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Epi Wit & Wisdom Articles
Community Members,
Epidemiologists, and Political Leaders: Essential Partnership For
Sound Health Policy
Ready! Fire! Aim! As one of my
favorite TV detectives methodically asks herself: What’s wrong with
this picture?
This odd sequencing of actions
seems to have produced two remarkable features of the US health care
system. We have the world’s most technically advanced array of medical
services, and we exclude one out of every seven citizens from third
party coverage for basic health care services. What are we aiming at?
Profit? Health? Solidarity? Costs? Efficiency?
Last year’s national flirtation
with system-wide health reform has passed into history. The managed
care revolution was already well under way before last year and
continues unabated. The full range of social goals behind this
revolution is not clear, and we risk firing off yet another round of
innovations before being sure what we really want to achieve. To be a
real government of the people, by the people, and for the people, we
need to clarify our social goals so that technical work by
epidemiologists and others can help determine the means to these
goals.
The Oregon Health Plan which
created a prioritized list of health services as a means of guiding
health care budget allocations is an important model for the necessary
partnership between the public and the technical persons who provide
needed data.
The distribution of tasks in
this process is the paradigm I want to highlight. The community was
charged with articulating values. The experts were charged with
determining facts—the probabilities that valued outcomes would result
from services used to treat specific health problems. The
epidemiologic experts provide the social capacity to determine whether
changes hit or miss the valued target. Epidemiology has a crucial role
to play in the political ethical work of the community as it seeks to
provision itself with the health care services it really wants.
For example, we need
epidemiological data to make sense of the apparently simple notion of
universality. Is universal coverage worth it from the point of view of
effect on the population’s health status? Other epidemiologic data is
needed to deal with the fact that coverage does not of itself provide
access to effective services. The continuing studies of small area
variations in medical care is an example of needed data.
Creating social impact is not a
new role for epidemiology. It is at the center of the public health
ethic. As managed care becomes more and more the delivery system of
choice in both the public and private sectors, epidemiologists need to
be ready to play a conscious role in this transformation. This is not
a call to abandon scientific canons of valid and reliable data. But it
is a challenge for epidemiologists to use the population-based
perspective which is uniquely theirs and pay attention to how their
facts affect (or fail to affect) social policy. The quality of life of
the whole society is affected by how well decision makers see the
consequences of policy choices and their impact on the values of the
community.
The contemporary challenge for
epidemiologists is to see themselves as partners with the general
public and with policy leaders in creating social ethics solutions to
complex problems. Policy leaders identify the next step agenda. The
public articulates the values that make outcomes worth achieving.
Epidemiologists and other technical experts provide the data by which
leaders can organize, coordinate and calibrate social effort and keep
it on target. Epidemiology, as a profession, should not stand apart
from politics, nor hope to replace politics with a higher rationality.
Society needs epidemiologists engaged in the political arena as
committed partners arguing for the data in the effort to make
political activity successful, democratic and fully human.
Published July 1995 v
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