June 2002 Public Health HIV/AIDS Journal Club

The fifth session of the 2002 Interdepartmental HIV/AIDS Journal Club series was held on 6 June in the Staff Diningroom, Nelson R Mandela School of Medicine, Durban, and featured two presentations from HEARD (Health Economics and HIV/AIDS Research Division). Research Director Professor Tim Quinlan's "From Impact Assessment to Management of HIV/AIDS: Socio-economic Methodological Considerations" reviewed the general framework of integrated research in which most HIV/AIDS scientists are attempting to work, while Research Fellow Ryann Manning's presentation, "HIV/AIDS and Democracy - What Do We Know?" offered a literature review linking the epidemic's effects on governance and the implications of these links for the medical community.

Quinlan's presentation offered a perspective on approaches to the philosophy of scientific study, with a focus on the impact assessment and the development of strategic plans. In most cases, these plans require collective action in order to try to contain the epidemic, and deliberations at the planning stage are often characterised by talk of collaboration and partnerships; however, devising the "whys" and "hows" of working together necessitates the rethinking of the design and organisation of research.

Such rethinking would necessitate theoretically based paradigm shifts as to the values and nature of the various discrete disciplines so that a broader, more unified approach can emerge. For example, in considering care and support for orphans, management of integrated research would require specifying and defining key areas, how and where they could be combined, as well as cross-referencing their relevant limitations. The principles of participatory research would also be essential, drawing in the subject community to act as a pool of consultants who would help to direct the research.

Investigators are thus led into a new creative process and a deeper vision of potential interventions. However, the process is not without its difficulties: there is a great deal of scope for conflict between scientists who do not understand each other's methods, and although tried and true methods exist for impact assessments (which have traditionally been conducted merely to uncover the knowledge), integrated research (directed towards action plans) is still very experimental. For example, surveys done at ante-natal clinics are baseline research studies which identify problems but do not yield solutions. In a similar vein, there are numerous rigorous surveys of households showing that HIV prevalence is as high as 26% in certain areas - but no indication as to why this is so. The question of whether AIDS causes poverty or poverty causes AIDS is widely debated, but how do we accurately measure this "cause and effect" issue so that we can design a response?

During the ensuing discussion, Quinlan reiterated that scientists from different disciplines working in the field of HIV/AIDS need to grapple with their individual definitions of "values" and "values-based approaches", so that ethics and morals become essential elements in management decisionmaking and the implementation of research protocols. Responding to this, one delegate felt that HIV/AIDS, in its very complexity, requires the involvement of many sectors and disciplines, and that this actually assists in making the research more effective and more intellectually sound and useful. It was also noted that progress in integrated research is much more evident in the South than in the North, one example of which (emanating from Environmental Science studies) lay in Zimbabwean meteorologists talking to farmers about climatic change.

Ryann Manning joined HEARD as a research intern from Princeton University in August 2001. Her research interests focus on the social and political dimensions of HIV/AIDS in South Africa, and at HEARD she has been examining the links between HIV/AIDS, democracy and governance, with her current project surveying the impact of HIV/AIDS on NGOs and civil society, and future plans to study its effect on local-level democracy.

Manning's review distilled the findings into three main factors linking the HIV/AIDS epidemic and democracy, those being (1) that democracy and governance may help combat HIV/AIDS, (2) that conflict and insecurity may drive the epidemic or worsen its impact, and (3) that HIV/AIDS may undermine or jeopardise democracy, governance and security. See downloadable PowerPoint document for key factors of these findings

The implications of these factors for the medical community include: the importance of developing treatments so as to extend life and give hope to citizens; the need for care and support for potentially excluded groups (e.g. soldiers, armed combatants, prisoners and streetchildren); and the need for healthcare practitioners to support and participate in democracy and public life, and to defend human rights and democratic principles.

Ensuing discussion focused on the issue of social cohesion, whether it can be measured and whether it is a positive factor in all circumstances - some countries might have very tight social cohesion but such control ends up as nothing more than legislated autocracy. Some felt that social cohesion was not always a question of democracy being effective or being "lived", but rather a multifactoral scenario involving family values and social processes working in tandem.