Degrowth: “Sustainable degrowth is a downscaling of production and consumption that increases human well-being and enhances ecological conditions and equity on the planet. It calls for a future where societies live within their ecological means, with open, localized economies and resources more equally distributed through new forms of democratic institutions. … Material possessions will no longer hold a prime position in the population’s cultural imagery. … Degrowth does not only challenge the centrality of GDP as an overarching policy objective but proposes a framework for transformation to a lower and sustainable level of production and consumption, a shrinking of the economic system to leave more space for human cooperation and ecosystems.” (Research & Degrowth, 2014)
As I write this blog post, the sea levels are rising and small islands populations are being submerged. The earth’s biodiversity is diminishing and species are being lost. The oceans are acidifying and the grasslands are turning into deserts. As I sip my tea and calculate my Ecological Footprint, deforestation rages on and millions of climate refugees are living in forced exile. It’s hard for me not to feel guilty, but it is is even harder to know what I should do about it.
Bill Gates argues in his 2010 TED talk that we need to “innovate to zero” (Gates, 2010). To reduce global carbon emissions enough to avoid planetary catastrophe, Gates says, we need technological solutions to meet our energy needs. These solutions must be safe, cheaper than the current, dirty alternatives, and be able to support the energy requirements of the growing global population. He presents his support for ‘safe’, ‘cheap’, ‘clean’ energy solutions as if all of the possibilities have been considered, this is the best that we’ve got, and it can work, dagnammit. He doesn’t really deny that the world could be “f**ked” (in the words of Naomi Klein) (Klein, 2013), but he definitely doesn’t use that language. He seems very optimistic about humans’ scientific capabilities, an appealing message to those who may feel the situation is beyond our control as individuals. According to Bill, we CAN solve problems using the same thinking (aka free market economy) we used when we created them. Einstein just rolled over in his grave.
The discussion that followed in the group with whom I sat watching this video, was telling. We were a group of peers; all graduate students in a faculty of health sciences in a ‘reputable’ Canadian university. Our diametric reactions to Gates’ proposition surprised me somewhat. There was outrage from one corner over the fact that we gave 20 minutes of our undivided attention to a billionaire who was basically arguing for “business-as-usual pursuit of profits and growth [that is] destabilizing life on earth” (Klein, 2010). From another corner, I interpreted a feeling of relief and promise: Wouldn’t it be nice if we (humans) didn’t need to change our lifestyles and consumption patterns in order to save the planet? Isn’t that what we all really want? From within our small cohort, our worldviews have led us to similar perspectives of climate change risk (Kahan et al, 2012)- we are all proponents -but quite different perspectives on what should be done about it.
Kahan et al (2012, p. 734) present evidence that “simply improving the clarity of scientific information will not dispel public conflict so long as the climate-change debate continues to feature cultural meanings that divide citizens of opposing world-views”. I agree with the importance of this line of inquiry and the authors’ call for strategies that “create a deliberative climate in which accepting the best available science does not threaten any group’s values” (Kahan et al, 2012, p. 734). I am, however, more concerned about how to “promote constructive and informed public deliberations” (Kahan et al, 2012, p. 734) among climate change proponents on how to get us out of this mess. If the first step is to agree that climate change is happening, it is (largely) manmade, and the consequences are disastrous, the next is to join forces to actually do something about it. Convincing people that climate change is real may be possible without threatening any group’s values, but unlike the Bill Gates camp, I think in order to change its course, altering dominant cultural values is an urgent necessity. My classroom observations provide evidence that step two may indeed be the more difficult battle.
As I put the finishing touches on this blog post, I am eavesdropping on a group of self-proclaimed activists who are fundraising for environmental justice. As I post my reflection, the word revolution is being tossed around and interrupting my thoughts. As difficult as it sounds, I think I have my answer.
Gates, B. 2010. Innovating to zero. TED2010 Conference. Video. URL: http://www.ted.com/talks/bill_gates
Kahan et al. 2012. The polarizing impact of science literacy and numeracy on perceived climate change risks. Nature Climate Change. Epub, Vol 2, October 2012.
