On potty training a black swan. Exploring the limits of the evidence base in public health

Posted by Heather Yoeli

In recent years public health has been trying to make itself more evidence-based, which is probably why policy making, commissioning and service providing organisations seem to be listening to and funding research centres such as Fuse at the moment. Evidence is an epistemology, a theory of knowledge. Evidence is the main epistemology which science believes in.

The primacy of evidence was first asserted by the eighteenth century philosophers Locke and Hume, who created empiricism as the theory that our only way of knowing anything is to see, hear, smell, touch or taste it. Empiricism has developed into the methodology of twentieth century scientific research by Popper, with the aid of a few black swans along the way. The processes and protocols for creating evidence bases from scientific research continue to evolve, with new mechanisms for ensuring rigour, validity and trustworthiness of peer review developing in response to new challenges.

At this present moment, however, one of the greatest challenges in my life is in trying to persuade my daughter (as many twee American parenting websites would put it) ‘to go potty in the bathroom’. As a research scientist I have sought help from the evidence-based publication Poo Goes to Pooland. Poo Goes to Pooland was written out of the doctoral research of local psychologist Tamsin Black, and is the of Poo, who is lonely and unhappy in a child’s bottom and wants to go home his mummy in Pooland, and about how Pooland is down the toilet and we can all send our poos there too. For clever empiricists, however, Poo Goes to Pooland has one inherent problem, and my daughter noticed it before me, asking ‘but Mummy how do we know that Pooland is down the toilet? How do we know that Pooland isn’t on the floor or in my knickers? Can you not pwove it?’ I can’t pwove it. She’s right. And she’s too bright to be fobbed off by my attempts to show her Poo’s Mummy peeping out from behind the U-bend, either…

And so, the need to locate Pooland reveals the limits of empiricism and the drawbacks of evidence-based methodology. I have therefore been attempting to use some alternative epistemologies to persuade her;

1. The rationalist method (Descartes, Leibniz etc): We can’t prove that Pooland is down the toilet but we can theorise that it’s there. Thousands of toddlers have successfully used Poo Goes to Pooland to teach them to poo in the toilet, so Pooland must be down there somewhere.

2. The psychoanalytic method (Jung, Klein etc): It’s a category error to demand proof. Poo Goes to Pooland is a story, a piece of literature. Pooland is a metaphor created to teach us where to poo, not a real place.

3. The ontological method (Anselm, Heidegger etc): We don’t need to prove it as such. Few of the millions of people who believe in God value any attempt to verify his existence, because even by believing something to be there we can create its existence for ourselves. Pooland is.

There are alternatives, then, to the empiricist epistemology of the evidence base. But I can report that none of them are working either; my daughter is still not going potty in the bathroom.

There are, of course, evidence-based alternatives to the Poo Goes to Pooland method. And even within evidence-based potty training practice, evidence bases can produce many approaches;

4. The medical approach: Stop thinking about Pooland for just a minute. Is there something making it sore for you to poo on the toilet?

5. The behavioural approach: It doesn’t matter where Pooland is. Just sit calmly on the toilet reading The Lorax until you poo and you’ll get a Peppa Pig sticker on your chart.

6. The hermeneutic approach: Let’s talk about Pooland, shall we? Let’s chat about poo and toilets for a bit…

So far, none of these are working either. And then, as is usually the case in most areas of public health, epistemologies get tangled up with ideologies and politics;

7. The communist/kibbutz method: All of you together, arrange your potties into a neat line and sit and poo together. Nobody moves until everyone poos. (Just to clarify, I haven’t tried this)

8. The authoritarian method: You will poo where I tell you because I am your parent. End of. (Again, to clarify, I’m not going there.)

9. The attachment-parenting approach: If we keep breastfeeding, co-sleeping and home-educating you for long enough and relax, you’ll poo in the toilet eventually, even if it takes a few more years.

So… it’s all providing a brilliant introduction to epistemology; fascinating insight into the range of ways we can think about what we know, and daughter is having a fantastic time intellectually out-manoeuvring me. But she’s still not going potty in the bathroom, so all further ideas (and/or donations of Ecover) are most welcome.