How to talk about folks reluctant to vaccinate

Diphtheria_vaccination_posterFirst it was Ebola, now it is the measles, not forgetting of course the annual debates about influenza. Of course I am talking about infectious diseases and the fact that every once in a while they become front-page news. Inevitably, the conversation quickly shifts to those among us who choose not get vaccinated or have their children vaccinated. While I think that everyone should do everything they can to get vaccinated, I have to concede that some among us do not share that view. More importantly, we need get beyond labelling anyone who is reluctant to embrace vaccination as an ‘anti-vaxxer’. The common account of a so-called anti-vaxxer is very negative indeed. These people are described as a bit nutty, reject the benefits of modern science and are thought by many to be the functional equivalent of folks who think the moon landing was a hoax or that the theory of evolution should be disregarded or who think Elvis still walks among us. This view is wrong.

A recent three-part series in Forbes magazine (you can find the first instalment here) offers a nuanced and effective argument that it is a mistake to think of our fellow citizens who are not as enthusiastic about vaccination as a single group of crazy people. To take but one example, parents who are reluctant to have their children vaccinated may not reject the basic idea of vaccination. Rather, they may be concerned about the absolute number of vaccines that are recommended be administered to their children in a short period of time. While the scientific evidence suggests there is minimal risk associated with the current vaccine schedule, it is critical to remember that these parents are acting out of deep felt and genuine concern for their kids. Similarly, the series does a good job of explaining that if we are to convince people who are opposed to vaccines to change their minds, shaming them is not a good idea. It is also more complicated than simply confronting them with the science. As the political scientist, Brendan Nyhan has suggested, “Current public health communications about vaccines may not be effective. For some parents, they may actually increase misperceptions or reduce vaccination intention. Attempts to increase concerns about communicable diseases or correct false claims about vaccines may be especially likely to be counterproductive.” He has also done research that shows that for some people, corrective information that show that the flu vaccine does not give you the flu, can backfire. As he and his co-authors conclude, “respondents with high levels of concern about side effects were less likely to report that they would be immunized after seeing this information”

To put it differently, in order to talk about folks reluctant to vaccinate we need a better strategy, one that perhaps begins with a bit of empathy and a recognition that this is a conversation with a diverse group of people (of which only a tiny minority reject vaccination outright). In this vein a good place to start is a recent book by Eula Biss, On Immunity: An Inoculation. Biss is a professor of English and an essayist. She writes from the perspective of a new mother who struggled to do what is right for her children. She is a strong supported of vaccination but in the book she describes her efforts to understand other new parents who, in an attempt to do what they think is best for their children, take a more critical stance. Hers is an empathetic approach which, while critical of parents who do not choose to vaccinate their children, tries to respect and understand the many reasons why not all of us are enthusiastic about vaccination.

(This post first appearred on the Policy Options Blog – http://policyoptions.irpp.org/?p=8000&preview=true)

Scientific evidence alone is not sufficient basis for health policy

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This photo shows a view down the middle of a boron nitride nanotube. Credit: Vin Crespi, Pennsylvania State Physics. Distributed under the Creative Commons license http://creativecommons.org/licenses/by-sa/2.0/.

Earlier this year two senior officials from the US and UK governments got together to write a short commentary in the BMJ provocatively (but appropriately) entitled “Scientific evidence alone is not sufficient basis for health policy“.  Some highlights:

Based on experience as researchers and as policy makers at the White House and United Nations, we argue that although science should inform health policy, it cannot be the only consideration.

Although it may frustrate scientists when politicians are swayed by the possible electoral consequences of various policy options, few scientists (including us) would want to live in a society in which politicians completely ignored the views of those who have elected them as their representatives. Voting, free speech, debate, and the push and pull of politics must have an important role in what free societies choose to do if the concept of democracy is to be meaningful.

To say that an advocate or policy maker is guided by more than technocratic considerations is a compliment and not an insult.

