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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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