Extending the rails: how research reshapes clinics.

The purpose of clinical research is to create the scientific foundation for medical practice. In this way of thinking, the effect on medical practice occurs after the research has been completed. Social studies of science have debunked the standard model of scientific research, observing that changes in practice associated with research occur not just because of the results of research but also because of the practice of research. Drawing on fieldwork in HIV clinics in the US, South Africa,Thailand, and Uganda, we argue that clinical trials shape medical practice by altering the organizations in which both medical treatment and clinical trials take place. Three general processes are central to this transformation: the modification of material environments, the reorganization of bureaucratic relations, and the prioritization of research values. These processes unfold somewhat differently in the clinics of poorer countries than in those of wealthier ones.