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Insight: Attacks on evidence, trust and truth wreak havoc on global health
Health systems in low and low middle-income countries (LMICs) struggle to deliver quality health care because of limited resources, poor infrastructure and a failure to use evidence wherever possible
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span>Health systems in low and low middle-income countries (LMICs) struggle to deliver quality health care because of limited resources, poor infrastructure and a failure to use evidence wherever possible.
There is, in fact, plausible evidence that policies informed by available evidence and rational analysis can produce better outcomes.
However, in most LMICs, this use of evidence remains aspirational. The reality is often very different — a reality in which opinion, values, beliefs, traditions and even ideology can trump facts, truth and evidence.
Why is this? There are four reasons.
First is the lack of good and relevant evidence. This is important because in forming policies, most policymakers in these countries place more weight on evidence derived from local research than on evidence obtained through other means. Unfortunately, such evidence is often lacking or of poor quality. In addition, the evidence is often not available in a timely manner and not relevant to the needs of policymakers.
A senior policymaker once said, “For research to be useful for me it has to be able to answer just three questions. Can it work? Will it work? Is it worth it?” Such questions are often not answered by academic research alone.
Second, there is limited scientific literacy among policymakers as many do not have science backgrounds. They may therefore undervalue the role of evidence in policy formulation and implementation. This led John Maynard Keynes to say, “There is nothing a politician likes less than to be well-informed. It makes decision making so much more complex and difficult.”
Third, while it is probably true that no policymakers want to make bad policy, the reality is that evidence is just one factor in their world. They also have to contend, among other things, with political pressures, a lack of resources, local beliefs and values, the media and — importantly — electoral exigencies. So, despite the cynical tone of what Keynes said, the reality is much more nuanced and nicely expressed by Sir Michael Marmot: “Scientific findings do not fall on blank minds that get made up as a result. Science engages with busy minds that have strong views about how things are and ought to be.”
Finally, today’s toxic climate of national populism, fake news and the denial of science has downgraded and downplayed the role of evidence in policy discourse and development. Science, truth and trust are being questioned like never before. Yuval Noah Harari said, “We humans know more truths than any species on Earth. Yet we also believe the most falsehoods.”
This volatile, uncertain, complex and ambiguous anti-science environment has, unfortunately, has led to two catastrophic outcomes in global health recently.
In the Philippines, misinformation, disregard for evidence and political factors resulted in the withdrawal of a long-awaited vaccine to prevent dengue fever.
More worrisome still, the withdrawal led to a disastrous general decline in confidence in childhood vaccination. Reduced vaccination rates resulted in 35,000 cases of measles with 477 deaths in 2019 and the reappearance of polio after a 20-year absence.
The World Health Organization said recently that measles had infected nearly 10 million people in 2018 and had killed 140,000 — mostly children — as devastating outbreaks of the viral disease hit every region of the world. Violence against health workers in the Democratic Republic of Congo has resulted in delays in the acceptance of a much-needed vaccine against the Ebola virus. This phenomenon of “vaccine hesitancy” has spread globally through many countries, rich and poor alike. It has caused serious outbreaks of vaccine-preventable diseases.
The second catastrophe is related to the existence of 1 billion smokers in the world. Six to 7 million people die every year due to smoking-related illnesses, mostly in LMICs. It is estimated that Indonesia has more than 60 million smokers with nearly 200,000 deaths annually due to diseases linked to smoking. A staggering 68 percent of the country’s male population are smokers.
While there is strong evidence that harm-reduction approaches using alternative tobacco products are safe, are 90 to 95 percent less harmful than combustible cigarettes and can help smokers quit, the evidence is being ignored and draconian policies of banning the products and fining and even jailing users have been implemented — or are being considered — in many countries, including Indonesia.
Such an approach will, in effect, deny smokers their right to better health.
So how can we try to overcome these challenges?
First, we need to improve scientific literacy among policy makers. Second, it is important to increase the accountability of the decision-making process to ensure that evidence is taken into account. Third, efforts must be made to facilitate and institutionalize knowledge translation and communication between scientists, policymakers, consumers and other stakeholders, including civil society. Fourth, evidence and data should be combined with the more humanistic approach of using stories that acknowledge the importance of personal autonomy — a critical ingredient for effective policy and practice.
While it is clearly important to distinguish opinion and fact, it is perhaps even more important to ensure that facts are used for shaping policies that improve not just health quality but also health equality, especially in the developing world. At the end of the day, this underscores the value of the research process.
