Thoughts on Research: All Doctors Are Religious

Anyone can be a researcher!   If you would like to join the self-indulgent world of research, start by learning how to write a scientific paper.  Care of Matt Schultz.

I recently attended the Annual Workshop of Advanced Clinical Care in Durban.  I realized – again – how religious physicians can be.  The conference opened with the typical call to arms that normally surrounds the AIDS “crisis.”  The charge was aimed at the audience of clinical providers present.  The front line physicians were told that all of the tools needed to curb the spread of HIV were available to them, and they must only wield them effectively to win the battle.  Susan Sontag would be horrified.

It is, in fact, far easier to eradicate HIV than I ever thought.  South African doctors must only work harder, then the disease will go away.  No, South African doctors only need to improve their clinical abilities when dealing with HIV-positive patients, then the disease will go away.

My sarcasm stems from a simple observation: the average South African doctor is extremely well trained, especially with respect to HIV.  From my outside perspective, South African general practitioners routinely perform the tasks usually reserved, in the US, for infectious disease specialists.  Is it fair, then, to say to this group of physicians, “You must work harder; you must get smarter”?

But that is exactly what was said.  And, the major problem is that there are essentially only two paradigms with which to deal with HIV: Treatment (but not cure) and prevention.  The former hinges on provision of HIV medications; and the latter is almost synonymous with modifying people’s behavior.

The news of the day was of the latter category: tenofovir gel.  It is an antiretroviral drug that has been formulated into a gel and can be applied in a woman’s vagina before intercourse.  A recent paper claimed a 40% decrease in HIV infection when this gel was used.  There was much anticipation to hear the head investigator speak and much excitement about her findings.  The major benefit is that it empowers women to control their own sexual health, without having to negotiate with their partner about condom use.  It makes slightly less hazardous the dangerous sexual situations into which some women are routinely forced.

I found myself thinking rather negatively throughout the entire conference.  There is, to me, nothing new here.  What we now have is another preventative strategy that works marginally well with intensive education and follow-up.  Even under the idealized conditions of the study, it was difficult to get women to use their product.

The most interesting talks at the conference, however, were by Steven Deeks from UCSF.  He concisely summed an enormous amount of information and then launched into something completely different.  What of the underlying pathogenesis of HIV?  Is there some unexploited fault in the virus’ almost perfect reproductive ability?  And, more broadly, how does our new knowledge of the immune system affect our understanding of other diseases?

In my opinion, that direction is where HIV research needs to go.  What is truly unknown?  Why publish a new edition of the tried-and-failing textbook we have written for the last 30 years?  The epidemic in South Africa appears to have leveled only because the same number are being infected as are dying.  It isn’t working.

And yet, the group of us in HIV research religiously hold to the idea that if we work harder or execute better, we will ultimately win the day.

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5 Comments

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5 responses to “Thoughts on Research: All Doctors Are Religious

  1. Hmn, I get what you’re saying, but perhaps I wouldn’t have interpreted the conference or doctors’ approach to managing patients with HIV/AIDS to mean doctors are religious in that they operate on faith. That implies that what they are doing isn’t based on hard science, when it is. I’d argue that our inability to reduce rates of HIV/AIDS significantly given our vast amount of knowledge on prevention & treatment is because health systems in these countries aren’t functioning properly-there’s a huge gap between what we know works and what we do. This isn’t just applicable to the doctors, but to NGO, philanthropic orgs & govt organizations as well, Even if these were functioning properly (aka no corruption), there’s all kinds of infrastructural problems to deal with as well (roads, education, water/sanitation). These same issues exist in every realm of medicine-including OB/GYN (see my blog about Malawi). Closing the gap is harder than we think, and people need to get off their podiums and decked-out offices and start working in the trenches and make sure doctors don’t have to do all the grunt work.

    • Perhaps I should have explained my use of the word religious. It seems to me that certain researchers cling to a certain dogma regarding how to approach HIV. I agree with you that all of these interventions have evidence behind them; but, they are not working the way we need them to work. None of them have solved the problem, or even stemmed the spread of HIV. South Africa’s HIV epidemic has levelled off very close to the natural curve of an epidemic. To me, it paints a bleak picture of our interventions.
      I also agree with your comment on infrastructure and its effect on HIV. I almost inserted a paragraph regarding the effects of wealth disparity and economics on the spread of HIV. Health, in general, correlates very well with a country’s disparity between rich and poor. It is not merely a medical issue, like you said. There are important social and systemic reasons for its spread, even in a relatively developed place, like South Africa.
      “Closing the gap is harder than we think, and people need to get off their podiums and decked-out offices and start working in the trenches and make sure doctors don’t have to do all the grunt work.” I could not agree more.

  2. As you well know, I’m lower than a neophyte when it comes to medical issues. That in mind, what do you think drives this false dichotomy between treatment and prevention? Is the research to find a cure simply too expensive? More cynically, would a cure deprive a thriving industry of societal relevance, economic gain and political capital?

    • Matt, it is timely that you mention a “treatment/prevention” dichotomy. One of the more popular recent paradigms for dealing with HIV is called “treatment as prevention.” In fact, treating HIV positive patients is so effective at preventing new infections that some have advocated pouring the majority of our resources into implementation rather than research. So, the dichotomy is really between new research and implementing the treatment approaches we already have. Though, Anthony Fauci, who directs the NIAID, notes that it will take a mere $7-8 billion to do both effectively. His answer is simply to raise the money and do it.

  3. Pingback: Playing with Babies and Calling it Research | The Blog of Topher

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