Klein, N. 2013. How Science is Telling us all to Revolt. New Statesman. Oct 29, 2013. URL: http://www.newstatesman.com/2013/10/science-says-revolt
Research & Degrowth. 2014. Definition of Degrowth. Research and Degrowth. URL: http://www.degrowth.org/definition-2
I recently embarked on an exploratory sojourn deep into the heart of the mysterious Laboratory. Having just read a volume on Henrietta Lacks’ intriguing immortal cells , I was excited to be there. I entered the land of workbenches, test tubes and pipettes, in awe. There was so much STUFF everywhere. Vial upon vial of liquids of various colours. Expensive, foreign looking equipment and unnameable apparatuses. Cluttered yet sterile. Bright and quiet with only a few people around, each seemingly doing his or her own thing. As I was still trying to take it all in, my unofficial tour began.
The set-up is open concept with three separate labs sharing the same room, each with its own section. To create order, there are sign-up sheets for some equipment but informal communication often occurs with other Labsters (my nickname for people who work in a lab) to indicate when certain equipment will be in use and to let others know if someone “will be hogging it” or if what someone is working on is “time sensitive”. Everyone is in charge of his or her own lab and is responsible for her or his own stuff. My host admits to getting a little “pissed off” with her labmates if there is a mess. “If you made the mess, clean it up!” Literally. Apparently I saw the “hoods” on a good (relatively neat and orderly) day. My host’s tone told me that this was not typically the case.
The lab boss is a molecular biologist. My host, a self-proclaimed molecular biochemist. She wants to go to medical school. Others who do similar work might get Research Assistant or Lab Manager positions. To be a Project Manager a PhD is required and likely a Post Doc. It is really competitive to get faculty positions and one’s own lab. Not surprisingly, if you don’t continue to get funding, the lab shuts down. Et voila. Pull in or perish. In her lab (and similar labs) they do not collaborate with other labs doing related research because of competition over funding, and for getting and publishing results.
With the basic introduction and tour complete, I was ready to get to down to some of the nitty gritty. I was an eager laboratory novice and my ever-generous host was keen to share her wisdom.
My host researches the effects of “knocking out” a specific cell protein on the rate of tumour growth. She is working on breast cancer tumour cells. She hopes her findings will contribute to the development of cancer treatment. When I came for my visit, she had already done the treatment on her cells – hypoxia versus normoxia – and that day she would be extracting the proteins. A lot of prep work is needed before actually starting the experimental protocol. Ice bucket, check. Label and set up test tubes, check. Create fresh buffer solution to burst cells open, check. Prepare scrapers for getting cells off the plate, check. Help burst the cells open using a Vortex Mixer, check. A Vortex Mixer!?!?! Awesome. Put the cells on ice and wait 20 minutes for them to burst so we can collect their contents, check. Needless to say, a lot of her work involves working with pipettes.
She meticulously records everything she does and all of her results in a lab notebook. If something works, she can see why, if something doesn’t work, she can (hopefully) see why. Everything she does must be precise and recorded precisely. To make good use of her time, she updates her lab book when something is “spinning” (for example) or when she has a “nice little chunk of time”.
My host has done her experimental protocols so many times by this point so knows them well. She has a number of experiments on the go simultaneously that she works on as she waits for other steps, such as cell growth, to finish. From preparing proteins to growing cells or running assays, there’s a lot to be done. During her ‘free’ time, she crunches numbers on the computer or reads up on papers to see what she can learn/do to make things work better.
Each Labster mostly just work on his or her own stuff. Each is working on different a “piece of the puzzle”, but they help each other with ideas. My host gets little direct supervision from her supervisor but has ongoing communication with him. After doing all steps of her experimental protocol on her own, she goes over the results of her analysis with her supervisor. She learns mainly through hands on training, and trial and error. Lab scientists attain and adapt different techniques from working in different labs. She follows chemical protocols and tweaks them as appropriate. There are so many protocols (and did I mention the pipettes?). Apart from knowledge of different chemicals and equipment, she has picked up and perfected an array of physical techniques and motor skills. Watching her hold petri dishes and aspirate liquid, it was obvious that she had done these things many times.
In the lab, one is always anticipating and hoping for a certain outcome. A successful day is when you gets the result that you want to see. If my host’s experiment does not work, she feels deflated, and is aware of the extra time she will have to spend to correct it, meanwhile never really knowing why something is not working because she “can’t talk to it”.
