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The facts, treatments, and ethical issues surrounding the banning of DDT DDT vs Malaria The facts, treatments, and ethical issues surrounding the banning of DDT Michael O’Driscoll MPH 560: Public Health Ethics Professor: Dr. Vicki Boye Concordia University February 21, 2015 The facts, treatments, and ethical issues surrounding the banning of DDT Any infection, disease, affliction, illness, or condition that affects a large number of people is worth examining – and finding solutions to conquer it. This is, of course, the goal of public health. What makes this journey challenging, however, is that only one human disease (smallpox) has ever been eradicated (Pfizer Global Pharmaceuticals, 2006). Bacteria mutate or become more resistant, new virus strains emerge, conflicting arguments are presented, and the ensuing debates (especially in light of social media and online news venues) bring to the forefront ethical and moral issues which can make people fearful and mistrusting of any intervention or examining current actions. Malaria is such a condition. Believed to be largely eradicated in the United States by the end of 1951, when dichlorodiphenyltrichloroethane (DDT) proved effective, the World Health Organization (WHO) submitted at the World Health Assembly in 1955 and ambitious proposal for the elimination of Malaria worldwide (malaria.com, n.d.). In 1972 the United States banned DDT after claiming it was a carcinogen and caused the chemical to build up in human body fatty tissues (EPA, n.d.). Subsequently, the chemical was banned for agricultural use worldwide under the Stockholm Conventions and other countries began to stop using DDT as a pesticide to control mosquito populations (Ovuorie, July 2013). According to the World Health Organization, Malaria is caused by a parasite called Plasmodium, which is transmitted via the bites of infected mosquitos. The parasites multiply in the liver of the human host and then infect their red blood cells. If not treated, Malaria can become life-threatening by disrupting the blood supply to vital organs. In many parts of the world, the parasites have developed resistance to many of Malaria medicines. There were an The facts, treatments, and ethical issues surrounding the banning of DDT estimated 627,000 malaria deaths worldwide in 2012 and 77% of those are children under 5 years of age; there were an estimated 207 million cases of Malaria in 2012 and 80% occur in sub-Saharan Africa. Between 2000 and 2012, estimated mortality rates decreased by 42% worldwide and 49% in the African region and the estimated incidence of Malaria fell by 25% globally and 31% in the Africa (WHO, n.d.). Many of the African nations are using DDT as part of their integrated pest management program to reduce the mosquito population which has led to the significant decrease in Malaria rates. These biostatistics and the controversy surrounding the use of a known carcinogen— DDT--to control mosquito populations and prevent Malaria is worthy of examining and analyzing the ethical and moral aspects of the decisions by leaders in affected countries to use the chemical, reducing morbidity and mortality from Malaria. The Epidemiology of Malaria A highly contagious disease, Malaria parasites are transmitted via the bite of a female Anopheles spp mosquito. In humans, the parasite grow and multiply first in the liver cells and then in the red cells of the blood. In the blood, successive broods of parasites grow inside the red cells and destroy them, releasing daughter parasites than continue the cycle by invading other red cells. The blood stage parasites are those that cause the symptoms of Malaria. After 10-18 days, the parasites are able to be transmitted to another human by the Anopheles mosquito (CDC, n.d.). When it first presents, Malaria can be indicated by a variety of symptoms such as, fever, chills, sweats, nausea and vomiting, body aches, and a general malaise (CDC, n.d.). Such mild symptoms are often tolerated or misdiagnosed. Indeed, those infected can defend these symptoms as allergies, influenza, or simply a common cold. Advanced symptoms can include The facts, treatments, and ethical issues surrounding the banning of DDT acute kidney failure, cardiovascular collapse, severe anemia, seizures, coma, and death. Left untreated or undiagnosed, Malaria can spread quickly in regions with high populations of mosquitos and cause severe pain and suffering in a community. Currently, the WHO estimates that an estimated 80% of Malaria deaths occur in just 14 countries and together, the Democratic Republic of the Congo and Nigeria account for over 40% of the estimated total Malaria deaths globally (WHO, n.d.). Dichlorodiphenyltrichloroethane Better known as DDT, dichlorodiphenyltrichloroethane is an organochlorine insecticide that was used freely around the world for insect control. Historically, DDT was used in the U.S. to eradicate Malaria with excellent results. Organochlorine pesticides are nerve toxins that when ingested or introduced into the human body, can cause convulsions and death, but their acute toxicity to humans is low (Maxwell, 2009). Because DDT accumulates in the body, exposure is cumulative, and increases over time, however, the data is somewhat unclear about its long-term damage to human health and has been difficult to prove. Furthermore, data shows that when the amount of DDT used is significantly reduced, Malaria increases exponentially. For example, data from 1993 to 1995 in South American countries showed a sharp increase of Malaria in countries that decreased their usage of DDT and a 61% decrease in Malaria rates in the one country that increased its use of DDT –Ecuador (Roberts, Laughlin, Hsheih, and Legters, 1997). The primary concern with DDT continues to be the length of