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Epi Wit & Wisdom Articles
APHA Committee Reports on Policy
Making in the Absence of Incontrovertible Evidence
Warning About Special Interest
Groups Know Thine Enemy
Making public health policy
decisions in the absence of totally convincing evidence is never easy.
Yet, this situation is more often the rule than the exception in
epidemiology.
Apparently struck by how often
regulatory and other public health actions are impeded by economic and
political considerations, an ad hoc group of epidemiologists and other
public health professionals have stepped in to provide some guidance
in the form of a position paper entitled “Public Health Policy Making
in the Absence of Incontrovertible Evidence.” Although not everyone
will agree with the causes of the problem or with the suggested
approaches to a solution, hardly anyone will disagree that the issue
is one of interest and importance for epidemiologists. After all,
epidemiologic data are often at the heart of actions initiated to
protect public health.
Impediments
According to the APHA Committee,
needed public health actions can be impeded by 1) true scientific
doubts; 2) concerns about costs of the intervention; 3) concerns about
logistics; 4) lack of understanding of scientific matters by the
general public and policy makers; and 5) special interest groups whose
opposition because of political and economic interests is disguised as
scientific uncertainty. The purpose of the report by the APHA
Committee is to further clarify the issues and forces which influence
public health policy decisions, and to make recommendations to APHA on
how to enhance its effectiveness in influencing these decisions. Such
a role for APHA is viewed as important both in the United States and
abroad, according to the report.
Issues
What are the issues when
deciding whether or not to undertake a certain public health action?
Obviously, the impact of the problem, defined as the number of people
affected and the severity of the problem are prime considerations.
Also, the strength of the evidence is a prime consideration since the
evidence may still be evolving, may range all the way from “anecdote
to absolute proof,” and different scales of proof may be applied in
different circumstances such as when the potential impact of the
problem is very great.
Constraints on policy makers may
exist in the form of time constraints (e.g., swine flu), public
demands (e.g., Love Canal, Times Beach), or other administrative or
legislative considerations.
Risks/Benefits
An important series of
considerations is made up of the anticipated risks and benefits of any
contemplated action, and both the direct and indirect risks and
benefits must be weighed. Also likely to come into play is the
estimated efficacy of the proposed action and the likelihood of
compliance by the population affected.
Any public health action is also
influenced by the anticipated costs of the intervention. Although cost
savings arguments can often be used to “sell” the intervention, the
extra funds needed may compromise available resources for other
worthwhile activities.
Special Interests
An important issue according to
the report are the “strong influences” of population sub-groups or
special interest groups with a one-track mind and/or with ample funds.
According to the report, “There are many frustrating examples of
public health programs that have been thwarted, delayed or weakened by
political pressures from such groups. The successful use of less than
absolute proof of causation as a shield to protect special interests
is epitomized by the sad saga of aspirin and Reye syndrome. A group of
aspirin manufacturers and their attorneys exploited the recognized
but, on balance, inconsequential epidemiologic problems in the studies
that linked Reye syndrome to aspirin. Direct approaches by this near
billion dollar industry... persuaded the deregulation-minded Office of
Management and Budget to block the FDA’s proposal for such a warning
(label) from 1982 to 1986. There is little question that this
politically and economically motivated delay resulted in death or
disability to at least one hundred children and adolescents.”
Other important influences on
policy decisions are those related to their potential infringement on
individual rights and the need to balance the constitutional rights of
the individual against the welfare of society as a whole. Also, poor
comprehension of science by regulators, legislators, and the lay
public serves to compromise effective communication of the rationale
for policy decisions.
Approaches
To help APHA influence policy
decisions when the evidence is less than incontrovertible, the
Committee made recommendations in seven areas:
1) Evidence
It should be evaluated carefully
and explored fully. Weaknesses should be acknowledged and aired. The
evidence should be provided to all involved.
2) Public Health Measure
It should be considered as
carefully as the evidence was considered by examining priorities,
alternative measures, costs, benefits and implementation aspects. All
inputs into the decision should be made available to those involved in
implementation.
3) Know Thine Enemy
Anticipate opposition so that
any negative impact can be prevented, neutralized or ameliorated.
4) Implementation Strategy
Spend as much time in developing
a strategy to promulgate the solution to a public health problem as in
assessing the problem and its solution. Consider implementation in
stages to mobilize support. Identify and organize the most effective
constituencies within APHA to develop advocacy. Communicate the
rationale for recommendations in comprehensible form to decision
makers.
5) Science and the Health
Professional
Strengthen training in analysis
of scientific evidence in schools of public health. Enhance teaching
of epidemiology and biostatistics in professional schools for health
care providers.
6) Science and the Consumer
Communicate the rationale for
recommendations succinctly and understandably. In the long term,
enhance science education.
7) Future Work
Prepare a more complete and
widely disseminated report “to the Nation” on the status of public
health decision making.
Authors
Members of the APHA ad hoc
committee who participated in the preparation of the report are:
Edward Mortimer Jr. (Case Western Reserve), Jeffrey Koplan (CDC),
Irving Lewis (Albert Einstein), Ruth Roemer (UCLA), Linda Rosenstock
(University of Washington), Robert Woolson (University of Iowa), and
Peter Lachenbruch (UCLA). The report was written principally by Dr.
Mortimer who is Elisabeth Severance Prentiss Professor of Epidemiology
and Biostatistics at Case Western Reserve and is slated for
publication in the American Journal of Public Health.
Published October 1989 v
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