“Economists are the gods of global health.” Richard Horton at it again!

Richard Horton dislikes the economics discipline. That should not come as a shock to anyone. But worse still, this animus appears to arise from a misunderstanding of what economists actually do. Not so long ago, we discussed the fundamental errors in a piece in The Lancet Horton had published. Well, a new tweet from Horton leads us to yet another piece denigrating the economics profession:

The essence of Horton’s latest tirade is that (1) “economists silence the smaller voices of medicine”, (2) economists are responsible for austerity, (3) austerity has had a harmful effect both socially and economically, so that (4) “The task of health professionals is to resist and to oppose the egregious economics of our times.” The implication of the four points being that the influence of economists should be (at least partially) extricated from medicine and medical research. I would agree with point (3) here, as do a large consensus of academic economists (read this post and others from Simon Wren-Lewis for a good summary). But the other points don’t really stand up to close scrutiny.

One of the goals of academic economics is to provide evidence to support an optimal allocation of resources. From a macro perspective this may be the allocative efficiency of spending on different sectors like education and health care. Or, in a context used for much health economic analysis, how to allocate a health care budget fixed by the government through a political decision making process. What is considered ‘optimal’ in each of these circumstances is a normative decision and is, again, a political choice in practice. Perhaps this overlap with politics and economics has confused Horton, who mistakes one for the other with claims like

It is economists we must thank for the modern epidemic of austerity that has engulfed our world. Austerity is the calling card of neoliberalism.

But Horton also claims economics has displaced the “modest discipline of biology” in medicine. So, a reductio ad absurdum argument would have economists doing all the medical research and then implementing all medical and health care policy. Why do we need anyone else?

One can certainly claim this blog post is an apologia for economics. Of course would defend it. But it is true that there are good examples of poor economics and academic overreach. The work of the late Gary Becker was often criticized along these lines; his rational theory of addiction in particular. However, criticisms of the work of economists frequently come from economists themselves. I hope this blog serves as a case in point. More and more, health economists work as members of interdisciplinary teams, where a plurality of approaches, qualitative and quantitative, can aid in making sound inferences and supporting effective policy.

Horton’s views cannot unfortunately be dismissed as the ravings of the uninformed. He occupies an important position in medical research, serving as the editor-in-chief of one of the top medical journals, and his voice is influential. It serves no useful purpose to anyone and undermines the positions he advocates for, which many economists actually agree with, to publish false claims about economics.



How to cite The Academic Health Economists’ Blog

Occasionally we get emails from people who would like to cite our blog posts. Usually, these requests are framed as ‘is this going to be published in a journal?’. It’s no surprise that people are more comfortable citing the traditional academic literature. But researchers are increasingly citing blog posts. Indeed, some of our blog posts have been cited in published academic literature.

There are plenty of guides out there for citing blog posts. You may like to refer to them for specific formatting styles. Cite This For Me is a useful tool for generating references in a variety of styles. Here I’d like to provide a few specific recommendations for citing posts from this blog.

1. Cite the author

Our blog posts are written by lots of different authors, not by ‘the blog’. The author’s name – assuming they have not claimed anonymity – will appear at the top of the blog post. Let’s take a recent example. To start with, your citation should look something like:

Watson, S. (2017). Variations in NHS admissions at a glance. The Academic Health Economists’ Blog. Available at: https://aheblog.com/2017/01/25/variations-in-nhs-admissions-at-a-glance/ [Accessed 8 Mar. 2017].

2. Use our ISSN

As of this week, the blog now has its own International Standard Serial Number (ISSN). This number uniquely identifies and distinguishes the blog. Our ISSN is 2514-3441. You can find it at the bottom of the sidebar and on our About page. So your citation could become:

Watson, S. (2017). Variations in NHS admissions at a glance. The Academic Health Economists’ Blog (ISSN 2514-3441). Available at: https://aheblog.com/2017/01/25/variations-in-nhs-admissions-at-a-glance/ [Accessed 8 Mar. 2017].

3. Use WebCite

Unlike journal articles, websites can change. One of our authors could (in principle) completely change the content of their blog post after publishing it. More importantly, it is possible that our URLs may change in the future. If this were to happen, the link in the reference above would become redundant and the citation would not be useful to readers. What needs to be cited, therefore, is the blog post at the time at which you accessed it. Enter WebCite. WebCite is a service that archives a webpage and provides a permanent link for citation. This can be achieved by completing an archiving form. Our citation becomes:

Watson, S. (2017). Variations in NHS admissions at a glance. The Academic Health Economists’ Blog (ISSN 2514-3441). Available at: https://aheblog.com/2017/01/25/variations-in-nhs-admissions-at-a-glance/ [Accessed 8 Mar. 2017]. (Archived by WebCite® at http://www.webcitation.org/6ooALaGyF)

4. Check the comments

Finally, authors may choose to subsequently publish their blog post elsewhere in another format or to upload it to a service such as figshare in order to obtain a DOI. Check the comments below a blog post to see if this is the case as there may be an alternative source that you might prefer to cite.

But as ever, if you’re struggling, get in touch.


What’s going on at the New England Journal of Medicine?

Editorial policies between the top medical journals differ. Some take a ‘crusading’ view and campaign on contemporary health issues. The BMJ falls into this camp, although this has sometimes led them to take political positions that might be contrary to the evidence. Nevertheless, the editorial agenda of the BMJ is clear, readers know what they are backing. The NEJM on the other hand seems to have adopted a more opaque position.

On the face of it the NEJM seems to support a position of ‘if a randomised controlled trial (RCT) has been conducted and it’s published then that’s the last word on the matter’. Some recent examples illustrate this. Ben Goldacre and colleagues in the COMPARE project received a dismissal of their letters penned to the NEJM that expressed concerns over trials that had not reported on the primary outcomes specified in their protocols or reported different outcomes. The New York Times reports on potential flaws or even misconduct in a mega trial of Xarelto, an anticlotting drug, for which the manufacturers are currently being sued. The NEJM, which published the trial, dismissed the relevance of the claims and defended the trial. And, in a recent, controversial editorial, the NEJM appears to endorse the view that researchers who re-analyse trial data from other studies are ‘research parasites’.

This view is not unique to the NEJM. It reflects a broader view that RCTs are definitive and research in top impact factor journals more so. But, scientists are fallible, and RCTs can be flawed and present biased results. For example, in a study of the top four medical journals 95% of RCTs had some missing data, with a median percentage of 9% dropout, and in many cases adequate missing data methods were not used. Publication should not be the final stage of a piece of research but part of an ongoing process.

Part of the problem may lie with the false dichotomy imposed by hypothesis testing and statistical significance. A treatment either works or does not work or it is safe or it is not safe. But, for the most part, these tests are based solely on asking whether the data are compatible with the hypothesis or whether it’s unlikely. All the other forms of uncertainty are not taken into account such as missing data, a lack of adequate allocation concealment, or a lack of double blinding. The researchers could have chosen any number of different tests or comparisons and the choice could be contingent on the data, potentially rendering the p-value meaningless.

Results from RCTs are used to make important clinical and policy decisions. Scrutiny and debate are essential to ensure that the best decisions are made. This includes allowing for an appropriate representation of the uncertainty surrounding a decision. The trust endowed by a high impact factor should bring a responsibility to ensure that well founded critical or dissenting views on published research are appropriately represented. RCTs should be subject to as much scrutiny as any other form of research. Vioxx should serve as an important reminded of this.