Commentaries by the University of Texas’ Roberta Ness and the University of South Carolina’s Robert McKeown published in Epidemiology on the Accountable Health Advocates (AHA’s) proposal by David Dowdy and Madhukar Pai to create a new subspecialty in epidemiology have been critical. The commentators did not offer support for the concept of AHA’s even though both said they agreed with many of the key points in the arguments made.

Why then not support the concept?

Ness Commentary

According to Ness, knowledge translation should be the responsibility of all epidemiologists, not just those who want to specialize in that area. Ness called knowledge translation epidemiology’s “raison d’etre, our reason for being.” She disagreed on the specifics of the proposal but raised the ante for the entire profession by calling for a “Universal Health Advocacy” role through which all epidemiologists would actively engage in public health policymaking. More specifically, she would have all epidemiologists engaged in translation 1) by making public health recommendations, 2) implementing intervention programs, and 3) participating as advocates.

Audacious Idea

Ness recognizes that her proposal is, in her words, “audacious” because prominent epidemiologists have argued against involvement in policymaking. But as she told The Epidemiology Monitor, “the crux of the argument against advocacy is that it will ‘bias’ us and…bias is universal—conflict of interest is what we must guard against.”

Lack of Consensus

This lack of agreement about the role of epidemiologists in the profession as a whole was reaffirmed recently by the International Society for Environmental Epidemiology. It  stated in the recent update of its code of ethics that “there is no consensus among ISEE members as to whether environmental epidemiologists have a duty to go beyond objectively communicating facts or to become policy advocates.” (Epi Monitor, September 2012). For these reasons, the proposal by Dowdy and Pai is less audacious and perhaps more pragmatic since it seeks to garner support for epidemiologists who already have a shared value around knowledge translation activities.

Public Health Inaction

Ness agrees with Dowdy and Pai that translation of evidence is a problem. She called current translation efforts “deplorably slow” and cites examples about the delay in uptake of interventions to prevent cardiovascular disease long after the evidence for the value of certain interventions had been established.

Also, Ness highlights that financial interests can often block effective use of data. She believes that in addition to individual advocacy, there is “strength in numbers” and professional epidemiology organizations must also take on the task of advocating for evidence based public health interventions if there is to be improved chances of removing obstacles to evidence-based public health. The proposal by Dowdy and Pai is focused only on individual epidemiologists and their roles.

McKeown Commentary

Robert McKeown also withholds his support for the concept of AHA’s because he believes the same objectives can be achieved without the creation of a new subspecialty.

And, in agreement with Ness, he believes such a new creation would encourage other epidemiologists not focused on translation to believe they do not have responsibilities in this domain.

Team Solution

More specifically, McKeown argues that a better approach would be to rely on multidisciplinary teams since many members of these teams will possess the skill sets which epidemiologists may lack. The importance of such teams has been highlighted in recent reviews of case studies of successful translation by the American College of Epidemiology. As reported in The Epidemiology Monitor the most important ingredient for success…seems to be placing a high priority on a specific issue, and recognizing that this decision needs to be followed by a strong and long-term multidisciplinary approach.” (Epi Monitor, June 2012).

No One Size Fits All

Also, epidemiologists take on different roles at different times in the process of addressing public health problems, according to McKeown. Some may not be able to engage in data translation activities because of employers or lack of know-how, and they are nevertheless still responsible for conducting research that has as its goal the improvement of public health.

Ethical Obligation

Going further, McKeown argues that all epidemiologists have a fundamental ethical obligation and commitment to enhance population health and that accountability is part and parcel of responsible epidemiologic practice in general. McKeown elaborated on his view that the obligations to improve public health may take the form of doing excellent research that produces results important to public health.

Stalemate In Epi

There appears to be a stalemate on reaching agreement about core values in epidemiology. However, in academia, knowledge generation activities receive extensive support and translation activities receive significantly less support and attention. The Dowdy and Pai proposal seeks to break this stalemate, not by persuading all epidemiologists to act on translation, but by creating a new and incentivized career pathway for those who do agree about the paramount importance of improving public health and are willing to actively work to make this happen.

Need For More Complex Model

McKeown does not comment on public health inaction or the “deplorably slow” pace of translation, however, he does point to a variety of issues surrounding the challenge of translation which he believes should be explored further. If the policymaking and translation process are indeed complex as many observers have noted, then McKeown argues we need a model of this process which is more nuanced and sophisticated than what Dowdy and Pai are offering. He says “the probing exploration of these issues…would require asking why the movement from discovery to meaningful implementation and impact is so hard and takes so long and is often so limited or selective.

Rejoinder

In a rejoinder to the commentaries by Ness and McKeown, Dowdy and Pai express their opinion that the creation of the AHA’s will not make non-AHA epidemiologists less concerned with improving public health and less accountable for achieving that objective.  They believe that only time will tell how useful the AHA approach might be. But for now, “the desire to improve health is an urgent one, and we need alternatives to the status quo,” they argue. The goal of this proposal is to get us closer to the goal of improved public health, they told The Montor.

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