A couple of things

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I posted these two things on Google+ the other day, but not everyone can see it and I don’t think there are many users yet.  Just some musings on a couple of papers I’ve been reading.

1. On the appeal of “miracle cures” and what lessons public health might draw

It’s natural to react with mockery or despair at people like President Jammeh of Gambia, who claims he can cure AIDS. But it’s also important to think about why what he does is appealing to so many people in Gambia. This article by Rebecca Cassidy in AIDS Care discusses Jammeh’s “cure” in the context of the Gambian national response to HIV:

Cassidy, R. (2011). “Global expectations and local practices: HIV support groups in the Gambia.” AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 22(1 supp 2): 1598 – 1605. (Paywalled I’m afraid).

It hints at the possibility that some activists, previously aligned with donor-funded national antiretroviral treatment programmes, became disenchanted for various reasons, and sees their support for Jammeh as effectively a change of allegiance. Although I’ve never seen a Jammeh-type scenario, I have seen HIV activists become disenfranchised and change their allegiances in this way, in other countries.

Cassidy’s analysis is interesting because it goes beyond simply concluding that the people following Jammeh’s treatment have been duped. They have been duped as far as the effectiveness of his cure is concerned, but as the article argues, their decision to follow Jammeh is not necessarily about health or getting the best treatment… it may be to do with other benefits and advantages, and it certainly has something to do with what they weren’t getting from ARV programmes. It should be seen not just a health-seeking act, but also as a political one. As such the article tells us something about how best to tackle fake cure situations, but more importantly it tells us quite a lot about the behaviour of foreign aid programmes, and the problems they can help generate.

 

2. On evidence based policy and randomised controlled trials

There is a lot of talk these days about the contributions Randomised Controlled Trials (RCTs) should make to policy. Often there is an assumption that getting policy based on evidence is a linear process: do the science (a few times), write it up, develop policy, and GO. This is a somewhat rose-tinted view of the policy process; nonetheless I do agree that getting the science right is a good place to start.

I’m reading an interesting paper on scaling up health services:
Yamey, G. (2011). “Scaling Up Global Health Interventions: A Proposed Framework for Success.” PLoS Med 8(6): e1001049. (Open access).
One of the people the author interviews says the following about scaling up neonatal health programmes:

‘‘In neonatal health, if we don’t have pediatric associations on board, forget it! For oral rehydration solution, after it was unequivocally demonstrated that it saved lives, the WHO and UNICEF were still doing local trials, randomized controlled trials. These didn’t have scientific value but it led to buy-in locally.’’

I think this is interesting because it suggests that studies are useful not just because they help show which interventions are effective and how effective they are, but also because they can help generate ownership. 
On the other hand I wonder how this sits with ethical principles since, if an intervention has already been proved beyond doubt to be effective, it is pretty difficult to carry on doing RCTs during which the effective intervention is withheld from the control group. Perhaps in this situation the best option – for getting buy-in, and showing something can work in a given context – is not an RCT, but something more like an operations research approach. And one that involves not just local associations, but community members themselves (I’m a bit unsure of the assumption, in the quote above, that the only people we need buy-in from are paediatricians).

 

— ** PS apologies for the fact that the font keeps changing in this post. I can’t figure out how to deal with this, it’s a common problem on this platform.

Thought experiment

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If I offered you a vaccine against a serious infectious disease, and told you it would reduce your chances of being infected by 60%, would you take it?

If I told you there was an alternative that would reduce your chances of being infected by 95%, would you choose the vaccine or the alternative?

The disease is AIDS, caused by the HIV virus. The vaccine is not really a vaccine. It is male circumcision. So I admit my thought experiment may seem a little bit irrelevant to readers without a penis.  In fact, whether your penised sexual partner is circumcised or not, if they are HIV positive it makes no difference to how likely you are to get infected by them.  Circumcision is not protective for either partner during anal sex.

The alternative described above is condom use. You’ve got to use them properly. They’ll protect you whatever your gender and whatever type of intercourse you are having, though you might want to consider using lubricant as well.

There are other alternatives too. You could just not have penetrative sex at all, or you could stick to sex with one non-infected partner (assuming it is someone you can talk openly with about their infection status and other partners). Circumcision won’t make any difference to you if you take these other alternatives.

There’s more. If you are having sex with someone infected who is on antiretroviral treatment, that will go a long way to protecting you.  You can even take ARVs to protect yourself, but like circumcision it will cut down your risk by something like 60%.

Now put yourself in a policy maker’s shoes. You don’t feel you are making inroads on HIV prevention.  People aren’t using condoms or abstaining enough – you’re more or less giving up on the idea that risky sex will ever reduce enough to make a difference. You aren’t getting people on to treatment quickly enough, and the treatment bills are skyrocketing. You figure that if you circumcise a lot of men, you’ll win a major reduction in overall susceptibility to HIV in the population, irrespective of what happens to condom use and treatment.  How to convince men to get circumcised though? What’s in it for them?

