sarahkeenihan

Ethical dilemmas in malaria research

In April 2016 on April 8, 2016 at 9:21 am

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Sarah: ‘Slow motion genocide’ of native West Papuans is currently taking place just north of Australia according to a recent report presented on Australia’s Radio National. Sister Susan Connelly recently told Andrew West on The Religion and Ethics Report, ‘the people are being erased from their own land.’ It’s a pattern that reminds her of activities in East Timor around 20 years ago, with Indonesian military forces acting to control and murder indigenous peoples.

A key factor at play is a huge influx of migrants – not from another country, but from the Indonesian island of Java. Known in the Bahasa Indonesia language as ‘transmigrasi’, this process provides land grants and work to families willing to leave heavily overcrowded and dominant Indonesian islands, and move to more sparsely inhabited places like West Papua (officially part of Indonesia since the late 1960s). It rapidly brings different cultural groups together under competitive conditions, although technically they are one nation under the Indonesian flag.

“The white ship comes every week and disgorges thousands more migrants,” says Sister Connelly. “Forty years ago, Papuans were 96% of the population. Now they’re about 48%”.

Notwithstanding the social and human rights issues presented by Indonesian transmigration programs and the enforcement of them, there’s a health angle to this story too. Papua has a deadly form of malaria (due to the parasite Plasmodium falciparum), whereas Java and many other heavily populated Indonesian islands do not. Freshly arrived transmigrants are welcomed by infected Anopheles mosquitos, and soon commence their first cycle of febrile malaria.

I first learnt about Javanese transmigrants to Papua when I was working in immunology research in Jakarta, the capital of Indonesia. At my place of employment, a collaborative project between Indonesian and American scientists examined anti-malarial immunity in migrants who had arrived in Papua during the period 1996-1999. It should be noted that all study subjects gave their consent to participate in the study, received free health check-ups, and were provided with treatment immediately following a diagnosis. (I do not know whether transmigrants in general were provided with advice regarding malaria prevention, or had avenues for treatment by Indonesian health services).

The blood samples we worked with were highly unique, because they provided the rare opportunity to examine a question that vexed malaria researchers and health professionals around the world. Why do children suffer so much from malarial illness compared to their adult counterparts? Of course you can’t address this question studying immune responses in people born and bred in malaria-rife regions, because first exposure to the parasites happens during childhood for everyone. So you never know in these cases if immunological protection against the symptoms of malaria in adults is due to cumulative exposure to the parasites, or the age of the infected person. However, when entire families are plonked down in a malarial area, you can study the first infection in children and adults alike, and compare their responses.

And this is just what we did. A paper I published with colleagues details the findings – host age was found to be a significant factor in determining the antibody response of people to a key component of the parasite. While the peak antibody response in adults was achieved after a single infection, comparable responses in children required at least 3–4 infections. Those kids that did produce a high antibody response were less likely to experience symptoms with a subsequent high parasite load.

I recall that prior to it being accepted for publication, one of the reviewers of our paper asked about the ethics of the transmigration program. At the time, the question did prick my ears and my conscience a little. And now I find myself wondering about it again. It’s understandable that a modern nation would attempt to reduce overcrowding on its most inhabited islands. But when blokes with guns are sent in to enforce the process, and tales of cultural bias and even extermination start to filter out, it’s a whole other story.

Interestingly, it was not long after I left Indonesia (in late 2002) that Indonesia stopped their program of collaborative Papua-based research with the Americans. More recently, they’ve not been happy when foreign media attempted to document life in that province either.

[image thanks to Matt Brown]

 

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