She tries to maintain a good work-life balance and avoids being in the lab for twelve hours a day like other labsters she knows. But at the end of the day, she feels pressure for results – “Negative results are results too but nobody publishes bad results” nor do they attract funding. “PhD students have a heavier workload and have to be able to show that they have four years of results by the end of their program.” The invisible college may be hard to see, but it sure was loud and clear.
 Skoot, Rebecca. (2011). The Immortal Life of Henrietta Lacks. Large Print Press, 2011.
“I have nothing against diamonds (or rubies or emeralds or sapphires). Gems are beautiful and desirable. To buy or not to buy is an individual decision. But is has to be an informed decision. … I find it unconscionable that the resources of the third world would be exploited for the sake of our vanity, and above all that billions of dollars of corporate profit are built on the backs of workers paid a dollar a day.” – Edward Zwick, Director of Blood Diamond (Amnesty International, 2006)
Drawing links between the thoughtful gifts bought for loved ones, and environmental degradation, human suffering, and death is not something that many consumers enjoy being confronted with. Diamonds and gold are some of the worst offenders. The production and/or extraction and processing of these “symbols of love” have caused and continue to cause immense public health, human rights and environmental consequences (Donahoe, 2008). ‘Conflict diamonds’ have been used by rebel armies to pay for weapons that have killed tens of thousands of people during civil wars in Sub-Saharan Africa. Diamond’s riches largely allude the millions of actual ‘diggers’ and ‘miners’ in developing countries, and foreign “middlemen, diamond dealers, and exporters earn the lion’s share of mining income” (Donahoe, 2008, p. 170) while arguably giving little back to the host country besides environmental damage, forced resettlement, and human rights violations. The same (and much worst) has been said about gold mining. Gold extraction has been linked to many worker deaths, union-busting, human rights abuses pollution, loss of traditional livelihoods, long-term economic problems, and deteriorating public health in local communities (Donahoe, 2008).
How can all this knowledge be translated into the adoption of better, more responsible resource extraction that is known to be technically and economically feasible? The problems are complex and so are the solutions. Legally mandated impact assessment is one way to use this knowledge to inform and influence development related decision making. But this also involves changing the behaviour of powerful corporations with powerful pocketbooks. Targeting consumers is another way to bring about change by urging people to be responsible and informed, and to ‘vote-with-their-wallets’.
‘No Dirty Gold‘ is an international campaign that attempts to raise awareness of the environmental, social, health, and human rights impacts of irresponsible gold mining. It’s goal is to create a gold mining sector that respects communities, workers, and the environment by educating and influencing consumers, retailers and manufacturers, so in turn they will help to influence mining companies to reform ways in which they extract and produce metals. No Dirty Gold employs a variety of knowledge translation (KT) techniques from the IDRC toolkit – social marketing ads mimicking the ads of the World Gold Council (see ads below); storytelling; consumer education through online fact sheets and twitter; and publications – to spread their message and try to bring change (No Dirty Gold, 2013). Edutainment has also been used to raise awareness among consumers of the externalities of their obsessions with bling. Two recent Hollywood blockbusters, Blood Diamond and Avatar, are good examples, the former of which had official support from Amnesty International.
As a researcher and a consumer, I want to learn. Are consumer awareness campaigns like the ones described effective in influencing corporations’ behaviour? What kinds of behaviour change techniques are most useful when attempting to change consumer behaviour in relation to products that do not harm or improve their own health or local environment? Products whose value is heavily based on culture and tradition as well as their ability to confer status? I personally do not desire to buy and/or own diamond and gold jewelry but I do desire to travel in a highly polluting fashion. Do jewellery owners ignore the ‘externalities’ of their purchases in the same way I ignore the environmental impact of my flight record?
Amnesty International. Companion Curriculum to Blood Diamond. 2006. URL: http://www.amnestyusa.org/sites/default/files/bd_curriculumguide_0.pdf Accessed November 19, 2013.
Donahoe, M. Flowers, Diamonds, and Gold: The destructive public health, human rights, and environmental consequences of symbols of love. Human Rights Quarterly, 2008, 30(1):164-182.
