I have long been a proponent of evidence-based medicine (EBM), and evidence-based health care, public health, and health policy. EBM, for example, is about medical-decision making based on critical review of the best applicable evidence from clinical research informed by knowledge og biology and medicine, of the patient's biopsychosocial circumstances, the patient's values, and of ethics and morality. We have discussed challenges to EBM based on manipulation and suppression of clinical research, often in the financial interests of those hawking particular medical products of services.
A newer challenge to evidence-based medicine, health care, public health and health policy seems not to be commercial, but ideologically or theologically based. I noticed the following recent cases that illustrate this concern.
Theologically Based Medicine and Public Health Promoted at the DHHS
In July, 2018, we discussed the case of Dr Diane Foley, who was appointed Deputy Assistant Secretary for Population Affairs in the US Department of Health and Humas Services (DHHS). At the time we noted that Dr Foley publicly proclaimed that adoption of children is harmful because it is a "double death;" and teaching children about barrier contraception is harmful because it is "sexually harassing." Dr Foley also ran an organization called Life Network, which ran so-called "crisis pregnancy centers," which ran abstinence-only sexual education programs in part based on Dr Foley's beliefs about the harms of teaching about barrier contraception. There seems to be no good evidence about the sort of harms Dr Foley attributed to adoption or barrier contraception.
Nonetheless, on April 4, 2019, ReWire reported that the DHHS would give control of Title X federal family planning and teen pregnancy prevention and the Office for Adolescent Health (OAH), which administers the Teen Pregnancy Prevention Program to the Office of Population Affairs, which is run by Dr Foley. In response, Senator Patty Murray (D-WA),
the ranking Democrat on the Senate appropriations subcommittee with oversight over HHS, questioned the Trump administration’s motivations behind the plan. 'It is unclear how the reorganization will result in better policies and services for those served by these offices, including adolescents, women, low-income communities, and individuals with infectious diseases, including HIV/AIDS,' she wrote. 'In fact, it is difficult to understand how this reorganization does anything other than consolidate control at HHS headquarters and prioritize ideology over the needs of the women, teenagers, and children the affected programs serve.'
In fact, there is reason to believe that Dr Foley based her beliefs more on her ideas about theology than on a political ideology. Life Network's website has stated (see our post linked above)
'Through our pregnancy centers we have the opportunity to see God use the miracle of ultrasound to change and save lives,' Life Network’s website says. The first element of its mission is 'presenting the gospel of Jesus Christ.'
Thus the Trump administration seems to be consolidating power over US government family planning programs in the hands of an individual who is basing her decision making not on medical or public health evidence, but on her version of a particular type of Christian theology.
Ideologically or Theologically Based Public Health Policy about Pornography Promoted in Another State Legislature
NBC Montana reported on April 16 that Montana legislators are the latest to join the quest to label pornography a public health hazard.
One resolution state house lawmakers are taking up in Helena would label pornography as a public health hazard in Montana.
If passed, Montana would have to address pornography through education, research and state policy.
The state would have to implement measures to prevent pornography exposure and addiction, offer recovery help, and create programs that hold broader influences accountable.
The proposed resolution included assertions that, for example, pornography causes
violence and abuse of women and children by presenting rape and abuse of women and children as harmless
psychological and physical distress, deviant sexual arousal, difficulty in forming or maintaining intimate relationships, and problematic or harmful sexual behaviors and addiction
increases sex trafficking of women, sex trafficking of children, child sexual abuse, and child pornography;
Yet as we noted in March, 2019, there is no clear evidence supporting any of these assertions. So Montana Republican legislators join those in Arizona, and also those in Kansas, Utah, and Idaho (look here) in pushing legislation that attacks the "public health" hazards of pornography based on no clear evidence.
The genesis of the notion that pornography is a dire public health hazard is not clear. As we noted here, though, in Utah, at least, beliefs about pornography could come from the doctrine of the Church of Latter Day Saints, which includes:
'depiction, in pictures or writing, that is intended to inappropriately arouse sexual feelings' to be 'a tool of the adversary,' the descriptor Mormons often use for Satan.
At any rate, since the proponents of these measures all seem to be Republicans, there also is suspicion that their beliefs about pornography are ideologically-based.
Ideologically Based Beliefs About Vaccination Policy Espoused by President Trump, the Governor of Kentucky, and in Multiple State Legislatures
We recently discussed how a Russian disinformation campaign has led parents in the US and elsewhere to avoid vaccinating their children for various diseases, in turn leading to outbreaks of measles in the US and other countries. Along with this disinformation campaign, various government leaders have also espoused views about the benefits and harms of vaccination, and vaccination policy that are virtually free of evidenciary support.
In March, 2019, the Louisville Courier Journal reported on the example set by the Republican Governor of Kentucky.
Gov. Matt Bevin said in a radio interview Tuesday that he deliberately exposed all nine of his children to chickenpox so they would catch the disease and become immune.
'Every single one of my kids had the chickenpox,' Bevin said in an interview with WKCT, a Bowling Green talk radio station. 'They got the chickenpox on purpose because we found a neighbor that had it and I went and made sure every one of my kids was exposed to it, and they got it. They had it as children. They were miserable for a few days, and they all turned out fine.'
