Evidence-based health economics

Health economics is an increasingly important field of study because health care resources are becoming more limited and because of the need to make choices among competing demands for them. The use of economic evaluation is a key tool that can guide decisions about the allocation of resources that are increasingly scarce. An economic evaluation is a comparative analysis between two or more alternatives in terms of both costs and effects [1].

Evidence-based medicine (EBM) plays an important role in health research and also in health economics. EBM is defined as: “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients [2].” In order to use the term EBM within the context of health economics, it is important to differentiate between a) evidence-base of health economic evaluation and b) evidence-base of the methods which health economists apply [3].

In regards to the evidence-base of economic evaluation, a distinction is being made between trial-based economic evaluation and model-based economic evaluation. Within a trial based economic evaluation, where additional data are collected alongside a clinical trial (piggy-back study) [4], effects and costs are measured in the same population. A model, on the other hand, allows us to combine multiple sources of evidence, to extrapolate outcomes to the longer term, to extend the analysis to the relevant comparators, and to generalize from specific trial populations to the full target group for an intervention and to other settings and countries [5]. Nevertheless, randomized controlled trials (RCTs) have a central role in the evaluation of health care interventions. Since 1994, approximately 30% of the published economic evaluations on the NHS Economic Evaluation Database have been based on a single RCT [6]. RCTs are, therefore, seen as the vehicle for analysis. But given the fact that economic evaluations should guide resource allocation decision, it is questionable whether the explicit use of a single RCT is appropriate. An RCT might be considered as a gold standard and is free of selection bias, but it has also some limitations. Within an RCT it is not possible to compare all relevant options, an RCT usually has a short follow-up time, and an RCT fails to incorporate all existing evidence [6].

Although economic evaluation is an important tool for health economists, there are many unresolved issues around the methods, which leads to the second aspect of EBM in health economics. These methodological issues are associated with 1) observed variations in the measurement of health benefits due to the different use of instruments 2) the fact that utility scores used for quality-adjusted life years (QALYs) are being influenced by the choice of respondents, 3) important theoretical problems around the welfarism framework and the extra-welfarism approach, and 4) issues around discounting costs and effects. These concerns have been identified as important barriers to the use of economic evaluation in decision making [7].

In the recent years, many countries have developed national Health Technology Assessment (HTA) agencies, such as the National Institute for Health and Clinical Excellence (NICE) in the UK or the Canadian Agency for Drugs and Technologies in Health (CADTH), to inform and guide reimbursement decisions. Although an important pillar of HTA, cost-effectiveness is not the only consideration in the health technology appraisal. The trend towards evidence-based decision-making reinforced the need to base resource allocation decisions on rational criteria and include also safety, clinical efficacy and effectiveness, social consequences, or legal and ethical considerations [8]. Within the UK context, a review and empirical investigation looked at the extent to which health economic information is used in health policy decision-making [9]. This analysis showed that cost-effectiveness analysis had a minor role in the local decision-making process as the primarily focus was on evidence of clinical benefit and cost implications. However, at the national policy level in the UK, cost-effectiveness analysis were highly integrated into NICE’s technology appraisal program. While NICE also considers other decision-making criteria besides cost-effectiveness, such as severity of underlying illness, stakeholder persuasion, or end-of life treatments etc., a recent analysis showed that cost-effectiveness alone predicted 82% of NICE decisions [10].

The aim of an economic evaluation is to guide resource allocation decisions. Although health economists would claim that economic evaluation is by nature evidence-based, it is in general acknowledged that more research is needed to address the methodological issues. Finally, it should be noted that an economic evaluation can never be comprehensive enough to capture all factors important for resource allocation decision-making.

 

References:
1. Drummond M.F., Sculpher M.J., Torrance G.W., O’Brien B.J., Stoddart G.L. (2005): Methods for the Economic Evaluation of Healthcare Programmes. 3rd Ed. Oxford University Press.
2. Sackett D.L., Rosenberg W.M.C., Gray J.A.M., Haynes R.B., Richardson W.S. (1996): Evidence based medicine: what it is and what it isn’t. BMJ, 312(7023): 71-2.
3. Cairns J. (1998): Economic Evaluation and Health Care. Available from: http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/Economic-Evaluation-and-Health-Care.pdf Accessed on February 26th, 2014.
4. O’Brien B. (1996): Economic Evaluation of Pharmaceuticals. Frankenstein’s Monster or Vampire of Trials? Medical Care, 34(12): DS99-DS108 Supplement.
5. Brennan A. and Akehurst R. (2000): Modelling in Health Economic Evaluation. What is its Place? What is its Value? Pharmacoeconomics, 17(5): 445-459.
6. Sculpher M.J., Claxton K., Drummond M., McGabe C. (2006): Whither trial-based economic evaluation for health care decision making? Health Economics, 15(7): 677-687.
7. Brouselle A., Lessard C. (2011): Economic evaluation to inform health care decision-making: Promise, pitfalls and a proposal for an alternative path. Social Science & Medicine, 72(6):832-839.
8. Tylor R. and Tylor R. (2009): What is health technology assessment? Available from: http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/What_is_health_tech.pdf Accessed on February 26th, 2014.
9. Williams I., McIver S., Moore D., Bryan S. (2008): The use of economic evaluations in NHS decision-making: a review and empirical investigation. Health Technology Assessment, 12(7): iii, ix-x. 1-175.
10. Dakin H., Devlin N., Feng Y., Rice N., O’Neil P., Parkin D. (2013): The influence of cost-effectiveness and other factors on NICE decisions. Available from: http://www.herc.ox.ac.uk/downloads/nicethreshold Accessed on February 26th, 2014.

