Portal de Periódicos da CAPES

Thinking in time: does health policy need history as evidence?

2010; Elsevier BV; Volume: 375; Issue: 9717 Linguagem: Inglês

10.1016/s0140-6736(10)60334-0

1474-547X

Virgínia Berridge,

Obesity and Health Practices

History is more popular than ever as a public subject—history as heritage, family history, and television history series all attract our attention. And health and medicine are part of that expansion. Visiting the old operating theatre; going on the history of medicine walk; watching the Spanish flu television programme; visiting the exhibition on medicine and war, are part of everyday public experience. Digitised images and access to online archives involve the public in making health history too. Such history is both illumination and entertainment. At the same time as this efflorescence of enthusiasm for history, the field of health and medicine has been marked by another, seemingly unrelated, tendency. That is the rise of evidence. This has been rooted in a multiplicity of influences, from McMaster's clinical epidemiology, to Archie Cochrane's desire for effectiveness and efficiency, and not forgetting the need of western nations to cut health costs after the 1970s' oil crisis. But the end result has been that “the evidence base” has become a mantra to which developments in health and medicine and health policy pay overt attention. These two sets of changes—the rise of popular health history and that of evidence for health—seem far removed from each other. My argument is that they should be closer than they are. Historians, by their very discipline, use a multiplicity of types of evidence to form interpretation and analysis. They are what the social scientists would call mixed method people, both qualitative and quantitative. They assess and interpret a wide range of information and data. History is the evidence-based discipline par excellence. Much decision making in health policy is currently formed in an absence, or partial use, of history. Policy advisers are sometimes unaware of the historical resonance of what they propose. The British health adviser Lord Darzi's promotion of polyclinics, for example, spoke of antecedents in revolutionary Russia, but did not allude to the more recent British history of the health centre as the intended fulcrum of the early National Health Service (NHS), the lynchpin of coordination between the different arms of the service, which never took off. Such a historical failure might have helped in understanding the response likely to be evoked by the recent proposals. In the UK, those involved in the regular health-service reorganisations are often unaware of past organisational histories. Do politicians and commentators know that health services were once located and managed within local government, or that public health personnel were the intended coordinators of primary care at the local level? The discussion of a possible revival of heroin prescription to addicts as the result of a number of recent North American, European, and British trials has tended to pass by the history of heroin. In the UK at least, heroin prescription to all addicts was the normal mode until the late 1960s; not so in the USA. And debates about social policy, the family, adoption, lone motherhood, are regularly informed by a type of folk history and beliefs about past patterns of family life that bear little relation to the conclusions from evidence which have been drawn by historians. The breakdown of the family or the rise of cohabitation and serial relationships as recent developments have been discussed by historians, and some have pointed to a much longer history for these practices. It is not always that history is ignored, but often that “bad history” (on the model of “bad science”) is used. In the UK, politicians in the health field routinely invoke Nye Bevan as a sounding board for what they want to promote, for the latest innovation. Nye would have approved, they say, of our new initiative. It fulfils the ideals that animated the NHS at its foundation. So history is used, but historians would say often that the wrong conclusions are being drawn from the wrong historical analogies. Take Queen Victoria's cannabis use: this historical fact emerged sometime in the late 1990s as part of attempts to rehabilitate the drug's use. It made a good policy point—if such a respectable person as the Queen had used cannabis with no problems, why not now? But the history wasn't quite right. Cannabis was in fact promoted by the Queen's physician for dysmenorrhoea; it had very limited usage in European medicine in the 19th century. The Victorians as a whole did not use cannabis. It could have been more appropriate to draw attention to another part of the drug's history—the almost accidental way, the result of international politics, in which cannabis was first scheduled under the international conventions in the 1920s. Or take an example from alcohol policy. Alcohol prohibition in the USA, so we are told, did not work. This argument is to be found everywhere. Advocates of drug liberalisation use it; the alcohol industry uses it. Anyone who opposes stringent control and killjoy attitudes to alcohol knows of it. But is it correct? Historians