By Dr. Joseph Matare
One of the early-recorded circumstances in which objectively gathered evidence was used to resolve a “political” impasse and define the consequent course of action is found in the Bible. In the first chapter of the Book of Daniel, it is recorded that Daniel and his peers were among the young men who had been selected to serve in King Nebuchadnezzar’s palace because of their exceptional intelligence, good looks and physique. Daniel and others refused to be contaminated with the food and wine from the royal table and they vowed not to touch it. The master of the eunuchs who was in their charge pleaded with them to partake of the food because his own life would be at stake if the King would find them miserable. The witty Daniel then suggested to the attendant to consider a proposal to break the impasse:
“Submit us to this test for ten days: give us only vegetables to eat and water to drink; then compare our appearance with that of the young men who have lived on the king’s food, and be guided in your treatment of us by what you see for yourself. He agreed to the proposal and submitted them to this test.
At the end of the ten days, they looked healthier and nourished than any of the young men who had lived on the food from the king. So the attendant took away the food assigned to them and the wine they were to drink, and gave them vegetables only”
Research does not come any better than this. There was a problem to be solved; a hypothesis to be tested and validated; a proposal was submitted and approved, complete with a methodology; measurable outcomes indicators for comparison declared prior to the execution of the study;
comparison groups defined (intervention/treatment group versus placebo/control group); a measurement strategy; research conducted within a prior defined time-period; findings presented; application of the evidence in practice; and finally, and very critically, results were published!
In the same vein, evidence from scientific and biomedical clinical research finds great utility in informing and shaping the broad-spectrum of health systems design, management and policy, and prevention and clinical management of disease. The purpose of this discourse is to philosophise the concept of the truth and evidence in health and disease from the perspective of biomedical research directly involving human participants. Given a high demand for such scientific research in Namibia, I wish to make a case for a deliberate strategy for building a critical supply of credible research evidence in our setting.
Unpacking the Concepts of Truth and Evidence
So what is the “truth” and “evidence” and how are the two concepts interrelated? The Macmillan English dictionary defines truth as “the actual facts or information about something, rather than what people think, expect, or make up; or the quality or condition of being true; or an idea that is accepted by most people as being true”. The same dictionary defines evidence as “facts or physical signs that help to prove something”.
In the “study” by Daniel et al, the truth lay with God. None of the protagonists knew what it was. They thus had to rely on gathered evidence to prove that the two dietary regimes would give different outcomes, and that one was significantly better than the other. For them to be convinced, they had to be certain the evidence was credible and unimpeachable.
The concepts of truth and evidence apply in many aspects of life: in science, in health, in criminology, in religion and so on. For instance, in criminology, even if someone confesses that he/she committed a crime, the prosecutor has to provide the evidence to substantiate beyond reasonable doubt that what has been confessed is indeed true. The onus is upon the prosecutors to build a body of evidence around the case. The process issues, that is, the conduct of the investigation, the tests, the presentation of the evidence all add up to determine the credibility and strength of the evidence. In essence, each piece of evidence contributes partially to the truth. The final summation of the evidence gathered should then help the judge, jury and others to be convinced on how close or further from the truth the sum of the evidence is for a conclusion of a guilty or no guilty verdict. Partial or incredible evidence results in acquittal of someone who may have truly committed a crime.
The same process of criminology is fundamentally replicated in evidence gathering in scientific and health research. Research does not create the truth. In essence, the truth is already there, and has to be discovered. Researchers are thus never certain if the truth has been revealed in totality.
Thus, each research conducted should be credible in terms of processes (the design, the data collection, analysis, publication). A rigorous research study presents a great opportunity for building strong or high-level evidence that approximates the truth. A mass of published rigorous research studies with credible findings substantially increases the probability of revealing the truth, whether any of the studies shows positive or negative results about whether an intervention is effective or not; or if it is better than another.
Publication bias is a critical element that has deprived human kind of opportunity to reveal the truths about the effect of medical interventions in preventing or treating disease. It is widely believed that commercially sponsored research is unlikely to be published if the results are in the negative. Whatever the motive, this is considered inherently unethical.
Case for Namibia
The demand for research evidence to inform strategies to ameliorate and mitigate the effect of disease in our country far exceeds the supply. We cannot continue to rely on evidence from elsewhere. Our nation has the responsibility to contribute to the evidence regarding the effectiveness, or lack of it, of available interventions, or to the development of novel modalities. Studies with a higher level of evidence, called randomised clinical trials or experimental studies, are a worthy investment in our setting. Many readers may be aware of the fierce and intense debates around HIV prevention strategies such as male circumcision and mother-to-child transmission. Despite these debates, researchers are seeking context specific and effective remedies to the health and medical problems in those settings.
The findings may not necessarily be generalised or applicable to other settings, even within the same country because of effects of a cocktail of factors such as religion, customs, culture, politics, economy, health systems, habits, geography, genetics, to mention but a few determinants of health. We read about rigorously evaluated programmes in other countries. However, little is documented about our own peoples’ experiences.
Conclusion and Recommendations
The urgency of a critical mass of locally generated and relevant research evidence for health practice; and for specific and general disease management in Namibia cannot be overemphasized. One strategy that may prove effective and sustainable is the establishment of a consortium of health and scientific researchers deliberately constituted and tasked to initiate health research, build capacity for research among health providers, and mobilise external expertise and resources for health research in Namibia.
Responses to diseases and ill-health would be evidence based, thus much closer to the truth, and therefore timely, more effective and less wasteful of resources. However, any other stakeholders who may wish to make a contribution should be encouraged and supported to execute ethically sound and impeccable evidence relevant to our environment. We should not look any further than Daniel et al for inspiration.
Article contributed by a clinician with interests in research and public health. He can be contacted on email@example.com