When You Have a Hammer: The Multiple Utilities of Evidence Based Medicine in Public Health Practice Jennifer J.

Carroll

Background Since 2007, my research has focused on public health responses to two major epidemics in Ukraine: HIV and injection drug use. As a student who is training as both an anthropologist and an epidemiologist, I have been approaching the issue of HIV-prevention in Ukraine as an object of both social and scientific inquiry. As an anthropologist, I have studied identity and subjectivity among IV drug users (IDUs) in the harm reduction sphere and clinical engagements with biomedical models addiction. My dissertation research in anthropology explores the factors influencing IDUs entry into substitution therapy programs and the decision-making processes that lead people towards treatment-seeking behavior. As an epidemiologist, I am interested in somewhat more practical public health problems posed by HIV and drug use, especially the production of and engagement with epidemiological data. In Ukraine, public health interventions for these epidemics are offered not by the government but by a growing network of non-profits that are completely dependent on foreign, philanthropic sources for their financial livelihood and claims to legitimacy. With this international money, HIV-prevention organizations adopt biomedical public health models of Western European and North American design, such as needle exchanges, methadone therapy, and other harm reduction tactics, with high expectations that the efficacy of these interventions will maintain in this new environment. Despite international donors financial largess, coverage of HIV-testing services in Ukraine is inadequate, and sentinel surveillance mechanisms are practically non-existent. Ukraines Ministry of Health maintains registries of drug users and of HIV-infected persons, but under-reporting is a serious problem, and these registries produce prevalence estimates that fall below the more trusted UNAIDS estimates by as much as 90%1. In

The 2009 MOH estimate of population HIV-prevalence in Ukraine, based only on the number of registered cases, was 198 cases per 100,000 persons or 0.198% (Ministry of Health 2009). The estimate published by UNAIDS four years earlier in 2005 was 1.46%, with a confidence interval ranging from

short, public health services for IDUs, which purport to offer evidence-based harm reduction programs, are blossoming in the complete absence of reliable epidemiological knowledge about what the drug use or HIV epidemics even look like. Research Questions and Methodologies What I currently seek to better understand is (a) how bodies of knowledge about the HIV and drug use epidemics (and public health interventions designed to fight them) are being produced and (b) how that knowledge is engaged for decision-making, for social ends, and for other symbolic purposes. How do Ukrainian public health workers manage to run what are ostensibly evidence-based public health programs in the absence of reliable evidence? How are scientific and non-scientific data used by public health professionals to generate actionable knowledge? How should these processes of knowledgemaking and meaning-making be taken into account should we attempt to improve the acquisition of empirical data and the production of an epidemiological understanding of HIV and drug use in Ukraine? My research questions have emerged out of two phases of ethnographic work in Ukraine that took place during the spring of 2007 and the summer of 2010. I observed the work of local harm reduction clinics and conducted semi-structured interviews with doctors, program directors, and harm reduction activists in the cities of Lviv, Cherkassy, Kyiv, and Odessa. From these interviews, I was able to draw a number of conclusions. I discovered a power differential between social workers and addicts that shaped interpersonal relationships and limited the roles and social spaces that women could occupy in the program (Carroll 2011). I observed that biomedical models of addiction were rarely applied to female IDUs, whose drug use was often considered to be the result of personal or social problems, not an underlying disease (Carroll 2010). Over time, it also became clear to me that public health professionals were frequently reinterpreting medical categories and strategizing their engagements with medical knowledge and narratives in ways that affected their decisions on the job.

0.8% to 4.2% (UNAIDS 2007)a difference made even more significant my the fact that all sources, government and otherwise, have reported steadily increases in the rate of new infection every year, meaning that the UNAIDS estimates from 2005 should be considered an underestimate for prevalence in 2009.

Theoretical Frameworks The work of Bruno Latour is frequently used to problematize interactions between so-called universal or scientific knowledge and local knowledge. According to Latour, scientific knowledge is created through abstractions, by measurements that place distance between a concrete reality and scientific discourses about that reality (1999). Scientific knowledge, then, claims the ability to operate at a certain distance from world, to travel far without sacrificing its relevance and its applicability (Latour 1987). Clark and Murdoch argue that this characteristic allows scientific discourses to reshape localities into more convenient forms: Herein lies the success of science and the basis of its universal claims. They observe. It remakes the world in its own image (1997, 41). Despite this, I believe that two things allow for Ukrainian public health workers to resist and, in some ways, redefine scientific (or, one could say, universal in the hegemonic sense) global health paradigms: namely, the robustness of the general uncertainty about the HIV and drug use epidemics and a flexibility in scientific discourse that is unique to the Post-Soviet region. This interactions that Ive seen between Ukrainian public health workers and dominant scientific discourses do not mirror the predictions of Clark and Murdoch, in which scientific ideas carve through local knowledge like an iceberg, remaking the world in its image. Instead, it seems like something of the opposite is going on. Ukrainian public health workers are adapting scientific discourses to their own political purposes, and that they are the ones working towards a correspondence between local and scientific knowledge on their own. Preliminary Findings In todays Ukraine, there is a profound distrust, both among the public health workers that I interviewed and among the general population, of the bureaucratic state apparatus. I was frequently advised that I should not trust the television, newspapers, official statements, statistical surveys, or other government claims of any kind. Especially in the medical sphere, most of my informants were poignantly aware of how flexible and manipulable hospital records and regional statistics could be. Every epidemiological record, survey, or artifact was viewed, at the very least, as requiring some sort of qualification or interpretation in order to read clearly.

