Ness, Roberta B.
In this issue of EPIDEMIOLOGY, Dowdy and Pai1 call for the creation of a new breed of epidemiologist they call “Accountable Health Advocates” (AHA). An AHA is someone, in their parlance, who “enables society to judge the value of research, develops new methods to translate existing knowledge into improved health, and actively engages with policymakers and society.” It is not a new appeal. In 1989, Foxman2 called for a forum whereby epidemiologists would help policymakers formulate public health policy. A decade ago, Weed and Mink3 argued eloquently for “active participation in public health policymaking,” using a definition that I adopt here: “making public health recommendations, implementing intervention programs, and participating as an advocate.”
The key question that Dowdy and Pai1 pose is: How can the profession of epidemiology support a few expert advocates in their successful pursuit as knowledge translators? Here, I reframe the question and instead ask: How can our profession not insist that all of us pursue, to the best of our abilities, not just knowledge generation, but knowledge translation? In other words, shouldn’t a key, professional obligation be to engage in Weed and Mink’s domains of making recommendations, implementing interventions, and participating as an advocate—what I will call “Universal Health Advocacy”? Such a restatement may seem audacious, particularly because, Foxman and Weed aside, other prominent epidemiologists4,5 have argued that professionally appropriate behavior confines us to science. How, then, do I reach this conclusion?
Knowledge translation is epidemiology’s raison d’etre, our reason-for-being. Epidemiology informs public health. Public health, in turn, has as its purpose to improve the health of populations. Ergo epidemiology moves from a cerebral exercise to a useful pursuit only when it directly affects its objective: the attainment of better population health. It is not enough to simply generate knowledge. Only when knowledge is transformed into rational and widespread practice and policy does it attain its usefulness.
Despite its centrality, translating knowledge into action has been and continues to be deplorably slow. To be clear, the subset of “knowledge” to which I refer is that which is “established,” that is, has attained the imprimatur of scientific consensus. Various studies suggest that it takes 1 to 2 decades for a scientifically accepted clinical intervention to become part of usual practice. On the occasion of his retirement from his position as director of the National Health Lung and Blood Institute, Lenfant6 described the painfully protracted uptake of established, secondary and primary prevention interventions that reduce the risk of heart disease (β blockers, antihypertensives, low-dose aspirin, and weight loss). He then said, “The practices no longer require research to demonstrate efficacy and effectiveness; as a practical matter, everything that needs to be known is already known.”
We, as the generators of much of the knowledge that could eliminate an estimated 40%–75% of all chronic illness, must ask ourselves, Is it acceptable to sit back and watch Americans be denied the benefit of progress? What obligation do we have individually and collectively?
Many of our greatest role models in epidemiology have been at the forefront of Universal Health Advocacy: John Snow figuratively removing the Broad Street pump handle; Joseph Goldberger delivering fresh vegetables and meat to asylums to combat pellagra; Herb Needleman advocating for removal of lead from paint. Other prominent members of our profession4,5 have argued that championing or taking any public stance on a public health policy may create a real or perceived loss of objectivity, the harm from which might be an erosion of credibility. Admittedly, “overselling” results during the tumultuous period when consensus has not been reached can cause confusion at best and obfuscation at worst. However, the notion that scientists are objective is simply not supported by science. The goal of scientific objectivity arises from Karl Popper’s theory of empirical falsification, that is, that no level of empirical evidence can “prove” a theory, and yet a single counterexample can decisively establish it is false.7 In principle, scientists should hold themselves aloof from any particular hypothesis in the hopes of disproving it. Yet, Popper also acknowledged that human knowledge is conjectural and that conjectures (or hypotheses) arise in specific historical and cultural settings. The field of the sociology of scientific knowledge argues that scientific certainty arises from competing belief systems and through the disputes of partial practitioners.8 That is, scientists are not impartial falsifiers but instead combatants in battles for supremacy. Even the most well-meaning scientists engage in advocacy for their own lines of reasoning. Shouldn’t we meaningfully engage in making recommendations, implementing interventions, and participating as advocates (particularly when consensus has been reached)?
Can any scientist be entirely unbiased? The Institute of Medicine, National Academies, which prides itself on “Advising the nation, improving health” thinks not.9 It chooses committee members not to exclude personal bias (although they do prohibit financial conflict of interest) but instead to balance interpersonal bias. Thus, one member’s bias is balanced against another’s opposing bias. Another model to ensure fairness is that used in creating clinical guidelines by the US Preventive Services Task Force. This body uses rigor and transparency of its process to limit the human tendency toward a priori opinion and any resultant concerns about objectivity as an impediment to the promotion of knowledge translation.10
Beyond my belief that scientists should concede the dream of objectivity, I argue that, in the case of health advocacy, inaction outweighs the harm of action. In the words of John Stuart Mill, “A person may cause evil to others not only by his actions but by his inaction, and in either case he is justly accountable to them for the injury.”11 Once consensus has been reached, what is the risk of bias as opposed to the risk of inaction?
The inaction of individuals within a group has a name: “diffusion of responsibility.”12 Psychologists posit that an individual’s willingness to intervene or assist someone in need is inhibited by the presence of other people. The classic example of diffusion of responsibility, perhaps as much a parable as an accurate account, was the murder of Kitty Genovese. Genovese was raped and killed on a street in Queens, a fatal outcome that may have been prevented if observing neighbors had been more proactive in calling the police. People in groups allow events to occur that they would never allow if they were alone. Thus, I imagine that any of us, if the only witness to a heart attack, would do everything possible to aid the victim. In contrast, a smaller percentage of us who are experts in cardiovascular risk feel an obligation to do everything possible to press for smoke-free laws or taxation of sugary sodas.
