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April
2002
The Zigzag Path
to Truth
Debate over the effectiveness of mammography illustrates
puzzles central to the work of translating science into policy and
practice.
Leading biostatisticians indicate that, contrary
to previous views, early breast cancer screening may not have much
to do with progression of the disease. It is a hard conclusion to
swallow for most women and for the elected officials in charge of
appropriating federal science dollars.
The dilemma, communications experts tell us, is
that the public cannot adequately evaluate evidence and therefore
demands simple "yes" or "no" answers to problems
that grow ever more complex. The same experts also tell us that
science can be understood best when it is put into a social and
political context. Thus, the mammography debate may be necessary
for better understanding of risk but at the same time results in
misapplication of resources and raising of false hopes.
Here is an example of how science is supposed to
work; in fits and starts, with new findings shedding light on old
data, the new evidence leading to deeper understanding -- and sometimes
different conclusions. A generation ago, chest X-rays were routinely
prescribed to diagnose lung cancer. Evidence eventually showed it
was not effective, and now the chest is zapped only for good cause.
If science did not take this zigzag path toward the truth, we would
still be walking around in the dark with leeches hanging off of
us.
However, the public remains deeply ambivalent about
science. This is demonstrated every day as people cruise the food-as-medicine
supplement aisle of the local supermarket, pay out-of-pocket for
care by purveyors of services of dubious effectiveness and order
up designer blood and radiology tests never prescribed by their
doctor.
So now we have a technology -- mammography -- that
over the years has become superbly suited to accomplishing its focused
task: identifying irregularities in breast tissue. This investment
must be balanced by a similar commitment to use science to translate
what we know into what we do through: synthesis and meta-analysis;
research that integrates biological, behavioral and social perspectives;
applied, clinical and health services research; and policy research.
Unfortunately,
evidence is often seen by policy makers as not necessary, and it
is never sufficient, for policy development. A new approach to using
scientific knowledge to shape effective health policies and practices
is long overdue. The question is whether those who are accountable
for the health of the nation -- leaders of government, medicine,
business, labor, the media and community associations -- are ready
to talk to one another about them.
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