Neda Ashtari
UCLA David Geffen School of Medicine
One term has dominated medical education and the medical field over the last decade: evidence-based medicine. When facing decisions regarding various treatments, or telling caregivers how long loved ones will live, physicians may not rely on gut instincts or personal experience. Instead, they ask: “What does the peer-reviewed evidence say?” We ensure patients have the information they need to make informed decisions, which ultimately are based not only on scientific evidence, but also on finances, beliefs, and personal values. There’s a reason we turn to evidence, and it’s because the decisions we make as healthcare providers directly influence patients’ lives. But as we’ve witnessed with the coronavirus pandemic, so do the decisions of policymakers. Why then, has research evidence played such a minor role in pandemic-era policymaking?
Competing factors in decision-making
Almost immediately after the first reports of the novel coronavirus, scientists and epidemiologists across the globe began studying the mysterious pathogen—its spread, virulence, and clinical outcomes. These early studies revealed important characteristics of the virus—including an extended asymptomatic period and an uncontrolled doubling time of cases from four to seven days—corresponding to alarming growth rates of 10.4% to 26% per day [1]. These findings led to a consensus among the scientific community: social distancing and widespread testing were essential for slowing the spread of the virus. But despite experts’ urgent recommendations to mandate social distancing and vastly expand testing capacity, the federal government and many states were slow to act. Scientific skepticism, political motives, and competing social values can explain why policy decisions often stray from evidence and lead to worse outcomes—in this pandemic and long before it.
The federal government has been a leading force for scientific skepticism in recent years. The Trump administration’s slow dismantling of scientific institutions hindered the country’s ability to combat a public health emergency. In 2017, President Donald Trump signed a bill that cut $1.35 billion of funding from the CDC’s Prevention and Public Health Fund, a resource that supports programs to monitor rapidly emerging diseases and improve public health immunization infrastructure [2]. In 2018, the National Security Council removed the top official responsible for pandemic response and disbanded the global health security team. That same year, Trump’s drastic cuts to the CDC budget forced the CDC to cut 80% of its efforts combating disease outbreaks overseas, even as CDC experts warned that a public health emergency was inevitable [3]. And in 2019, the Department of Health and Human Services discontinued a maintenance contract for over 2100 ventilators in the federal government’s emergency supply, foreshadowing the disastrous shortage of medical and personal protective equipment we face today [4].
It comes as no surprise, then, that Trump has failed to adopt, in many circumstances, evidence-based policies throughout the coronavirus pandemic. For example, the government’s initial response to the COVID-19 outbreak centered solely around containment, funneling limited federal resources into a strategy that experts gravely warned against [5]. The president also ignored experts’ pleas to mandate a national lockdown and to use the Defense Production Act to mass-produce desperately needed ventilators and medical equipment [6]. Decisions regarding allocation of these scarce resources have also failed to incorporate data and evidence. Research shows that unhealthier states, defined as those with higher age-adjusted all-cause mortality rates, have lower testing rates than healthy states, putting populations with the highest risk of morbidity and mortality at even greater risk [7].
Trump’s rhetoric, including contradiction of scientific facts and spread of misinformation, has also endangered American lives. On March 4, Trump insisted that COVID-19 was similar to the flu; two days later, he incorrectly claimed the situation in Italy was improving, and that the US was handling coronavirus better than other industrialized countries [8]. In addition, his unsubstantiated statement regarding the effectiveness of treatments such as hydroxychloroquine and chloroquine have not only caused fatalities but have also led to a shortage of the medications for patients with conditions that require them [9,10].
State governors have also been slow to heed the advice of experts in adopting strict social distancing measures. A recent study across all 50 states found that the single greatest predictor of governors’ decisions to mandate social distancing was not scientific evidence but political partisanship [2]. Researchers found that states with Republican governors and Republican electorates were slower to adopt social distancing policies, which may have substantially influenced health outcomes. In Kentucky, for example, Democratic governor Andy Beshear took early measures to halt the spread of COVID-19, declaring a state of emergency on March 6, 2020, immediately after the state’s first diagnosed case [11]. Across its southern border, however, Tennessee’s Republican governor Bill Lee waited until March 12, 2020—when 18 cases had already been confirmed—to issue stay-at-home orders. Despite being one of the top 10 “at risk” states for COVID-related hospitalizations, Lee explained he would not issue a mandated shelter in place order because it was "deeply important” to him to protect personal liberties [12,13]. Tennessee’s week-long delay in adopting social distancing policies led to a steep rise of cases, while Kentucky maintained a flatter curve [11].
