Published on September 27, 2018 by

Editorial: The bigger picture

Health-related research tends to look at single issues at a time, due to the complexities of what is involved. Indeed, formal scientific experimental investigations tend to rely on comparing situations where differences are to some extend directly controlled, or at least known. Especially when the differences are small in number – possibly one key factor only, such as a choice of treatment – the comparisons can lead to insights into the direct effects of the relevant factors.

Having said that, it is clearly impossible to investigate, in such a manner, every detail of life, or even a slightly narrower aspect like ‘healthcare’ – by examining each choice and evaluating its role in a ‘total package’ of ‘lifestyle’, ‘care’ or ‘policy’. So, is discussion about the bigger picture to be based on political machinations underpinned by naked narrow self-interest? Or is it ultimately a matter of faith or at least shared ‘values’? Or is there in fact something resembling a scientific thread that can be maintained throughout discourse?

The current edition of the SACEMA Quarterly features several pieces grappling explicitly with this challenge of understanding a bigger picture than any particular ‘scientific investigation’ can formally take on.

The theme of treating HIV with lifelong antiretroviral therapy (ART) has featured many times in these pages, and is unfortunately not one that is likely to become irrelevant and uninteresting any time soon, given how deep in the HIV hole much of Africa and other regions find themselves. Brian Williams and Reuben Granich take stock of current ambitions to ‘end’ the HIV/AIDS epidemic, reflecting on some key historical milestones and recent trends – with both of which they are very familiar. In short, we appear to be at a crucial juncture where real lasting success may be reachable, or great opportunities may be created by much effort and investment. On a closely related thread, in a separate short piece, Nathan Geffen reviews the tortuous path to consensus on the current view that anyone diagnosed with HIV should be offered immediate ART.

Matthew Chersich et al. take one step further back from the specifics of HIV management, to consider the role of sexually transmitted infections (STIs) more generally, in the context of the international framework of the ‘Sustainable Development Goals’ (SDCs). They note that health per se features explicitly in fewer of the SDGs than of their predecessor framework, the ‘Millennium Development Goals’ (MDGs), but that the overall structure of the new framework is deliberately less compartmental, and intended to foster holistic approaches to raising a tide that floats all boats. A short item by SACEMA colleague Cari van Schalkwyk sheds light on the association between the burden of HIV and human papillomavirus (HPV), two heavy hitting STIs, by using a model that includes sexual-network factors, something that is difficult to look at in observational studies.

A particular angle on the question of disentangling HIV and related ills is showcased by Simon Rigby, who reviews progress in understanding the role of ‘Intimate Partner Violence’ (IPV) in the transmission of HIV. He reviews recent attempts to model the interactions of the various behavioural factors that lead to transmission, and finds that there is no convincing case that IPV ‘directly’ contributes to elevation of transmission, although it is almost certainly associated with a total context of high risk in which some (mainly women) find themselves. Be that as it may, he concludes by reminding us that relevance to HIV epidemiology should not be the litmus test for whether a social ill is accorded importance and attracts serious attempts to address it.

In a similar vein, Roxy Beauclair considers the discourse around ‘age-disparate’ relationships – i.e. sexual relationships between people of significantly different age. Crudely put, there has been much debate about the role of ‘sugar-daddies’ in exposing young women to unreasonable risk of acquiring HIV from older men, but indeed, the formal evidence is mixed, and the interpretation is not uncontroversial. Her take away messages are about the importance of nuance and context, the need to broaden the debate to encompass all aspects of the empowerment of women, and a call not to neglect opportunities to reduce acquisition risk amongst men.

Finally, stepping furthest back and showing us the broadest view in this issue, is George Lueddeke, outlining the One Health Education Task Force (OHETF) and his forthcoming book (entitled Survival: One Health, One Planet, One Future). He offers potent reminders that most of the big challenges we current face are interlinked, and that unless a more fundamentally caring paradigm underpins key decisions about development in general, it will be difficult to make much progress on any particular goal. The process behind the sustainable development goals seems to embrace this point, but it is still far from clear whether actual developments will automatically be driven by such a broad view, given the inevitably grubby details of particular lines of evidence, varying priorities, and political constraints.

We hope you enjoy these thoughtful pieces and that they take your own engagement with the issues up a notch or two.