Aids Policy – Evidence, Ideology and the Making of an African Success Story
The growing notion that for any policy -including social policy – to be successful it must be evidence based or informed, has been shattered by Uganda’s successful story of a largely well controlled and managed HIV and AIDS epidemic. John Kinsman, in this groundbreaking book, which boldly departs from the usual evidence/science-is-supreme flow, argues that Uganda’s spectacular ABC (abstinence, behaviour change and condoms) strategy originated from no more than a “hunch”. Intrigued by what could actually have guided AIDS control in Uganda, the author investigated a flagship research which was set up in the early days of the epidemic to guide policy.
The research – Masaka Intervention Trials – which sought to promote delay in sexual debut among youngsters, zero-grazing (limiting the number of sexual partners) and treatment of STDs, conducted from 1994 – 1998 found that HIV incidence was identical in both intervention and control populations. Simply and bluntly put, the much coveted trial interventions had remarkably failed. And yet, as argued by many – scientists, politicians and ordinary people alike – since there was a general trend of improvement in the HIV and AIDS situation over time, Uganda must have been doing something right, and the “right thing” was precisely these interventions. Uganda’s HIV prevalence reduced from as high as 39% in late 1980s in some places to just 6% in 2004 nationwide.
Clearly these interventions must have played a key role, but research had shown that they had not. Part of the problem was “too much epidemiology and too little social science” in the research, as pointed out by Maxine Ankrah, a sociologist. Paraphrased, her observation was what Albert Einstein had observed earlier about scientific research in general: “not everything that can be counted counts, but not everything that counts can be counted”. Kinsman argues that the AIDS policy in Uganda was heavily influenced by dominant international and national ideological contexts of the day, with pragmatism ultimately defining policy decisions. Evidence, including negative evidence, was simply interpreted to support prior policy positions.
Kinsman’s tacit conclusion is that politics and pragmatism can assume primacy over evidence and can determine successful policy. And that evidence-based policy making, especially where evidence is viewed as if it is from Randomised Controlled Trials, whose evidence is considered by some to be a gold-standard definition of any evidence, can be of limited use in a complex, socially and sexually dynamic epidemic such as HIV and AIDS.
But pragmatism and politics are not the only determinants of policy. As was the case in Uganda, two other key factors, perhaps typical of Africa (as Kinsman implies) have been critical in shaping policy. These are: big men (powerful western personalities backed by powerful institutions and aid money, and powerful national/ local politicians) and external aid money, with strings attached to certain policies.
Thus Kinsman’s title “…the making of an African success story…” is very telling. This sub-title is not about the failure of an elaborate and “rigorous” research to guide policy being typically African, no. That can happen in western and other developed countries too.
What Kinsman calls “African” refers to the role of “Big men”, a description, which western authors and critics derogatively use to describe Africa’s political leaders, but which Kinsman uses to include powerful characters from the west, who participated as policy actors in Africa. These big men from the west used aid money to create, shape and reshape the Anti-Retroviral Therapy (ART), condom and abstinence policies in Uganda with no reference to evidence at all.
The lesson the book teaches us all is that for a socially and sexually determined epidemic such as HV/AIDS, the linkages in collaboration, cooperation and investment of resources must be multilevel: at global, institutional, patient-doctor and individual patient levels. The MIT study in Uganda, like most donor- driven studies in Africa, was dominated by external actors who relegated local experts and subjects to subordinate roles.
The resultant resentment and resistance, albeit largely masked, to the well paid and fed foreign researchers were only predicable. Donor-funded research in Africa has become an industry far removed from the realities of daily suffering of the local people. Thus, it is common to find a world class, ultra-modern donor-funded research unit side by side with appalling and dilapidated health care infrastructure. The perennial excuse that the lack of technical capacity is responsible for the failure of African institutions and governments to absorb and translate research into policy could be overcome if a requisite proportion of donor research funding is invested to uplift this national “technical capacity”.
What cannot be missed from the book is the interesting but perfunctory ideological divide, where people (scientists, politicians and others) on either side of the divide argued furiously and endlessly about the relative roles of abstinence and faithfulness versus condoms in reducing Uganda’s HIV prevalence. The debate was inconclusive. The debate was prematurely and conveniently brought to a close through a widely distributed letter published in the Lancet in 2004, signed by over 200 scientists and prominent politicians, including President Museveni of Uganda. The letter advised that the debate be stopped and that it was time to move on.
Hon Dr Sam Agatre Okuonzi MP, MD, PhD is a member of Uganda’s parliament.
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