Is Your Program Ready for the Ethical Challenge? Lee B. Reichman, MD, MPH NJMS Global Tuberculosis Institute

Health Care Worker Rights Do healthcare workers who administer DOT have the right to refuse traveling to what they consider to be “unsafe” places for their work? Is this the practice where you work, and, if not, what can be done to remedy the situation?

Staff Training Should staff members who work with TB patients be trained on the latest medical standards and practices? Is this currently done in your setting, and, if so, is it selective (i.e., only certain staff get the opportunity for training) If not, what are the barriers and how can they be surpassed? Do certain types of staff get to attend trainings more than others?

Patient Isolation and Confinement If a patient needs to be isolated or confined, is there always an appropriate facility for such action (e.g., do they put the patient in jail or a hospital ward for criminal patients because they have no better place to put him or her?) If not, what may need to be done to make this happen?

Research Do the patients who are part of research protocols in your facility know or have access to the results of the studies conducted? If not, is there a condition in your human subjects review process that stipulates this? Do you think this is consistently done elsewhere?

HIV Testing HIV testing is recommended in all TB patients. Are all patients being counseled and offered testing? Does whether a patient is tested depend on the type of patient or the provider?

Contact Investigation - 1 Can most programs test contacts and initiate source case investigations under only certain circumstances? If so, why and how do staff choose which investigations to initiate and which contacts to pursue for testing and evaluation?

Contact Investigation - 2 Most programs do not make it mandatory for identified contacts to be followed up for medical evaluation. Should this be legally mandated? What would it take for this to happen and what resources need to be mobilized to do so?

Lessons Learned What can the NAR learn from other regions about ethics and TB control?

External Support What makes American/Canadian organizations (e.g., CDC, USAID, CIDA) qualified to lend technical support to other countries when TB is at an all-time low and their own expertise possibly waning?