Category Archives: Health Policy

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.

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

tophc_ca

 

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.

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.

 

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