In the rapid response to their commentary someone effectively asked if it is possible to find anyone who would defend the position that science alone should determine (health) policy.  Admittedly, this may be a challenge.  However, the implicit assumption in so much of the writing in health policy is that policy decisions should be based on evidence.  The very large literature on knowledge translation, at least as it applies to public policy, seems to assume that the problem to be solved is finding the best ways to bring to the attention of “policy makers” (who are rarely if ever defined very clearly) the best available scientific evidence.

publicPolicy

Source: Safe Kids Kansas Coalition http://www.kansassafekids.org/public_policy.html

Defining (global) public health and its challenges

19th century remedies

Creative Commons license via Flickr: http://www.flickr.com/photos/aussiegall/309391023/

 

 

An outfit called “Thought Economics: Interviews With the World’s Leading Thinkers” recently posted an interview with some leading members of the public health enterprise: Dr. Julio Frenk (Dean of the Harvard School of Public Health, and former Minister of Health of Mexico), Sir Richard Thompson (President of the U.K. Royal College of Physicians), Baron Peter Piot (Director of the London School of Hygiene and Tropical Medicine) and Dame Sally Davies (The United Kingdom’s Chief Medical Officer).

The questions were, at times very broad (e.g., what is public health; to what extent should health be considered a human right?).  In other cases, the questions were almost predictable (e.g., What are the key challenges and opportunities in the sphere of communicable disease?).

All very useful for a very high level overview of the challenges facing contemporary public health.  Of particular interest was Peter Piot’s answer to the question, “what is global health?”.  His pithy answer was interesting:

Many of our health problems challenges cannot be solved within one specific border. In the old days, we had ‘tropical medicine’ which was a colonial approach. This led to international-health during the cold-wars which simply meant the health of those far away. Now we have the concept of ‘global health’ which reflects the globalisation of the world.

global health

Source: BMC Medicine

Alas, I think that too much of what is written under the rubric of global health remains in the style of “the health of those far away”. There are good and bad reasons for this.  On the one hand, there is just the continuing interest in investigating the health of people in other countries.  On the other hand, what is perhaps new in the last 10-15 years is an acceleration of research that is written from a more normative perspective.  On this account, we need to be concerned about the health of those far away because all too often their health status is very poor indeed and this is, quite simply, unacceptable.

Perhaps this is simply an expression of life in a globalized world.  We are very much connected one to the other, not just by the speed at which infectious disease can travel, but also by the fact that we have a shared humanity and it is unacceptable to turn a blind eye to the plight of others.  And of course, in a globalised world what we do in our own backyard can have such a large effect on the health of people in far away places.  The migration of highly skilled health professionals is but one example of this.

All of this may be self-evident to specialists in global health but for a more lay audience, these distinctions are interesting and important.

Debating the merits of Tamiflu

Source: Social Science Space April 15, 2014

Source: Social Science Space April 15, 2014

A few weeks ago, the British medical journal the BMJ published an article that offered a critical appraisal of Tamiflu.  While there have been other bits of research that challenge the efficacy of Tamiflu and the decisions of governments to stockpile the medication in anticipation of a flu pandemic, this most recent article was remarkable because it was a systematic review and was prepared as part of the Cochrane reviews.

For the uninitiated, a systematic review is quite different from an individual study.  Rather, as the Cochrane Library puts it: “A systematic review attempts to identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a given research question. Researchers conducting systematic reviews use explicit methods aimed at minimizing bias, in order to produce more reliable findings that can be used to inform decision making.”  And Cochrane reviews have been described as “the highest level of evidence on which to base clinical treatment decisions.”

Serious stuff.  In other words, when a Cochrane review is published, people stand and take notice.

The political result of the publication of the review critical of Tamiflu was a chorus of criticism of governments that had stockpiled the medication at a cost of millions of dollars, pounds, Euros and yen.  Some even have begun to refer to the vaccine as “Scamiflu”.