time it can remain in our environment, up to 15 years, and the adverse effects seen in wildlife (ATSDR, 2011). DDT can build up in the fatty tissues of animals and cause long-term exposure damage including, neurological, liver, or reproductive impairment. The facts, treatments, and ethical issues surrounding the banning of DDT Human Rights: The Universal Declaration of Human Rights contains 30 articles listing the political, civil, economic, and cultural rights entitled to all human beings. For the purposes of my discussion I will refer specifically to Article 25 of the declaration, which states, “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care” (United Nations, 1948: p.76). These basic human rights are understood to be universal, with equal weight given to all women, men, youth, and children; and, without discrimination. Health and human rights were not necessarily linked together when the universal declaration of human rights was presented to the world. In fact, Mann et al. assert that with few exceptions, discussions about health have rarely included human rights (Mann et al., 1994). In particular, Mann conceptualized the linking of human rights and public health offering a differing perspective and new framework for interventions at the international level (Mann, 2006). The challenge of applying human rights in response to health problems such as infectious diseases like Malaria, is defining precisely what constitutes a health problem that rises to the level of violating recognized human rights. For example, pertussis (whooping cough) was believed to be largely eradicated in the 1950’s when a vaccine proved effective, it has recently seen a large increase in the prevalence rates around the world. Since 1990, Pertussis has claimed an estimated 400,000 lives globally each year and caused hundreds of thousands more to suffer its consequences (Tan, et al., 2005). Would this rise to the level of violating human rights by not acting on finding a solution to pertussis? If we use Mann’s framework for human rights, public health action to limit human death and suffering must be considered and resources allocated to reduce Pertussis in the human population; the same should apply to Malaria. The facts, treatments, and ethical issues surrounding the banning of DDT Ethical Considerations: There are distinct differences between clinical and public health practice. Each area is guided by a set of values (individual morals + social norms) that influences the way in which transactions are carried out. These become ethical “standards” that may change over time. While the development and application of values may be different, the application, i.e., deciding what is right versus what is wrong, is usually the same. Medical ethics applies to the relationship between two individuals, e.g., physician-patient. And, public health ethics are applied within a population-based context, e.g., the relationship between public health professionals and society. For example, medical ethics would encompass the treatment of individuals with Malaria while public health ethics would contain guidelines on eliminating the cause of the disease in the community, i.e. abatement of mosquitoes and their breeding grounds. By using another public health framework developed by Nancy Kass, there are six primary questions designed to help public health professionals consider the ethics implications of proposed interventions, policy proposals, research initiative, and programs (Kass, 2001). The six questions are: 1) What are the public health goals of the proposed program? 2) How effective is the program in achieving its stated goals? 3) What are the potential burdens of the program? 4) Can burdens be minimized or are there alternative approaches? 5) Is the program implemented fairly? And, 6) How can the burdens of the program be fairly balanced? Making sound ethical decisions and utilizing a set of ethical principles is essential when considering on a course of action in a population which can have an enormous impact on the lives of millions of people, such as, banning or severely limiting the distribution of DDT as an insecticide to aid poor countries in their struggles against malaria. The facts, treatments, and ethical issues surrounding the banning of DDT The concern over DDT stems from the way it stays in the environment. As an organochlorine pesticide, it is persistent. When absorbed by an animal, it is lipophilic, meaning it concentrates in the fatty tissues and as the pesticide moves up the food chain, it biomagnifies. Ultimately, DDT becomes a toxic at higher levels in the food chain, which was the premise of the book Silent Spring (Maxwell, 2009). There existed slim scientific evidence that the biomaginfication of the organochlorine chemical in bald eagles caused the shells of the eagles’ eggs to weaken and crack, and the birds were not able to breed successfully (Maxwell, 2009). After DDT was banned in the United States during the 1970’s, other countries followed and Malaria saw resurgence around the world, especially in the endemic areas of Africa where millions of people continue to become infected and die from the disease. The question I am attempting to answer by using the six primary questions posed by Kass in her framework is, “what is worse, Malaria or DDT?” The World Health Organization acknowledges that Malaria is one of the world’s most deadly diseases that kill about 880,000 people, mostly children in sub-Saharan Africa annually (WHO, n.d.). Yet, methods and chemicals to control Malaria continue to be elusive and a subject of controversy. Currently, DDT is classified as one of 21 “Persistent Organic Pollutants by the UN Environmental Program which over 150 nations have agreed to ban production of those chemicals (MercoPress, 2009) making this product unavailable to the