Commentary
Towards “evidence-making intervention” approaches in the social science of implementation science: The making of methadone in East Africa

https://doi.org/10.1016/j.drugpo.2016.01.002Get rights and content

Abstract

In this commentary, we take the recent introduction of methadone treatment in response to emerging problems of HIV linked to heroin addiction in Kenya as a case for reflecting on the social science of implementation science. We offer a framework of ‘evidence-making intervention’ which we hold as distinct from mainstream ‘evidence-based intervention’ approaches. Whilst accepting that interventions are shaped in their contexts, evidence-based intervention approaches tend to imagine a stable intervention object with universal effect potential. By contrast, an evidence-making intervention approach investigates how an intervention, and the knowledge which constitutes it, is made locally, through its processes of implementation. Drawing on qualitative research generated in Kenya prior to (2012–2013) and during (2014–2015) the implementation of methadone treatment, we explore the making of ‘methadone promise’ as a case of evidence-making intervention. We show how enactments of methadone promise make multiple methadones, through which a binary is negotiated between the narratives of methadone as hope for addiction recovery and methadone as hope for HIV prevention. Addiction recovery narratives predominate, despite methadone's incorporation into policy via its globally supported HIV prevention evidence-base. Key practices in the making of methadone promise in Kenya include its medicalization, and renaming, as ‘medically assisted treatment’ – or simply ‘MAT’ – which distance it from prior constitutions elsewhere as a drug of substitution, and the visualisation of its effects wherein unhealthy people can be seen and shown to have become well. We also show how actors seek to protect the story of methadone promise from counter narratives, including through mass media projects. We conclude that there is no single biomedical object of methadone intervening on a single biological body across contexts, and no single universe of evidence. By giving weight to local rather than outside expert knowledge, and by tracing how the meaning of intervention is made locally through its implementation, we can make visible the multiple enactments of an intervention and how these shape local ecologies of care, including in ways beyond those foreseen by an intervention's evidencing elsewhere.

Section snippets

HIV, addiction, and East Africa

The East African countries of Kenya and Tanzania are witnessing growing HIV incidence linked to drug injecting. In Kenya, for example, estimates of HIV prevalence among people who inject drugs (PWID) are as high as 50% in Nairobi and 20% in Coast Province (NASCOP, 2012). Prior to the introduction of MT (December 2014 in Kenya, and March 2011 in Tanzania), treatment for heroin addiction largely comprised private-only short-term residential detoxification and rehabilitation, affordable to few,

Evidence-based intervention

The introduction of MT into East Africa is primarily cast as an instance in the translation of evidence-based biomedical interventions in global health into new settings, of which a key element is expanding the international evidence-base in its support across different contexts of high and low income, within and beyond the West. There are parallels here with the building of global discourses of evidence-based harm reduction more broadly, which accentuate the potential positive effects of a

Evidence-making intervention

Rather than evidencing known interventions as responses to given policy problems, we advocate a critical social science approach which asks how such evidence, intervention and problem came to be. This perspective draws first, on the study of ‘problematisations’, which investigates policy, science and other texts for what they represent and how they construct a problem which they purport to address (Bacchi, 2009, Bacchi, 2012), and second, on ‘actor-network’ theories, which investigate how

Context-made methadone meaning

The basic idea that methadone, as with any intervention, is somehow shaped by its context is a familiar one (Bourgois, 2000, Fraser and Valentine, 2008), and this is part of the mainstream rationale underpinning the need for an implementation science in the translation of evidence-based interventions (Duke & Thom, 2014). For instance, we can refer to the example of Russia, or that of the UK and U.S.A. Each demonstrate variable constitutions of methadone in context and time; that is, different

Multiple methadones

The idea that a given substance – like methadone – is subject to different interpretations on account of its context is the primary thrust in applied public health discourses for incorporating social science methods as part of implementation science approaches. In this theorisation, the substance itself remains the same, and it is the interpretations which differ. This is a kind of weak form of social constructionism which does not trouble the idea of the substance of methadone as an inanimate

