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“He believed in the democratic tradition that making the facts
known to those who need them is the basis for achieving effective
action,” and “…it is the epidemiologists’ function to get the
facts to the decision makers.”
Quoting William Farr, an early pioneer in epidemiology, in
the first instance, and Alexander Langmuir, the father of
shoe-leather epidemiology, in the second instance is how the
University of Southern California’s Jonathan Samet began
his Langmuir lecture at the 86th annual meeting of the
American Epidemiological Society in East Lansing Michigan in late
March.
A
key objective for Samet’s talk was to depict the conceptual model
of the research and policy or data translation process which has
guided epidemiologists since about the time of John Snow and the
removal of the Broad Street pumphandle.
This model, which Samet labeled the Snow model for the Langmuir
lecture, and which has been referred to as the “public health
model”, consists of five steps-1) identifying the problem, 2)
gathering data, 3) analyzing and interpreting the evidence, 4)
translating from evidence to action, and 5) surveillance or
continued tracking of the problem. The underlying assumptions
behind this model are that decision makers are listening to the
facts, and the facts will speak for themselves about what public
health action should be taken.
Whether or not the Snow model ever pertained quite as
straightforwardly as implied is beside the point for Samet. A
second key objective of his talk was to demonstrate that the Snow
model no longer characterizes the evolving real-world of policy
making today. Something more than facts is needed, according to
Samet, and he encouraged epidemiologists to adopt new models for
thinking about epidemiology and the policy process, and to play
new roles in it.
Snow Model in Action
Samet used the example of tobacco and lung cancer to walk his
audience through the five steps of the Snow model and how they
were carried out for that exposure/disease combination. While
uncertainty about the evidence provided by epidemiologists has
always been part of the assessment of evidence, that assessment
process in today’s world has become more complicated by the
involvement of more activists, greater attention to costs,
attention to more political considerations, and by attacks on the
quality of evidence itself, Samet told the group.
In using the Snow model today to help decide about potential
public health actions, the strategies are to conduct more studies,
carry out systematic reviews, and communicate the findings.
However, for each of these steps which can help to tip the balance
in favor of taking or not taking public health action, counter
strategies are being used by special interests to question the
very existence of problems, conduct bad studies, attack the
methods used in good studies, provide alternative interpretations
of findings, and discredit findings---all to block action.
Samet described the activities of tobacco companies
and of industries wanting to block ozone standards
required by the Clean Air Act as
examples of the new realities facing 21st century
epidemiologists. Samet cited several recent books with titles such
as “Merchants of Doubt”, and “Doubt Is Their Product” to buttress
his observations about the current policy process.
What To Do About It?
One option would be for epidemiologists to take more direct action
to bring about evidence-based public health interventions. Samet
cited a recent editorial in the Journal of the World Public Health
Nutrition Association which claims that John Snow actually
succeeded in removing the Broad Street pump not by the force of
his data, but rather by taking the law into his own hands,
defying the decision makers, and breaking off or removing the
handle himself from the Broad Street pump. Samet asked
provocatively, “Did John Snow break the pump handle?”
Is that what it would take? The same editorial quotes Frederick
Douglass, “Power concedes nothing without a demand. It never did
and never will…”
The editorial asks if public health professionals are too polite
for the good of their cause.
While not asking the same question about epidemiologists, and not
advocating defiance on their part to get things done for public
health, Samet told his audience that researchers could be doing a
better job in bringing the data to the policy process. He called
for 1) quantifying uncertainty, 2) enhancing the informativeness
of research for decision- making, 3) changing evidence evaluation
schemes, and 4) preparing researchers for translation.
Core Responsibilities
Samet put forth that epidemiologists may have core
responsibilities in communicating to stakeholders and decision
makers, assuring that their evidence is interpreted correctly,
monitoring the policy process, and engaging in the policy process.
Assuming these responsibilities are core, he identified roles for
epidemiologists in the process as experts, consultants, committee
members, stakeholder representatives, and as participants in the
policy process.
In addition to these more proactive stances, Samet suggested that
additional efforts to create a new policy process model might
address additional training in policy translation, the creation of
translation specialists such as was suggested recently by Dowdy
and Pai in Epidemiology (1), conducting surveillance for
the use of evidence, adopting new roles for professional
organizations, and creating new partnerships.
Conclusion
In his concluding remarks, Samet reminded the audience that
epidemiology is important for policy, times have changed since
Snow and even since Langmuir, policy approaches are evolving, and
epidemiologists should be involved in their evolution.
References:
1. Epidemiology 2012; 23(6) :927-8
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