Health economics – what it is and what it isn’t

Economics is the science of scarcity. Within the health care context, health economics reflects a universal desire to obtain maximum value for money by ensuring not just the clinical effectiveness, but also the cost-effectiveness of healthcare provision [1]. Although there is a growing interest in health economics, there is still a poor understanding about health economics as a topic and as a discipline. As a health economist by training, I want to demonstrate in this reflection the fundamental misconceptions about health economics. Moreover, I want to investigate whether Snow’s ‘Two Cultures’ [2] still exist in today’s world by looking at health economics as a discipline.

The first important thing to note is that a health economist has to address different needs in the market than an economist. Why? Because the health care market is not comparable to a well-functioning market. We do have a market failure within the health care context for the reason that none of the assumptions for a well-functioning market, such as the absence of market power, symmetry of information, and absence of externalities hold true [3]. The unique features of health and health care as commodities are the reasons why we do not accept market forces in health care and require government intervention. It is also important to note that health economists address different needs across countries because of the variations in the health care systems and the different values by which the countries are characterized.

The second misconception results from the fact that all too often people believe that health economics is all about money [4]. But in fact, health economists are interested in resources and not in money. Money is not considered as a resource but only a medium of exchange that expresses our value for the economic resources. Resources are those things that contribute to the production of output. Within the health care context, these include pharmaceuticals, surgeons, nurses, operating theatres, hospital beds, imaging technologies, implants, etc. The concept of opportunity cost is often used, which illustrates that choosing to use resources for one purpose precludes using it for another and, therefore, indicates a forgone benefit [5].

Very often the terminology also causes problems in this discipline. People tend to use the terms economic evaluation, cost-effectiveness analysis, and cost-benefit analysis interchangeably. In fact, cost-effectiveness analysis and cost-benefit analysis are specific types of economic evaluation, depending on how the effect is being measured [6]. In general, the term economic evaluation should only be used if there is a comparative analysis between two or more alternatives in terms of both costs and effects. Concentrating on one intervention only or collecting cost data only is not sufficient for a full economic evaluation.

The role of economic evaluation became increasingly important based on the rising demand of health care, the rapid development of medical technological possibilities, and the budget constraints. Many countries have now developed national health-technology assessment (HTA) agencies to inform and guide reimbursement decisions. While economic evaluation is part of the HTA pillar, other criteria such as safety, clinical efficacy and effectives, or social consequences etc. are also taken into consideration. In this context, it is worthwhile to say that a health economist is not the decision maker but provides only evidence on the economic evaluation.

When I recently read Snow’s ‘The Two Cultures and the Scientific Revolution’ [2], I was wondering if we still live in a world where two or more cultures exist. I remembered a series of tweets last year from the Editor of the The Lancet, Richard Horton [7]. These tweets with the subject ‘Economics, second only to ‘management’, may just be the biggest fraud ever perpetrated on the world’, listed ten cases against economics. Three economists had then the opportunity to respond to these tweets in The Lancet itself and argued that there is still a poor understanding of the discipline and that there is no evidence to support the assertions that economics is a ‘fraud’ and offers ‘false promise’. The authors pointed out that economics is seen as a toolkit that enables a better understanding of how people live, and how societies work, but it does not exclude other explanations of human behavior derived from other disciplines, such as anthropology or psychology [7]. As a health economist, I hope that one day these biases and prejudices can be overcome, in particular in the view of the increased interest in doing interdisciplinary research.

 

References:
1. Haycox, A. (2009): What is Health Economics? Available from: http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/what_is_health_econ.pdf Accessed on February 25th, 2014.
2. Snow, C.P. (1959): The Two Cultures and the Scientific Revolution. Cambridge University Press, New York.
3. Hurley, J.E. (2010): Health Economics. First Edition. Toronto: McGraw-Hill Ryerson.
4. Gergely, V. (2013): But, money is not the central problem of health economics. Available from: http://www.molnlycke.com/blog/But-money-is-not-the-central-problem-of-health-economics/ Accessed on February 25th, 2014.
5. Mooney, G.H. and Drummond, M.F. (1982): Essentials of health economics: Part 1 – What is economics? Br Med J, 285(6346): 946-950.
6. Drummond M.F., Sculpher M.J., Torrance G.W., O’Brien B.J., Stoddart G.L. (2005): Methods for the Economic Evaluation of Healthcare Programmes. 3rd Ed. Oxford University Press.
7. Parkin, D., Appleby, J., Maynard, A. (2013): Economics: the biggest fraud ever perpetrated on the world? Lancet, 382(9900) e11-5. doi: 10.1016/S0140-6736(13)61178-2.

When nothing means something

The movement towards evidence-based medicine (EBM) is gaining attention and momentum. It is really quite a simple concept: EBM is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al. 1996, p. 71), just as its name suggests. Efforts are being made to translate research into practice (e.g. the tagline of the British Medical Journal *applause* is helping doctors make better decisions), but this is not without controversy and pitfalls (well that escalated quickly).

The above mentioned definition of EBM is by no means the only definition of EBM, but is one that reveals, in my opinion, its greatest weaknesses: it suggests that practitioners be informed by current best evidence. Current evidence? Then how to proceed in the absence of evidence? Or rather, was there an absence of evidence? How could we know? And why might there be such an absence of evidence?

Take the example of oseltamivir, commonly known as Tamiflu. The time is 2003 and three published study suggests that this drug is effective in reducing complications associated with influenza. At roughly the same time, SARS, avian flu, swine flu etc. raged across the globe. Governments panicked and poured billions into stockpiling this drug. Turns out, oseltamivir isn’t really the miracle drug that everybody thinks it is: a 2009 meta-analysis reveals that is really no evidence to suggest that oseltamivir is effective in any way. We were literally blinded from the entire truth: there was not just three but at least eight other RTCs conducted on oseltamivir, only three ended up being published while the others were locked up by Roche (big phrama) (Ebell et al. 2013). Why were they not published? If you guessed because those studies didn’t find that oseltamivir was a “good drug”, good for you!