The making of methadone in Kenya

We have begun to document methadone's implementation in Kenya through qualitative research. This has included longitudinal research, led by TR and AG, with 110 PWID in Nairobi (n = 30), Malindi on the North Coast (n = 50) and Ukunda on the South Coast (n = 30) undertaken in the two years prior to methadone's implementation (Rhodes, Guise, et al., 2015). Participants in this study had a mean age of 31 years (19–49) and were predominately male (70%; 76). All but two had injected in the last four weeks,

Conclusions: friction and flux

In this commentary, we have depicted the object of methadone as multiple, open to negotiation, and crucially, the product of competing inscriptions arising from actor-networks of local effect. We have illustrated this through the specific example of the making of ‘methadone treatment promise’ in Kenya. The making of methadone promise and expectation arises out of a friction in conversation between as well as across global and local representations of what constitutes methadone, and

Acknowledgements

This commentary was developed through a visiting lecture invitation at the Center for AIDS Research at the University of California in collaboration with the University of California at San Diego. We are grateful to the International AIDS Alliance for supporting our work researching the development of harm reduction in Kenya, and to participating outreach projects who have assisted with our fieldwork (Omari Project, Malindi; Nairobi Outreach Services Eastlands Team, Nairobi; TeensWatch,

References (40)

  • C. Bacchi

    Analysing policy: What's the problem represented to be?

    (2009)
  • C. Bacchi

    Why study problematisations? Making politics visible

    Open Journal of Political Science

    (2012)
  • J. Biehl et al.

    Symptom: Subjectivities, social ills, technologies

    Annual Review of Anthropology

    (2009)
  • P. Bourgois

    Disciplining addictions: The bio-politics of methadone and heroin in the United States

    Culture Medicine and Psychiatry

    (2000)
  • N. Brown et al.

    A sociology of expectations: Retrospecting prospects and prospecting retrospects

    Technology Analysis and Strategic Management

    (2003)
  • C. Colvin

    Anthropologies in and of evidence making in global health research and policy

    Medical Anthropology

    (2015)
  • S.D. Cunningham et al.

    Realities of replication: Implementation of evidence-based interventions for HIV prevention in real-world settings

    Implementation Science

    (2014)
  • S. Fraser et al.

    Habits: Remaking addiction

    (2014)
  • S. Fraser et al.

    Substance and substitution: Methadone subjects in liberal societies

    (2008)
  • E. Gomart

    Methadone: Six effects in search of a substance

    Social Studies of Science

    (2002)
  • Cited by (48)

    • The line of vulnerability in a recovery assemblage

      2022, International Journal of Drug Policy
    • Bereaved mothers’ engagement in drug policy reform: A multisite qualitative analysis

      2021, International Journal of Drug Policy
      Citation Excerpt :

      ‘Evidence’ used in support of policy is frequently considered to be knowledge drawn from scientific research and expert ‘objective’ opinion; however, failing to understand evidence as a product of local knowledge can limit the applicability and efficacy of policy reforms (Rhodes & Lancaster, 2019). Including the voices of local experts can reframe what is meant by ‘evidence’-based policy and can shift policymaking processes that embed policies within local contexts (Lancaster, Treloar & Ritter, 2017; Rhodes, Closson, Paparini, Guise & Strathdee, 2016). Ritter, Lancaster and Diprose (2018) argue that while drug policy processes frequently aim to engage in evidence-based reforms with a focus on ‘what works’, such approaches are “not configured to integrate a diversity of voices and knowledges that arise from sources other than scientific evidence” (p. 2).

    • A geology of drug morals

      2021, International Journal of Drug Policy
    • Assembling and diversifying social contexts of recovery

      2021, International Journal of Drug Policy
    View all citing articles on Scopus
    View full text