Adapting Treatment Strategies for Low-Resource Settings
Updated: Sep 7, 2019
When designing and studying the POCkeT colposcope, researchers considered how to balance financial constraints with ethical concerns over treatment efficacy. In cases of cervical cancer, early detection is critical. It affords the opportunity for less invasive treatments, a higher survival rate and, perhaps most importantly in resource-limited settings, can remove the need for follow-up appointments. Increased access to screening dramatically increases the likelihood of early detection. For a large percentage of cases, this opens the door for a see-and-treat approach, something critical due to the massive losses to follow-up currently experienced.
By proving an opportunity for patients in low resource settings to have better and more frequent screening, the POCkeT colposcope provides a critical service. Since the colposcope isn’t a form of treatment itself, the device falls outside the ethical concerns of treatment efficacy. However, researchers must still consider the forms of treatment that will follow use of the colposcope and the ethical ramifications of using a screening device that is not equivalent to standards in the developed world.
How does increasing access to screening and early detection change the constraints for successful treatments?
Early detection allows for a much more efficient treatment process. Treatment is simpler and less involved. This means lower use of consumables and shared equipment in a resource-limited facility. It also means less time required from trained professionals. Together, this results in massive financial savings for all involved entities. The healthcare facility is able to pass along these savings to its patients, something critical when a lower cost may well be determining factor in a patient being able to afford and in turn elect to undergo treatment. The healthcare facility is also able to allocate its finite resources to other patients who, with a less efficient system, may have never even been able to be seen.
The constrains for successful treatments in resource limited settings include, but are not limited to, access to treatment facilities, insufficiently trained health workers, lack of patient follow-up and patient financial barriers. Increasing access to screening can detect diseases at the early stage of progression. In general diseases are more likely to be treatable at the early stage than later. The required equipment and medicine used to treat early-stage disease can vary largely from late-stage disease. For example, cervical malignancy when detected early as low-grade dysplasia in situ can be treated with cryosurgery or loop electrosurgical excision procedure (LEEP). Cryosurgery with liquid nitrogen is commonly used as the standard of care in low-resource settings for this stage of progression. However, if the cancerous cells invade the blood vessels or lymph vessels, a radical hysterectomy along with pelvic lymph nodes removal would be necessary to prevent further disease progression.
During this later stage, accessibility to radiation facility can be constrains to the success of treatment. Hence, once the cancer cells start to metastasize and colonize other tissues, aggressive chemotherapy and radiation would be the treatment options. However due to the limited access to these facilities, treatment for late-stage cervical cancer can be limited in many low and middies-income countries. Increasing access to screening and early detection enables health workers to capture the early stage of disease, which can just require simple and low-cost treatment for the patients. This can greatly shift the treatment window and increase the chances of success.
What are the ethical implications of purposely designing a less effective treatment for resource limited settings?
The distribution of health care is extremely unequal around the world. Those in the developing world have little or no access to health care, while individuals in developed countries have access to new treatments, vaccines, medicines, safe water, etc. Most clinical research is done by individuals from developed countries and many of the communities that lack access to good health care are located in developed countries. This leaves those communities to be exploited because they are not being provided with standard of care in developed countries. However, researchers are confronted with the ethical dilemma of providing the most effective treatments and designing treatments that are in the realm of the existing health care system. Designing a less effective treatment for a resource limited setting can be seen as ethical because they typically do not have access to the world wide best methods. Creating a treatment that is more effective than a community’s previous options provides beneficence and social value. Thus, while purposely designing a less effective treatment for low resource settings may seen unethical, it is a necessary value creation until more effective treatments are feasible