Paul Farmer: The World Is Not a Clinic

We’ve discussed a number of studies here on development studies using randomized controlled trials to study the outcome of intervention programs. The way RCTs generally work is that one group — a village or community — is enrolled in a particular program, while another is not.  Abhijit Banerjee and Esther Duflo make the case for randomization here.

The more methodologically rigorous method has certainly had an impact in development studies, raising serious questions about the effectiveness of much-touted ideas like microfinance and One Laptop Per Child. But some have raised questions about whether it’s really applicable, or even ethical, in all the situations in which it is used. 

In a blog post for the Lancet,  physician Paul Farmer, best known for his work in Haiti, questions the use of RCTs in global health research:

The world we inhabit, as researchers and clinicians and policy-makers and journal readers, is not in equipoise. It is one in which great disparities of risk for disease, and for unequal access to already proven preventions and remedies, are marked and often extreme. For example, it has been demonstrated in Haiti, Cambodia, and in settings across Africa, that, among patients with active tuberculosis and advanced HIV infection, even brief delays in the initiation of ART are associated with increased mortality. In fact, it has been shown in every study in which this question has been proposed and evaluated. It’s not clear that randomized, controlled trials are necessary to show this yet again, especially in settings in which HIV disease and tuberculosis are the ranking causes of young adult death. This is one of the reasons that the recent publication of one South African trial, which sought to compare outcomes with delayed ART to concurrent initiation of combination chemotherapy for both diseases, occasioned recrimination from some ethicists. The debate underscores the question of where research resources should be invested: some of these trials cost tens of millions of dollars. Our own colleagues used rigorous observational methods to reach the same conclusions in Rwanda. The study cost well under US$30,000.

In addition to focusing scant resources on answering the wrong questions, Farmer also argues that RCTs can strip away important context in a "world riven by poverty and social disparities," leaving researchers "knowing the true answer without knowing what the right answer is."

Farmer’s post is focused on medical research, but it strikes me that a lot of the critiques could apply to economic development work as well. It will be interesting to see what kind of reaction it gets. 

Via Tom Murphy