It is the mission of the physician to safeguard the health of the people. His or her knowledge and conscience are dedicated to the fulfillment of this mission. The Declaration of Geneva of the World Medical Association binds the physician with the words, “The health of my patient will be my first consideration”, and the International Code of Medical Ethics declares that, “A physician shall act only in the patient’s interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient”.Pregnant women and children are not getting enough medical attention
The situation with children is at least as difficult. Like women, they are barely taken into account in medical research
Mohammed Abul Kalam, PhD
It is the mission of the physician to safeguard the health of the people. His or her knowledge and conscience are dedicated to the fulfillment of this mission. The Declaration of Geneva of the World Medical Association binds the physician with the words, The health of my patient will be my first consideration, and the International Code of Medical Ethics declares that, A physician shall act only in the patients interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient.
Remembering the above, no one wants to test new drugs on pregnant women or children. But they, too, need treatments that are effective and safe. Drugs are taboo during pregnancy. Thats the guiding principle. But the reality is different. According to an international study that was published in 2014 in the British Medical Journal, 80 percent of all women take drugs during pregnancy. So its all the more important for medical personnel to know which substances could be dangerous to the unborn child, and which are safe. But pregnant women are often excluded from medical studies because no one is prepared to take a deliberate risk with the health of the fetus.
Although no one denies the fact that women and men are fundamentally different, medical researchers still generally test their new drugs and therapies on men. Its simply assumed that they will have the same impact on women. But thats by no means always the case.The metabolisms of men and women sometimes process drugs differently. The female liver contains certain other enzymes that can ensure that drugs work (or not). Furthermore, drugs are distributed differently in a womans body. Women are mostly smaller than men, and have a higher proportion of fatty tissue. Certain drugs collect there, which again has an impact on their effectiveness. Then theres the female kidney, which only performs to 80 percent of the capacity of the male kidney. This fact naturally has an impact on how metabolites are excreted from the body. And this is all without taking womens menstrual cycle into consideration.
The situation with children is at least as difficult. Like women, they are barely taken into account in medical research. Researchers only develop very few drugs specifically for them. But when it comes to drugs and therapies, children are not merely small adults for whom one can simply reduce the dose according to their weight. And paediatric medicine covers a vast range of ages: you cant compare new-born babies with school-age children, any more than you can compare young people in puberty with toddlers.
Various initiatives have been set up in a few developed countries that hope to change this untenable state of affairs and is investigating methods to help find non-hazardous drugs for pregnant women. There was little awareness of this topic until the 1960s, when the Thalidomide scandal happened. Children were born with deformed arms and legs after their mothers took the sedative Thalidomide to help mitigate morning sickness during pregnancy. Since that scandal, everything has been done to try and keep pregnant women from taking any drugs at all. Regrettably, that isnt realistic -there are diseases that you simply have to treat during pregnancy because they would be more dangerous for the unborn child than any drugs used to treat them.
Even if pregnant women dont take part in clinical trials, there are still two ways of getting usable data about them. Time and again there are cases of women taking drugs without being aware that they are pregnant. Then there are women who for medical reasons are compelled to take certain substances. In this manner, a database could be constructed, listing drugs that are harmless to pregnant women. The rule of thumb is: wherever possible, no new drugs should be given to a pregnant woman, because we just dont know enough about them.
In the USA and northern Europe, good progress is being made on just such databases. In Bangladesh, however, no effort is being invested, and the situation is made more difficult by the far more modest amounts of data available. Its not just about determining whether a drug is harmless to pregnant women. The permissible dose can also often vary during pregnancy. Women gain weight and retain more water in their bodies, which mostly means that doctors have to increase their dosage. And for this, too, doctors ought to have the relevant data to help them make the right decision in individual cases.
In Bangladesh, no efforts have been made to improve the situation with children. There is no organization is campaigning for the development of more drugs and therapies specifically for children. The dilemma is similar to that with pregnant women. No one wants to test drugs on healthy children, but at the same time there are many situations in which children need drugs. That is why a professional research structure is needed in paediatrics, along with the corresponding finances to enable researchers to collect and analyse data. Society has to increase its awareness of just how important medical studies are in general, and especially for children. Especially in the case of cancer, there is a great need for new drugs that can specifically help children, because they usually fall sick from cancers that are different from those that affect adults.
Thanks to the initiative of various researchers of the developed countries, it has been proven in recent years that there is a clear gender difference in cases of heart disease. Women die of heart attacks twice as often as men and if they withstand an actual heart attack, they also have less chances of surviving afterwards and older women are barely represented even though it has meanwhile become clear that male and female hearts develop differently in old age. It is known far too little about why women die more often than men after a heart attack. The problems begin already at the lowest level. Tests on lab animals are carried out in advance of clinical studies on humans, but almost all the lab animals used are male. The assumption is that the results will also be valid for female animals. Thereis now running research projects to find out why womens hearts age differently. In the near future, women with heart disease should be able to get targeted medical help just the same as pregnant women and children.
Doing good anddoing no harm date back to the Hippocratic Oath as medical principles. Collapsing them both into beneficenceunderscores the practical consideration that biomedical decisions generally aim to optimize net benefit over harm, rather than to maximize only benefits or minimize only harms or risks. However, these principles are distinct, not mere opposites. Not doing harm has a certain priority (first, do no harm), because not benefitting someone seems a less serious offense than doing that person harm. That priority partly reflects the human tendency more readily to forgive overlooked benefits (errors of omission) than deliberate actions resulting in harm (errors of commission).
The writer is Former Head, Department of Medical Sociology,
Institute of Epidemiology, Disease Control Research (IEDCR)
Dhaka, Bangladesh
E-mail: med_sociology_iedcr@yahoo.com
