Tuesday, 10 June 2014

Not necessarily useful, and unapologetic: Speaking out on health equity

Posted by Ted Schrecker

We should now be familiar with some hard facts about health equity. In the United Kingdom, despite rhetorical commitments by the previous government to reduce health disparities between rich and poor, by 2007 such disparities were on many measures greater than at any point since the 1930s. This was before the economic crisis and subsequent austerity measures, which have disproportionately affected the UK’s poorest regions, including of course the North-East.

North end of Stockton high street
Yet in discussions of how to reduce health disparities, a frequent refrain is that the evidence is not strong enough to serve as the basis for new policies that change the conditions in which people live and work. Tobacco control initiatives and encouraging people to eat a healthy diet are fine, but not so challenges to ‘the inequality machine [that] is reshaping the whole planet,’ in the words of the editor of Le Monde Diplomatique. Since (for example) the Canadian experience shows that a healthy diet is often unaffordable for benefit recipients or the working poor, and more than 46 million people in the United States are relying on the government vouchers known as food stamps, that would seem to be a major omission.

Debates about the strength of evidence are hardly new: think about tobacco, or climate change, or any number of environmental and workplace exposures the lethality of which is now widely acknowledged. The ethical and political nature of choices about standards of proof (how much evidence is enough) in these debates is often neglected. I began a recent article on this point with an analogy to the case of former professional athlete O.J. Simpson. Acquitted of the murder of his estranged wife and her friend in a criminal trial, he was nevertheless found liable for damages in a civil proceeding initiated by the survivors of his alleged victims. The difference simply reflects the much higher standard of proof that must be met, in common law countries, in criminal proceedings.

My points were that (a) the concept of a standard of proof is crucial for public health policy; (b) the choice of a standard of proof with respect to social determinants of health, as for environmental exposures, is a matter of public health ethics with respect to which scientists qua scientists have no special competence; and (c) unreflective insistence on a definition of scientific quality organised around avoiding false positives, or Type I errors, can be highly destructive of health, and in particular health equity, under conditions of uncertainty. Waiting for more evidence is itself a decision about risks and benefits. This point has been made in the literature for decades, yet it continues to be either ignored or willfully misunderstood.

A case in point: in The Body Economic, David Stuckler and Sanjay Basu assemble abundant evidence of the destructive consequences of austerity for population health, although much of it is not derived from experimental or quasi-experimental studies. Stuckler and Basu correctly observe that ‘in countries where austerity is ascendant, we’re undergoing a massive and untested experiment on human health, and left to count the dead.’ In ten or 20 years, that experiment may indeed provide answers to some of the questions epidemiologists would like to ask about social determinants of health, although there will always uncertainty because in the real world many things go on in people’s lives at the same time. Whether or not the experiment is justifiable is a matter of public health ethics, although it is seldom recognised as such.

Indifference to the role of competing values in making policy based on scientific evidence, and to the politics of such choices, is a generic problem. It is exemplified by the frequency with which speakers at a recent conference on urban health in Paris talked about the need for research to be useful to decision-makers. Similarly, an article on the relation between health research and public policy exhorts social epidemiologists to concentrate on narrowly defined questions amenable to experimental or quasi-experimental study designs that will generate ‘the kind of evidence wanted by policymakers.’

Anyone familiar with contemporary politics and public policy will realise that the quality of evidence demanded by policymakers – and that term is itself curiously decontextualised – depends entirely on what those in power have at stake. Often, no evidence or fabricated evidence is sufficient; think about the weapons of mass destruction that Iraq was declared to possess, or the nonexistent jobs into which George Osborne wants to herd impoverished under-25s. And in the population health context, what if policymakers have decided that some segments of the population are disposable, even though they cannot state this for public consumption?

I would argue that this is true of many national governments, as demonstrated by the policies they adopt. But even those who disagree should recognise the need for critical (and explicitly normative) perspectives on the relations between researchers and those in official positions outside the academic world. Local-level public health practitioners and organisations trying to reduce health disparities in a hostile environment deserve all the support we can give them. At the same time, progressive health researchers must choose our allies and audiences, and I for one have little interest in whether my findings are ‘wanted’ by David Cameron, Eric Pickles, or Iain Duncan Smith. The most appropriate guidance for health researchers of conscience as they interact with governments is sometimes the three R’s: Resist, Ridicule, and Replace.

All views expressed are exclusively those of the author. 

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