No Dirty Gold. The No Dirty Gold Campaign. URL: http://nodirtygold.earthworksaction.org/about_us#.UorjGhZwo20 Accessed November 18, 2013.
“Gold – Making an Impact on the World” (WGC, About Gold, 2013). An apt slogan for the World Gold Council (WCG) whichever way you look at it. But the way you look it makes a world of difference.
Recent WCG research reportedly demonstrates the positive role played by ‘responsible’ gold mining in supporting ‘sustainable’ socio-economic development, highlighting in particular the importance of the sector for development in non-OECD host nations (WGC, Advanced by Gold, 2013). Data from 15 WGC member companies on their 2012 expenditures, including payments to suppliers, employees and governments, were combined in an attempt to comprehensively measure how, on a global scale, value generated by the formal gold mining sector is distributed including how much remains within host nations. These findings, along with other recent evidence of the direct economic impact of gold, provide one indication of the economic value created by gold mining and its contribution to national economies (PwC, 2013). This report concludes that gold plays a fundamental role in advancing economic development and the needs of society. Last week, an online news headline for these study findings boasted that, “New research indicates that responsible gold miners contributed more than $55 billion to sustainable economic development in 2012.”
The aforementioned evidence is just one take on the effects of gold extraction and deals with economic impacts at the global and national levels. Other sources provide a very different perspective. Media examples from the opposite end of the spectrum include: “Barrick ignores UN High Commissioner for Human Rights recommendation regarding Papua New Guinea Rapes” (Oct. 28, 2013); “Destruction of Peru’s rainforest by illegal gold mining is twice as bad as experts thought” (Oct. 28, 2013); “Canadian mining company Infinito Gold seeks to extort $1 billion from Costa Rica” (Oct. 10, 2013); and “Romanian gold rush cancelled as protesters defeat Europe’s biggest gold mine” (Sept. 9, 2013).
Research on formal gold mining at a more local level can also point to quite different conclusions about the impacts of gold mines on local economies and societies. Jobs, income and better education were positive effects of the establishment of a gold mine on nearby villages in Mali, but along with these, mining brought land expropriation, environmental degradation and social tensions. Entrepreneurship and diversification of the local economy related to mining projects were minimal (Jul-Larsen et al, 2006). Harmful socio-economic impacts related to the expansion of gold mining in Peru include adverse effects on water resources, livelihood assets and social relationships, resulting in increased social conflict. At the local level, there is weak evidence of any positive effects on Peruvian livelihoods, especially in rural areas (Bebbington et al, 2009). The socio-economic impacts of small-scale ‘informal’ or ‘illegal’ gold mining have also been studied. Evidence from field surveys, airborne mapping and satellite imagery from the southern Peruvian Amazon region links the greatly increased number of small mines – a 400% increase from 1999-2012 – and resultant forest destruction, to global consumption of gold and the dramatic jump in gold price in 2008 (Asner et al, 2013).
So is gold mining contributing to sustainable development or hindering it? How can we best answer this question? Terry Heymann, the WGC’s Gold for Development Manager, argues that “gold, produced in conformance with high safety, environmental and social standards, provides opportunities in the form of jobs, skills, improved infrastructure and tax revenues, but maximizing the development potential of mining requires continued attention and discussion” (WGC, Advanced by Gold, 2013). Population health intervention research offers a meaningful way of contributing to that discussion.
Population health interventions are policies, programs and events that operate within or outside of the health sector and have the potential to impact health at the population level, by generating and shifting the distribution of health risks through their effect on underlying social, economic and environmental conditions (Hawe et al, 2009; Hawe et al, 2013). The intentionality of those interventions, whether inside or outside the health sector, is neutral (Hawe et al, 2009). Gold mining, and any type of resource extraction project, fits into this definition of a population health intervention due to its impact on population health through the environmental, social and economic changes to which it contributes (see the arguably busy causal diagram above for examples). Population health intervention research (PHIR) offers a way of connecting the impacts of mining at multiple levels and on multiple determinants to the actual population health outcomes and health equity, important measures of sustainability. This type of research is necessary if we are to fully understand how gold is making an impact on the world.
To be continued.