Publication bias, or positive-outcome bias, is an issue. This is something that happens beyond clinical trials, even without the “forces of big corporation”. Let’s face it, nobody likes to publish negative results (Fanelli 2012).

My evil twin recently experienced something similar. She has been trying to publish one of her papers since July 2011. Said paper, reporting a negative result, was rejected by four journals, and she kept getting comments like:

So you didn’t find anything. You learned nothing. Then what are we trying to publish here? (paraphrased)

Other reasons for not liking negative results?

You must have done your analysis wrong.

Your experiment was poorly designed.

Your need a more robust question. (whatever that means)

Negative results appear to mean no impact, and this is very problematic. What really matter should be scientific rigor in the design of the study and not the outcome. Every single study, regardless of the outcome, should be scrutinized in the same way. Studies that report positive results could be flawed as well, and those that report negative outcome really doesn’t automatically mean that something is wrong. A negative outcome is an outcome, and it is nice to know that.

In response to this, there are now journals that are dedicated to publishing negative results (as well as replicated studies, which is a great topic for another post another day). The Journal of Negative Results (appropriately named) is one of them. I particularly like this quote from the journal’s home page:

“The primary intention of Journal of Negative Results is to provide an online-medium to publish peer-reviewed, sound scientific work in ecology and evolutionary biology that is scientifically rigorous but does not rely upon arbitrary significance thresholds to support conclusion

In ancient India, the great mathematician Muhammad ibn Mūsā al-Khwārizmī made one of the greatest breakthroughs in math by acknowledging that the number zero could mean something (more preciously, that 0 has a place on the number line between +1 and -1). Looking back today, this discovery isn’t exactly groundbreaking, but if not for this we would not have algebra today (good news?!) (Barrow, 2001).

Realizing that nothing could mean something, pursuing and revealing those nothings, might very well lead to our next genuine breakthrough in biomedical practices and research.

References

 

Barrow, J. (2001). The Book of Nothing. Random House: London.

Ebell, M., Call, M. & Shinholser, J. (2013). Effectiveness of oseltamivir in adults, a meta-analysis of published and unpublished clinical trials. Family Practice, 30, 125-133

Fanelli, D. (2012). Negative results are disappearing from most disciplines and countries. Scientometrics, 90, 891-904

Sackett, D., Rosenberg, W., Muir Gray, J., Haynes, B., Richardson, W. (1996). Evidence based medicine: what it is and what it isn’t: it’s about integrating individual clinical expertise and the best external evidence. British Medical Journal, 312, 71-72

Planetary Interdisciplinarity

As the population of Earth quietly soared passed 7 billion recently, a few more people bumped shoulders and came to appreciate the finite nature of this magnificent planet. Perhaps more interestingly, a few more lifted their gaze from what they had always perceived as reality and looked up for the first time to realize that their view of the world, their paradigm, is but one perspective in a sea of possibilities. And that no matter how much they wanted to hold onto the idea that their paradigm was the ‘right’ one, they could not help but acknowledge the possibility that it was not, nor the idea that perhaps the notion of ‘right’ was a complete fallacy. And finally, that uncertainty is ok. It is my belief, that as our world grows smaller with every newborn child (and every activated cellphone) that more people will come to see the world as the rich tapestry of worldviews that it is. In academia, I believe that the increasing use of the concepts of interdisciplinarity and transdisciplinarity are a reflection of this much larger phenomenon that is unfolding all around us as a result of a rapidly changing world (Refer to an article by Choi and Pak (2006) for concise definitions of these terms). While academics might be tempted to pat themselves on the back for having come to appreciate the value of these integrated approaches to research, it is the tardiness of their arrival that worries me.

As an interdisciplinary researcher myself, I am experiencing firsthand just how little communication occurs between researchers of the various disciplines that are approaching inter-related phenomena; each one from a different angle and through a different lens. Some see the intricacies at the atomic level, others on the social or economic level and yet others on the ecological level, embedding the entire story into the fabric of the living and non-living. Only now are we beginning to realize that we are often all looking at the same thing and that in appreciating the entire spectrum of perspectives that exist, we can get a most comprehensive view of reality. Huby and Adams (2009) recognize that while we appreciate this as the ideal, so far we have largely failed at actually putting it into practice. 

One might suspect that academics would have recognized the need for an integrative approach years, if not centuries, ago and surely that by now we would have many success stories from which we could draw upon as examples. In my view, aboriginal peoples of the world had been practicing transdisciplinary ways of life for millennia before Western science arose. And now it has taken centuries for Western science to come to realize that while specialization can put a human on the moon, it falls far short of offering the sort of integrated perspective we require if we are to overcome the complex challenges we now face as a species. Certainly we are spending a great deal of energy on trying to understand these new concepts, and even so, we struggle to agree on a definition of interdisciplinarity just within the health sector (Aboelela et al., 2006), let alone one for its abstract cousin transdisciplinarity.

