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Medicine wasn't always science-based. Much of it still isn't. But over 100 years ago there was a paradigm-shift away from thinking about health care as a healers' art towards a professionals' science.
Opinion was downgraded; unbiased, experimental trials, upgraded. By the second half of the 20th century, the medical community realized that it needed to use randomized control trials — which split up a group of people by lottery and give one half a treatment and the other nothing or a placebo — to find out whether the medicines, surgeries, and other interventions doctors were using actually helped patients.
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The number of randomized control trials by decade. (Test, Learn Adapt via the UK government.)
Yet, as medicine has moved closer to science, the notion that we should run high-quality experiments to figure out whether policies work hasn't taken root in government.
In the US, former Obama and Bush officials recently estimated that only 1 percent of government spending is backed by any evidence at all. Perhaps unsurprisingly, evaluations of government-sponsored social programs found that three-quarters of them have no effect on the people they were designed to help. That's right: the government spends trillions every year on what often amount to blind guesses.
Internationally, there's a movement to change this state of affairs. Both the United States and United Kingdom have made substantial progress in recent years in backing up their public programs with actual research evidence. The Canadian government, meanwhile, has lagged behind. The tale of these three countries can prove instructive in how to get evidence into policy — and the obstacles that governments face in their attempts.
A quiet, evidence-based revolution
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The White House. (Karen Bleier/Getty)
Since Obama took power in 2009, a group of evidence-based nerds in the White House have been trying to change the status quo by way of a quiet, evidence-based revolution. Their goal? Funding programs — from home visits to low-income families, to pregnancy prevention and K-12 education — that have high-quality studies demonstrating they work and cutting those that don't.
In other science-minded moves, almost as soon as he took office, Obama appointed a science adviser and a Nobel-winning physicist to lead the Department of Energy. This was seen by many as a deliberate effort to draw a contrast with his predecessor George W. Bush, who was often accused of ignoring scientific evidence in environmental and drug policy.
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UK Prime Minister David Cameron. (Dan Kitwood/Getty)
The UK has also undertaken its own evidence revolution. In 2010, the government — led by Conservative David Cameron — launched a Behavioral Insights Team to apply knowledge from behavioral science that can nudge people into making better choices for themselves. (Automatically enrolling them into pension schemes, for example, or prompting them to pay their taxes on time and join organ donor registries).
In 2013, the UK government went even further, launching the What Works Network. Instead of just applying science to policymaking, the network is aimed at running tests on new policies and then sharing the evidence that's generated so that it can be used to inform decision-making all over the country. This is now being done in everything from education to health and crime reduction.
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Canadian Prime Minister Stephen Harper. (Menahem Kahana/Getty)
Canada, meanwhile, has lagged on the science front. Shortly after Conservative Prime Minister Stephen Harper took power in 2006, federal government scientists starting complaining about being muzzled. The most recent editorial in the Canadian Journal of Public Health even exclaims, "Canadian public health is under siege!" after the government, among other things, stripped the chief public-health officer of his power to act.
The environment has been another particularly contentious battleground, since the government has been trying to promote Alberta's oil sands in the face of mounting evidence about climate change. One Environment Canada scientist wasn't allowed to give media interviews about his research on the then largest-ever hole in the ozone layer over the Arctic; his Environment Canada colleagues were followed around by government media personnel at a conference — as if they were entering North Korea — to stop any conversations that might bubble up with reporters about climate change. Those are just a couple of anecdotes in a laundry list of many.
To top it off, Canada's National Science Advisor was not replaced in 2008. The national census data-gathering was scaled-back in 2010. And funding for basic research has been snipped away over the years as the government pushes an agenda of commercialization in science.
Why does evidence take root in some places, not others?
We wondered why a scientific approach has taken hold in some places, and not others. This is an especially important question during a time of global, economic austerity, when it makes sense to spend money on what we know will work — and to rigorously study those policies for which we don't have any evidence.
To figure out how these three countries have recently gone in different directions, we called people who worked behind the scenes in science and policy and asked them why evidence did — or didn't — become a dominant theme in governance.
They gave us wildly different impressions, but they shared some important themes.
