Testing treatments in policy

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?

Read the rest at 14 Points, and check out the posts by my classmates.


Why is so much real policy debate done behind closed doors? Joseph Stiglitz's "The Private Uses of Public Interests" (PDF) argues that sometimes it's for security... but most of the time it's to protect private interests:

The one argument that may have some merit is that hiding information may sometimes provide a tactical advantage in the political bargaining game. But my own experience is that all too often, secrecy is neither justified by national security interests, nor as a prerequisite for rational and thoughtful debate, nor even as a tactical necessity in a broader strategy, but rather, secrecy serves as a cloak behind which special interests can most effectively advance their interests, outside of public scrutiny. There is an old expression that sunshine is the most powerful antiseptic. In this sense, I understood why discussions concerning privatizing the production of enriched uranium-the critical ingredient of nuclear bombs-had to proceed in secrecy. It was not because national security would have been jeopardized, but because there rightly might have been a public outcry if it was known that we wererisking nuclear proliferation for at most a meager few hundred million dollars. I also understood why discussions concerning ethanol had to be conducted in secret-again, private interests seeking favorable treatment might have might have failed to get what they wanted had there been an open public discussion, especially amidst accusations that campaign contributions seemed to affect public policy.


Elizabeth Warren:

There is nobody in this country who got rich on his own. Nobody. You built a factory out there? Good for you. But I want to be clear: you moved your goods to market on the roads the rest of us paid for; you hired workers the rest of us paid to educate; you were safe in your factory because of police forces and fire forces that the rest of us paid for. You didn’t have to worry that marauding bands would come and seize everything at your factory, and hire someone to protect against this, because of the work the rest of us did. Now look, you built a factory and it turned into something terrific, or a great idea? God bless. Keep a big hunk of it. But part of the underlying social contract is you take a hunk of that and pay forward for the next kid who comes along.

Spot on, from the social contract to the big hunk and paying it forward. (h/t Jesse)

The next step in tobacco control?

From The Guardian:

Iceland is considering banning the sale of cigarettes and making them a prescription-only product.

The parliament in Reykjavik is to debate a proposal that would outlaw the sale of cigarettes in normal shops. Only pharmacies would be allowed to dispense them – initially to those aged 20 and up, and eventually only to those with a valid medical certificate.

The radical initiative is part of a 10-year plan that also aims to ban smoking in all public places, including pavements and parks, and in cars where children are present. Iceland also wants to follow Australia's lead by forcing tobacco manufacturers to sell cigarettes in plain, brown packaging plastered with health warnings rather than branding.

Under the mooted law, doctors will be encouraged to help addicts kick the habit with treatments and education programmes. If these do not work, they may prescribe cigarettes.

I'll hazard a guess that this approach would not be popular in the United States.