Because we as academics have been so late in the game in acknowledging the necessity of these holistic approaches, while cultural neuroscientists investigate potential sociocultural and biological interactions (Chiao, 2009) to explain our delay, I would suggest that we agree to disagree on the specifics of their definitions and begin getting our hands dirty actually applying whatever it is we think they mean to us. One thing I think we can agree on is that they show notable potential for tackling some of today’s most complex challenges. Perhaps by its very nature, the beast of transdisciplinarity is not one that can be caged, defined and filed away but one that deserves to be left alone in the wild to continually confuse, wonder and inspire us as we work towards our individual and collective goals. I have an ironic image in my head that I hope does not manifest itself, one of a world that is going up in flames, so to speak, while the greatest thinkers of our time focus their energy on trying to reach a consensus on a definition of an abstract term that they struggle to conform to their worldviews; a term that seeks to describe the very process that would have saved the world from disaster, had it actually been applied.

 

References

Aboelela, S., Larson, E., Bakken, S., Carrasquillo, O., Formicola, A., Glied, S., Haas, J. & Gebbie, K. (2007). Defining interdisciplinary research: Conclusions from a critical review of the literature. Health Services Research, 42; 329-346.

Chiao, J. (2009). Cultural neuroscience: a once and future discipline. Progress in Brain Research, 178; 287-304.

Choi, B. & Pak., A. (2006). Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med, 29; 351-364.

Huby, M. & Adams, R. (2009). Interdisciplinarity and participatory approaches to environmental health. Environ Geochem Health, 31; 219-226.

Taking a Cue from Improv

After watching a performance of Sci-Fi Double Feature–a mash-up of live video performance and puppet theatre– an enthusiastic patron asked the creators of the production: “How did you come up with this brilliant piece of work?”  They explained that their artistic differences could have hindered their collaboration, but instead synergized their talents pushing them beyond their comfort zones.  Edward Westerhuis, the animator/filmmaker, stated he learned from his partner’s improvisation skills, mainly by saying “yes” to any idea and playing with it until it led to something new. He also stated that saying “no” to an idea hinders the process, and is much more defensive and restrictive.  It made me think, could this approach work for multi-inter-trans-disciplinary research teams with disparate “epistemic cultures” (Knorr-Cetina 1999)?

sci-fi

Tina Fey, a known improvisation comedian states with her line of work you need to contribute by being open-minded and non-judgmental, always with the intention of saying “yes and” and with the goal of being part of the solution (2011: 85-85).  Paul Farmer a clinician-anthropologist states that complex life or death problems, he terms general problems, are commonly punctuated by, “this can’t be done” (2005b).  Like Fey, Farmer asserts that it’s better to say “yes, and” to continue the conversation so that originality, creativity, and innovation can flourish (2005b).

Yet, Farmer is realistic and asserts that innovation and progress require a change in the way disciplines collaborate (Farmer 2005a).  I whole heartily agree, as being a Master of Science candidate in an interdisciplinary faculty has allowed me to preview challenges faced in multi-inter-trans-disciplinary contexts.  As “research is essentially knowledge production” (Hall et al 2006:766), it would seem one’s epistemology, value judgments, and disciplinary allegiance –read as inter-personal barriers –are obvious places to begin transforming disciplinary work (LeLe and Norgaard 2005).   However, inter-personal barriers are only half of the equation (LeLe and Norgaard 2005).  For example, the academy is set up to maintain boundaries through granting agencies (Albert et al 2009; Hall et al 2006; Lamont 2009), academic appointments, publication processes, professional scopes of practice, regulatory bodies, professional associations, and medical and research hierarchies (Hall et al 2006).  Thus, true health science multi-inter-trans-disciplinary collaboration requires changes in disciplines relational understandings as well as transforming systemic structural level constraints (LeLe and Norgaard 2005).

Sci-Fi Double Feature may seem an inept example for health sciences researchers endeavoring to deal with general problems, but I disagree.  These artist-practitioners have come from different disciplines with different epistemologies, value systems, languages, theories and skill sets, yet they were able to collaborate to create an innovative production that pushes the boundaries of video and theatre.  Paul Farmer and his organization, Partners in Health, did the same.  Through advocacy and persistent innovative thinking, he not only continued the conversation, but changed it for many individuals who believed that HIV medications were not “cost-effective” for resource-poor countries (Farmer 2005ab).  We should be like the Sci-Fi creators, Paul Farmer, and Tina Fey and respectfully think flexibly by saying, “yes, and.”

 

References

Albert, Mathieu with  Suzanne Laberge and Brian D. Hodges

2009  Boundary-Work in the Health Research Field: Biomedical and Clinician Scientists’ Perceptions of Social Science Research

Farmer, Paul

2005a  Pathologies of Power: Health, Human Rights, and the New War on the Poor. Los Angeles: University of California.

2005b  Pathologies of Power: Rethinking Health and Human Rights in the Global Era. 56:52 min. Calvin College. January 10.               http://www.calvin.edu/january/2005/farmer.htm, accessed February 4, 2014.

Fidler, Brian and Edward Westerhuis

2014  Sci-Fi Double Feature. http://www.ramshackletheatre.ca/shows/sci-fi-double-feature/, accessed February 4, 2014.

Fey, Tina

2011  Bossypants. New York: Little, Brown and Company.

Hall, Judith with Lesley Bainbridge, Alison Cribb, Jane Drummond, Carlton Gyles, T. Philip Hicks, Carol McWilliam, Barbara Peterson, Pamela Ratner, Elizabeth Skarakis-Doyle, and Patty Solomon.

2006  A Meeting of Minds: Interdisciplinary Research in the Health Sciences in Canada. Canadian Medical Association Journal 175(7): 763-771.

Knorr Cetina, K

1999  Epistemic Cultures:  How the Sciences Make Knowledge. Cambridge, MA: Harvard University.

Lamont, Michele

2009  How Professors Think : Inside the Curious World of Academic Judgment. Pp. 53-106. Harvard University Press: Cambridge, MA.

