Technological Decision-Making Under Scientific Uncertainty Preventing Mother-to-Child Transmission of HIV in South Africa Martin Weinel Cardiff School of Social Sciences, Cardiff University (PhD Thesis, December 2010) UMI Number: U564796 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U564796 Published by ProQuest LLC 2013. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. 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Summary Between October 1998 and August 2000, the South African government refused to make AZT, an antiretroviral drug, available to pregnant women living with HIV/AIDS to reduce the risk of mother-to-child transmission of HIV. From October 1999 onwards, leading government figures justified this policy choice by claiming that the safety of AZT was the subject of a scientific controversy. President Mbeki played a pivotal role because he was the one who identified the alleged scientific controversy about AZT by reading scientific literature on the Internet. The main objective of the this thesis is to establish whether President Mbeki and other leading government figures should have participated in making policy­ relevant judgements related to the safety of AZT. A new STS approach, known as the ‘Third Wave of Science Studies’, provides the theoretical and conceptual tools that inform a normative model of technological decision-making, the ‘3W model’, which guides the analysis of the South African case study. By relying on a realist theory of expertise, which links expertise with experience and tacit knowledge, the 3W model allows social analysts to make judgements about the extent of participation in making policy-relevant technical or scientific judgements. The normative analysis focuses on three aspects. First, it is evaluated whether the government acted correctly when it ignored expert advice that suggested the benefits of using AZT to prevent the risk of mother-to-child transmission outweighed the risks. Second, by exploring Thabo Mbeki’s level of expertise, it is explored whether he was in a position to make a reliable judgement about the state of the scientific discourse about the safety of AZT. Third, a proposal is made that prescribes how actors should proceed if they want to judge the authenticity of scientific controversies that are invoked in the context of technological decision­ making processes. Table of Contents Acknowledgements ................................................................................................i Autobiographical Preamble ................................................................................ iii Introduction ...........................................................................................................1 A Very Practical Problem ........................................................................... 1 A Very Theoretical Problem ......................................................................4 Purpose of the Thesis................................................................................. 7 Structure of the Thesis................................................................................9 On Method ................................................................................................ 12 1. Technological Decision-Making and the Problem of Extension ................... 17 1.1 Introduction .......................................................................................17 1.2 The Problem of Extension .................................................................19 1.3 The Meaning of Technological Decision-Making ........................... 19 1.4 Locating the Problem of Extension .................................................. 25 1.5 A Realist Concept of Expertise ........................................................27 1.6 Understanding, Tacit Knowledge, and Expertise .............................28 1.7 The ‘Periodic Table of Expertises’ (PTE) ........................................31 1.8 Demarcating ‘Technical Knowledge’ from Other Domain-Specific Knowledge ....................................................................................... 35 1.9 Conclusions ......................................................................................43 2. Technocracy, Technological Populism, and the Problem of Legitimate Participation ..............................................................................................46 2.1 Introduction ......................................................................................46 2.2 Against Wrongful Boundaries: Technocracy and the Problem of.... 48 2.3 The Need for Boundaries: Against Technological Populism ............53 2.4 Understanding Misunderstanding: Reviving a Critical Debate ........ 62 2.5 Conclusions .......................................................................................67 3. The Minimal Default Position ......................................................................68 3.1 Introduction .......................................................................................68 3.2 Relationship between technical and political phase .......................... 69 3.3 Minimal Default Position ..................................................................71 3.4 What’s Different? Comparing the Minimal Default Position ........... 76 3.5 Technocracy and Political Decision-Making ....................................77 3.6 Technological Populism and Technological Decisions ..................... 80 3.7 Conclusions ....................................................................................... 83 4 The Context of the South African Policy-Making About PMTCT ................ 86 4.1 Introduction ........................................................................................86 4.2 Aspects of South Africa’s AIDS Policy until 1999 ...........................87 4.3 MTCT in South Africa .......................................................................91 4.4 Technical responses to MTCT - The state of treatment ................... 93 4.5 Political Power in South Africa ..........................................................98 4.6 Conclusion ........................................................................................ 102 5. Testing the MDP: Technological Decision-Making About PMTCT in South Africa........................................................................................................ 104 5.1 Introduction ......................................................................................104 5.2 PMTCT as an issue and the formation of a consensus: July 1997- October 1998 ................................................................................. 106 5.3 The consensus crumbles: October 1998 - October 1999 ............... 110 5.4 Just not safe enough: October 1999 - August 2000 ....................... 114 5.5 Further Developments: August 2000 onwards ................................ 121 5.6 Conclusions ..................................................................................... 123 6. Domain-Specific Discrimination: studying the problem of extension for meta­ expertises................................................................................................. 126 6.1 Introduction ..................................................................................... 126 6.2 Credibility and the Judgement of the State of a Scientific Discourse .......................................................................................................130 6.3 Thabo Mbeki’s Expertises............................................................... 134 6.4 Mainstream Experts ......................................................................... 147 6.5 Domain-Specific Discrimination (DSD) as a New Type of Expertise? .......................................................................................................159 6.6 Conclusions ..................................................................................... 164 7. Sociological Discrimination and the Identification of Inauthentic Scientific Controversies ........................................................................................... 168 7.1 Introduction ......................................................................................168