Why Is 'Evidence-Based' Such A Controversial Term?

Late Friday, the Washington Post ran an article reporting the Trump administration requested the CDC remove seven terms from the their next budget request. Those terms are “vulnerable,” “entitlement,” “diversity,” “transgender,” “fetus,” “evidence-based” and “science-based.” A vast array of scientists and communities immediately responded with outrage.

Over the weekend, in response, Dr. Brenda Fitzgerald, the new CDC director, reached out to concerned staff via an all agency email. The email explained that the terms were in fact, not banned, and the agency was committed to continuing evidence and science-based policy. Other comments from HHS (CDC’s parent agency) suggest the report mischaracterized the situation.

The government budgetary process is a political one. And it’s not uncommon to suggest wording changes to improve support for the budget in the current congress. While reprehensible, given the current political environment, it’s not surprising that terms like “fetus” and “transgender” might make a budget proposal less attractive.

But why is “evidence-based” such a controversial term?

At the CDC (and other health agencies), evidence-based means that programs, treatments, and initiatives have verifiable proof that they have the desired impact. It means that they work.

With payers, including governments, foundations, and insurers, making massive investments in health and social wellness, they want to make sure money spent isn’t wasted. In fact, over the past ten years, 42 states have passed more than 100 laws prioritizing public funding to evidence-based programs.

The evidence base is relatively small. The techniques used to create that evidence, the randomized controlled trial, longitudinal outcome study, and programmatic evaluations are so expensive and difficult very few of them get done. In a 2006 Institute of Medicine roundtable report, experts suggested that a half to 80 percent of all medical treatments conducted in U.S. hospitals don’t have evidence to suggest they work. Outside the walls of a hospital, where most health happens, that number is even higher.

We actually know very little about what affects personal and societal health. The studies that are done are often limited, conducted in a small number of communities, populations and situations. Culture, environment, education, behavior, genetics and available resources have an outsized impact on our health. These variables can change dramatically from community to community. Time passes. Culture changes. Something that worked in one community, at one point and time and situation may be completely irrelevant in another.

However, lawmakers focused on fiscal responsibility forced a small collection of evidence-based information into environments and situations where they weren’t intended.

These initiatives may not work in these new environments. Worse, it limits the flexibility of local professionals to tailor solutions to individuals and communities based on their professional judgement. With limited funding for evaluation, they aren’t able to prove out their home-grown solutions.

In our knee-jerk political environment, it’s no wonder “evidence-based” has a bad connotation in certain political circles.

“Evidence-based” as a term needs some help. Removing the word is not the answer. Playing into political stereotypes doesn’t help either. If liberals insist this is bowing to evangelical political pressure, we risk repeating the mistakes over the past two years. If conservatives don’t address the issue, we risk losing a key fiscal control measure.

The appropriate solution is to support health and social service innovation across the geographic and political spectrum and build capacity to evaluate the impact of those innovations. Only then will we have adequate answers to what works in varying communities and situations... and what doesn’t.

Matthew Amsden is CEO of ProofPilot, a venture-backed online platform to design, manage and participate in research studies that determine what works to improve lives.

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