Asner, G. et al. Gold mining ravages Peru. Carnegie Institution of Science. Monday, October 28, 2013. URL: http://carnegiescience.edu/news/gold_mining_ravages_perú
Bebbington, A.J. & J. Bury. Institutional Challenges to Mining and Sustainability in Peru. Proceedings of the National Academy of Sciences of the United States of America, 106(41), October 2009. URL: http://www.pnas.org/content/106/41/17296.full?sid=ecb93442-632a-4083-aaf6-04be0359aee1.
Hawe, P. & L. Potvin. What is population health intervention research? Canadian Journal of Public Health, 2009, 100(1):I8-I14.
Hawe, P., E. Di Ruggerio, & E. Cohen. Frequently asked questions about population health intervention research. Canadian Journal of Public Health, 2012, 103(6):468-71.
International Council on Mining and Metals (ICMM). Best practice guidance on health impact assessment, 2010. URL: http://www.icmm.com/library/hia
Jul-Larsen, E. & S. Lange. Socio-economic effects of gold mining in Mali: A study of the Sadiola and Morila mining operations. Chr. Michelson Institute, 2006. URL: http://www.cmi.no/publications/publication/?2340=socio-economic-effects-of-gold-mining-in-mali.
Price Waterhouse Cooper (PwC). The direct economic impact of gold, 2013. URL. http://www.pwc.com/gx/en/mining/publications/mining/the-direct-economic-impact-of-gold.jhtml 2013.
World Gold Council (WGC). About Gold, 2013. URL. http://www.gold.org/about_gold/sustainability/socio-economic/responsible_mining_value_distribution/
World Gold Council (WGC). Advanced by Gold 2013. URL: http://www.gold.org/advanced_by_gold/#impact
Health Impact Assessment (HIA) is “a practical approach used to judge the potential health effects of a policy, programme or project on a population, particularly on vulnerable or disadvantaged groups” (WHO, 2013). The product of an HIA is a set of recommendations for decision-makers and stakeholders, which aim to enhance the proposal’s positive health effects and mitigate possible negative ones (WHO, 2013). A key underlying value of HIA, and also one of it’s strengths, is the engagement and involvement of stakeholders, including impacted communities, in the assessment and decision making process. Current developments in extractive sector HIA research provide a good reminder that HIA is meant to be a support tool for making shared-decisions among diverse stakeholders, and as such, could benefit from an update aimed at helping community members become more empowered and better informed. Promising research is underway.
Decision support tools (DST) exist in abundance. They target all sorts of decision makers, claiming to support the making of all sorts of decisions. DSTs can help decision makers: gather and organize information and knowledge; better understand (“get a handle on”) the situation or context; formulate answers to “what if?” questions; analyze or narrow the field of choice; and/or visualize the data or problem space (University of Cambridge). In the health care realm, Patient Decision Aids are used to involve patients in decisions related to their own care (Ottawa Hospital Research Institute). Other DSTs target clinicians, such as Cochrane reviews, clinical practice guidelines, and condition-specific order sets. The Lives Saved Tool (LiST) is meant for health policy makers to aid in priority setting for service delivery models (Campbell, 2012). If there is a decision to be made, there seems to be a DST to help.
Health Impact Assessment (HIA) is a DST that has been highly promoted by the World Health Organization in recent years as a tool for health promotion and a way of improving health across sectors (WHO, 2013). It is a process used to systematically consider and predict the health consequences of various implementation options for policies, programs and projects (Kemm, 2008). As a DST, HIA is ideally carried out alongside a decision making process during the policy or program development stage instead of after a decision has already been made (Kemm, 2008). A number of HIA toolkits and methodologies exist, but the general procedure for HIA is described in this flowchart:
(Source: WHO HIA. http://www.who.int/hia/about/en/)
HIA is used to inform many kinds of shared decisions at local, national and global levels. The implementation of resource extraction developments is but one example. Mining projects can affect the health of impacted communities both directly and indirectly by causing rapid change in the local social-ecological contexts (Winkler et al, 2012). Along with mining companies and local/national governments, impacted communities are obviously important stakeholders in project related decisions. HIA is an important method for including them in the planning process and supporting their informed-decision-making, in theory. Often however, there are barriers preventing this from happening in practice, especially in low- and middle-income countries. These include “high levels of illiteracy, language barriers, cultural, demographic, gender and social differences between stakeholders” (Winkler et al, 2012). These barriers put into question how ‘shared’ the decision making process actually is in these situations, and undermine the utility and success of HIA.
