy; critics may argue that an ethical principle doesn’t solve problems related to real-world health systems or the distribution of scarce resources, such as a future coronavirus vaccine.
Hassoun, however, believes that ethical principles inspire us to think creatively about how to solve logistical problems while honoring our fundamental commitments, something that she terms “the virtue of creative resolve.” This resolve is seen through the genesis and the continuing work of the public health field, she said.
“Sometimes it really is impossible to help everyone — in those cases something more significant will be lost,” she said. “But the burden of proof, if you will, is put on those who want to say that we don’t have a right to healthcare, that we can’t help somebody access the medicines that they need.”
Hassoun’s book is her own attempt to think creatively about global access to lifesaving medicines. The first step to improving access is evaluating where successes have been made, and where and why failures remain.
While it can be tempting to focus on the failures, there have been significant successes in expanding access to critical medications. Hassoun pointed to Partners in Health, a human rights-based organization that refused to accept the World Health Organization’s claim that treating drug-resistant tuberculosis wasn’t feasible or cost-effective in poor nations. Instead of accepting defeat, the organization practiced creative resolve, using community health workers to promote adherence to treatment and expand the global access to needed medicines.
The AIDS crisis in the 1990s similarly prompted creative thinking from global organizations, which educated patients and worked to reduce the cost of medication in developing countries. There are other public health wins, too: the complete eradication of smallpox, for example, and the ongoing eradication of polio.
Tracking these successes and failures is the Global Health Impact Project, a collaboration of scholars and individuals from civil society that launched in 2015 at the World Health Organization and relaunched at Princeton last year. The project provides a database of information that evaluates medications by country, drug, disease and by the firms that manufacture and distribute those drugs.
To take the project a step further, Hassoun envisions a new type of reward system based on health impact for pharmaceutical companies committed to improving global health. Consider, for example, a global public health label that companies can put on all their over-the-counter products, from pet vitamins to mouthwash. Even if that label lures only 1 to 2 percent additional customers, that can equate to a significant amount of money — perhaps enough to fund the development of a new drug.
Universities, the source of around a third of pharmaceutical research, can also provide pressure, mandating that the companies that seek to profit off their research meet certain targets. Hassoun has other ideas, too.
But in addition to hope, there is also some frustration that such measures aren’t already in place. An alternative, more cooperative research and development system could have potentially accelerated the creation of a coronavirus vaccine, saving more lives.
“We could have simplified this a lot and said, ‘This is a global public good. Everything related to it needs to be in this shared public domain, and you will be rewarded per dose distributed at cost or with some profit. Whoever comes up with it can be be rewarded additionally for innovation,’” she reflected.
“I hope we can get people to do this better so that when the next pandemic hits, which it will, we can be ready,” she said.