From the fascinating MAQ Blog curated by the fascinating and delightful Theresa MacPhail:
[a] story-centered approach to examining health policy, however, is barely tolerated in mainstream policy circles. One recent example is a blog post on the Health Affairs website written by economists Katherine Baicker and Amy Finkelstein. Based on their own research into Medicaid expansion in Oregon, these authors argue that stories are little more than anecdotes that are incapable of providing the “evidence” necessary to develop and assess health policies. Instead they contend that more “rigorous” methods, and particularly randomized controlled trials (RTCs) are needed.
Interesting. I’ll say right off the bat I’m a friend and a fan of med anthro, qualitative work, and ethnography in general. I rely on it heavily for my work.
I’m also not here for the epistemic chauvinism evident in the notion that “stories are not rigorous,” which is abject nonsense if you know the first thing about ethnographic and qualitative methods (more specifically: stories in and of themselves may not constitute rigorous data, but neither is a random internet survey. Rather, systematic and careful methodology can render either collection and analysis of stories or insurance claims data rigorously produced, valid, and reliable).
I have firsthand practical experience of the power of narratives. I practiced pharmaceutical, hospital, and insurance litigation for 5 years in Texas, including mass tort pharma litigation. Causation in these cases is almost impossible to prove, b/c the plaintiffs were often quite sick already, there’s a zillion confounders, and epidemiologic causation is brutally difficult to establish.
Plaintiffs should basically have never won, by the standards required under the law. But they did, and when they did, it was because their stories were compelling.
When I teach about the use of stories in public health policymaking, we work from the notion that such stories are crucial, indispensable, and yet also dangerous. We ignore these stories at our peril — there is so much that is so important in them.
And yet, public health policy made on the basis of a few stories — note that in this context the stories would NOT make for valid and reliable data — can be disastrous, and there are many examples of this. The one I use are the horrifying patient dumping stories of the early 1980s, which led Congress to enact the unfunded mandate of EMTALA. There is good evidence that EMTALA has actually DECREASED access to emergency care for people in at least some rural and resource-poor settings. The use of stories in the congressional testimony prompted Congress to run off and apply a fix that was in too many cases actually worse than the status quo.
This is not a basis for rejecting the use of stories in public health policy, of course. As I said, they are indispensable to sound, humane public health policymaking. But basing public health policies only on stories that are not collected and analyzed in rigorous ways in indeed dangerous for sound, humane public health policy.
Here‘s a nice defense of the use of stories in both clinical practice and in health policy, in JAMA, no less.
(For those interested in looking further into this issue, the work of political scientist Sylvia Tesh is quite fascinating).