LeLe, Sharachchandra and Richard B. Norgaard

2005  Practicing Interdisciplinarity. BioScience, 55(11): 967-975.

“On Being a Scientist and a Red”: Living the 11th Thesis

“Philosophers have hitherto only interpreted the world in various ways; the point is to change it.”
Karl Marx, Theses on Feuerbach, 1845

 “The irrationalities of a scientifically sophisticated world come not from failures of intelligence but from the persistence of capitalism, which as a by-product also aborts human intelligence.”
Richard Levins and Richard Lewontin, The Dialectical Biologist

Recently I started graduate school after several years working as a midwife in Vancouver and rural Philippines with Community-Based Health Programs.  And, yup, I’m definitely a ‘red’.  Prior to grad school my research experience stemmed from my pre-midwifery years as a community organizer, activist, and participatory action researcher for anti-poverty, feminist, and environmental justice organizations. During those years I had a handful of interactions with academic researchers; interactions fraught with tension over world views, priorities, and the commodification of research for professional advancement.  Yet, during my work as a midwife I faced questions I wanted to explore; graduate school allowed me to carve out time to address challenges facing Registered Midwifery.

Reading Lélé and Norgaard’s “Practicing Interdisciplinarity” (2005) resonated for me as they discuss how world views, values, and theories shape supposedly value-neutral scientific research.  My orientation towards social justice, human rights, and reciprocity fundamentally shape my research on the prenatal care experiences of poor and marginalized women.  My love of dialectical materialism, a profoundly trans-disciplinary method of understanding complex social and ecological phenomena, helps me grasp the social, political, institutional and economic relations which shape the design and provision of medical care in modern society.  The closest (not openly Marxist) ‘fit’ with dialectical materialism I have read thus far in the scientific literature comes is Nancy Krieger’s eco-social model (eg: 2012).  My feminist standpoint necessarily allies me with the women I care for, am with as midwife, and challenges me to break down the false dichotomies of experience and ideas (Oakley, 1998).  Our economic and social position in society shapes our perspective on the world.  The concepts of research evidence as ‘proof’ and the confines of discipline have been challenging for me, and brings up the tensions I have previously had with academics, that in order to be rigorous, knowledge and ideas must be crystallized through the lens the Western academic project.

Caring for a babe born too early in the Philippines countryside

Caring for a babe born too early in the Philippines countryside, where forced underdevelopment is a legacy of Spanish colonialism, and US neo-colonial domination.

CP Snow’s seminal 1959 lecture “The Two Cultures and the Scientific Revolution” challenges the culture of Western intellectual life, or rather the ‘two cultures’ of natural sciences and the humanities, to collaborate to tackle the growing chasm of underdevelopment.  CP Snow calls on the ‘two cultures’ to unite in the grand project of exporting the Western scientific revolution and its capital, scholars, scientists, systems of education, and colonial gaze to the (forcibly) underdeveloped world. He poses capitalism as the correct path forward and the neo-colonial project the goal.  CP Snow was a Baron, a peer in the House of Lords, and in my opinion espoused the world views of the European bourgeoisie who had flourished precisely because of the colonial plunder of developing nations and the mass export of surplus labour to the settler states in the Americas.  In his context, the shift from colonialism to neo-colonialism is strategic.   But as Richard Levins states in Living the 11th Thesis, “…there was another view, that each society creates its own ways of relating to the rest of nature, its own pattern of land use, its own appropriate technology, and its own criteria of efficiency” (2008, p. 30).  Not only did the wealth of the colonies bolster Western development but many technological, agricultural, and pharmacological advances originate in appropriated indigenous knowledge and practices which have sustained communities and worked in harmony with the environment for many generations.

So here I am in graduate school struggling with the confines of discipline, contradictions in the ownership and authorship of research based in community experiences, and grieving the fact that Western medicine (midwifery) can actually harm people.  I believe we’re in this grand environmental and social catastrophe because of the inherently self-interested, short-term, national chauvinistic and narrow-minded nature of the capitalist system.  I’m inspired by Richard Levin’s “Living the 11th Thesis” and his call, which in some ways is similar to CP Snow – to meld the social and natural sciences – but in many ways different – to meld academia with social justice.  Our scientific endeavors can and must respect unique (and oft poorly understood) world views, uphold human rights and self-determination, promote reciprocal collaboration, and contribute to the betterment of humanity.  My attempts to live the 11th Thesis are to enter my research with intention to make change, to shift the practice of midwifery care, and to incorporate the concept of social justice in all aspects of my work.  Living the 11th thesis keeps alive the challenges that brought me to my research to begin with:  the discounting of the voices of the ‘other’ in clinical work, the overemphasis on Western biomedical viewpoints, and the underlying truth that Registered Midwifery is predominantly a white, middle class, colonial project.

Image

Being a midwife for the people means getting your feet dirty.

  1. Krieger, N. (2012). Methods for the Scientific Study of Discrimination and Health: An ecosocial approach. American Journal of Public Health, 102(5), pp. 936-945.
  2. Lélé, S. & Norgaard, R.B. (2005). Practicing Interdisciplinarity. BioScience, 55(11), pp. 967-975.
  3. Levins, R. (2008). Living the 11th Thesis. Monthly Review, 56(8). Available on line.
  4. Marx, K. (1845). Theses on Feuerbach. Available on line.
  5. Oakley, A. (1998). Gender, Methodology and People’s Way of Knowing: Some problems with feminism and the paradigm debate in social science.  Sociology, 32(4), pp. 707-731.
  6. Snow, C.P. (1961). The Two Cultures and the Scientific Revolution [the Rede Lecture].  New York: Cambridge University Press.

