I really like and admire Stephen Lewis — the guy has been an enduring, committed, and vocal advocate for global HIV/AIDS for a long time. And I suppose what distinguishes an advocate who really gets things done from academic types, is the degree to which the latter feels compelled to make claims based on evidence and to explain the limitations of arguments and conclusions. In other words, I admit that much of what has been accomplished on global AIDS would likely not have been the case if every policy decision were rooted in an arduous process of research and analysis rather than on a good measure of instinct and emotion.
But in reading Lewis’ remarks from the recent international conference on AIDS and STI’s, I found myself a bit frustrated. He seems to cherry pick ideas that looked promising and were not rapidly embraced until there was substantial scientific consensus. He writes,
I’m thrilled when I hear animated talk of male circumcision. But I know that we didn’t need to wait for the results of the three studies in Uganda, Kenya, and South Africa. Nothing would have been lost if we’d focused immediately on making circumcision safe and available for informed parents to choose for their male babies; it’s a minor procedure that has been performed for centuries. Instead, during nearly a decade as the evidence piled up that circumcision was a defense against AIDS-evidence provided by experts in the field-we waited and waited and waited, in that self-justifying paralysis of excruciating scientific precision. As we come to this thrilling moment of progress I cannot forget the numbers of lives that might have been saved had we acted sooner.
I’m thrilled with all the talk of “Treatment as Prevention” and how it has suddenly become the mantra of the international AIDS community. But back in 2006, I sat beside Dr. Julio Montaner, about to become President of the International AIDS Society, when he first expounded the proposition at a press briefing at the International AIDS Conference in Toronto. His evidence and argument were rooted in science and common sense in equal measure. But he had to endure scorn and derision, and we had to endure a five-year delay until Treatment as Prevention was definitively authenticated by the National Institutes of Health in Washington. Julio’s theory suddenly became the 96% solution five years later, and it doesn’t-I emphasize-it doesn’t apply only to discordant couples. As we come to this thrilling moment of progress, I cannot forget the numbers of lives that might have been prolonged if we hadn’t waited nearly five years to create the momentum that now propels us.
Ok, with 20/20 hindsight, ideas that seemed right, and turned out to be right, ought to have been embraced earlier. But what about something like microbicides that were the darling of the international AIDS community until the scientific community showed them to be ineffective? Imagine if those had been promoted on a wide scale without evidence? Or imagine if widespread circumcision had been promoted and the evidence showed it to be ineffective?
It’s certainly good rhetoric to blame the “international community” for going too slow on some issues, and when he complains about things like donors reneging on their commitments, he’s dead on. But when he begins to suggest that we should not impatiently wait for good scientific evidence before launching global health problems, he really loses me.
One thought on “Stephen Lewis needs to be a bit more cautious about how he treats scientific evidence”
It’s still way too soon to claim that male circumcision will have any effect on the HIV epidemic. The latest of several reviews damning the studies is in the (Australian) Journal of Law and Medicine this month.
The ENTIRE basis of the claim is 73 out of 5,400 circumcised men who didn’t get HIV in less than two years, who MIGHT have if they hadn’t been circumcised, while 64 circumcised men DID get it.
In their review G. Boyle and G. Hill unravel some of the many reasons that may not be cause and effect:
researcher expectation bias;
participant expectation bias;
inadequate double blinding;
selection and sampling bias;
attrition bias; and
Contacts were not traced so we don’t even know which if any of the men got HIV from women or even by sex.
Women are at several times greater risk than men, and circumcision does NOTHING to protect them. It may even INcrease the risk to women, according to a Ugandan study (Wawer, et al., Lancet 374:9685, 229-37) it was cut short for no good reason (nothing they could then do or not do would prevent any new infections) before that could be confirmed.
Non-sexual transmission is a large and unaddressed issue in Africa. Circumcision does nothing to protect men who have sex with men, a large and unacknowledged risk in Africa (expecially not in countries like Uganda, where to even admit to being gay is dangerous).
Stephen Lewis’ enthusiasm for male genital cutting seems to derive more from his own background than any facts. (He’s reported enthusiastically on the “male bonding” with African men that followed his announcement that he is circumcised.) And he leaps from VOLUNTARY ADULT circumcision, as recommended by the WHO, to circumcising non-consenting babies without a moment’s thought for the ethical issues that raises.