The students at the Woodrow Wilson School have a group blog on public policy called 14 Points. I've been helping promote the blog for a while but just got around to writing my first submission this week. It's titled "Testing Treatments: Building a culture of evidence in public policy". Here's an excerpt:
Similar lessons can be gleaned from the history of surgical response to breast cancer. In The Emperor of All Maladies (2010), a new history of cancer, oncologist Siddhartha Mukherjee chronicles the history of such failed interventions as the radical mastectomy. Over a period of decades this brutal procedure – removing the breasts, lymph nodes, and much of the chest muscles – became the tool of choice for surgeons treating breast cancer. In the 1970s rigorous trials comparing radical mastectomy to more limited procedures showed that this terribly disfiguring procedure did not in fact help patients live longer at all. Some surgeons refused to believe the evidence – to believe it would have required them to acknowledge the harm they had done. But eventually the radical mastectomy fell from favor; today it is quite rare. Many similar stories are included in a free e-book titled Testing Treatments (2011).
As a society we’ve come to accept that medical devices should be tested by the most rigorous and neutral means possible, because the stakes are life and death for all of us. Thousands of people faced with deadly illnesses volunteer for clinical trials every year. Some of them survive while others do not, but as a society we are better off when we know what actually works. For every downside, like the delay of a promising treatment until evidence is gathered properly, there is an upside – something we otherwise would have thought is a good idea is revealed not to be helpful at all.
Under normal circumstances most new drugs are weeded out as they face a gauntlet of tests for safety and efficacy required before FDA licensure. The stories of the humanitarian-exemption stent and the radical mastectomy are different because these procedures became more widely used before there was rigorous evidence that they helped, though in both cases there were plenty of anecdotes, case studies, and small or non-controlled studies that made it look like they did. This haphazard, post-hoc testing is analogous to how policy in many other fields, from welfare to education, is developed. Many public policy decisions have considerable impacts on our livelihoods, education, and health. Why are we not similarly outraged by poor standards of evidence that leads to poor outcomes in other fields?