Rethinking knowledge translation for public health policy

We live in a world where populist political projects are reviving the latent suspicion of many that elites, intellectuals, and their allies are not to be trusted. The public good, so the argument goes, can only be advanced by listening to ‘the people’ and at the same time by limiting the role of traditional elites and their academic allies. The inevitable response is that some of these same elites double down on the critical importance of science and evidence as the basis for government action. There are repeated calls for ‘evidence-based’ (or at least ‘evidence-informed’) policy as a partial offset to the populist and-intellectual surge.

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Uris Library Cornell (Source: Flickr)

But what does it take to actually move scientific knowledge into policy? While much has been written about this I recently published an article, with my friend and colleague Steven Hoffman, that seeks to bring to bear on this question some insights from the political science literature on the policy making process. We use the case of public health to argue that all too often efforts to do move evidence into policy rely on mechanistic and unrealistic views of the process by which public policy is made. As a result, traditional dyadic knowledge translation (KT) approaches may not be particularly effective when applied to public policy decision making. However, using examples drawn from public health policy, it is clear that work in political science on multiplicity, hierarchy and networks can offer some insight into what effective KT might look like for informing public policy. To be effective, KT approaches must be more appropriately tailored depending on the audience size, audience breadth, the policy context, and the dominant policy instrument.

You can read the full argument here.

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Why did it take so long to (sort of) finalize the CETA?

In the Fall of 2013 the Government of Canada finally announced that it had finalized (sort of) an agreement with the European Union for a comprehensive trade and economic agreement. I say “soft of” since the all that was released was a general overview of the agreement .

While a number of questions still remain about the agreement, one of the most puzzling (at least for some of us) is why it took so long for Canada and the European Union to come to an agreement?

Negotiations began in the Spring of 2009 and the Government of Canada began hinting that a deal was imminent as early as 2011.  The fact that the two sides disagreed on some key issues like patent protection, access of Canadian beef to European markets, to name but two, is not, in of itself a sufficient explanation for the long drawn out process of concluding an agreement.  And, strictly, speaking, absent a final legal text it is likely that a form of negotiations is ongoing.

My colleague Patrick Leblond and I have followed the CETA negotiations from the beginning.  We are particularly interested in the role of provincial and territorial governments in the negotiations.  (For a comparative perspective on the role of subnational governments in trade negotiations see the paperforum of fed image2 we wrote for The Federal Idea).

Simply put, for the first time, provinces were invited to be part of the negotiations rather than merely consulted.  This is in large part because the EU insisted that provinces be present given several parts of an eventual agreement lie in provincial jurisdiction.   We are interested in understanding what this means in practical terms.

We believe that one of the reasons it took so long to finalize an agreement is that Ottawa and the provinces did not put in place a formal process for securing provincial approval of the final shape of an agreement.  Absent such a process, the federal government found itself negotiating bilaterally with individual provinces (and associated powerful economic actors e.g., Alberta beef producers).  To put it another way, a process was put in place to involve provinces in parts of the CETA negotiations but nothing was done to formalize a process for eventual decisions about the final terms of an agreement.  This, we believe, is at least a partial explanation for the delay in securing a final agreement.  This argument is developed more forcefully in a paper we recently published in the International Journal along with a strong set of related  papers on the provincial role in the CETA negotiations.

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And the story is by no means over.  While several provinces have publicly signalled their support for the draft agreement with the European Union, de facto negotiations continue.  Quebec is concerned about the impact of the proposed agreement on Quebec cheese producers and several provinces are concerned about the impact of a deal with the EU on the price of prescription drugs. More importantly, perhaps, it remains to be seen what, if any mechanism will be put in place to formalize provincial support for the CETA.  Absent some sort of agreement, if and when a provincial government fails to implement its promises pursuant to the CETA negotiations, the federal government will be on the hook to pay any financial penalties that may be levied.

In effect, even though much was made of involving provinces in the negotiations, the CETA may end up being quite similar to the NAFTA.  In that case, because Ottawa is the sole signatory to the deal, it is responsible for ensuring compliance and, failing that, paying any financial penalties that may be levied.  More generally, there are limited ways for provincial and territorial governments to “sign on” to the NAFTA. The same appears to be the case for the CETA.  From both an economic and political point of view, surely we can do better than this.

A clash of ideas is not a war on science

(This first appeared in the Ottawa Citizen on October 10, 2013)

dna-pictures4The Professional Institute of the Public Service will soon release the results of a poll of scientists employed by the Government of Canada. The poll results will fuel an already-heated debate about what some feel is a “war on science” waged by the government of Prime Minister Stephen Harper.

However, the problem is not so much a war, as it is more a mix of politics and competing visions of the public good.