Among public health workers in Ukraine, this legacy of distrust allows for two things to happen. First, it helps to maintain a tenacious skepticism about scientific knowledge whenever and wherever it is produced. For instance, a staff member at the Alliance told me that it is impossible to know anything about drug overdoses in Ukraine, since most hospitals classify these deaths as either heart failure or as accidental poisoning. Another program coordinator openly questioned the validity of epidemiological research. She referenced one study, in particular, which observed equal numbers of men and women in the IDU population. She said, That just isnt the real picture. Female users are much more stigmatized, and if they even get drugs at all, its from their husbands [emphasis mine]. This coordinator insisted that her familiarity with the IDU population, gained through her daily work, allows her to draw her conclusions with certainty. Regardless of how or why scientific data is questioned, the end result is that knowledge gained through research is unable to trump the understanding that NGO workers gained on the job, the local knowledge that is produced through their own experiences on the job. Second, the maintenance of this uncertainty opens the doors for science and scientific discourse to be considered an end as well as a means. For example, one supervisor emphasized the scientific aspects of her work to me, saying, We have a team, which also does a lot of regular studies and surveys and so on. Like sentinel surveillance and quite scientific stuff, using respondent driven sampling and going deep into the population [emphasis mine]. Later on in our interview, she described these same surveillance efforts as problematic, owing to inconsistencies in study design and method from year to year. The existence of these difficulties, however, did not prevent her from reportingwith pridethat these surveys reach nearly 1500 respondents year after year. She claims that her organization is unique in that it builds its programs based on evidencefrom the field. This evidence might not be ideal, but having hard numbers to report, regardless of their statistical strength, is a desirable end in and of itself. Another program manager spoke with heartfelt pride about an HIV-sensitivity training for doctors that she had been a part of. She was able to claim that the training was affective, because her organization had sought out the same doctors several months after the training for a follow-up survey that was meant to measure the their changes in attitude over time. This program manager beamed at me and said, Our

results were 20%! At the time, I held my breath and kept waiting for her to let me in on the punch line (20% of what?), but the answer never came. The answer didnt matter to her. She was simply excited to have a value of any kind. Who knows if this is a good or bad result, she said, but it was so wonderful to have real numbers to report, and to receive the feed back from our colleagues. It seems that this ability to be conversant in scientific paradigms is desirable, because it affords more legitimacy to these actors both in Ukraine and in the eyes of their Western, public health-oriented benefactors. The desire to look and sound Westerna term which was frequently used interchangeably with the word advancedis pervasive in the public health programs I have observed. Im totally proWestern, one NGO staff member told me. This is the only good thing that can happen to usbecoming part of the international community, and not just part, but a full fledged member. Despite the distrust in scientific data, adopting scientific (or advanced or modern) discourses about public health is seen as an integral to becoming part of the international community. Directions for Future Research We can describe a decision as evidence-based, but the deliberation process after that evidence is presented and reviewed is still a fundamentally moral one, and our sense of morality shapes the rules of thumb and mental short cuts through which we reach our conclusions (Dolan 2007). All scientific discourse is embedded in the social structures and political schemas that surround it, but in Ukraine and, I would argue, in many other Post-Soviet spaces, the fact that science is often tool of politics is no secret. Katherine Verdery argues a critical exploration of new social realities (and here, medical realities) in the Post-Soviet sphere requires a theoretically grounded understanding of the system that has crumbled and an ethnographic sensitivity to the particulars of what is emerging form its ruins (1996, 10). We must take into account not only the forms in which local knowledge about the drug use and HIV epidemics in Ukraine emerge, but also of the historical legacies that have made the social and political character of scientific knowledge much more tangible in the Post-Soviet sphere. My hope to find a way to step back from these abstract analyses of scientific discourses in order to develop new tactics for facilitating public health research that avoids the unique pitfalls and harnesses

the unique advantages of the Ukrainian context. How can we to make substantive changes to the quality of epidemiological research on HIV and drug use in Ukraine with out feeding the historically embedded skepticism of scientific knowledge that frames public health activity? Likewise, how can discourses of human rights and social morality be incorporated into scientific or epidemiological research so that political and ontological realities can be created in tandem? The relevance of these questions will continue to grow as the coverage and scope of public health services for IDUs and HIV-positive persons in Ukraine expand.

Works Cited: Carroll, Jennifer. 2010. Bodies at Risk: Determining Health and Responsibility in Ukrainian Harm Reduction and HIV-Prevention Programs. Paper Presented at the Annual Meeting of the American Anthropological Association, New Orleans, LA. Carroll, Jennifer. 2011. A Woman Among Addicts: The Production and Management of Identities in a Ukrainian Harm Reduction Program. Anthropology of East Europe Review 29(1): 23-34. Clark, Judy and James Murdock. 1997. Local Knowledge and the Precarious Extension of Scientific Networks: A Reflection on Three Case Studies. Sociologia Ruralis 37(1): 38-60. Dolan, Brian. 2007. The Art of Evidence and the Morality of Medical Decisions. Unpublished research paper. Center for Humanities and Health Sciences at UCSF. Latour, Bruno 1987. Science in Action: How to Follow Scientists and Engineers Through Society. Cambridge: Harvard University Press. Latour, Bruno. 1999. Pandoras Hope: Essays on the Reality of Science Studies. Cambridge: Harvard University Press. Ministry of Health of Ukraine ( ' ). 2009. - . 31, 1991 . Verdery, Katherine. 1996. What Was Socialism, and What Comes Next? Princeton: Princeton University Press. UNAIDS. 2007. Eastern Europe and Central Asia: AIDS Epidemic Update - Regional Summary. Statistical Report. Geneva: Author.