Whether it's a nuclear power plant melt-down, a deep sea oil drilling disaster, or a financial crisis, we've seen many instances where apparently obvious problems have been overlooked by panels of experts.

Some of the answers to this question lie in the field of epistemology - the study of how we know which things are true.

        For more information:  Wikipedia entry on epistemology

To help understand why experts in the medical field make mistakes, we contacted a different kind of expert.  Dr. Fran Collyer studies the way societies make decisions about what things are correct in the field of medicine.

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       “We all have to keep working hard to produce good health policy,
        good health programs, and good health research.”
               - Dr. Fran Collyer

BRF: Your work suggests that debates between researchers can play a big role in what becomes accepted as medical fact, even if the results are detrimental to public health. Do the professional interests of researchers really trump public health?

DR. COLLYER: The answer to this is a little complicated, but perhaps my argument is that it is not so much researchers who are so powerful in determining public health, but a structured network composed of researchers, practitioners, policy-makers, administrators and corporate interests. Researchers certainly have input, but they are constrained in what they can research - after all, they are dependent on sponsors for research funds, on practitioners and administrators for access to clinics and patients, on policy-makers for appropriate laws and ethics approvals etc.


BRF: Can you give some examples, other than H pylori, where this is occurring?

DR. COLLYER: All medical facts go through a process of debate and uncertainty, where different individuals and groups take up positions and seek to have their views adopted. This process is the research front, and is what Bruno Latour calls ‘science in the making’. Eventually, in most cases, a consensus of some kind is reached and theories and ideas become ‘fact’. In the late 1980s, HIV/AIDS was in this stage, and offers a pretty good example of how controversies eventually lead to a consensus (in this case, about the existence of a virus). Of course, the whole process can be stirred up again at any time if new evidence emerges, but it is less likely to as everyone tends to assume it is ‘fact’.


BRF: How can public interest groups recognize when researcher self-interest is driving a medical policy? What steps can we take to ensure that medical thought follows a rational development process?

DR. COLLYER: The best approach is to work toward making decision-making processes transparent and accountable. This can be done in small and large ways. For instance, as an editor of a journal or magazine, we can insist that authors always divulge any conflicts of interest, especially concerning the financing or sponsorship of research. In larger ways, funding agencies for example, need to have a range of measures in place to check and double-check decisions, and ensure they have inter-disciplinary committees keeping an eye on applications for funding.


BRF: In your work on H pylori and ulcers, you noted that medical thought shifted the burden of the illness onto the patient, who was viewed as a deviant, expected to cure himself by controlling diet and stress levels.  The discovery of H pylori changed that, as physicians discovered  that an infection was responsible.  The latest buzzword from the Rome Foundation is "multi-determinism", which says that since bacteria are present in people who don't have symptoms, patient behavior should again be considered as a cause of illness.  What is your view of this trend?     Is this a setback for patients?

DR. COLLYER: Yes, it does cause me some concern. The focus on patient behaviour assumes that patients are entirely ‘free to choose’ healthy life-styles and keep themselves free from disease. Yet we know this is not the case. Individuals have very few ‘free choices’, and our lives our quite constrained - even if the knowledge of this might make us feel quite uncomfortable. Almost any individual will ‘choose’ to look after their health if they are given the chance, but circumstances are largely such that we cannot choose this. Our social and physical environments are such that it is difficult to act in a healthy way. For instance, if we look at a long distance truck driver, they are unlikely to get enough exercise or healthy food. Yet what food options are presented to them along their route? It is likely to be high in fat, salt and sugar, and unlikely to contain fresh vegetables or fruit. And their work involves sitting, virtually motionless, for many hours a day and most days in the week. As health advisers and researchers, we need to examine the constraints on individuals, not the ‘choices’ we wish they would make. We need to examine the social environments which make it difficult for patients change their behaviours.


BRF: Is there a tendency for physicians to view patients with hard-to-treat diseases as deviant?

DR. COLLYER: ‘Deviant’ is a word no longer used by sociologists in Australia or the United Kingdom, or at least, no longer used without quote marks around it, though I believe it is still widely used in American sociology. We don’t use it because we see it as potentially devaluing those to whom the label might be attached, so I cringe a little when I hear it! That aside, I assume you mean that doctors may blame patients with difficult to treat diseases, assuming they are non-compliant in some way. I suspect it may occur in rather too many cases. Doctors with more experience, and perhaps a greater understanding of human nature, may be more likely to realise that there are limits to knowledge, that the world is more complex than we might like it to be, and that we cannot always ‘fix’ the problem with science or medicine.

There is a rather good literature on this in sociology, and we talk about it using the term ‘medical uncertainty’. Some rather good work has been done by Karin Knorr-Cetina on this problem, who suggests that doctors tend to be uncomfortable with uncertainty, and the problem begins when they are in their medical training.

      Links:
         Knorr-Cetina, The Manufacture of Knowledge (Free downloadable Google Book)
         Knorr-Cetina, Epistemic culture: How the Sciences Make Knowledge  (Book from Amazon.com)

Another way of looking at the problem is to state that medicine is unfortunately assumed to be a science, rather than an art or a social science, and this means it adopts the position of certainty rather than complexity. The social sciences are much better at working under conditions of uncertainty - the grey areas - and building solutions based on knowing only partially.


BRF: Does this trend appear more prominently in some cultures?

DR. COLLYER: The work of Martin Roemer and William Cockerham shows this to be the case. Western paradigms concerning health interact in some cultures with traditional knowledges and paradigms from Asia, Africa and South America. There are different ways of understanding and different ways of ‘knowing’, and most are not as reductionist as we tend to be in the West. A little bit of awareness of these other cultures is always helpful to finding solutions to our own problems.

    Links:
             WC Cockerham, Social Causes of Health and Disease  (Book from Amazon.com)
             Show all WC Cockerham articles on Google Scholar
    

BRF: In your paper, you discussed how discovering a cure for a chronic disease can negatively impact corporate profits, and that vested interest work against identification of treatments based on the germ theory which can cure the disease. Do you see  parallels with the current trends in Blastocystis research?

DR. COLLYER: Yes I do.


BRF: What kinds of things can public interests groups do to identify and counter drug company influence?

DR. COLLYER: In Australia and elsewhere there are some very active consumer groups, who have run very successful campaigns. They have used the internet and other forms of media. Engaging the interest of sociologists and other social science researchers is also a very good strategy.


BRF: In the 1990's, most pioneering research was performed in Western countries.  Will the rising role of China, Asia, and other countries in science make it more difficult for a researcher or drug company to control scientific knowledge?

DR. COLLYER: No, I don’t believe this will change the situation. It may mean some small changes in which companies control scientific knowledge, but it won’t shift the balance of power between the public, the researchers and the companies. If we look at the global context, we find a very clear imbalance between countries, and the system has developed in such a way that American and European countries are largely in control. It is very difficult for other countries to break into the upper echelons of power. However, as China and some other countries continue to expand, they will use business alliances and take-overs to enter into this network of science. This will mean some ‘different faces at the top’, but it won’t make it any easier to produce good health policy, because in order to ‘break into’ the science-medicine industry, the newcomers will adopt the same sets of practices and systems.


About Dr. Fran Collyer

Dr. Collyer is a senior lecturer at the University of Sydney, and a former editor of Health Sociology Review.  She has over 70 peer-reviewed articles, book chapters, and related publications on the subject of health policy.