Final Report Summary - ERADICATION (Eradication: the science and politics of a world without AIDS)
This project examined the science and politics of efforts to eliminate HIV transmission and effectively eradicate the epidemic. Our first achievement was the development an interdisciplinary approach at the intersection of medical anthropology, medical historiography, and social studies of science and technology. This approach allows four separate streams of data to be collected and integrated: (1) ethnographic observation of specific social settings (2) interviews with experts and other key informants (3) desk research to survey “grey literature” (4) informed and systematic literature reviews. These different streams of data were integrated in a framework that analyses biological phenomena, such as pathogens or illnesses, as “surface” phenomena or crystallizations of dynamic on-going social processes – complex adaptive systems rather than simple cause-effect mechanisms. Snapshots or stills can be captured in everyday life, in narratives and discourses, and in material archives such as documents or genomes.
We used this framework to analyse attempts to eradicate HIV epidemics by eliminating transmission. Our hypothesis was that such efforts would succeed if they addressed local bio-social configurations allowing transmission, and fail if they used a purely biological universalist framework.We focused specifically on pre-exposure prophylaxis for HIV, as this was a highly promising though controversial strategy at the time of the research. Initially rejected, then embraced, by various HIV constituencies around the world (such as gay men and sex workers) PrEP was found to be highly effective but only in some groups – a difference initially attributed to a combination of behavioural (i.e. compliance) and biological (i.e. co-morbid infections) differences. In fact, we found, the ability to demonstrate PrEP’s efficacy ultimately stemmed from the ability to successful mobilize broad support for, enrolment into, and compliance within PrEP trials.
This “anthropology of biomedicine” framework was used to illuminate the relationship between social processes, scientific evidence, and the development and implementation of interventions. We considered how illness – and therefore the material efficacy of interventions – may in fact differ biologically between different populations and locations. Efficacy is contingent on local biological and social factors and the “translatability” of specific biosocial configurations across groups and places.
A key finding was that the ability to demonstrate the effectiveness of using antiretroviral drugs to prevent HIV was finally cobbled together when pharmaco-virologic effects could be harnessed to the ability to mobilize high risk populations (i.e. gay men in large Western cities) into prevention trials due to a shift in sexual representations in desires, but that this efficacy was challenging to reproduce in other populations (e.g. heterosexual women in Africa) because of distinct biological and social factors. Other findings were:
• The crucial importance of “trust”. Trust in public health authorities leads to “buy-in” for trials that translates into timely and sufficient enrolment to test interventions; effective interventions generate trust.
• Parallels between epidemiology and finance in the use in of mathematical models to make future forecasts and use these as levers in the present; these parallels converge when pharmaceuticals manufacturers “tweak” epidemiological data to generate future markets for drugs, allowing them to assetize drug lines and leverage capital for mergers and acquisitions. Innovation results not from research and development of new drugs but “repurposing” drugs for ever-larger markets. We call this “biofinance”.
• “Therapeutic sovereignty”, initially understood as the selective exercise of therapeutic power through health systems and biomedicine to triage patients by prioritizing disease for treatment – in effect deciding who lives and who dies – also encompasses (as is now visible in the CoVID era) the ability of nation-states to assert sovereignty over supply chains vital for diagnostic and therapeutic capacity.
• The paradigm of eradication reflects a mechanistic cause-effect view of microbiology and human health, and is unlikely to succeed because human-microbe interactions are part of larger complex adaptive systems; simply eliminating one “cause” inadvertently allows other disease configurations to emerge, such as is the case with the current global spread of antimicrobial resistance (AMR). An alternative paradigm exists even with biomedicine, likely with roots in Galenic medicine, that in line with the thought of Canguilhem posits “living-with” disease, and which may ultimately be a more sustainable approach.
We used this framework to analyse attempts to eradicate HIV epidemics by eliminating transmission. Our hypothesis was that such efforts would succeed if they addressed local bio-social configurations allowing transmission, and fail if they used a purely biological universalist framework.We focused specifically on pre-exposure prophylaxis for HIV, as this was a highly promising though controversial strategy at the time of the research. Initially rejected, then embraced, by various HIV constituencies around the world (such as gay men and sex workers) PrEP was found to be highly effective but only in some groups – a difference initially attributed to a combination of behavioural (i.e. compliance) and biological (i.e. co-morbid infections) differences. In fact, we found, the ability to demonstrate PrEP’s efficacy ultimately stemmed from the ability to successful mobilize broad support for, enrolment into, and compliance within PrEP trials.
This “anthropology of biomedicine” framework was used to illuminate the relationship between social processes, scientific evidence, and the development and implementation of interventions. We considered how illness – and therefore the material efficacy of interventions – may in fact differ biologically between different populations and locations. Efficacy is contingent on local biological and social factors and the “translatability” of specific biosocial configurations across groups and places.
A key finding was that the ability to demonstrate the effectiveness of using antiretroviral drugs to prevent HIV was finally cobbled together when pharmaco-virologic effects could be harnessed to the ability to mobilize high risk populations (i.e. gay men in large Western cities) into prevention trials due to a shift in sexual representations in desires, but that this efficacy was challenging to reproduce in other populations (e.g. heterosexual women in Africa) because of distinct biological and social factors. Other findings were:
• The crucial importance of “trust”. Trust in public health authorities leads to “buy-in” for trials that translates into timely and sufficient enrolment to test interventions; effective interventions generate trust.
• Parallels between epidemiology and finance in the use in of mathematical models to make future forecasts and use these as levers in the present; these parallels converge when pharmaceuticals manufacturers “tweak” epidemiological data to generate future markets for drugs, allowing them to assetize drug lines and leverage capital for mergers and acquisitions. Innovation results not from research and development of new drugs but “repurposing” drugs for ever-larger markets. We call this “biofinance”.
• “Therapeutic sovereignty”, initially understood as the selective exercise of therapeutic power through health systems and biomedicine to triage patients by prioritizing disease for treatment – in effect deciding who lives and who dies – also encompasses (as is now visible in the CoVID era) the ability of nation-states to assert sovereignty over supply chains vital for diagnostic and therapeutic capacity.
• The paradigm of eradication reflects a mechanistic cause-effect view of microbiology and human health, and is unlikely to succeed because human-microbe interactions are part of larger complex adaptive systems; simply eliminating one “cause” inadvertently allows other disease configurations to emerge, such as is the case with the current global spread of antimicrobial resistance (AMR). An alternative paradigm exists even with biomedicine, likely with roots in Galenic medicine, that in line with the thought of Canguilhem posits “living-with” disease, and which may ultimately be a more sustainable approach.