In response to this shortcoming, ‘HIA visualization’ techniques are being developed as a tool to communicate complex information about large development projects to various stakeholders including communities in rural and remote areas, health authorities, and project staff (Winkler, 2012). The approach is to visually display quantitative information “so that the maximum information is conveyed in the simplest and most visual manner” (Krieger et al, 2012). This is meant to address the problem of HIA inaccessibility. Typical impact assessment reports are lengthy, technically complicated, and difficult for most stakeholders to understand (Krieger et al, 2012). Adaptable spacial-temporal HIA visualizations in the form of short videos and ‘supergraphics’ for mining, oil and gas, and water resources projects have been created. The researchers behind this work suggest that their experience shows that these ‘aids’ have facilitated communication and understanding of HIA findings among various concerned groups. They call for other researchers to build upon their work (Krieger et al, 2012; Winkler et al, 2012).
Campbell S. (2012). Knowledge Translation Curriculum. Canadian Coalition for Global Health Research: Ottawa. http://www.sandy-campbell.com/sc/Publications.html
Kemm J. (2008). HIA: An aid to political decision-making? Scandinavian Journal of Public Health, 36:785-788.
Krieger GR, et al. (2012). Enhancing Impact: Visualization of an intergrated impact assessment strategy. Geospacial Health, 6(2):303-306.
Ottawa Hospital Research Institute. Patient Decision Aids. http://decisionaid.ohri.ca/index.html
University of Cambridge. Institute for Manufacturing. Research: Decision Support Tools. http://www.ifm.eng.cam.ac.uk/research/dstools/
Winkler MS, et al. (2012). Health impact assessment of industrial development projects: a spacial-temporal visualization. Geospacial Health, 6(2):299-301.
World Health Organization. (2013). Health Impact Assessment. http://www.who.int/hia/about/en/
Last week I attended the International Health Impact Assessment (HIA) 2013 conference in Geneva, Switzerland. HIA is “a combination of procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population” (WHO, 2013). It is a practical approach used to judge the potential health impacts of policies, programmes or projects in diverse economic sectors (i.e. transportation, resource extraction, agriculture, housing) on a population, particularly on vulnerable or disadvantaged groups (WHO, 2013). Using best available evidence, recommendations are produced for decision-makers and stakeholders, to help them make choices about alternatives and improvements to prevent disease/injury and to actively promote health (WHO, 2013). As you can see, HIA itself is a KT tool. It’s importance as a way of achieving “Health in All Policies” is growing, but I do not bring it up now as a KT tool per se. I bring it up because of questions/themes that featured prominently in my mind while at the conference and to think a bit more about the ‘Scientist – Policymaker Divide’ and what that means for global health researchers.
The HIA process involves many stakeholders, including researchers whose judgements about potential impacts of the policy and/or program under study are meant to be objective and impartial. During one of the HIA2013 panel discussions on ‘HIA for equity and Social Justice’, one of the speakers started out by asking the audience why we were all here. “Put up your hand if you are involved in HIA because you are concerned with social justice and equity”. (Note: It was something along those lines, but I didn’t write it down verbatim). Every hand in the house went up. The speaker than commented on the fact that HIA is in fact a tool to achieve a goal, the goal being (Global? Local? Both?) equity and social justice. During the final panel session, another rhetorical question was posed: “Are HIA practitioners advocates or impartial assessors?” Given our shared desire to be ‘agents of change’ I think these are relevant questions for global/public health researchers whether or not we have any connection to HIA. And the answers really depend on why were are in this field in the first place.
