Strategic Science Assignment
John Ruffin, former head of the National Institute of Minority Health and Health Disparities wrote:
"The 19th-century scientist and pathologist Rudolph Virchow gave voice to many of our present-day concerns about disparities and went a long way toward defining the task before us. A socially minded man, he believed that science should speak the language of the common people and that medicine should serve the public's health. He wrote, 'If medicine is to fulfill her greatest task, then she must enter the political and social life…'"
Do you agree and why?
Yes, I strongly agree. In sub Saharan Africa, the leading causes of under 5 mortality remain diarrhoea, malaria and pneumonia despite the fact that there are proven effective interventions that can reduce this mortality by over 70%. Yet, a google search of this topic- you will realize there is no paucity of new ideas of how to prevent them and cure them and focusing on vaccination. The gap between the proven intervention and their uptake and utilization at the household level is because the science does not make sense to politicians (not policy makers) and the common man or mwananchi as we would call them back home.
Specific to my own work in adolescent sexual reproductive health and psychosocial functioning – there are to a large extent scientific evidence about the need to have tailor made programs for adolescents but this group has either been handled as “big children” or “small adults” and with the expectation that benefits will trickle down from child and adult health programs. As teenage pregnancies and HIV increase in this population, in my country and indeed in most African countries, there is a pushback against sex education in classrooms and against provision of contraception to adolescents who are not emancipated. Although it is well established that nearly 10% of adolescents will have sex before the age of 15 and that contraceptives are safe in this population – that translation of proven scientific evidence to implementation and acceptance at community level has yet to happen. In fact, there have been boycotts to feeding programs in primary schools and vaccination programs as people think these are laced with contraceptives and/or sterilization agents.
From the readings, it is clear that determinants of health and disparities are largely behavioural, social and economic. Ultimately, however, these determinants are influenced by the larger macro-environment in which people live and the policies that govern their society. And with policies come the politics and leadership and governance angles. Scientists must strive for “cross-disciplinary education as well as opportunities for shared problem solving.”
Is it permissible for scientists to become advocates in the areas of their research?
Yes. It is permissible for scientists to become advocates in the areas of their research for the following reasons:-
- First, since scientists are also citizens of a country or a global community, it is improper to deny them the opportunity to advocate for things they think are important.
- Second, the scientists who are experts are the ones with the knowledge, understanding and access to objective studies relating to policy issues and as such to exclude them would be a disservice
- Third, I don't even think we should be separating the two issues. I don't believe that advocacy for policy issues equals a failure of objectivity. In fact, to not advocate, would imply to be neutral and to advocate for research in support of only ones research (Selfishness) is equal to poor science and poor advocacy. Ethically and morally, objective advocacy is an integral aspect of good scientific conduct
What steps can one take to balance advocacy with the objectivity that is considered the ideal in scientific inquiry?
I think that what is needed as stated in the texts is a high level of mutual respect and trust among the partners, and an appreciation of the complementary skills and resources each partner brought to the table. I believe that these partners need to be engaged right from the start – from the framing of the research question, the methods, analysis and dissemination. An example I like to draw from was the changing of the pneumonia treatment guidelines for children under 5 years in my country. It took us 5 years to change the guidelines. Although WHO had changed the guidelines, politicians, academicians, researchers and clinicians felt that there was no evidence among high mortality settings and particulary there were no African children who had been involved in the trial and as such refused to adopt oral amoxicillin for lower chest in drawing pneumonia. What the WHO did was to identify local experts (academicians, researchers and clinicians) as well as policy makers, lay people and politicians in Kenya to participate in a Child Health and Nutrition Research Initiative (CHNRI) methodology priority setting exercise. These experts generated and systematically ranked research questions for newborn and child health interventions to reduce child mortality in Kenya. During this politicians and the lay community requested for more context specific evidence regarding use of oral amoxicillin for treatment of pneumonia by community health workers. To address this evidence gap, I, working with WHO, UNICEF, the County governor and community health workers generated evidence for CCM for lower chest indrawing pneumonia using oral amoxicillin in rural western Kenya to increase access to pneumonia treatment over 2 years. We held monthly community dialogue meetings to discuss progress at a lower level and quarterly national meetings bringing together over 20 partners working in the field of child health. Of course the research expanded to beyond pneumonia but to also cover nutrition. When the study ended, we went through the GRADE process to finally change the guidelines. It took 5 years but I believe the working together with different partners brought us the “right kind of evidence” that the leadership wanted to see, gave direction on how it could be implemented and monitored and moreover, we were able to even change the formulation and dosage of the amoxicillin which was another bone of contention. Even to the last day - I learnt that getting consensus is not easy and we still had to have back room deals and off table negotiations to make it happen!