First, if there is a war on science, it has been going on for some time. There is an ongoing debate about the role and place of science in the making of public policy. Moreover, since the 1990s, successive governments, Liberal and Conservative, have limited funding for government labs while increasing funding for university-based research and development. Similarly, the pressure to increase the commercialization role of federal labs did not begin with the current Conservative government but began in the late 1990s, if not earlier. This may weaken the ability of the federal government to regulate and make policy but it is not new.

Second, while we might agree that the scientific research funded by or done directly by government should serve the broader public interest, we do not agree on how to define it. Traditionally, much of government science was linked to the policy and regulatory process in areas like health and the environment. Yet a major part of this science has always been linked to promoting economic growth by using government labs to develop new technologies linked to such things as nuclear energy, agriculture or biotechnology.

The Harper government, like the Liberal governments before it, believes that economic growth is in the public interest and government science should be directed to support that goal along with more traditional public interest objectives like limiting pollution and products that put human health at risk.

Third, a big part of the current debate turns on how best to balance the right of a government to control what is said in its name and the right of scientists to freely talk about their research.

Many of the current rules governing what federal government scientists can say, to whom they can say it and when are ridiculously restrictive.

Scientists working for the Government of Canada should be able to speak freely about their research. We are not well served by a government that is excessively preoccupied with controlling the message in order to secure short-term partisan advantage.

However, government scientists are public servants and, unlike university researchers, they have a responsibility to avoid overt criticism of the government of the day. This is challenging when the media goes looking for a gap between government science and government policy and, having found it, tries to convince us this is a problem.

Finally, we need to ask if scientific evidence alone should determine public policy. Science does not and indeed cannot be the only basis for public policy. The opposite of evidence-based policy is not, as some of the critics seem to assume, ideologically driven chaos. Our elected representatives are tasked with making judicious choices that balance scientific evidence, public opinion, job creation, economic growth, environmental protection, trade and foreign-policy objectives, and much else besides.

In essence, much of the current debate about science and government is based on a fundamental misunderstanding of democratic politics. Nothing is gained by saying “science” is good and “politics” is bad. This is a caricature of both science and politics and the relationship between the two.

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On the politics of cancer screening – a case of governance?

thOn a regular basis newspaper articles appear calling for more and less screening for various diseases, notably cancer.  Just this week I came across two on breast cancer screening.  One, in the New York Times, was sceptical of the merits of mass screening raising the very real risks associated with false positives.  On the argument that “overtreatment is typically more common than avoiding a cancer death” H. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, calls for more research to develop a finer grained understanding of the risks and the benefits of breast cancer screening.  A second article in the Huffington Post took issue with the claims of Dr. Welch, making the case for continuing emphasis on screening. (For an excellent overview of the evidence on breast cancer screening – albeit arguing for less screenign – see here).

What I find most interesting about these debates is that governments try hard not to get directly involved.  In the spirit of medicine as a self-regulating profession, most governments offer citizens limited advice and we told to discuss our options with our doctor.  (There are some interesting exceptions when, for example, a provincial government (in this case Ontario) actively promotes breast cancer screening while refusing to pay for PSA tests except where a physician or nurse practitioner suspects prostate cancer. For an excellent primer on prostate cancer screening see here.)

Prostate_Cancer_ScreeningsOccasionally, a task force or advisory body will release new guidelines for screening and a spirited if not vociferous debate ensues as different groups weigh in arguing the new recommended guidelines are too lax or too strict.  In 2012, for example, the U.S. Preventive Service Task Force issued a new set guidelines for the screening of prostate cancer. The Task Force took a dim view of PSA tests which precipitated a very strong reaction from the American Urological Association.  And less than two years later Prostate Cancer Canada issued its own set of guidelines calling for more rather than less use of the controversial PSA test.  This underlines the fact that there are, in fact, a plethora of guidelines issue by different authoritative groups.  Sometimes they are similar, very often they differ in important ways, and occasionally they are contradictory.

What is the citizen/patient to make of all of this?  I am not sure.  But it seems to me that cancer screening is a potentially useful area for political scientists interested in governance, policy networks, and the general trend of authoritative rule making by entities other than elected governments.

Now the search begins for a good model of non-state governance that would contribute to the systematic study of health sector governance in general and, in particular, the politics of cancer screening.  Suggestions welcome.

Governance

Behavioural Economics and Public Policy

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Source: CAD Soft Consulting

Behavioural economics is all the rage these days, particularly so when it comes to what it might mean for public policy. We repeatedly read that both UK Prime Minister David Cameron and the Obama White House are very much interested in the use of behavioural economic techniques as a tool of public policy.

But as is so often the case what we mean exactly by behavioural economics is not clear. The Financial Times recently ran an excellent primer – you can find it here.

Who sits on the Supreme Court as a window on the decline of federalism

Supreme Court of Canada building (Source: Creative Commons)

Supreme Court of Canada building (Source: Creative Commons)

Who should sit on the highest court in the land and by what process should these people be chosen?  For some, these may be somewhat esoteric questions.  Yet given the enormous power and influence of the courts, particularly in a country like Canada where the Charter of Rights and Freedoms leads to legal challenges of a wide range of government decisions, these who and how questions are actually very important.

