Science and Policy: A Perpetual Dilemma

Many policy watchers are anticipating a golden age of science-led policy in health and environment under the presidential leadership of Barack Obama. After 8 years of frustration at bowdlerized reports, derailed rule making, and policies based on stubbornly held beliefs-despite the facts pointing government policies in another direction-it’s time for clearheaded thinking and the best use of sound information to formulate health and environment policy-even when a policy needs to be based on findings that make us uncomfortable. Of course, it’s this last condition that’s the kicker: none of us want to feel anything other than good when a policy is enacted, and that’s not always going to be the case.

There are 2 points that are worth keeping in mind as we move forward: science does not always have the answers, and sometimes the best science can support several, even contrary, approaches; findings from different disciplines might lead in very different directions. With regard to the first point: science is the sum of our knowledge about the discernible world. It’s the facts, only the facts. Some of them are “hard” facts, ie, things we can weigh and measure. Others are what can be called “soft” facts, ie, summaries of opinions, feelings, perceptions. Accurately described and summarized, these softer facts are also something we know. However, a policy decision is not a factual decision, it is a valuing decision; that is, it reflects how we assess the importance of the factual information and the degree to which we are willing to put resources (read “time and money”) behind it. There will be a lot of revaluing going on in the coming weeks and months as the available information is reevaluated by a new leadership team in the executive and legislative branches and as resources are rearranged to suit newly valued outcomes.

The second point concerns the challenge of competing facts, or competing value decisions. This is well illustrated by the findings of Leibowitz, Desmond, and Belin¹ reported in the January 2009 issue of the American Journal of Public Health. Based on data from several randomized clinical trials and supported by a meta-analysis of other studies done in Africa, it is now reasonable to state that we know male circumcision reduces the risk of female-to-male transmission of HIV by 50% or more. Some African countries are now strongly supporting male circumcision as a part of a comprehensive HIV/AIDS program. The United States presents a different programmatic picture, however.

Circumcision in the United States is generally a pediatric event, often done in the hospital as a part of neonatal care. Questions raised about the utility of circumcision, the amount of pain inflicted on the infant, and thus the reason for this procedure without a strong religious rationale led to a reduced interest. In 1999, the American Academy of Pediatrics (AAP) began presenting a neutral stance on the procedure, as reflected in their current comments to parents: “Because circumcision is not essential to a child’s health, parents should choose what is best for their child by looking at the benefits and risks.”² Apparently related to this change in the current reimbursement restriction under Medicaid: at least 16 states no longer include newborn circumcision as a reimbursable charge under Medicaid.¹ Analysis of data from recent years shows a drop in all circumcisions, but a much steeper fall in hospitals that will not be reimbursed by Medicaid for the procedure. This suggests a disparate impact on boys born to poor families, a group at higher risk for HIV infection when sexually active.

The first boys who were not circumcised because of the AAP and subsequent Medicaid policies are now preteens and are just coming into serious risk of HIV infection from sexual activity. I am sure somewhere in the United States there is an activist group suggesting that the US AIDS policymakers are remiss in not jumping on the AAP for their neutrality and on state Medicaid programs for their tight-fistedness and for not promoting circumcision in all sexually active men who did not have the procedure done as infants. I hope anyone inclined to these lobbying actions stops and thinks a bit about the available information. Female-to-male transmission is not a major mode of HIV transmission in the United States. The evidence that circumcision reduces male-to-male transmission is weak at best. And the costs of circumcision, while low for neonates, would be higher for adults. The same dollars spent elsewhere on age-appropriate prevention education for preteens and teens might have greater impact.

In fact, we lack good cost-impact studies of many prevention programs, in part because they are so difficult and time-consuming to conduct. The impact of HIV prevention education in middle school will not really be evident for 5 to 10 years, and following a cohort of teenagers to find out what happens is itself expensive. We have difficulty in supporting longitudinal studies in all areas of health, and prevention studies are no exception. The surrounding community will change over the 10 years, the participating youngsters will move, our knowledge will grow, and we will begin other interventions. Tracing forward from peer-group education and outreach to cases of disease that do not happen will require incredible patience and attention to detail. Part of the challenge is that the investment in prevention is rarely in the same budget category as the outgo for treatment, so the participating organizations or agencies do not always see the trade-offs, and the payoff, if there is to be one, comes 3 to 5 budget cycles later. That doesn’t mean we should abandon the attempt to assess the eventual benefit of money invested in prevention. It does mean not jumping to quasi-scientific conclusions when only part of the equation is available.

Science is not the answer. And policy (the value decision) is often made in the absence of science or in the face of incomplete science. But science is a source of information on which to base an answer that makes sense for each time and place. A program that is critical in one place on the planet may be only peripheral elsewhere. And bringing both biomedical science and the so-called dismal science of economics together is an essential mating if public policy is to make sense and make a difference.

References:

References1. Leibowitz AA, Desmond K, Belin T. Determinants and policy implications of male circumcision in the United States. Am J Public Health. 2009;99:138-145.
2. American Academy of Pediatrics. Parenting Corner Q&A: Circumcision. http://www.aap.org/publiced/BR_Circumcision.htm. Accessed January 16, 2009.