third world countries that struggle with Malaria. Certainly, by following the selected framework by Kass, we can apply her six primary questions to assist in determining if limiting the supply of DDT to the poorer nations where Malaria is endemic might be considered unethical: (1) the public health goal of any chemical application program is to reduce prevalence of Malaria and deaths associated with the disease; The facts, treatments, and ethical issues surrounding the banning of DDT manufacturing and providing DDT for mosquito abatement programs must be considered part of a prevention program; (2) program effectiveness can be measured by annual data collected by the WHO; (3) potential burdens are the environmental issues associated with DDT, cost of the chemical and training applicators; (4) burdens can be minimized by educating and training people in the use of DDT and supplementing chemical applications with other less damaging approaches such as using environmentally safe larvacide and mosquito netting around beds. In addition, by requesting developed nations provide the funding and resources to needier countries, and allowing the WHO to monitor outcomes and progress can also reduce the burdens to the poor countries; (5) to implement a mosquito abatement program with DDT fairly, other nations should provide resources to the poorer nations and the WHO should work with the local governments to make sure the resources are spread evenly; (6) an appropriate Malaria reduction program can be fairly balanced by using a combination of DDT and other prevention methods such as bed netting and treating standing water with larvacide. Discussion: The question of DDT’s risks and benefits as an all-or-nothing proposition which fails to examine the complicated environmental, public health, medical, socioeconomic, and wide range of geographic locations is a failure on both sides of the argument to determine an ethical solution to save millions of lives. Science has not been successful in finding a replacement chemical to replace DDT effectiveness. The UN and WHO recommends the following prevention techniques to reduce malaria: 1) sleeping under a mosquito net; 2) the use of skin repellent and mosquito coils, 3) hanging mesh screening or cloth nets implanted with approved insecticides over doors and windows, and 4) educating people about how to eliminate standing water in ditches to destroy mosquito breeding grounds. While these techniques may be helpful, they alone are not The facts, treatments, and ethical issues surrounding the banning of DDT nearly enough to control malaria in the endemic nations. In fact, one of the biggest ethical challenges the developed countries must overcome is the fact that most of the world’s wealthiest nations who are part of the UN are malaria fee and it’s easy for the leaders in those nations to ban DDT while many of the poorer, undeveloped countries have little input. Thus, it would appear that ethical questions continue to exist with this issue and restrictions are being placed on countries, which do not have the resources to implement more costly mosquito abatement programs in lieu of DDT. Safer alternatives should be tested first and if successful, DDT should be reduced, especially in many African countries and parts of Central America where Malaria is endemic and hardest hit by the disease. DDT is a fat loving, halogenated compound that has been found to persist in the environment, can accumulate in body tissues, and has been found to biomagnify in the food chain (Maxwell, 2009). Because DDT accumulates in the environment and body and, even if acute human toxicity is low, DDT is still a chemical, which can cause harm and needs to be managed appropriately. In low doses, DDT can still effectively kill mosquitos reducing the risk of contracting Malaria and minimize risk to the environment and human beings. Millions of people contract Malaria each year and hundreds of thousands of those die; and, most are from very poor sub-Sahara African and South American countries. Ethically, I believe it is incumbent upon the world leaders of the wealthier nations to develop and support a Malaria reduction prevention program in those undeveloped countries. By following the public health ethics framework outlined by Nancy Kass, a solution that meets those six guidelines can be found to protect both the environment and reduce Malaria. The facts, treatments, and ethical issues surrounding the banning of DDT References: Agency for Toxic Substances and Disease Registry. (September 2002). ToxFAQs for DDT, DDE, and DDD. Retrieved January 29, 2015 from http://www.atsdr.cdc.gov/toxfaqs/tf.asp?id=80&tid=20 Centers for Disease Control and Prevention. (n.d.) Malaria Biology. Retrieved January 25, 2015 from http://www.cdc.gov/malaria/about/biology/index.html Environmental Protection Agency. (n.d.). DDT. 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Pfizer Inc. Roberts, D., Laughlin, L., Hsheih, P., and Legters, L. (1997). DDT, global strategies, and a malaria control crisis in South America. Emerging Infectious Diseases, 3(3), 295-302. The facts, treatments, and ethical issues surrounding the banning of DDT Ovuorie, T. (July 2013). African countries adopt controversial deadly chemical, DDT, for malaria treatment. Retrieved January 22, 2015 from http://www.premiumtimesng.com/news/141150-african-countries-adopt-controversialdeadly-chemical-ddt-for-malaria-treatment.html Tan, T., Trindade, E., & Skowronski, D. (May 2005). Epidemiology of Pertusis. The Pediatric Infectious Disease Journal, 24(5), S10-S18. United Nations. (n.d.). Universal Declaration of Human Rights. Retrieved January 30, 2015 from http://www.ohchr.org/EN/UDHR/Pages/Introduction.aspx World Health Organization. (n.d.). Malaria. Retrieved January 29, 2015 from http://www.who.int/topics/malaria/en/