Monthly Archives: May 2014

Scientific evidence alone is not sufficient basis for health policy

nationalscie

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.