Preventing the next pandemic
With modern advances in research technology and data-sharing, we’ve made discoveries about the virus and how to curb its spread at an unprecedented rate. But knowledge has no value if it doesn’t reach and influence those who shape our most critical policies. Thankfully, there are evidence-based solutions that demonstrate how.
Develop decision-maker and researcher competencies
Policymakers must be trained to access and effectively utilize research evidence. This begins with expanding access to reputable sources of information, including journals, research articles, and academic search engines (i.e., PubMed). Today, because lawmakers and staffers lack access to peer-reviewed sources, many rely on Google searches and lobbyists. Even with access to research evidence, lack of experience interpreting studies has been shown to decrease evidence use in decision-making [14]. To help policymakers engage with research effectively, governments can offer scientific literacy training. For example, the Ontario Ministry of Health offers policymakers one-day seminars intended to help ensure that they have access to rigorous, relevant research and can draw upon it as they make policy decisions.
Researchers, too, must develop their knowledge of policymaking. This includes understanding the timing of the legislative cycle, the importance of providing objective evidence without advocating, and the value of building relationships with policymakers. In addition, researchers must learn to adapt their language and their medium to their audience. It has been shown that policymakers are more likely to uptake research evidence with relevant policy implications that is presented without academic jargon as a short brief. This means scientists must develop the capacity to communicate research findings in a way that is clear, concise, and fits lawmakers’ specific needs.
Facilitate researcher-policymaker interactions
Over decades, many studies have proposed methods of increasing evidence use in policymaking. But among almost all of them, one concept remerges repeatedly: relationships are the currency of the capitol [16]. Policymakers are more likely to use research if they trust the knowledge-broker bringing it to them. And although building strong relationships takes time and commitment on behalf of both parties, it can be done. The Wisconsin Family Impact Seminars, an initiative of the Robert M. La Follette School of Public Affairs at University of Wisconsin-Madison, demonstrates how institutions can facilitate relationship-building. Each year, the seminars bring together academic experts and policymakers to discuss one to two topics of legislative interest, and the program’s success has since become a model for similar programs in 35 other states.
Institutional change
Rather than relying on the efforts of individual researchers or policymakers, institutions can facilitate the uptake of evidence in policymaking. For example, governments may enact internal procedures that address bias and lack of transparency in decision-making. Alternatively, governments can improve channels of communication between various departments to address complex issues that require multidisciplinary expertise. One study in the UK found the division of responsibilities within government bureaucracies limited the use of evidence, arguing that “individual civil servants are compelled to focus on small, specific areas of policy activity, making it extremely difficult for them to engage with ideas beyond their immediate area of responsibility” [15]. Universities can also serve as knowledge brokers by changing the current academic model to incentivize researchers to conduct policy-relevant research and disseminate the results.
The potential of evidence-based policy
It has long been known scientific evidence is underutilized in policy making decisions. But in the unprecedented time of the COVID-19 pandemic, we are reminded of the consequences: human lives.
Policymaking is inevitably influenced by factors besides research evidence, including shared values, political partisanship, and financial incentives. Research evidence alone doesn’t tell us whether an intervention is socially desirable, and unlike evidence-based medicine, policymakers and constituents rarely agree upon the optimal outcome. This means that, occasionally, the same evidence will lead to different decisions.
In the case of the COVID-19, businesses and governments have had to consider not only the public health risk but also the social and fiscal implications of their policies. They must weigh a society’s values—the American notion of autonomy—against the public health benefit of the common good. But to ensure the best health outcomes, we must start with the evidence. We must agree that evidence has value and should guide our decisions. Only then can we reaffirm the role of facts in decision-making and thereby transform our societies, governments, and institutions to best serve the people.
REFERENCE
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