In 1989 at an epidemiology and ethics meeting in Birmingham Alabama just prior to the meeting of the Society for Epidemiologic Research, a professor of ethics asked epidemiologists---What are your allegiances? Do these allegiances have priorities? To the truth? To the social welfare? To employers? What is epidemiology all about? (Epi Monitor, October 1989).

New Context in 2012

At that time, reaching agreement on the answers to these questions was considered important for the development of a proper code of ethics. Now some 23 years later, the questions of allegiance and purpose have been raised again in a recent series of papers in Epidemiology. This time the issue is not about ethics per se but about a proposed new subspecialty in epidemiology focused on knowledge and evidence translation. The authors have stated very clearly that while epidemiologists have allegiances to the truth and the public health, the primary allegiance should be to the improvement of human health.

A Proposal

Writing in this month’s issue of Epidemiology, David Dowdy and Madhukar Pai make a case for creating “Accountable Health Advocates” (AHA’s), a new subspecialty of epidemiologists which would focus more intentionally on the translation or use of epidemiologic findings to improve public health.

Support for this work would come from a reallocation of resources or creation of new rewards and incentives for epidemiologists who choose this career path. At present, the authors say there are many disincentives for epidemiologists to advocate for the utilization of established evidence, including “professional fallout” from a perceived lack of objectivity and difficulty of publishing such work in scientific journals.

Why Needed

Why are Accountable Health Advocates needed? According to Dowdy and Pai, there is a surplus of relevant public health evidence, and a deficit in the utilization of these findings to improve population health.  At some point they argue, greater balance needs to come about and will come about between the creation of knowledge and the use of this knowledge. Otherwise public support for the creation of knowledge will become unsustainable and unjustifiable, according to the authors. This conclusion applies to all of the science enterprise, and they believeepidemiology should begin to correct this balance now because it has a “head start” on other disciplines which lack epidemiology’s history as a public health or applied discipline.

Interview With Dowdy

In an interview with The Epidemiology Monitor, Dowdy expressed his view that the prime reason many epidemiologists entered the field to begin with is because they want to make the world a healthier place. But, according to Dowdy, “the current incentives structure in academia cannot be fixed by tinkering at the edges. Rather, a fundamental shift in that structure is necessary if the incentives of epidemiology are to be re-aligned with the goals of public health.”  It is focused on promotions through grants and publications designed to generate and disseminate new knowledge deemed useful by other scientists. This incentives structure is preventing epidemiologists from achieving the ideal of improved public health that inspired them to enter the field in the first place. According to Dowdy, we have to create new structures to better achieve our ideals, and to meet the goals society sets for us.

Ultimately, the authors envisage all of the new practices as making a direct impact on health and thus being appreciated by the public as more relevant to their health needs. This increased relevance could in turn help maintain the support for research institutions that are contributing in this way.

Not About The Model

Dowdy told the Epidemiology Monitor that he would be among the first to admit that the AHA model proposed is a “simplistic” one. He said the primary aim of the paper was not to put forth and defend the specifics of a particular model for more active advocacy by epidemiologists, but rather to jump start a conversation about the disconnect between epidemiologists and their ideals for improving public health.

He said the idealist in him hopes that when epidemiologists read the article they will sense this disconnect between current structures and their ideals, and as more colleagues recognize this and that others feel this way, then he hopes an organic uprising will occur directed at reform of existing incentive structures.

The skeptic in him, he said, believes that existing power structures are aligned against such a fundamental restructuring , and only external pressures from a new reality such as deep funding cuts will succeed in bringing about reform.

Comments From Pai

In comments to The Epidemiology Monitor, co-author Madhukar Pai pointed out some of the difficulties in knowledge translation. “Acting on evidence is hard because it requires engaging with policy makers, funders, communities, and field level health workers who have to act on the policies/evidence,” he said. Also, other reasons this work is hard are it may take years before impact is

visible and the work can become political which “pure” scientists want to shy away from. According to Pai, “it is also worth noting that the US is probably much more focused on basic knowledge creation and discovery that other countries which are much more friendly to knowledge translation and policy work. For example, Canada is big on knowledge synthesis, knowledge translation and converting evidence into policies. There is a lot of emphasis on evidence-based clinical and public health practice, and funding agencies such as Canadian Institutes of Health Research are quite happy to fund such work. The US/NIH , on the other hand, is very discovery/basic science focused.

Call  For A Discussion

Our main concern said Dowdy is not so much about whether the model is right but about whether or not the status quo is acceptable. He stated that he and his co-author are interested in continuing the conversation in the hope of eventually achieving a collective vision of the status quo which is better than the current one.

Comments from readers on this topic are welcome and encouraged. Responses from the authors will be posted online as well as those from our readers. Join and follow the conversation at :

www.epimonitor.net/Forum.htm

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