Being a Renaissance Wo/man: Modern education, interdisciplinary research and a multidisciplinary life

 Image

Source: http://karenswhimsy.com/renaissance-clothing.shtm

An engineer-scientist-painter-sculptor-inventor? That is an impressive, if disparate combination and of course describes Leonardo Da Vinci. From religious art to human anatomy to bicycles, Da Vinci had rather multidisciplinary interests. He is the eponymous Renaissance man. Merriam-Webster defines a renaissance man, sadly with no equivalent definition for a renaissance woman but let’s assume they are one in the same, as someone who has “wide interests and is expert in several areas”. In Renaissance Europe, being an academic was not the sole propriety of the scientific discipline. Rather a rounded education resulted in great inventors also being master artists. Fast forward 500 years and this archetype is virtually unknown, what would such a rare creature even look like in today’s academic world?

 Image

Source: http://www.lukesurl.com/comic/191-p-t-yay

in modern education…

The modern Renaissance person would learn about a variety of subjects, equally applying their interests in various scientific and artistic pursuits. Transferring this concept to North American post-secondary education, students would study sciences like chemistry, mathematics, biology but also perhaps theatre, art history and English literature. Not to mention the numerous other disciplines ranging from beer brewing to environmental archaeology. Though I would argue that one would be infinitely more interesting while consuming the products of the other. Basically this person would acquire at least a base knowledge in several different disciplines. This can happen, especially in universities like my own with a focus on interdisciplinarity, but is not the rule for the majority of academics (Castán Broto, Gislason & Ehlers, 2009).

 Image

Source: http://xkcd.com/755/

…in academic research…

In academic research, there is a special application of the Renaissance perspective, namely interdisciplinary research. Defined, varyingly in sources, as collaborative examination of a research problem from two or more disciplines (Choi & Pak, 2006). In this concept the researchers are not themselves Renaissance men but rather they take a Renaissance-like perspective on the problem at hand. The goal is to understand the research question in a more holistic way (Choi & Pak, 2006). The problem with applying Renaissance ideals to research is it clashes directly with university structure. We become increasingly specialized through Masters and Doctorate degrees, limiting our perspectives but becoming experts in one particular field (Castán Broto, Gislason & Ehlers, 2009). In this current structure, understanding where another discipline may add to our research is complicated. Science has greatly evolved since the 16th century; modern technology is difficult to keep up with within my own field, let alone understanding the context of another discipline. Therefore to examine an issue from multiple perspectives requires immense time and effort (Lélé & Norgaard, 2005). Interdisciplinary research teams are just beginning to chip away at the possibilities.

 Image

Source: http://xkcd.com/435/

…in academic life…

What about beyond the doors of the university? What does a “true” Renaissance man or woman look like? A quick Google search for modern renaissance men and women produces many actors and a few academics. The criteria seems a bit confusing as I think many would agree Justin Timberlake wouldn’t be their first choice. According to this quiz I am “Totally Renaissance”, I must be doing something right. In this category being a Renaissance person is, well, personal. What we consider to be different and interesting is up to the individual. Someone who loves jazz and molecular biology is as much “Renaissance” as someone who studies anthropology and has an active interest in feminist literature. In the classical sense, your interests should include some kind of art as well as science (“Renaissance man”, n.d.). Where those lines are drawn is up to you, no pun intended.

 Image

Source: http://www.biography.com/people/leonardo-da-vinci-40396

…as an ideal.

In the end, what ideal are we working towards by being Renaissance? Da Vinci was no doubt a genius, but is being a Renaissance wo/man a goal in itself? What inherent value is there in having multidisciplinary interests? With research the benefit is clear, we can see a question in new and potentially more accurate ways. From a personal perspective, having an interest in theatre, sociology and chemistry may help you approach your research in innovative ways and perhaps improve your life.

-Emily Rempel-

A self-described epidemiologist-pianist-film fan-amateur archaeologist-photographer-travel enthusiast-home cook-general geek-voracious reader-graduate student.

 

References

  • Choi, B.C.K. & Pak A.W.P. (2006). “Multidisciplinarity, interdisciplinarity, and transdisciplinarity in health research, services, education and policy:  1.  Definitions, objectives, and evidence of effectiveness.” Clinical and Investigative Medicine, 29, 351-364.
  • Lélé, S. & Norgaard, R.B. (2005). Practicing interdisciplinarity.  BioScience, 55(11), 967-975.
  • Renaissance man. (n.d.) In Merriam-Webster online. Retrieved from http://www.merriam-webster.com/dictionary/renaissance%20man
  • Castán Broto, V., Gislason, M. & Ehlers, M.-H. (2009). Practising interdisciplinarity in the interplay between disciplines: experiences of established researchers. Environmental Science and Policy, 12(7), 922-933.
  • Leonardo da Vinci (1452 -1519). (n.d.) Retrieved February 2, 2014 from http://www.bbc.co.uk/history/historic_figures/da_vinci_leonardo.shtml

Out of the lab and into the fray

In mentioning the word “scientist” when describing one’s self, one runs the risk of evoking an image of an individual in a white lab coat, staring into a microscope, using a vocabulary so specific that she would have a better chance of finding someone on the street that could speak a lost dialect of English than one that could understand her, and a person that is so far removed from everyday life that in the unfortunate event she encountered a layperson she would struggle to find anything in common to speak of. While the degree to which these preconceptions are true can be debated, whether they would like it or not the scientists of today are being forced out of the perceived comfort zones of their labs and into the fray of the general public.