Source: Twitpic

This does not mean, however, that systematic reviews, be they from Cochrane or elsewhere are faultless.  Therefore, almost as soon as it was published, the article that was so critical of Tamiflu attracted its own chorus of criticism (see also here and here).  Critics pointed to what they saw as flaws in the analysis and argued that the study as such did not justify the conclusion that governments were wrong to stockpile Tamiflu.  Some pointed out that in the real world of policy making governments have to manage risk and that the Cochrane systematic review did little to consider.

I am not qualified to evaluate the claims and counterclaims.  And I am cynical enough to ask about the motives of the various parties in the debate.  Having said that, governments are routinely faced with having to make decisions when the evidence is conflicting and where they must balance clinical effectiveness against public confidence that the health system will be able to protect them from harm.  In this case governments opted to stockpile Tamiflu, knowing it might only be somewhat useful.  However, in the face of the prospect of large number of people dying in the event of a serious pandemic, being able to do something, however limited, is preferable to being able to do nothing. This is the real world of politics and difficult political decision making.

More generally, I think that a systematic review critical of Tamiflu appeals to those of us who are, justifiably I think, quite critical of large pharmaceutical companies and their motives and ultimate goals.  In other words, combine a nascent mistrust of Big Pharma, add a systematic review done by the Cochrane collaboration no less, and you inevitably get a torrent of criticism not only of the drug but of the governments who spent large sums of money acquiring it.

Yet it is in the nature of scientific inquiry to subject any given study to critical appraisal and this case was no different.  Systematic reviews, even the best ones, are not the final word on an issue.  And when it comes to translating scientific research into policy, systematic reviews, be they good, bad or indifferent, are but one factor shaping policy decisions.  And as I and many, many others have argued, this is as it should be. Scientific evidence shapes and informs public policy but does not and indeed cannot determine policy.

Inside the black box: science, politics and healthy public policy Notes for an address to The Ontario Public Health Convention, April 1, 2014

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Yesterday I had the honour and the pleasure of speaking to The Ontario Public Health Convention.  The title of my talk, “Inside the black box: science, politics and healthy public policy” gives a good sense of the themes developed in my presentation.  I specifically made an argument about the limits of evidence for making public health policy, presented some key ideas about the policy process arising from political science theories of policy making; and ended with a short defense of “politics”.

A copy of the notes for my presentation is available here.

Policy as Values

In July 2012 I published a short piece entitled “Policy as Values” in the newsletter of the Institute for Science, Society and Policy. While this was a response to an earlier item by my University of Ottawa colleague, Scott Findlay, I think my contribution stands on its own and may have continuing interest to a wider audience.

I am reproducing the piece here since it is no longer avaialble in its entirety from the ISSP.

ISSP logo

Policy as Values

Patrick Fafard

June 2012

Long ago and far away I took a course in philosophy of the social sciences. Surprisingly, this philosophy course involved a field trip and a very peculiar one indeed. On campus there was a small office in a bit of commercial space that housed, if memory serves, Technocracy Inc. The organisation was committed to advancing the cause of a rational and scientific approach to life in general and government in particular.

I have repeatedly encountered variations on this desire for a scientific approach to government, most recently in the blog post by my University of Ottawa colleague Scott Findlay provocatively entitled (at least for me) “Policy as Science”. To summarize and oversimplify, he advocates a rational policy process that selects among candidate policies in a rational manner, using the scientific method. My first inclination was to discount if not dismiss the argument by simply asserting that in real life things are not so simple and grumble about the hubris of scientists.

But the very fact that the desire for a rational approach to policy making is always present and, at first glance, quite seductive, demands a more fulsome response. There are any number of possible objections: much has been written on why policy making is not rational and indeed cannot be so. In fact, I have argued, as have many others, that policy making should not be reduced to rational problem solving.

But for the moment I want to focus on one aspect of the argument for a more rational or scientific approach to policy making. To reduce policy making to problem solving, as Scott suggests, assumes that we can agree on the nature of the problem and on the desired outcome. Let us consider each of these claims in turn.