Brownson et al (2006) and Choi et al (2008) both discuss, inter alia, the researcher characteristics that create challenges in the researcher-policymaker working relationship. According to Brownson et al (2006), one of the main challenges to successfully translating evidence into policy is researchers’ need/inability to balance objectivity and advocacy. They explain the disagreement that exists about the extent to which scientists should be involved in the policymaking process. One side of the argument, they say, is that “researchers who take on a public stance on a given healthy policy issue may face real or perceived loss of objectivity that may adversely affect their research. Objectivity implies that a researcher seeks to observe things as they are, without falsifying observations to match some preconceived view…[and] may be influenced by the research questions in which a researcher is personally interested” (Brownson et al, 2006, p. 166). Others argue that it is actually a researcher’s ethical obligation to take part in policy development. The fact that some researchers are not up to the challenge and possible consequences (i.e. Being the target of personal attacks and harassment due to involvement of heated policy debates) of contributing to the policy process is another challenge to evidence-based policy (Brownson et al, 2006). Another suggested problem with (stereotypical) scientists, is that they are less interested in social or policy aspects of their work, and even if they are interested, they are not required to focus on issues that have policy relevance or application (Choi et al, 2008).
Of the multiple barriers and challenges that arguably contribute to and maintain the ‘Scientist – Policymaker Divide’, I think it is interesting, and a little amusing, to consider the research scientists supposed weaknesses and barriers here. I like to think they they do not apply to those working in the field of global health, and thus I return to a version of the question raised at the conference: Why are you involved in global health research? Is it because you are concerned with social justice and equity? And I would like to add a few more. What would Paul Farmer do?*** Who are our global health research role models? How have they successfully married objective research and advocacy? And isn’t that the point?
It is not surprising to me that at the Canadian Society for International Health Conference in 2008, after giving a keynote address, Dr. Paul Farmer was mobbed by a group of young, aspiring global health researchers (and no, I was not part of the mob) and medical students. I think in the field of global health research, we are here because we want to affect policy – the sea of hands at the HIA conference attests to that – but the question is what is the best means to that end. If being too ‘vocal’ (I’m imagining myself with a picket sign in front of the office building of a Canadian company that mines golds in rural Guatemala shouting solidarity chants…) in trying to influence policy makes your research ‘biased’ and thus less likely to be used as evidence, then perhaps we need to be more creative in how we communicate evidence, but we should not stop trying.
**I would love to hear your thoughts on other activist/advocate researcher role models.
Brownson RC, Boyer C, Ewing R, McBride TD. Researchers and policymakers, travelers in a different universe. American Journal of Health Promotion 2006; 30(20):164-172.
Choi B et al. Can scientists and policymakers work together? Journal of Epidemiology and Community Health 2005; 59:632-637.
HIA 2013. Conference website: http://www.unige.ch/medecine/eis2013/accueil_en.html
World Health Organization. (2013). WHO Health Impact Assessment. http://www.who.int/hia/en/
Still stuck on the question of adaptation (so vague!), I explored a little more…
Clinical guidelines are often irrelevant in LMICs due to the fact that they are not commonly developed for or in these types of settings (Ehrhardt et al, 2012). The evidence on which many of these guidelines are based does not come from trials conducted in LMICs either because the research isn’t being done in these settings or there is an issue with study quality. Low quantity and quality of trials in LMICs is often the result of technical and infrastructure constraints, ethical issues, overburdened health systems, and lack of funding (Ehrhardt et al, 2012). Clinical guidelines based on evidence from high-income countries are thus not necessarily appropriate or applicable in LMICs and site-specific adaptation of guidelines might actually be less efficient and possibly harmful. Ehrhardt and Meyer (2012) argue for the mandatory, rigorous evaluation of guidelines in LMICs because, in their opinion, ‘adaptation without evaluation by use of adequate study designs is not good enough’.
This call for rigorous evaluation (i.e. using meaningful study methods such as clinical trials) is an important aspect of the the adaptation phase of the knowledge to action cycle that is missing from the framework presented by Graham et al (2006). It does make reference to the “activities that [individuals or groups] may engage in to tailor or customize the knowledge to their particular situation” (Graham et al, 2006, p. 20), but the language used to described how this is done (i.e. The process by which knowledge is adapted to a local setting “may be more or less formal”…; Some sort of “vetting or tailoring to the local context” is required…) leaves one believing that the ‘how’ is not overly important.