The documentary entitled “Silence of the labs” by The Fifth Estate (CBC, 2014) was a wake up call to those who were not closely following Canadian news over the past few years. For those that were, it was an affirmation of what many of us have been thinking all along, that the Harper government has an agenda that is being hampered by science and, as a result, funding is being drastically cut and the capacity for scientists to convey their findings to the public is being stripped. While some targeted research like the Experimental Lakes Area might have fuelled support for industry regulation (and if one waded through the details of the omnibus bills passed last year they would see de-regulation as a common theme), The Fifth Estate describes an anthropological project in northern Canada that was uncovering an inconvenient history for a nation whose government is bent on exploiting the resources of a disputed territory, research that was making global headlines and has since been shut down.

Perhaps one contributing factor for this authoritarian-like control over public research is explained by Alister Scott (2007) when she describes a change that has been occurring in recent decades. She argues that publicly-funded research before the 1990s was more narrowly focussed on generating wealth and making direct improvements in the quality of life, whereas modern research has an obligation to serve society more broadly by finding solutions for often-complicated problems that can span disciplines. It might be understandable, then, why this government is no longer supporting scientists for they are becoming too focussed on addressing relevant issues that society actually cares about but that many in government would rather ignore. 

As Gerry Reed said, “we have a long way to go, and a short time to get there (Orr, 2010)”, which may explain why some scientists are now feeling the urgency to voice their opinions on purported muzzling of government scientists. A recent rally in Ottawa raising awareness of this issue (supposedly organized and attended by scientists) was a novel expression of the frustration that surely many scientists feel since, at its core, science is objective and thus free of politics. One could surmise that some of the reluctance scientists might have towards speaking out publicly on the issue has to do with the hidden curriculum of their respective institutions (Mossop et al. (2013) describe this concept nicely). Specifically, I wonder if some researchers hesitate to engage in political affairs out of concern for what others from their affiliated institutions might say or think. While an institution may not explicitly state that scientists are not to speak publicly on the issue of muzzling, the fact that nobody is could be discouraging the very act. Of course, the flip side of this is that once some scientists have spoken publicly on the issue (and have subsequently managed to retain their jobs), then the hidden curriculum will begin teaching this as an acceptable practice.

While some dramatically warn us of an impending “nightmare” that scientists are perceived to be predicting (Jamail, 2013), many want science to be free to objectively explore the important issues of today, irrespective of political agendas. Misconstrued information and lies are running amok on the internet, exploiting the vacuum that grows stronger with every silenced researcher. In an environment that would rather them study oil extraction technology than socioecological impacts of oil spills, it is no wonder then why these elusive creatures are beginning to crawl out of their dens and into the the public eye. Science has been under attack since its conception by those who feel threatened by it, and there is little doubt that the scientists of today will sit idle while the powers at be assure us that the earth is flat.

Literature Cited

Canadian Broadcast Corporation. “Silence of the Labs”. Aired January 10, 2014. Retrieved on January 22, 2014 from http://www.cbc.ca/fifth/episodes/2013-2014/the-silence-of-the-labs

Jamail, D. The Coming ‘Instant Planetary Emergency’: How will climate change affect the future of the planet? Scientists predict it will be nothing short of a nightmare. December 17, 2013. Retrieved on January 22, 2014 from http://www.thenation.com/article/177614/coming-instant-planetary-emergency

Mossop, L., Dennick, R., Hammond, R. & Robbe, I. 2013. Analysing the hidden curriculum: use of a cultural web. Medical Education, 47; 134-143.

Orr, D. “This I Believe – David Orr.” Posted January 26, 2010. Retrieved on January 22, 2014 from http://www.youtube.com/watch?v=k6z-Ln0vc20

Scott, A. 2007. Peer review and the relevance of science. Futures, 39; 827-845.

Selective Mutism: How I Learned to Stop Worrying and Love the Impact Factor

There is an unwritten rule in academia that good research, however you may define it, is less important than published research.  This does not preclude good research being the backbone of the academic world, but rather suggests the priorities of science, as a paradigm, have shifted.  Specifically, to the rule of publishing as much as you can (Elizabeth & Grant, 2013).   This trend has roots both in the audit culture and modern political structure, particularly in Canada.

An increasing focus on ‘numbers’ outside of the academic world has bled in to the most hallowed halls of higher thinking.  A major component of evaluating researcher’s quality is quantity of publications, the dreaded impact factor (Burrows, 2012).  The more you publish, the better your evaluation.  This audit culture forces researchers to, as Burrows (2012) says, either “’play’ or ‘be played’” (p. 369).  The implication is an increasing number of academics publishing to add a line on their CV, rather than to solve or study some novel question (“The cost of salami slicing”, 2005).  Either you keep publishing or you drop out of the race.

This is arguably an even bigger concern for new researchers, who have the added challenges of navigating both an unknown world and limited resources.  The poor student cliché exists for a reason.  Articles describing quick tips on how to boost your resume in graduate school and the need for social income services  after graduating, demonstrate the necessity of playing by the rules to increase your chances of paying rent (Keslky, 2012; Patton, 2012; Utell, 2011).  Publish as much as you can, as early as you can. Science for the sake of science seems to be an antiquated concept.  As Scott (2007) states, in his article on peer review processes, being published relies heavily on having conclusive results and complex problems rarely have conclusive answers.  Supervisors may need to push students to research simpler concepts, those that minimize political, temporal and financial burdens, in order to publish.

A key phrase in that last sentence, political burdens, is a concern for both new and experienced academics.  Being funded, and therefore producing any form of publications, relies increasingly on government approval, especially for those researchers working in the public sector.  The recent documentary on the Canadian government’s disregard for academia, “The Silence of the Labs”, demonstrates the danger of this influence (Rumak, 2014).  Not just in social arenas like public health, but archaeological and environmental fields. If research even slightly contradicts the message the Harper government wants to put forward, large-scale cuts and eventual job loss may result (Rumak, 2014).  The mantra should be ‘get published not political’.  Researchers have to operate under some assumption of topical, selective mutism.

