Author's Commentary on "Political Points"

Commentary On

This case is based on real studies that were conducted in Vancouver and Montreal (Bruneau et al., 1997; Strathdee et al., 1997a, b; Archibald et al., 1998). When researchers found that needle exchange did not reduce the spread of HIV among their subjects, congressional leaders in the United States and conservative Christian groups like the Family Research Council demanded an end to NEPs. (E.g., Maginnis [1998a] specifically cites the Bruneau et al. [1997] and Strathdee et al. [1997a] studies.) Though some may find the reference to "religious extremists" biased and even inflammatory, it reflects the political environment in which needle exchange and needle exchange research take place. (See Maginnis, 1996a-c, 1997a-d, 1998a-c for Family Research Council articles on the topic.) Relevant policy research necessarily hits on such hot-button issues.

Dr. Lang and the real-world researchers on whom this case is based are indeed needle exchange advocates (Bruneau and Schechter, 1998b), but it is up to the reader to decide if whether theirs is a well-researched, rational, professional opinion or the view of passionate activists. It is important to address the issue of bias in research head on. What are the limits to the objectivity of science? Relevant to the issue of needle exchange and HIV/AIDS in particular is the role that social injustice plays in disease, which is increasingly recognized by the public health and medical communities. How researchers deal with bias varies across and even within fields.

Is bias something to be minimized, avoided and downplayed, or is it something to be named in order to contextualize the work and help others understand it? Is it possible to be a competent, well-read researcher on such a hot-button issue and not have an opinion on the efficacy of NEPs? Does having no opinion in this environment reflect a kind of bias against the existing research? How confident is Dr. Lang in her explanation of confounding variables in her study? What if she is wrong? What if needle exchange really does increase HIV through some as yet unknown mechanism? What is her responsibility as a scientist to report her results as she finds them, and where is the line between experienced interpretation of results and unfounded argument?

What are researchers' obligations in the process of policy making and politics? In the Montreal and Vancouver studies, the misrepresentation of results in the public arena was so significant that the studies' authors published an op-ed piece in the New York Times about the distortion of their findings by American policy advocates, politicians and journalists. (Bruneau and Schechter, 1998a) Local government in Canada responded to the studies by expanding needle exchanges and adding other health services for injection drug users. In the United States, however, the Clinton administration upheld the federal ban on funding for needle exchanges, which had a chilling effect on many less established local needle exchanges. (Freedberg, 1998; Neal, 1998).

One might ask if Dr. Lang is obliged to be similarly active in communicating her results in the political sphere; while Bruneau and Schechter responded only after damage had been done, Dr. Lang anticipates the misrepresentation of her results and has the option to act preventively. Where does Dr. Lang's role as a researcher meet the ethical responsibilities of journalists reporting on science and health policy issues or the responsibilities of policy advocates and public servants to accurately represent research findings?

This case raises further questions about the social consequences of scholarly research and the responsibilities of researchers to various communities with which they interact. What should be done when these interests and responsibilities conflict? On the one hand, Dr. Lang's finding that needle exchange did not aid HIV prevention could result in the shutdown of the exchange and any future research she had planned there. On the other hand, she is under pressure from her funders to publish, and findings that so blatantly contradict the dominant belief in her field could be her ticket to fame or notoriety, depending on whether she is right.

One might explore the possible alternatives Dr. Lang faces in her choice to publish. She might, for example, choose to present her results in the best light possible, perhaps falsifying or omitting some of her data. She might delay publication, wanting to collect more data that might alter her findings. What are the implications of these decisions for each party involved in and affected by the research?

The nature of Dr. Lang's relationship with the NEP's activists and clients is a key issue. There is a strong possibility that the trust the exchange had established with clients would be eroded by articles in the paper against needle exchange that used Dr. Lang's findings for support. To what extent are the needle exchange activists and clients partners in research? What kind of role would they ideally play in such a project?

Because injection drug users have so little access to health care, needle exchange can be their only bridge to health care services (including, in many cases, drug treatment). Might access to certain forms of medical care such as free HIV testing serve as a coercive inducement to participation in research? How might Dr. Lang address the concerns of some community members who view needle exchange as part of a racist effort to bolster the influx of drugs to poor, African-American communities? What are the ethical issues involved in a research project that monitors the spread of HIV through the voluntary use and refusal of needles? For example, what follow-up care should be planned for those who do contract HIV during the course of the study? With a disease like HIV for which effective treatment is not an option in poor communities, what is the researcher's responsibility to disseminate information about HIV prevention? Does this responsibility compromise the "objectivity" of the study? How can such a conflict be resolved?

Perhaps Dr. Lang's situation could have been avoided entirely with a more appropriate research design. Discussions of this case may include brainstorming about what kinds of designs might have eliminated or minimized the flaw in Dr. Lang's work. Could she have foreseen this problem? What should scientists do when they make such mistakes?


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