Evidence-making controversies: the case of hepatitis C treatment and the promise of viral elimination

In search of a 'good number': knowledge controversy and population estimates in the endgame of hepatitis C elimination

We explore the contentious life of a metric used to assess a country's progress in relation to global disease elimination targets. Our topic is hepatitis C elimination, and our context is Australia. A fundamental metric in the calculation of progress toward hepatitis C elimination targets, as set by the WHO, is the population prevalence of people living with hepatitis C. In Australia, this modelled estimate has generated some controversy, largely through its repeated downsizing as an effect of calculus. The 2015 baseline population estimate in Australia, from which measures of current elimination progress are assessed, has reduced, over time, by around 30%. Informed by a social study of science approach, we used qualitative interviews with 32 experts to explore the knowledge controversy. The controversy is narrated through the core concerns of 'scale' and 'care', with narratives aligning differently to imaginaries of 'science' and 'community'. We trace how constitutions of 'estimate' and 'number' circulate in relation to 'population' and 'people', and as affective values. We show how enactments of estimates and numbers materialise hepatitis elimination in different ways, with policy implications. The event of the knowledge controversy opens up the social and political life of enumerations-for science and community-inviting deliberation on how to make 'good numbers' in the race to eliminate hepatitis C.

Pandemic modelling and model citizens: Governing COVID-19 through predictive models, sovereignty and discipline

Pandemic modelling functions as a means of producing evidence of potential events and as an instrument of intervention that Tim Rhodes and colleagues describe as entangling science into social practices, calculations into materializations, abstracts into effects and models into society. This article seeks to show how a model society evinced through mathematical models produces a model not only for society but also for citizens, showing them how to act in a certain model manner that prevents an anticipated pandemic future. To this end, we analyse political speeches by various Norwegian ministers to elucidate how various model-based COVID-19 responses enact a 'model citizen'. Theoretically, we combine Rhodes et al.'s arguments with Foucault's concepts of law, discipline and security, thus showing what a model society might imply for the model citizen. Finally, we conclude that although the model society is largely informed by epidemiological models and liberal biopolitics that typically place responsibility on individual subjects, sovereign state power remains manifestly present in the speeches' rhetoric.

Medical Populism and COVID-19 Testing

This paper uses the lens of medical populism to analyze the impact of biocommunicability on COVID-19 testing through a case study approach. The political efficacy of testing is traced through two mini-case studies: the Philippines and the United States. The case studies follow the approach of populism scholars in drawing from various sources that ‘render the populist style visible’ from the tweets and press releases of government officials to media reportage. Using the framework of medical populism, the case studies pay attention to the ways in which coronavirus testing figured in (1) simplification of the pandemic; (2) spectacularization of the crisis; (3) forging of divisions; and (4) invocation of knowledge claims. Identifying and critically analyzing how knowledge is generated is an essential step to recognizing the impact that political styles have on the COVID pandemic. The political actors in each case study have shaped knowledge of the epidemic, in the way they construct the idea of ‘testing’, and in how they mobilize testing as an ‘evidence-making practice’. Their actions shaped how the pandemic—as well as their responses—is measured. This framework contributes to public policy debates by providing evidence of the impact of medical populism on pandemic response efforts.

Managing risks or generating uncertainties? Ambiguous ontologies of testing in Australian healthcare

Medical testing promises to establish certainty by providing a definitive assessment of risk or diagnosis. But can those who rely on tests to offer advice or make clinical decisions be assured of this certainty? This article examines how Australian health professionals, namely clinicians, microbiologists, specialist physicians and health policymakers, delineate the boundary between certainty and uncertainty in their accounts of medical testing. Applying concepts from science and technology studies, and drawing on qualitative data from a sociological study of testing in Australian healthcare, we consider how professionals ascribe meaning to testing and test results. As we argue, for these health professionals, the 'evidence' that testing generates has ambiguous ontological significance: while it promises to provide diagnostic certainty and clear direction for advice or treatment, it also generates uncertainties that may lead to yet further tests. Our analysis leads us to question a key premise of testing, namely that it is possible to establish certainty in medical practice via the measurement of individual health risks and disease markers. Against this dominant view, the responses of the health professionals in our study suggest that uncertainty is intrinsic to testing due to the constantly changing, unstable character of 'evidence'. We conclude by considering the implications of our analysis in light of healthcare's increasing reliance on sophisticated technologies of 'personalised' testing using genetic information and data analytics.

HIV pre-exposure prophylaxis and the 'problems' of reduced condom use and sexually transmitted infections in Australia: a critical analysis from an evidence-making intervention perspective

HIV pre-exposure prophylaxis (PrEP) has been embraced in Australia, making PrEP available with public funding to people at risk of HIV. Here, we consider the associated 'problems' of reduced condom use and sexually transmissible infections (STIs), as seen by HIV professionals. Twenty-one interviews were conducted during May-August 2017. All agreed that PrEP was a valuable addition to HIV prevention, but their views about reduced condom use and STIs were variable. Using poststructural policy analysis, three main stances were identified: (1) Concerned/alarmed. PrEP was seen as causing reduced condom use, STIs and antibiotic resistance, posing threats to the general population; (2) Neutral/normalising. Stakeholders emphasised that condom use was declining and STIs increasing independently of PrEP, and that PrEP was simply a new tool to be accommodated; (3) Optimistic/critical. PrEP was seen as diminishing fear of HIV and engaging users in more frequent testing and treatment that could lead to declining STI rates. What linked all three stances was the selective performance of evidence, deploying a mixture of personal experience, clinical observations, behavioural data and epidemiology. Anticipating possible futures through evidence-making suggested practical, political and moral consequences for what PrEP could become. We encourage others to consider these consequences with care.