Similarly, the identification of some subgroup as the responsible party indemnifies individuals within the larger group. Back in 1993, when women’s health was an emerging field, I argued against deeming it a subspecialty within internal medicine. If some limited subdivision of internists became women’s health subspecialists, which would imply that others could eschew their responsibility to learn the subtleties of women’s (i.e., half of the American population’s) health. I fear the same outcome if only a selected group of epidemiologists deem ourselves AHAs.
Beyond the question of the obligation of the individual, I believe we have an obligation as a profession. A first principle here is the truism that there is strength in numbers. In the absence of numbers, there is marginalization. The “Occupy Wall Street” movement, which became the lifestyle of a few, seems to have had little lasting effect. On the other hand, the political crowd sourcing that resulted in thousands protesting in the streets of Cairo brought down a government. When we founded the Joint Policy Committee of the Societies of Epidemiology, I argued that our professional organizations needed to organize so as to jointly affect policy. Lenfant argued it more eloquently when he said, “I believe, however, that professional organizations must also assume a greater role, if not the leading role, in our collective efforts to realize the full public health benefits of research by minimizing what gets lost in translation.”6 In fact, many professional societies have extensive lobbying capabilities, unfortunately not all without conflict of interest.
A particularly salient rationale for collective action within public health is that information is less powerful than money. Deep-pocketed industries have repeatedly halted or slowed translation in environmental science.13 But to stick to cases from the cardiovascular literature, consider the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study. In December 2002, the widely anticipated results of the largest ($130 million) US clinical trial on hypertension ever conducted demonstrated that diuretics, costing a few cents a day, were just as effective as medications that cost up to 20 times as much.14 Clinical guidelines quickly changed. ALLHAT embarked on a dissemination program to support changes in clinician behavior. Nonetheless, research published a decade later showed only marginal increases in use of diuretics (from 30% to 35% of all patients to 40%).15 Despite their best efforts, academics were outspent and outtalked by Big Pharma, which blanketed physician offices with thousands of drug representatives. The only hope that epidemiology has to counter such clout is to speak with a common earsplitting voice.
“If not us, who? If not now, when?” This famous quote by the Babylonian Jewish scholar Hillel sums up the case for epidemiologists as individuals and as a group to engage in the widespread pursuit of translation into action. What, specifically, does that mean—what can we do?
The activities of “making public health recommendations, implementing intervention programs, and participating as an advocate,”3 suggest a series of actions. First, within the confines of our own science, we must remain cognizant of the end objective. This entails pushing beyond “circular epidemiology,” that is, ad infinitum repetition—and moving expeditiously from observation to intervention.16 The 2 major roadblocks to intervention are risk aversion and cost. Many of us “specialize” in observational studies and would be uncomfortable moving into intervention, whether it be inventing a device, launching a trial, or founding a commercial venture. This is where working within groups with diverse expertise can be vital. Moreover, we must bite the bullet and support clinical trials, even when they are costly. As participants in study sections or as professionals within funding agencies, we must not meet the enemy only to find that “it is us.”
Second, making recommendations involves not just participating in guideline formulation but more generally advocating for “evidence-based public health” over “feel-good public health.” At the University of Texas School of Public Health, I have seen 2 evidence-based programs battle to be recognized while untested programs are disseminated. One, “It’s Your Game: Keep it Real,” is a computer-gaming program for teens that has been demonstrated in clinical trials to reduce sexual activity and thus reduce teen pregnancy and sexually transmitted infection.17 Another, “CATCH,” is a school-based, comprehensive diet, and exercise program that has been demonstrated to reduce the rate of increase of childhood obesity.18 In the same communities where a few schools or providers have adopted these evidence-based interventions, many more are using untested, “feel-good public health” platforms. Each of us should argue locally, regionally, and nationally against allowing proven knowledge to sit on a shelf while taxpayer dollars are spent on unproven pet programs.
Third, we live in a country in which we have an opportunity to influence policy through political advocacy. Is belonging to the “correct” political party or making the “correct” donations alone enough? I argue that our expertise imparts a higher level of responsibility. Each of us can and should use our knowledge to promote helmet laws, safe food initiatives, indoor smoking bans, taxation of tobacco, alcohol, and sugared beverages, and on and on. To do such work, we should encourage training on how to contribute to policy decisions and undertake advocacy within our educational programs, professional meetings, and journals.
Fourth, and perhaps most importantly, I would argue that our professional societies should forcefully participate in advocacy. Because our associations are typically not well funded, the Joint Policy Committee as an umbrella group might be the best vehicle. However, for that group to function effectively, it must be ensured both a mandate and steady financing. Activities in which this committee could engage include letter-writing campaigns, speakers’ bureaus, rapid outreach to major media as issues arise, and federal and state lobbying, to name a few.
Individually and together, our knowledge and our numbers afford us power. I believe it is our professional duty to use that power and Universal Health Advocacy in the service of improving the health of the public.
ABOUT THE AUTHORS
Roberta B. Ness, a recognized expert in women’s health research, became dean of The University of Texas School of Public Health in November 2008. Dr. Ness also holds the M. David Low Chair in Public Health and is a professor in the Division of Epidemiology, Human Genetics and Environmental Sciences. Dr. Ness is also vice president of innovation for The University of Texas Health Science Center at Houston (UTHealth).
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