don't think so. They have pointed out that the situation was more complex. There was never complete prohibition. The USA in the 1920s had a system of partial availability. The crime statistics do not fully support the automatic link between “prohibition” and crime. The system had interesting effects on patterns of drinking. Beer drinking declined, there was a rise in women's drinking, and more consumption of “shorts” and spirits. So the period of prohibition and restriction of consumption has much potentially to tell policy makers about what forms of restriction can achieve, but its message cannot simply be summed up as a slogan, and requires more careful interpretation. Slogans and dates are often, however, what history is reduced to. For historians are not always in charge of the historical message. Economists, political scientists, epidemiologists, health-service analysts, scientists, and social scientists perhaps sit more naturally at the health-policy table. Their data offer models, predictable outcomes, apparently value free and unbiased evidence. Sometimes they will insert some history in that mix for “colour”. But history as practised by historians, the results of the latest historical interpretation or debate, rarely gets a look in, even though the equivalent, the “scientific breakthrough” might be welcome for discussion. Perhaps the contested nature of historical interpretation also prevents its use. Historians often disagree and consensus may ultimately emerge from diverse conclusions. But this is the case in other fields as well: science itself is more contested than it appears to be in public. Different countries have different traditions of using history. If we take the USA, we can remember the Tuskegee syphilis study, the historical investigation of which culminated in a Presidential apology by Bill Clinton; or asbestos litigation based on historical research; or historians on both sides of the court room during tobacco law suits. One national difference is clear: the use of the law court as an arena for decision making on health issues in the USA and the much greater prominence of the historian as expert witness. History has had a powerful influence in that arena. But some US historians have argued that the process of evidence and argument in the law court undermines the complexity of historical analysis. Does history go out of the window and advocacy come in? A cynic might ask whether it matters if history is used. Politicians will always use the evidence that best suits their particular objectives and “evidence” alone cannot be the only determinant of policy making. But there are opportunities early on in that process of developing policy where historical understanding could be inserted. And failure to use historical interpretation can lead to restricted and less than optimal policy analysis. Measles, mumps, and rubella (MMR) vaccination provides one example. Public concern about MMR has been ascribed to the effect of “bad science” and to the gullibility of the media and public in believing it. But a historian might well point to a much longer history of public concern and resistance to vaccination. The anti-vaccination leagues of the 19th century were informed by a mix of working-class sentiment, religious belief, and hostility to received science. Such deep-seated cultural beliefs are not reproduced in the same way in the present, but they provide antecedents, a history that needs to be analysed to understand public resistance. In seeking a better use of history, historians are not promoting what some have disparagingly called “advocacy history”. Historians should not become activists, and such a stance would detract from, not add to, what they have to offer. Nor should they simply offer the tired mantra of “it's all been done before”. Rather they can help enlarge the boundaries and the terms of the debate on health issues. In the USA at the moment, historians are doing this in the debate on health-care reform, and British historians also offer insights founded on the pre-NHS British experience with health insurance. The historical importance of civil registration as a tactic has been promoted in the debate on the social determinants of health. The objective of eliminating malaria through international action needs careful consideration in the light of similar campaigns in the 1950s. Our understanding of pandemic influenza has been informed by history, but that has largely been the scientific history of the virus and its antecedents; there is a historical literature that examines the response to influenza in terms of the nature of public behaviour, the forms of public health intervention considered appropriate. This too could be part of policy option analysis. Achieving change in health as in other policy areas is a messy and conflicted business, prey to vested interests, to networks of influence, to organisational tensions. All of these have their history: the history of science advice itself and the role of expertise in government could be brought in for discussion here. How best to achieve this historical “knowledge transfer” is something historians are now beginning to address. “Thinking in time” should also be a prerequisite for politicians and policy makers.