Before there can be a policy choice there has to be agreement that there is a problem to be solved or at least one that government can do something about. In effect then, the art of governing is to choose the problems that will be addressed and which are to be more or less ignored. However, among the many challenges of governing is the simple fact that we do not always agree on the nature of the problem. I say Canadians eat too much salt, which causes widespread high blood pressure. Others say that there is no scientific consensus on the matter and scoff at the idea that there is a problem to be solved. In effect, fighting over how to define the problem and the science underlying problems is often a big part of the policy process – witness the debates about climate change or drug addiction.

Assuming we can agree on the nature of the problem (or at least most of us can, at least for a time) according to Scott a rational policy process would see us choose the option that is most likely to achieve desired outcomes. However, we are confronted by the reality that we are unlikely to agree on what is desirable. Policymaking is never only about solving a problem. It is addressing a problem in a way that is acceptable to at least some citizens some or most of the time. It is making decisions that advance a broader overall agenda if not a broader philosophy. It is addressing public concerns in a politically prudential way.

To return to the case of dietary sodium, we have no way of demonstrating unequivocally whether what is required is social marketing, industry self-regulation or government regulation of the food industry. And even if it could be shown that government regulation of the food industry is the optimal way to reduce the amount of salt in our diet, small-c conservative governments are unlikely to want to do so on broadly philosophical grounds.   Government regulation of food raises concerns about undue government influence in the lives of citizens. The latter objection cannot be resolved with reference to science alone. It is a normative claim and requires a different kind of reasoning altogether.

In effect, most of the truly interesting and non-trivial policy issues do not lend themselves to rational decision-making. Why? Because they involve disagreements over values and such disagreements, as Hume reminded long ago, cannot be resolved with reference to science alone.

Why INSITE is a not a good case study of evidence-based decision making.

Calls for evidence-based policy are routine.  And in Canada, the saga of the Vancouver safe injection facility INSITE is cited as an example of where politicians tried to ignore the evidence.  Consider two recent examples.

Source: iPolitics

Source: iPolitics

On Tuesday my university hosted a panel discussion by leading politicians in federal politics with an overriding theme of why young people should engage in the electoral process and, if nothing else, vote.  A laudable effort to be sure.  As is common with this type of event there were the usual questions of the audience.  Interestingly enough, the first such question asked the assembled leaders to comment on the place of evidence-based policy making.  Needless to say, all were quick to endorse the idea, some with more nuance than others.  Of particular interest were the comments of the New Democratic Party leader Thomas Mulcair who went out of his way to point to the efforts by the current Conservative government to shut down INSITE as an example of ignoring evidence in policy making.

Consider as well a recent blog post by my University of Ottawa colleague Scott Findlay where he argues that the Supreme Court of Canada’s decision to overrule the Government and insist that INSITE must remain open was about the proper use of evidence.  In his words, “evidence was critical to the Court’s decision”.  (Note that Findlay’s larger argument is not so much for evidence-based policy making as it is for transparency and openness).

Does this mean that the story of INSITE is the story of how evidence can and should influence public policy?  I think not.

As I argued in a paper in the Journal of Urban Health a few years ago, that INSITE continues to operate is not the result of a straightforward application of evidence to a public health intervention. In that article I argued that, on the contrary, “INSITE is the result of coalition building, the mobilization of public opinion, lobbying, and political and ideational struggle.” Without a doubt the use of evidence by the Supreme Court of Canada was a critical part of the story.  But to focus on that is to miss the fact that INSITE exists as a result of a complex combination of factors of which scientific evidence is but one.

hb_coverWhat is more, for many policy problems, this is the predominant pattern.  Evidence does play a role in policy making but it is most influential, as Roger Pielke puts it in his book The Honest Broker: Making Sense of Science in Policy and Politics, “in circumstances where the scope of choice is fixed and the decision-maker has a clearly defined technical question”. So, it is not that scientific evidence is not important, it is that its role is variable.  In other words, while we may want evidence-based decision making, only some decisions can be, or for that matter should be based on evidence.