jeudi 1 décembre 2016

Don't send a doctor to do a politician's job

from the department of radical-wheelchair-ectomy
NICE logo in 2000 (C.E.) (source:
Somewhere between ~2001 and 2016 NICE morphed from being about "clinical excellence" to "health and care excellence".
At its inception, NICE was the British
medical establishment's co-option of the evidence-based medicine movement, which believed that medical treatment should be based on the best available (scientific) evidence, rather than, say, the doctor's personal experience or the blandishments of the last drug rep they'd seen. Very good.

At the heart of the approach was the systematic review of available studies on any clinical topic. This is a limited paradigm. Although one of the purposes of a systematic review is to identify avenues of future research, the problem remains that all the world is not a clinic, and so not all questions are amenable to study by methods available to the clinician.

Public health is different. Controlled experimentation is difficult, and is much more likely to be based on ecological study (i.e. non-experimental observations). And policy prescription based on it will be prone to all kinds of perverse effects, political compromise and subversion, partial implementation, and general motherfuckery. Put it this way: you can trust doctors to identify and quantify the scale of health problems; but you certainly can't rely on them to solve them alone.

The latest NICE guidance, on air pollution, which kills about 30,000 people each year in both the UK and France, was interpreted both as "anti-motorist" by the right-wing press, and a recommendation to remove traffic-calming speed bumps. Of course it says no such thing, and I saw it as my immediate duty to subvert this:

I don't like the NICE guidance for a different reason. A medical perspective of society is inevitably conservative: there is no social critique, no examination of the source of the problem, which is motor exhaust fumes of the ever-increasing numbers of motor vehicles on the roads. This is accepted as inevitable, or, if it is not, the authors of the report seem to have been unable to summon the courage to say so.

Well done if you can be bothered to comment on their advice:

Maybe they'll tweak it. But the guidance will be ineffectual without a clear overall demand for motor traffic reduction. Instead NICE contents itself with describing the existing evaluations of "clean air zones" as being of poor quality, and takes comfort in the forthcoming tighter Euro-6 standard for emissions with nary a mention of the VW scandal, nor the successful lobbying of the motor manufacturers to postpone tightening the regulations. So let's look elsewhere for solutions. The growing political recognition in Paris of the injustice of the present situation is heartening:

If memory serves, about 7% of trips to central London are made by car, so both cities are in roughly the same ballpark. But the less densely populated suburbs where providing frequent public transport is difficult, are a more difficult problem. It is an acute irony that moving out to the suburbs for a better lifestyle is poisoning everyone left behind. 30,000 dead! It's not quite the first day of the Battle of the Somme, more like a couple of 747s crashing each week of the year. And it dwarfs direct death from road trauma.
Any policy that does not address the overuse of the private motor car as a central issue in better urban air quality is doomed to ineffectiveness. Yet for all its claim to scientific excellence, NICE seems to consider a frank statement in favour of this treatment to be so radical as to be unworthy of evaluation. Ho hum!