Monthly Archives: January 2014

Political perspectives in public health

For several years now I have been pondering the intersection between public health and political science and between public health and politics.  How, where and with what effect the two intersect is manifest in a number of dimensions, some scholarly, many decidedly practical and real (my earliest effort in this area was published in 2008).

One of the perennial debates in public health generally and health promotion in particular is the role of “individual” vs. “societal” changes in improving the health of populations.

The “individual” perspective on public health (let’s call it IPH for short), emphasizes the importance of each of us making small and not so small changes in how we live our lives as the key to improving our own health and, collectively, the health of the population overall.  As my University of Ottawa colleague Yoni Freedhoff recently put it “what we choose to do with our forks and our feet” has significant implications for our health.

The “societal” or “structural” perspective on public health (let’s call it

John Locke

John Locke
Source: Wikimedia Commons

SPH for short) argues first, that societal or structural changes are required to improve population health, and second, that absent these structural changes, it is difficult if not impossible for many people to make the individual changes required to improve their own health (e.g., the poor cannot eat well if they live and “food deserts” and do not have access to health food choices where they live).  There are various versions of SPH from those that emphasize changes to our built environment (e.g., how we design and build cities) all the way to those that argue that the structural changes required go much deeper and point to the design of the welfare state.

My working hypothesis is that there is a set of relationships between these different perspectives on what matters for public health and different ideological if not philosophical positions.  IPH clearly has it roots in traditional liberalism with an emphasis on the central importance of individual choices about the good life.  Conversely, an SPH perspective is linked to a more social democratic interpretation of what makes the world go ’round.

In contemporary politics the IPH perspective is by far the stronger of the two (or at least something that most governments can agree on) and gives rise to the bureaus, agencies and departments devoted to health promotion.  The SPH perspective is not completely absent but pops up more selectively (e.g., the largely ineffectual interest of the government of Tony Blair in health inequality; the WHO Commission the Social Determinants of Health – which itself has been accused of being excessively liberal in its orientations).

Krieger

Source: Oxford University Press USA

This is by no means a novel observation, at least in public health circles. Nor is it anything close to a complete account of the different perspectives in public health (for this you would be well served to read Nancy Krieger’s magisterial survey of public heath theory).

I draw attention to it because it would seem that there is a growing awareness in the broader population that health is more than health care (a truism among students of public health).  Yet, when a well-intentioned citizen or politician wishes to take the claim seriously, she or he is immediately confronted by quite different accounts of what it means to tackle public health using tools beyond the health system.  In other words, perennial debates inside public health are being moved into a broader arena.  This means that the usually polite disagreements between proponents of different flavours of both IPH and SPH accounts of what keeps up healthy risk being transformed into a more partisan, and therefore more heated and perhaps partisan discussion if not debate.

And this could be a good thing.

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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

“To write or even speak English is not a science but an art. There are no reliable words. Whoever writes English is involved in a struggle that never lets up even for a sentence. He is struggling against vagueness, against obscurity, against the lure of the decorative adjective, against the encroachment of Latin and Greek, and, above all, against the worn-out phrases and dead metaphors with which the language is cluttered up.”

George Orwell, The English People

Policy as Values

(This first appeared in the newsletter of the Institute for Science, Society and Policy at the University of Ottawa.)

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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 whether policy making is rational and many have argued that it 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.

salt 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 observe that 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 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.

Closing_the_deal__What_role_for_the_provinces_in_the_final_stages_of_the_CETA_negotiations_

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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