“He Is Now like a Brother, I Can Even Give Him Some Blood”—Relational Ethics and Material Exchanges in a Malaria Vaccine “Trial Community” in The Gambia

London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
Social Science & Medicine (Impact Factor: 2.89). 06/2008; 67(5):696-707. DOI: 10.1016/j.socscimed.2008.02.004
Source: PubMed


This paper explores social relations within the 'trial community' (staff and volunteers) of a Malaria Vaccine Trial (MVT), implemented by the Medical Research Council (MRC) in The Gambia between 2001 and 2004. It situates ethical concerns with medical research within the everyday life of scientific fieldwork. Based upon discussions with volunteers and staff, we explore processes of mediation between scientific project and study population, and between formal ethics, local ethical debates and everyday practice. We observe that material contact and substantial transactions, notably of blood and medicine, are central to the construction of the MVT. These transactions are guided by a concrete and relational form of ethics, which contrasts with the abstract and vertical formal ethical principles underwriting the scientific study protocol. The success of the MVT owed much to these kinship-like ethics. One possible conclusion from these observations is that research ethics should be understood, not just as a quasi-legal frame but also as an open, searching movement, much in the same way that kinship is not merely a juridical institution and a prescriptive frame of rules, but a network made through relational work. However, this conclusion raises new problems: by contrasting formal, abstract principles to intimate, immediate relations, and economic justice to personal morality, we accept that the order of medical research is moved further out of the public and political, and into the domains of either quasi-legal claims or of private morality. Irrespective of the undeniable importance of clear-cut rules and of good face-to-face relations, a third essential foundation of medical research ethics is the democratically constituted public sphere, including equitable health services, and transparent institutions to facilitate open debate and regulate particular interests. Ultimately, the ethics of global science can rely neither on principles nor trust but requires citizenship and democratic government.

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Available from: Ann Horton Kelly, Jul 24, 2014
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    • "When we visited the country programme for malaria – which also received Global Fund money – they demonstrated that they knew there were high levels of endemic malaria in the country, including among pregnant women and small children (Geissler, Kelly, Imoukhuede, & Pool, 2008). They also found an alarming prevalence of endemic anaemia, both findings that are important for strategies into MCH. "
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    ABSTRACT: Global trends influence strategies for health-care delivery in low- and middle-income countries. A drive towards uniformity in the design and delivery of healthcare interventions, rather than solid local adaptations, has come to dominate global health policies. This study is a participatory longitudinal study of how one country in West Africa, The Gambia, has responded to global health policy trends in maternal and reproductive health, based on the authors' experience working as a public health researcher within The Gambia over two decades. The paper demonstrates that though the health system is built largely upon the principles of a decentralised and governed primary care system, as delineated in the Alma-Ata Declaration, the more recent policies of The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria and the GAVI Alliance have had a major influence on local policies. Vertically designed health programmes have not been easily integrated with the existing system, and priorities have been shifted according to shifting donor streams. Local absorptive capacity has been undermined and inequalities exacerbated within the system. This paper problematises national actors' lack of ability to manoeuvre within this policy context. The authors' observations of the consequences in the field over time evoke many questions that warrant discussion, especially regarding the tension between local state autonomy and the donor-driven trend towards uniformity and top-down priority setting.
    Global Public Health 09/2014; 9(8):894-909. DOI:10.1080/17441692.2014.940991 · 0.92 Impact Factor
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    • "describe care beyond trial procedures " on a case-by-case basis " (although in recent years, health benefits are sometimes more clearly defined in research protocols stipulating specific monetary amounts for inpatient and outpatient care per participant). This openness regarding health care benefits may partly be due to the silencing effect of ethics prohibitions against " inducement " —quality health care alone is an important incentive for potential study participants (e.g., Fairhead et al. 2006; Geissler et al. 2008). "
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    ABSTRACT: Unknown knowns—or “public secrets”—may play an integral part in publicly funded medical science. In one large transnational field research site in Africa, such unknowing pertains to vital material inequalities across the relations of scientific production. These inequalities are open to experience but remain often unacknowledged in public speech and scientific texts. This silence is not usually achieved by suppressing knowledge but through linguistic convention and differentiation between places and moments of knowing and ignorance. Switching between known and unknown according to situation and interlocutor is an important, largely implicit skill that maintains relations necessary to conduct clinical research—linking bodies, lives, institutions, and technologies across differentials of resources, expertise, and power. Unknowing, then, facilitates research; and it shapes the resulting work and perpetuates the political and economic contradictions that pervade the context and the research endeavor itself. Unknowing thus poses a challenge for conventional anthropological modes of critique and engagement.
    American Ethnologist 02/2013; 40(1). DOI:10.1111/amet.12002 · 1.41 Impact Factor
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    • "Our findings suggest that forms of sociality that enliven local relationships are an important element in decision-making regarding anonymous HIV testing. The work of Geissler et al. (2008) on relational ethics and material exchange involved in the giving of blood in the context of a malaria vaccine trial is an excellent example of a critical reconsideration of the kinds of relationships that emerge between study participants and researchers in long-term research engagements. Of particular interest to us is the way in which the symbolic associations of blood and its circulation carry the capacity to enliven or mobilise kin relations in the research activities and service provisioning of trial communities. "
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    ABSTRACT: In the context of low rates of participation in a prospective, population-based HIV surveillance programme, researchers at a surveillance site in rural KwaZulu-Natal, South Africa, conducted an operational study from January 2009 to February 2010, with the aim of improving participation rates, particularly in the provision of dried blood spots for the surveillance. Findings suggest, firstly, that consent to participation in the HIV surveillance is informed by the dynamics of relationality in the HIV surveillance “consent encounter.” Secondly, it emerged that both fieldworkers and participants found it difficult to differentiate between HIV surveillance and HIV testing in the surveillance procedure, and tended to understand and explain giving blood under the aegis of the surveillance as an HIV test. The conflation of surveillance and testing, we argue, is not merely a semantic confusion, but reveals an important tension inherent to global health research between individual risks and benefits and collective good, or between private morality and public good. Because of these structural tensions, we suggest, the HIV surveillance consent encounter activates multiple gift economies in the collection of blood samples. Thinking beyond the complex ethical dimensions provoked by new forms of long-term surveillance and health research, we therefore suggest that deepening relations between scientists, fieldworkers, and study participants in locality deserve more careful methodological consideration and descriptive attention.
    Social Science [?] Medicine 11/2012; 77(C). DOI:10.1016/j.socscimed.2012.11.015 · 2.89 Impact Factor
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