What’s worrying me is that it often seems like policy makers are framing male circumcision as something an individual man can opt for to reduce their risk of HIV.  Here is Michel Kazatchkine, head of the Global Fund to Fight AIDS, Tuberculosis and Malaria, talking about the role of treatment in HIV prevention:

This does not mean that we should tell everyone living with HIV or at risk of being infected to go on antiretroviral treatment and to drop established approaches such as male circumcision, using condoms and encouraging people to avoid risky sexual behaviour.”

This may be just a case of clumsy wording.  However, I recently read a national strategy on male circumcision from sub-saharan Africa, which stated that men undergoing the procedure should be told to use condoms until the wound heals.  It also said men should be advised to use condoms during anal sex “since circumcision does not protect during anal sex”.  As if those are the only circumstances under which condom use is still necessary for circumcised men.

And in this promotional video, the young men getting circumcised say they are becoming “real men”. Condom use is mentioned, but barely. Here’s another.

Circumcision is a big deal.  Male circumcision has certainly spared many countries from serious HIV epidemics.  It is relatively cheap and it is permanent. Policy makers want incremental results at population level, and can live with an approach that reduces susceptibility in a population even if it is not fully protective.  If men are consenting to the procedure then isn’t it fair enough? 

Can men be convinced to get circumcised and to use condoms? Maybe, and there are studies that have shown that, men who get circumcised don’t necessarily “risk compensate” by having more unprotected sex.  But if voluntary circumcision starts being sold to men as an alternative to condom use, that won’t do.  It won’t do because it’s not fully protective of those men. It won’t do because it won’t help people who have anal sex, or women whether they have anal sex or not. It won’t do because sex workers already find it hard enough to convince men to use condoms. It won’t do because millions of people still need treatment, and getting them on treatment in itself could have a huge impact on HIV transmission.  It won’t do because HIV has brought into relief myriad other social problems and human rights violations, and the people that will continue to be at risk if we give up on other means of preventing HIV, are also the most vulnerable.  This is demonstrated by the fact that in countries where most men are circumcised, such as in West Africa, population rates of HIV may be lower than 5% but the percentage of sex workers and men who have sex with men who are infected is often in the ten, twenty, and even thirty percent range.  

This is not a manifesto against male circumcision. As I said above, male circumcision has certainly spared many countries from serious HIV epidemics. But for it to work, it needs to be done in context with other interventions. A lot of policy documents acknowledge this, but I’m not sure we’ve figured out how to do it in practice yet.

 

Stakeholders

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I get asked to do stuff because I have some experience developing and managing HIV programmes. It’s a broad field, and while I have a basic understanding of most areas, I focus on a handful of technical themes that I know best. The idea is that a client – an NGO, a UN agency or a government – has some money to develop or evaluate something, and I get asked to help, and if I think I can help I say yes.

It is very rare, however, for me to pitch up and do the job as planned. I’m ok with that, as long as the revised job doesn’t stray out of my comfort zone. But that is not usually the problem. The problem, often, is that I find myself in a morass of different organisations, which ostensibly share the same overall aims (reducing new HIV infections! reducing deaths from HIV!), but all of which have their own unique way of going about it. Some emphasise communities, others emphasise clinical services; others still emphasise gender human rights, cost-effectiveness. Different organisations doing similar things but with different approaches, often slightly reluctant to share information, all wanting to be the game-changers, the innovators, the ones who will hit on the magic bullet. I’m sure I get dragged in to the same dynamic, and lots of energy gets expended on managing the wants and needs of everyone involved, rather than on the actual work.

At the point in time, about ten years ago, when funding for AIDS really started to take off, I remember watching NGOs and agencies recruiting AIDS advisors and officers, and thinking that it was like a form of nuclear proliferation. Everyone wanted one… and if they had an officer, soon enough they needed funding, programmes, a department… and more advisors to go to those policy meetings they were missing out on, to help set the agenda, to be a player. If they were lucky they might even set up a regional or sub-regional programme, more centres for attracting funding and from which to provide advice. And the more officers, programmes, and departments there are, the smaller the amounts of money are that each has, so they’ve got to work “strategically”. Everyone wants to be the leader of the pack, everyone wants to make a big difference with a small amount of resources.

It’s been about 13 years since I worked in any other sector so I have no idea if this is unique to aid work. Of course, I understand that a lot of work is about dealing with other people. I also understand that coordination and consensus can be overrated, and that plurality is an important way of testing new ideas. But something that almost certainly sets aid apart is that a lot of this jostling originates from outside organisations and individuals – not the people who aid projects are actually for.

Knowhow, new ideas, are all well and good. But it often looks more like organisations trying to preserve their influence; and rooms full of well-paid foreigners (yes, I’m fairly well paid, and I’m foreign – most of the time) spending more time managing each other than coming up with anything particularly new. It’s all very Lords of Poverty.

I think aid, whether in the form of money and advice, can be a great force for good. But I also think we need to get over ourselves a bit. All this synergy and strategy and positioning and beauty pageant stuff means there’s much less energy and fewer resources to really get down to the business of getting stuff done.