To address the issue of poor adaptability of clinical guidelines across settings, Ehrhardt and Meyer (2012) recommend that we pay more attention to: The setting in which a guideline has been developed and evaluated; the design processes addressing the question whether or not a guideline developed in HICs may also be suitable for LMICs; local adaptation of guidelines, and timely inclusion of relevant stakeholders and experts; and local evaluation of modified guidelines through either cost-effective implementation research or rigorous clinical trials. The issue of adaptability is not unique to the ‘knowledge’ contained in clinical guidelines. Spoth et al (2013) stress the importance of studying the adaptations of evidence-based prevention interventions and identify the need for strategies and methods for updating and adapting EBIs to local circumstances. This kind of implementation research will help in understanding whether adaptations affect outcomes, and if so, how (Spoth et al, 2013).
Although it seems to be accepted that adapting knowledge to local setting or context is an important part of the KT process, the rigor and formality with which this should be done is debatable. Ehrhardt and Meyer (2012) and Spoth et al (2013) both argue for the meticulous evaluation of modified/adapted interventions. Failure to do so can result in wasted resources, ineffective (or less effective) interventions, and possibly even harm. I think that the importance of this type of evaluation studies should not be glossed over, but I am left with these questions: What are the ethical implications of conducting clinical trials of interventions modified and/or adapted to LMIC settings when ‘best practices’ already exist? What are the ethical implications of not doing so?
Ehrhardt, S et al. (2012). Transfer of evidence-based medical guidelines to low- and middle-income countries. Tropical Medicine and International Health, 17(2): 144-146.
Graham, ID et al. (2011). Lost in knowledge translation: time for a map?. The Journal of Continuing ducation in the Health Profession, 26(1), 13-24.
Spoth, R et al. (2013). Addressing core challenges for the next generation of type 2 translation research and systems: The translation science to population impact (Tsci Impact) Framework. Prev Sci, 14: 319-351.
Adaptation of knowledge to a local context. If only it was that easy. This is a key element of the knowledge-to-action (KTA) process (Graham, et al, 2006). It involves “[t]he process individuals or groups go through as they make decisions about the value, usefulness, and appropriateness of particular knowledge to their setting and circumstances” as well as the formal (or not) tailoring of knowledge to a particular situation (Graham, et al, 2006, p. 20). In theory this seems appropriate, but what gets lost when knowledge is adapted? What if individuals or groups decide that ‘good’ evidence is neither useful nor valuable to them? And what if the ‘local’ context is ‘global’, such as in the case of climate change?
A lot of scientific evidence, or knowledge, is created “in isolation from its projected users…[and] often fits uncomfortably in the settings and populations in which it is intended to be applied” (Glasgow, et al, 2012, p. 646). How do we move from this ‘uncomfortable fit’ that is resulting in a lag in improvements in population health to a more impactful use of knowledge? More research! Or at least more of the right kind or research. Glasgow et al (2012) describe the need for the kind of research that informs this key step in the KTA process – implementation and impact research. Research, they say, that focuses on external validity, context and stakeholder relevance. In other words, research that facilitates the adaptation of knowledge to local contexts. The BetterBirth Project in which researchers took an evidence-based intervention, kangaroo-care, known to save babies lives and evaluated it’s implementation in a particular context in a practical setting (Gawande, 2013) is a good example of this.
Reflecting on KTA in this way makes me eager to discover other existing kangaroo-care-type lifesaving interventions that need only be adapted to a local context. Is that where we, new (global) population health researchers, should be focussing our attention? So far in my short (!) career in global health I have grappled often with these questions. Research or practice or both? Knowledge creation or action? And which element of KTA is the most important in terms of actually improving population health? Does one have to choose? I am left with (and leaving you with) more questions than I had before delving into this week’s material. I think Hanlon, et al’s proposition for the future public health (2011), may be able to help with some of the answers and definitely deserves a second read at least.
Glasgow, RE., et al. (2012). Evidence integration triangle for aligning science with policy and practice. American Journal of Preventive Medicine, 42(6), 646-654.
Graham, ID et al. (2011). Lost in knowledge translation: time for a map?. The Journal of Continuing ducation in the Health Profession, 26(1), 13-24.
Gwande, Atul. Slow ideas: why innvations don’t always catch on. New Yorker, July 29, 2013.
Hanlon, P., et al. (2011). Learning our way into the future public health: a proposition. Journal of Public Health, 33(3), 335-342.