Governor Bevin seemed to imply that chickenpox is an annoying disease, but one that does not cause severe adverse effects. However, varicella is not innocous. According to the CDC clinical summary, it can cause secondary bacterial skin infections in children. Rarely in children, but more commonly in adolescents, adults, pregnant women, and people with immunocompromise, it can cause severe complications including pneumonia, sepsis, and various other secondary bacterial infections. Varicella is highly contagious, so unvaccinated children can infect other unvaccinated people who are more susceptible to complications.
Yet Governor Bevin ignored all that. His rationale for not vaccinating his own children and not mandating varicella vaccine for other children was conveyed in his interview.
Bevin also suggested that the government stay out of mandating vaccines. In Kentucky, varicella (chickenpox) is among vaccines mandated for all children entering kindergarten, though parents may seek religious exemptions or provide medical proof that a child has already had the disease.
'And I think, why are we forcing kids to get it?' Bevin said in the radio interview, speaking about the chickenpox vaccine. 'If you are worried about your child getting chickenpox or whatever else, vaccinate your child. ... But for some people, and for some parents, for some reason they choose otherwise. This is America. The federal government should not be forcing this upon people. They just shouldn’t.'
So his ideology that "the federal government should not be forcing this upon people" seemed to trump any risks children run because their parents choose to not vaccinate them, even just "for some reason."
The Louisville Courier Journal also interviewed "Dr. Robert Jacobson, a pediatrician and expert in vaccines and childhood diseases at the Mayo Clinic in Rochester, Minnesota,
Before vaccination was available, chickenpox killed as many as 100 adults and children a year, he said.
'I think it is taking a big risk that you don’t need to take,' Jacobson said. 'It's not just a risk your children are going to have. You're putting other people in the community at risk because of your decision.'
Note that this is not the first time that Governor Bevin expressed beliefs about public health that were not evidence-based. In this post, we noted that in 2018 he suggested that mass school shootings are due to exposure to television shows about zombies, and in 2019 he suggested that exposing children to severely cold weather is risk free. So he does seem consistent in the absurdity of his public health beliefs. Unfortunately, he is in a position to endanger the public's health according to these beliefs.
There are other US state level political leaders who seem to rely on idology rather than evidence in making decisions about health care and public health. On April 16, 2019, Politico reported widespread attempts by Republican state legislators to free people from requirements that they vaccinate their children,
Democrats in six states — Colorado, Arizona, New Jersey, Washington, New York and Maine — have authored or co-sponsored bills to make it harder for parents to avoid vaccinating their school-age children, and mostly faced GOP opposition. Meanwhile in West Virginia and Mississippi, states with some of the nation’s strictest vaccination laws, Republican lawmakers have introduced measures to expand vaccine exemptions, although it’s not yet clear how much traction they have.
In Washington state, which has one of the biggest measles outbreaks, a bill in the state Senate to narrow vaccine exemptions passed through the health committee without the support of a single Republican. The same thing happened in legislative committees in Colorado and Maine over the past week.
Again, the Republicans seemed to base their attempts to decrease vaccination requirements on their ideology of expanding personal choice.
many are loath to diminish the right of parental control over their children’s bodies, and yield that power to the government.
Politico provided an example of a New York state legislative leader who opposed a bill that would limit religiosu exemptions to vaccination mandates.
Andrew Raia, ranking Republican on the New York Assembly’s health committee, said he wouldn't support the bill. While not totally convinced by constituents who link their children’s autism on vaccines, and unaware of any real religious injunction against vaccination, he said, 'I’m not a religious leader, and I’m not a scientist either, so it’s my job to weigh both sides.'
I suggest that his arguments are at best evidence free, but also could have been
complicated by the fact that President Donald Trump and two of his Republican primary foes, Sen. Rand Paul (R-KY) an ophthalmologist, and Ben Carson, a neurosurgeon who is now HUD secretary, both voiced support for disproven theories linking vaccine to autism during a 2016 debate.
In fact, as reported by the (UK) Independent in 2018,
On more than 20 occasions, Mr Trump has tweeted about there being a link between vaccines and autism, something experts at the government’s leading public health institute say is not true. He also repeated the claim during a Republican primary debate, a remark that was immediately dismissed as false by the Autistic Self Advocacy Network.
Outbreaks of infectious diseases previously considered controlled now bedevil the US and other developed countries. They seem to be caused in part by parents' resistance to vaccinating their children, despite strong evidence that the vaccines are relatively effective and have harms that exceed their benefits, both for the children vaccinated and the public health. In turn, the resistance to vaccination seems increasingly inspired by government leaders whose actions are based on ideology, or sometimes theology.
The ideologically based arguments seem to come from some sort of a crude libertarianism that holds that parents should be free to choose not to vaccinate, more or less regardless of the effects of their decision on their children, or other people. Such arguments should alarm health care professionals who are sworn to put the patients' and the public's health ahead of other concerns, including political ideology.
The theologically based arguments are also concerning because they seem to be an attempt to use the govenrment to promote a particular set of religious beliefs ahead of patients' and the public's health, and to impose these beliefs on people of other faiths. This apparently contradicts the US constitutional prohibition against governmental establishment of religion.
True health care reform would require government officials to use evidence, rather than personal ideology and particularly rather than their own religious beliefs when making health care and public health policy.