Recently these questions were front and centre as the Supreme Court of Canada heard arguments on the constitutionality of the appointment of Marc Nadon to the same Supreme Court.  As Andrew Coyne and others have pointed out, the very fact that the Court has been asked to rule on the constitutional merits of the Nadon appointment is awkward, to say the least.

With one exception, I will leave it to others to debate the question of “who” and whether Marc Nadon is an appropriate choice.  Suffice to say that many were surprised by his appointment and he was not on the short list of those who handicap nominations to the Supreme Court.  The exception that I am interested in is the widely accepted idea that three judges on the highest court “should be from the province of Quebec”.  I put this characteristic in quotation marks because what it means is subject to interpretation.

The Supreme Court Act provides in Section 6 that “At least three of the judges shall be appointed from among the judges of the Court of Appeal or of the Superior Court of the Province of Quebec or from among the advocates of that Province”.  Why?  Much of the commentary on the controversy around the Nadon appointment emphasize the fact that at least part of the rationale for this section is that it is critical that the Supreme Court of Canada have expertise in the Quebec civil code which addresses “all of the basic provisions that govern life in society, namely the relationships among citizens and the relationships between people and property”, including for example, family and property law.

quebec flagHowever, I think there are other reasons why at least three of the judges must be from Quebec.  While it is not specified in legislation there is a very strong constitutional convention in Canada that, taken together, the nine judges of the Supreme Court of Canada should “represent” all of the “regions” of Canada.  I put quotation marks around the notions of representation and regions because there is some debate as to what these terms mean.  For the moment suffice to say that all would agree that when it comes to regional representation on the Supreme Court of Canada, Quebec is a region unto itself.  Moreover, in most of Canada and especially in Ontario where most of our pundits live and work, the view seems to be that when we say that a judge on the court represents a given province or region we are not saying that they are to be delegates and seek to defend and advance the interests of their province or region.  Rather, the convention provides for representation in a narrower sense.  We want judges from across Canada so that the Supreme Court has represented on it, the geographical diversity of Canada.  In Quebec, however, there are those who believe that the judges from Quebec should be able to defend the interests of Quebec, assuming that a province can be said to have a discernable and coherent “interest”.

However, all of this is preliminary to my main concern which is “how” judges are appointed.  Simply put these are decisions of the Prime MInister and the Minister of Justice.  Prime Minister Harper has introduced a slight innovation whereby after the decision has been made, but before it is finalized, the candidate appears before an ad hoc committee of the House of Commons and relatively benign questions are asked.  We learn relatively little.

More importantly, the process does little to address the role of justice of the high court as representatives of regions.  All we have is the assurance of the Prime MInister and the Minister of Justice that the candidate will be able to serve as an able representative of the region she or he is from.  Again, they are not asked to be delegates, only to enjoy a degree of legitimacy as someone who understands “their” region.  Alas, Mr. Justice Nadon has not been deemed an able or particularly legitimate representative of Quebec.  While much of the commentary has focused on his ability to understand and judge civil law cases, my concern is linked but broader.  For me, the legitimacy of the Supreme Court of Canada lies in the extent to which citizens believe that court judgements will be fair.  And in Canada, a country with real and often sharp disagreements over region and language and culture, this legitimacy is defined by more than sheer intellectual or legal competence.

If the Supreme Court of Canada rules that Mr. Justice Nadon’s appointment is, in fact, constitutional, that is not the same thing as saying that it will deemed legitimate.  At some point the Court, of which Mr. Nadon is a member, may well be asked to rule on a regionally or linguistically divisive issue.  The judgement may well not enjoy the support and legitimacy in Quebec, precisely because of the controversy surrounding the appointment of Justice Nadon.

Source: McCord Museum

Source: McCord Museum

It does not have to be this way.  In the not so distant past Canada was on the cusp of amending the procedure by which members of the Supreme Court of Canada are appointed.  Precisely to to reflect the regional and linguistic diversity of Canada, both the Meech Lake and Charlottetown accords included provisions to give provincial governments a role in appointments to the high court.  Had the Harper government been required to publicly and formally consult with the Quebec government, it is almost certain that the person nominated would not have been so controversial with the risk of undermining the legitimacy of future decisions by the Supreme Court of Canada.

Changes to the process of appointing judges to the Supreme Court of Canada do not require constitutional amendments.  A future Prime Minister could quite easily announce that she or he would formally and publicly consult with the provinces before making appointments to the Court.  Of course, this would reflect a different and older conception of what Canada is about.  But the prospect of a victory by the Parti Québécois in the next Quebec election is a reminder that Canada and its constitution are yes, about rights, but they are also about regional and linguistic diversity and the federalism instituted to reflect this reality.

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.