Why what we study is shaped by our motivations, and what this means for what we know
This piece was co-written by Dr Salma Abdalla and is also cross-posted here
We all create our stories. Who we are and what we do are grounded in the foundational narratives that bring coherence to our day to day. Our work in public health is no exception. The foundational story of population health science and scholarship is that we work to advance health through the force of good ideas: the right questions rise, evidence accumulates, truth wins out. It is a flattering self-image. It is not, however, entirely accurate. Yes, there is much that we do that emerges as we follow the idea-trail, informed by our best thinking about how we generate health. But there is also much that we do that is determined by far more prosaic motivations: by what is funded, fundable, publishable, and institutionally rewarded. The “marketplace of ideas” is, in practice, a market, with budgets, buyers, and incentives. This is not a story of bad actors, but of structures. It is important to understand those structures in order to see where there are gaps in our thinking, and why it is that particular populations may be left behind in having questions that matter to them answered.
It is abundantly well-established that what is studied, and what is funded, are only weakly related to what the actual population burden of disease is. Gross, Anderson, and Powe found NIH funding tracked some measures of disease burden but diverged sharply for many conditions, with clear over- and under-funded outliers relative to need. Replications across decades have shown similar findings; Gillum and colleaguesfound funding poorly predicted disease burden, and a more recent analysis found very limited correlations between NIH funding and five measures of disease burden across 27 conditions.
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