The question comes down to this, at a personal level, is ‘doing’ science our job?  Are we just working at our chosen employment or are we attempting to understand and help the world?  If the former, the pressure to publish is still a personal challenge but not a systemic problem.  If the latter, there is a much greater barrier.  Your core ideals about what you think you are doing  do not match up with the day-to-day realities of your work.  Even a blending of both views of science can lead one to disenchantment (Elizabeth & Grant, 2013).

In conclusion, I do not want to suggest that academia is in a constant state of dredging up simple and repetitive research, but that as we allow the influence of audit culture and political preferences to seep in to the academic world, we lose what makes us important.  That is our ability to objectively examine and answer questions about the world around us.  It may be naïve to suggest that science should help people or the world, but I hope at the very least we do not end up ignoring what needs to be researched in favour of what is easy to research and ultimately publish.

 

References

Burrows, R. (2012). Living  with the h-index? Metric assemblages in the contemporary academy. The Sociological Review, 60(2), 355-372.

Elizabeth, V. & Grant, B.M.(2013). ‘The spirit of research has changed’: reverberations from researcher identities in managerial times. Higher Education Research & Development, 32( 1), 122–135.

Kelsky, K. (2012, March 27). Graduate school is a means to a job – manage your career. The Chronicle of Higher Education. Retrieved from http://chronicle.com/article/Graduate-School-Is-a-Means-to/131316

Patton, S. (2012, May 6). The PhD now comes with food stamps. The Chronicle of Higher Education. Retrieved from http://chronicle.com/article/From-Graduate-School-to/131795

Rumak, O.J. (Producer & Director). (2014, January 10). Silence of the Labs [Motion picture]. Canada: Canadian Broadcasting Company.

Scott, A. (2007). Peer Review and the Relevance of Science. Futures, 39(7), 827–845.

“The cost of salami slicing.” Editorial. (2005). Nature materials, 4(1), 1.

Utell, J. (2011, February 25). Practical wisdom and professional life. The Chronicle of Higher Education. Retrieved from http://chronicle.com/blogs/profhacker/practical-wisdom-and-professional-life/31442

Reflection 2: Peer review, metrics, and the audit culture

Peer review is one of my most feared subjects, especially when it comes in submitting research abstracts, presentations, and/or study protocols. I fear my peers review because of exact same reasons that are identified in Lamont’s research, which is described by Scott Jaschik in the “The ‘Black Box’ of Peer Review” article posted in Inside Higher Education – “judgment on proposals is clouded by their (professors) own personal interests, deal making among panelists to make sure decisions are made in time for panelists to catch their planes, and an uneven and somewhat unpredictable efforts by panelists to reward personal drive and determination over qualities that a grant program says are the actual criteria”. Although part of my brain felt relieved to learn that there are some research findings that supported my personal thoughts/fears on this subject, my other part of the brain felt gloomy. Due to my work in public health field of Mongolia I collaborate with many national and international professionals to prepare and submit grant proposals to various funding agencies inside and outside of the country. Therefore, I have found this article to be insightful in educating me on how reviewers think and work. Yet, the most interesting part of this reading was going through comments that people left on this site. The comments ranged from those who supported the research findings of M. Lamont –Wondering – to SS, who disagreed.

I had so many laughs when I watched Catharine Cross performance called “Why peer review is like your extended family” on youtube and when I read “When Peer Review Turns Frustrated Authors Into Hilarious Editorialists”. C. Cross used humor to describe main comments that we receive from our peer review committees and I thought her comparison of these comments with comments that we receive from our families was funny and smart. The last reviewer comments in the “When Peer Review Turns Frustrated Authors Into Hilarious Editorialists” spoke to me because I wrote the same comment in one my review and reading the part on How Not to respond, I realized this is how an author felt when he/she read my review comment.

I was bored reading the “Tenure’s Dirty Little Secret” by Milton Greenbergand I actually questioned myself and here my reflections on why I was not taken by this article. First of all, it discussed the tenure subject in American colleges and universities; secondly, academia is not a field that I wish to work in, and thirdly, I didn’t see any solution for the subject of tenure that M. Greenberg was addressing in his article. Then, it occurred to me that I should learn to stregch my limits and try to broaden my knowledge about different topics in other countries. If I plan to become knowledge translating person I should enrich myself with knowledge that myself may not benefit but others could use it at a great gain. So I have tried to use “peer review” approach in re-reading this article and prepared my review. I did re-read it and came to a conclusion that Milton Greenberg was describing this tenure situation in American education system, which is known to all but he has failed to provide his answers on how this tenure issue could be solved. Perhaps, I wasn’t a good peer reviewer.

 

 

 

Jaschik S. The ‘black box’ of peer review.  Inside Higher Education, Mar. 4, 2009. [read comments, too]http://www.insidehighered.com/news/2009/03/04/peerreview

Scott, Alister (2007), “Peer Review and the Relevance of Science”, Futures 39, 827–845.

Cross, Kate, on peer review. [Stand-up comedian & research fellow, at Bright Club, Edinburgh.] http://www.apeer.org/ Aug. 20, 2012

http://www.youtube.com/watch?feature=player_embedded&v=qf8Tw80kerA

http://www.nature.com/scitable/blog/labcoat-life/when_peer_review_turns_frustrated

Greenberg, Milton. Tenure’s dirty little secret. Chron Higher Educ, Jan. 1, 2012. http://chronicle.com/article/Tenures-Dirty-Little-Secret/130185/