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.