How public health policy is created: scientific process and political reality.

Abstract

Received for publication July 17, 2000, and accepted for publication November 3, 2000. From the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Reprint requests to Dr. Alfred Sommer, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Suite W1041, Baltimore, MD 21205 (e-mail address: asommer@jhsph.edu). The central premise of this symposium, that data can drive public policy, is both laudatory and even vaguely plausible. The historical record, however, is not encouraging. Galileo (1564–1642) recanted his solar-centric views rather than face the Inquisition. The Hungarian physician Ignaz Semmelweiss (1818–1865) was persecuted for blaming puerperal sepsis on his medical colleagues’ lack of hygiene; he died in an insane asylum. By definition, health policy is made in the public arena. The process is, therefore, subject to a complex array of considerations and influences, only some of which, sometimes none of which, have anything to do with data or with the public’s health. How else can it be explained that our ban on lead paint came over half a century after Australia’s? The most recent demise of national tobacco legislation had everything to do with manipulative powers of the tobacco industry and nothing to do with the 400,000 Americans who die prematurely each year from smoking. President Clinton’s decision in 1998 not to fund needle-exchange programs was admittedly made in the face of reliable data demonstrating such programs can dramatically reduce the incidence of human immunodeficiency virus infection without increasing the prevalence of intravenous drug abuse (1). More subtle than policy made in the face of existing data are research funding priorities and processes that determine whether data will exist at all. In an ideal world, health policy would be formulated in a rational, linear process, moving from data collection, to interpretation, to scientific consensus. These are the areas for which the epidemiologist is most responsible. Translating science to policy is far messier and convoluted, involving as it does societal priorities, resource allocation, opportunity costs, changing cultural mores, special interests, politics, prejudice, and pure greed.