Can We Afford to Wait for Better Evidence on Improving Child Health?

By David A. Kindig, MD, PhD

I recently spent two days at a terrific small conference in Madison, sponsored by the Institute for Research on Poverty. The conference focused on Child Health and Well Being, with many leading thinkers and researchers on socioeconomic disparities in child health.  Researchers highlighted what we’re learning about the relationship among prenatal environmental factors, body system and brain development, and health outcomes over the life course. While I was extremely impressed with the meeting itself, I was quite frustrated by the lack of evidence regarding causal pathways and cost effectiveness of programs and policies. As a former pediatrician, many of these linkages seem...well...almost obvious. And they're gaining mainstream attention through popular media outlets. Time magazine recently ran a cover story on Annie Murphy Paul’s new book entitled Origins: How the Nine Months Before Birth Shape the Rest of Our Lives.

From a research perspective, these complicated relationships take enormous time and effort to untangle, and researchers venturing into the sphere of policy and practice is seldom encouraged or rewarded. We also can’t expect policy makers to invest resources and take political risks without sufficient evidence, especially in cases where there is a risk for potential harm. There are many examples where things we thought to be true were not, and people suffered. Remember that the first rule of medicine is “First Do No Harm.”

On the other hand, the reality is that many current policies emerge from political advocacy (often not even in the public interest) rather than on the strength of scientific evidence. Former Milbank President Dan Fox has noted that “policy is the sum of anecdote.” In the case of child and fetal health policy, failure to act on the best -- albeit imperfect -- evidence could potentially cause a great deal of harm. Public and private policy environments influencing maternal health, fetal development, and the first five years of life have substantial health and development ramifications over a lifetime. While we study and debate the causality and cost-effectiveness of our options over the next decade, the adult health of the 40 million children born in the United States during that time period will have already been determined. Investments in healthcare in middle and old age can only partly remedy poor health outcomes determined earlier, and often at great individual and social cost.

How can we remedy this?  Unfortunately, I don’t have any silver bullet answers. I’ve often lectured that if I were Czar, and if 25% of health care spending ($500 billion per year) is inappropriate or ineffective, I’d allocate $100 billion to covering the uninsured (we are now doing that), $100 billion to prevention and public health, and the remaining $300 billion to early childhood, prenatal, and K-12 education to have the most impact on later health. But at this point, nobody knows exactly what programs or policy packages are the most cost-effective to produce these results.

We of course need more research to figure this out – this was the point of my recent JAMA commentary with John Mullahy called Comparative Effectiveness – Of What? -- but not at the slow pace of the past several decades. An August New York Times article described the massive and coordinated public-private “moon-shot” approach in the last decade on Alzheimers research, which has led to many important recent discoveries in a challenging field. We should use a similar approach to understand what policy approaches are most cost-effective for improving the health of our children. Given the certain costs associated with inaction, we may, in the meantime, need to relax our policy investment standards somewhat. Such an approach is not without precedent. In the 1990s, while pharmaceutical researchers were working hard to develop HIV drug therapies, the seriousness of the disease resulted in conditional approval of some drugs pending more complete and relevant evidence.

We know enough right now to predict that doing nothing will result in poor adult health outcomes of babies being born today. Aside from the obvious moral dimensions, my main argument for expediency is pragmatic: the health and economic competitiveness of our nation over the next 50-100 years is at stake. Surely investing in maternal and early childhood health should be a priority. We should focus our research efforts on figuring out what approaches are most effective and waste no time in directing current investments based on the best available evidence.

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Comments

[Ed Donovan, James M. Anderson Center for Health Systems Excellence]

I agree that we need to determine which policies and public investments are effective in improving the life course of children. But waiting for the evidence to accumulate should be accompanied by implementing the evidence-based approaches that are "ready to go".
One of many, many examples is appropriate use of antenatal corticosteroids, use of which has definitively been shown to result in a halving of mortality and major morbidity in infants born preterm.
In Ohio, with roughly 2,000 very preterm births per year, 400-500 of these infants do not currently reap the benefits of antenatal corticosteroids - thus doubling their risk of acquiriing a life-long handicapping condition.
Waiting 2 years for the results of a study (which certainly needs to be done) of a new child health policy (may have a negative result)without improving implementation of proven interventions, means that at least 160-200 Ohio infants will be permanently and unnecessarily injured.