Belinda Beresford
Political agendas appear to outweigh scientific evidence in South African government decision-making on the use of HIV drugs in pregnancy, according to a report by a leading international think tank.
The report, produced in September under the aegis of the worldwide Cochrane Collaboration, which is locally associated with the Medical Research Council, lays bare the role that politics rather than pure science plays in policymaking.
The authors say: “In the case of anti-retrovirals in pregnancy, it seems that scientific evidence is not yet a powerful force in government decision-making in South Africa. It appears to be eclipsed by political agendas and entrenched prior views that give undue weight to unsubstantiated opinion.
“Policymakers may have to ignore those who provide evidence or undermine their public standing in order to justifiy their action or inaction. Those who produce evidence are prevented from engaging further with policymakers once it is clear that their conclusions will not bolster the previously planned policy.”
The authors of the report include one of the most senior members of the Medical Research Council, Merrick Zwarenstein; Patrice Matchaba, director of pharmaceutical company Novartis; and Jimmy Volmink, director of research at the Global Health Council in Washington.
The report forms part of a six case study paper looking at the interaction between policymakers and researchers worldwide. The South African section is based on the Cochrane Centre’s experience with a study requested by the national Department of Health into the costs and benefits of using anti-retroviral drugs to prevent mother-to-child transmission of HIV.
The Minister of Health, Manto Tshabalala-Msimang, requested a risk benefit analysis from the Cochrane Centre in November 1999. The report was faxed to the minister a month later, along with a request for a meeting to discuss the findings. There was no response. However, in February 2000 the health department requested further information on nevirapine and at the end of that month the minister sent a letter of thanks to the researchers.
Despite requests from the researchers, there was no further input from national level policymakers. And after reading the initial draft report, the only provincial level policymaker involved requested that his name be removed without giving any reasons, and failed to attend meetings citing work pressure.
“We speculate that policymakers in South Africa do not feel at liberty to express their personal opinions on politically sensitive issues, fearing that doing so might be construed as criticism of their superiors,” say the authors.
The Cochrane researchers say that under pressure from stakeholders on the issue of anti-retroviral drugs for pregnant women the government appears to be responding “by seeking allies in the scientific community who will help bolster its chosen position
“First the government turned to the MCC [Medicines Control Council] its drug regulatory authority with a request for evidence on zidovudine [AZT]. The MCC report, submitted in October 1999, favoured the use of zidovudine but was rejected by the minister of health on the grounds that the review process had not been sufficiently rigorous. Next the assistance of the South African Cochrane Centre was sought.”
The researchers admit that they should have given more weight to the political side of decision-making.
“A policy decision is often determined by the outcome of a political struggle, with allies marshalled, favours called in, and compromises made. Scientific evidence has little impact; although evidence of clinical ineffectiveness of a medical treatment may be used to argue against its implementation, the most influential of all factors might well be financial cost to the taxpayer, rather than therapeutic efficacy.
“Our experience suggests that it is important to tailor the amount of effort expended on evaluating scientific evidence according to how such evidence is likely to be used. If it seems that the initial evidence assessment is producing unwelcome results, little point is to be served in delving deeper.”
The report concludes: “South Africa has a new government that, having democratically won power and accountability after a long and difficult struggle, finds the cup of freedom poisoned. Faced with the prospect of massive population loss, suffering on a scale greater than any previous holocaust, famine or way, is denial not an understandable response?”