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Knowledge translation and breast implants: A tale from a former policy advisor in Central America

By Francisco Oviedo Gómez
on March 13, 2015

Till recently, I worked as a staff advisor to the Office of the Minister of Health in my country Costa Rica. “What does an advisor to the Minister actually do?” was a question I often got from friends and peers external to the Ministry. I always found it difficult to explain in a brief way what my duties were. Then one day someone asked me if I considered myself a policy maker. That moment turned out to be my ‘Eureka’ moment.  From then on, I could explain in a straightforward way what my job was about: “No, I am definitely not a policy maker, I’m more of a policy reviewer.” Case closed.  Saved me many awkward moments ever since!

But what does being a policy reviewer involve? Well, most of my tasks at the time were related to going through proposals of policies supported by different stakeholders (medical associations, trade unions, congressmen and women, among others) for enforcement by  the Minister (laws, decrees, plans and projects, …). I had to provide the Minister with relevant information to determine whether those proposals were viable or needed adjustments.

In this job, like in most jobs related to decision-making, timing is critical. A clear answer must be given oftentimes in a very short period of time and supported with enough concrete arguments to defend the decision. Even though I was not quite familiar with the concept at the time, I have since realised that my job was basically about “knowledge translation”.

Knowledge translation (KT) is the umbrella term for all activities involved in moving research from its sources into the hands of people and organizations that can put it to practical use. The Canadian Institutes for Health Research (CIHR) defines KT as follows: “Knowledge translation (KT) is defined as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system.”  Since then, many other definitions and conceptualizations of KT and related terms have seen the light, also for LMIC settings and so K* is gaining prominence as an all-encompassing term.

But this is the ideal. Now over to the reality in Costa Rica at the time.

As you can imagine, a policy reviewer in my situation has a big problem when there is little or no information that matches his decision-making needs (i.e. related to the specific request). There is an even bigger problem if there is too much relevant material and particularly if the material is contradictory. In my experience, the second scenario was far more common.

As is probably clear by now, we didn’t have a structured way of “doing K*” in Costa Rica at the time, so my job wasn’t straightforward. The many different interests in play made my job even harder. But on the other hand, it was a welcome challenge, and I thoroughly enjoyed it.

As an example, one of the very first challenges I encountered in my career as ‘policy reviewer’ came when a global alert was issued, warning that a brand of silicone breast implants commercialized all over the world had been produced using industrial silicone instead of medical silicone (the only kind that has been approved for such devices). The problem became rather urgent for my boss since there was no knowledge available about the possible impact of this product on women’s health, and thus countless speculations started popping up, most of them coming from – you guessed it –  mass media reports.

So there was a huge amount of pressure on the Minister stemming from the general public, and especially from the women affected. They demanded a swift answer – did they need to proceed immediately to remove those implants or was a more conservative and observational approach favourable instead?  It is important to note here that these concerns not only affected us in Costa Rica, but in every single country where these implants had been sold. Nobody was exactly sure what to do.

At the time we counted around five hundred women with this issue in the country, with the majority of them (over 350) breast cancer survivors who had gotten their implants as part of reconstructive surgery after a complete mastectomy – surgical removal of breasts – in public hospitals. A massive removal and change of implants would have implied a rather large – and furthermore unplanned – expense for the public health services. So there were substantial financial consequences.

Within weeks, in December 2011, some “information” started emerging, with some of it saying that there was a clear risk that the product could cause some form of harm for the women, including possibly cancer. Although the evidence for these particular assertions was not very strong, and in some cases even non-existent, this was the information that most people in the general public were paying more attention to, and tended to rely on.

Six months after the media reports in June 2012, publications from a panel of experts came out which indicated that there was no major threat for women’s health and thus not necessary to proceed with the removal of the implants.

The challenge for us then became: how could we translate the evidence we had – which told us that no rushed actions needed to be taken – into a good decision that could achieve the multiple goals we were aiming for:

  • to prevent any harm for the affected women,
  • to avoid a (non-planned) additional economic burden on the public health system,
  • to release the fears and uncertainties of the affected people.

 

That process was not easy, to say the least. A lot of discussions and public debates took place with and among different stakeholders, with each one defending their point of view and interests.  In sum, the women who got the implants wanted a full replacement with no cost;  the private plastic surgeons did not want to take any responsibility in the matter, not even to remove the implants;  public hospitals only wanted to provide help with women they had treated and so on.  As a policy reviewer, I sometimes wished King Solomon was one of my ancestors.

Finally a decision was taken, palatable to all involved stakeholders: free services were offered by the public hospitals to all women who wanted a removal of the implants; as for those women who declined the surgery, they would be part of a periodic surveillance program. In addition, a new set of implants were offered to those women who had received their implants due to breast cancer (as opposed to elective breast enhancement). In the end most women opted for keeping their implants and not going for new surgery.

Ultimately the main lesson I learnt from this episode was that decision-makers will not always have the chance to communicate directly with researchers who are able tailor their research to policymaker needs. As a policy reviewer and advisor to the Minister, you will not always find the information you need to support your recommendations. And sometimes when you do find the needed information, it can actually lead to more trouble, for example when the technical scientific data points to an answer different from the one expected by the general public. In many circumstances, it is key to aim for translating the available evidence into a “good enough” and politically feasible decision, rather than the scientifically optimal one.

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