'Potential issues of morbidity, toxicity and dependence': Problematizing the up-scheduling of over-the-counter codeine in Australia

Until February of 2018, Australians were able to purchase low-dose codeine products (LDCPs) over-the-counter from pharmacies. In 2017, following review and public consultation, Australia's therapeutic drug regulator rescheduled LDCPs to prescription-only, in line with other higher-dose codeine and opioid products. In this article, we draw on Bacchi's 'what's the problem represented to be' approach to 'work backwards', analysing this 'solution' and the particular 'problematisation' of codeine it produces and relies on. We analyse the 'final decision and reasons for decisions' document, which outlines the consultation and decision-making process leading to the rescheduling of LDCPs. We contend that abuse and dependence of codeine by people with chronic pain is the 'problem' constituted by the decision to reschedule LDCP. We consider the ethical and political implications of this problematisation. First, we argue that this problematisation limits the ways the LDCP consumption, particularly by people with chronic pain, can be understood. This problematisation effaces the multiple reasons people with chronic pain may consume LDCPs long term and works to naturalise notions of 'misuse'. We next argue that notions of the 'legitimate patient' and the 'illegitimate consumer' or 'abuser' are in different ways positioned as primarily responsible for managing their health. From here we argue that the problematisation of LDCPs in Australia produces codeine as the sole agent of harm in ways that background wider harm-producing social arrangements. Our analysis also suggests that the 'problem' of LDCPs unreflexively reinforces medical authoring and expertise as the primary solution. Finally, we suggest that the use of LDCPs in Australia could instead be re-problematised as an issue of 'chronic health mismanagement'. Responses to this problematisation would require a reorientation away from attempts to reduce accessibility such as up-scheduling to significantly more focus on long-term healthcare engagement for people consuming LDCPs to manage chronic health issues.

Evidence-making hepatitis C cure: Towards a science that knows more carefully

There has been some controversy concerning the curative potential of new treatments for hepatitis C. This follows a systematic review of the Cochrane Collaboration questioning the clinical benefits of direct-acting antivirals (DAAs). This controversy has been debated as a matter of methods regarding how best to evidence treatment in an evidence-based medicine (EBM) approach. Drawing from science and technology studies (STS), we offer an alternative perspective. We propose a different way of thinking with evidence; one which treats 'evidencing as performative'. Using the Cochrane review and its linked published responses as a resource for this analysis, we consider how hepatitis C cure is differently made-up through the knowledge-making practices performing it. We show how matters of apparent fact in evidence-based science are enacted as matters of clinical, social and ethico-political concern. We notice hepatitis C cure as a fluid object in negotiation. We highlight the limits of current debate to advocate a more critical and careful practice-based approach to knowing hepatitis C cure. This calls upon public health researchers to reflect on the performative work of their evidencing. We propose a 'more-than' EBM approach which treats 'evidence-based' science as an 'evidence-making intervention'. We consider the implications of such an approach for the evidencing of public health interventions and for treating hepatitis C in the DAA era of 'viral elimination'.

"Towards eliminating viral hepatitis": Examining the productive capacity and constitutive effects of global policy on hepatitis C elimination

In 2016 the World Health Organization published the first global health strategy to address viral hepatitis, setting a goal of eliminating viral hepatitis as a major public health threat by 2030. While the field has been motivated by this goal, to date there has been little critical attention paid to the productive capacity and constitutive effects of this policy. How is governing taking place through the mechanism of this global strategy, and how are its goals and targets shaping what is made thinkable (indeed, what is made as the real) about hepatitis C and its elimination? And with what effects? Taking the Global Health Sector Strategy on Viral Hepatitis, 2016-2021 as a text for analysis, we draw on poststructural thinking on problematisation and governmental technologies to examine how 'elimination' - as a proposal - constitutes the problem of hepatitis C. We critically consider the conceptual logics underpinning the elimination goal and targets, and the multiple material-discursive effects of this policy. We examine how governing takes place through numbers, by analysing 'target-setting' (and its accompanying practices of management, quantification and surveillance) as governmental technologies. We consider how the goal of elimination makes viral hepatitis visible and amenable to structuring, action and global management. Central to making viral hepatitis visible and manageable is quantification. Viral hepatitis is made as a problem requiring urgent global health management not through the representation of its effects on bodies or situated communities but rather through centralising inscription practices and comparison of estimated rates. It is important to remain alert to the multiple makings of hepatitis C and draw attention to effects which might be obscured due to a primary focus on quantification and management. To do so is to recognise the ontopolitical effects of governmental technologies, especially for communities 'targeted' by these strategies (including people who inject drugs).