1) The US case study
In the US, we spoke to Robert Gordon, the former executive associate director of the Office of Management and Budget, which has been credited with moving the government toward being more rigorous in its use of science to inform policymaking. Gordon told us that it was a combination of "strong and knowledgable civil servants" and "political leadership" that encouraged him and his colleagues.
Signals from the very top — that science was valued — were key. "The President is a pretty non-ideological guy interested in evidence and research on what works and what doesn't," he said. "In his campaign he talked about particular evidence-based programs like home visiting, and that was an important signal."
2) The UK case study
In the UK, David Halpern — who led the Behavioral Insights Team and now the What Works initiative — also emphasized the importance of leadership for moving the evidence agenda along.
"In 2010 the Prime Minister was very interested in [a scientific approach to governance] and supportive of it. The deputy Prime Minister came into it, and the coalition agreement was formed around 'supporting people to make better choices for themselves.' That became the motto for a lot of our work."
They managed to not only turn the "nudge unit" into a global model for using behavioral insights in policy, but also to get What Works going. So they're now essentially harnessing the federal administration to generate new evidence and experiments as they try policies out.
"We're testing and trialing different ways schools can teach kids," he said. "We have more than 90 large scale trials in more than 4,000 schools to look at questions like: what is the best way of teaching math? When you drop your kids off at school, what makes you think the approach being used is the most effective?"
Neither of these initiatives would have succeeded, however, had they not delivered results. "Departments are filled with bright but skeptical people who hear new ideas all the time, and take them with a pinch of salt," Halpern added. "When we were able to show within eight months the kind of results coming through, that changed people's opinion."
3) The Canadian case study
Paul Gully in Canada, who was the country's senior medical adviser, had a view on what went wrong there. He was transferred to the World Health Organization in 2006 — when Stephen Harper took power — and returned to Canada in 2009. At that time, he said, "I got the sense within government that the support for scientists... and the utilization of science in policy was less valued than before."
In this case, there was no science-minded leadership. "The major concern in Canada is that even if the science is put forward, it's not even taken into account in terms of making those policy decisions," he said. "Is there a culture of empiricism? I don't see it here."
Because of this, an "Evidence for Democracy" movement has emerged. Led by a band of frustrated scientists, academics, and nerds, the group "strives to ensure that the best-available scientific knowledge and evidence is used to inform decisions that affect the health and prosperity of Canadians."
Whether they've made any progress, as Gully notes, is up for debate. Recent decisions by Harper to halt smokestack emissions monitoring (that tracked air pollution), defund the Health Council of Canada (that monitored health care reform), and end federal sponsorship of the world-renowned Experimental Lakes Area (that allows scientists to manipulate lakes and measure resulting ecosystem changes) do not bode well for science in Canada.
What these governments have in common
These government insiders were all articulating the fact that creating a culture of using research evidence in policy mattered. And to do that, leadership seemed to be the single biggest factors in terms of getting an evidence-based revolution going.
In other words, you cannot have a government that values applying knowledge to make policy if there is no support at the highest levels. This means that it comes down to voters rallying behind leaders who are interested in an empirical approach. It also involves embracing doubt and the possibility that, by studying new programs and policies, you may find out you were wrong.
This isn't easy in politics — anywhere. But a paradigm-shift, like the one we saw in medicine, would help evidence trump politics more often. Not knowing, and figuring out how to know, is the bread and butter of science. Applying this attitude in medicine is what moved it along from an art closer to a science. The shift is happening in policymaking, albeit slowly, painfully, and one, brave leader at a time.
For now, the White House's Robert Gordon told us, even when programs appeared to be working, science doesn't always win out. Under the new Republican-led congress, it's not clear whether the evidence-backed initiatives of the last several years will go forward. "We got all these programs launched in a Democratic congress, and they survived in a divided congress," he said, "but we'll have to see how they do in a Republican congress."
Welcome to Burden of Proof, a regular column in which Julia Belluz (a journalist) and Steven Hoffman (an academic) join forces to tackle the most pressing health issues of our time — especially bugs, drugs, and pseudoscience thugs — and uncover the best science behind them. Have suggestions or comments? Email Belluz and Hoffman or Tweet us @juliaoftoronto and @shoffmania. You can see previous columns here.
