【从婴儿睡觉说起】FT专栏作家哈福德:儿科权威在1948年建议让婴儿趴着睡觉,这条未经随机试验鉴定的建议导致6万婴儿猝死。当今许多社会政策也面临同样的不幸。
2010年04月08日 06:06 AM

从婴儿睡觉说起
POLITICAL IDEAS NEED PROPER TESTING

背景
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I don't recall it myself, but like most babies born in 1973, I apparently slept face down in my cot. This was the standard advice, made famous by Benjamin Spock in 1948. We now know that for many unlucky families, this well-meaning advice was fatal. According to research published in 2005, putting babies to sleep on their fronts has led to about 60,000 cot deaths.

我自己不记得了,但与1973年出生的大多数婴儿一样,显然我在婴儿床里是趴着睡觉的。这是那个年代的标准建议,由赫赫有名的美国儿科医生本杰明•斯波克(Benjamin Spock)于1948年提出。现在我们知道了,对于很多不幸的家庭来说,这条善意的意见是致命的。根据2005年发布的研究报告,让婴儿趴着睡觉,已导致大约6万起婴儿猝死事件。

The story is a favourite of Sir Iain Chalmers, a campaigner for better standards of evidence in medicine and beyond. Because it is possible to do so much unwitting harm in medicine, many medical interventions are now subjected to a randomised controlled trial. Austin Bradford Hill performed the first properly controlled clinical trial in 1948, although he had predecessors, including James Lind, who used a randomised trial to show that citrus fruit prevented scurvy. There's even a controlled trial in the Bible (Daniel 1:8). Such trials have proved the effectiveness of countless treatments, and the dangers of countless others.

这是伊恩•查默斯爵士(Sir Iain Chalmers)最爱讲的一个故事——他大力倡导提高医学及其它领域的证据标准。由于在医学中有可能造成如此严重的无意伤害,目前许多治疗都须经过随机对照试验(randomised controlled trial, RCT)。1948年,奥斯汀•布拉德福德•希尔(Austin Bradford Hill)进行了第一个真正意义上的对照临床试验。不过,此前已有先例,例如,詹姆士•林德(James Lind)曾通过一项随机试验证明,柑橘类水果能预防坏血病。甚至在《圣经》(但以理书1:8)中也出现过一例对照试验。这些试验既证明了无数治疗的有效性,也证明了无数治疗的危险。

It is a shame, then, that there is so little appetite from politicians for the same standards of evidence outside medicine. In fact it is more than a shame – it's a scandal. While randomised trials are not going to tell us when to raise interest rates or get out of Afghanistan, there are many policies that could and should be tested with properly controlled trials. Is Jamie Oliver right to emphasise healthy school meals? Run a trial. Should young offenders be sent to boot camp, or to meet victims of crime? Run a trial. What can we do to persuade households to use less electricity? Run a trial.

因此,政客们基本上无意在医学领域外追求同样的证据标准,就是件憾事了。实际上,这不只是件憾事,简直就是丑闻。尽管随机试验不会告诉我们何时加息或从阿富汗撤军,但的确有许多政策可以(也应该)用规范的对照试验来检验。杰米•奥利弗(Jamie Oliver)强调健康校餐的做法对不对呢?那就做个试验好了。未成年罪犯应该被送到劳教营,或者与受害者见面吗?做个试验好了。我们能做些什么来说服家家户户减少用电呢?做个试验好了。

Yet such trials are not common in the US, and downright rare in the UK. There is no financial, ethical or practical excuse for this. Trials are cheap. (Even if they were expensive, solid practical knowledge is well worth paying for.) This is not a question of carrying out dangerously speculative crank experiments, but simply adding the essential ingredient of randomisation to a standard pilot project that would have happened anyway. Randomising is often what distinguishes proper evidence from statistical mush, by removing biases in the setting of experiments – such as running pilots only in the most needy areas.

但此类试验在美国并不普遍,在英国更是绝对罕见。无论是从资金上、还是从道德层面或实际操作上讲,这都找不到理由。试验成本非常低。(即使成本很高,扎实的实践知识也绝对值得投资。)这不是要进行某种危险、投机的怪诞试验,而只不过是给一个本来就会实施的标准试点项目,添加不可或缺的随机成分。通过消除试验设定中的偏差(例如只在最贫困的地区进行试点),随机试验往往能区分适当的证据与统计干扰。

When the UK government recently introduced the “synthetic phonics” method of teaching young children to read, they were told by Carole Torgerson, an evaluation expert at the University of York, that they could easily bolster the slim evidence base by randomising which schools joined the programme first. They didn't. (More encouragingly, Ms Torgerson has been commissioned to evaluate maths teaching.)

英国政府近来开始推行“看字读音教学法”(synthetic phonics),教幼童阅读。约克大学(University of York)评估专家卡罗勒•托格森(Carole Torgerson)向政府保证,通过随机选择第一批加入该计划的学校,很容易就能增强不充分的证据基础。但结果并非如此。(更令人鼓舞的是,托格森女士已接受政府委托,去评估数学教学。)

Some people feel queasy at talk of “experimentation” in the classroom, prison or benefit office – but politicians experiment on us all the time with their latest policy wheezes. We learn little or nothing because the experiments are badly designed.

一些人觉得在教室、监狱或福利办事处里谈论“试验”令人不自在,但政客们一直在用他们最新的政策伎俩来拿我们做试验。由于这些试验设计得太糟糕,我们从中得不到什么知识积累。

What is missing is the political demand for tests of what really works. Too many policies on education, welfare and criminal justice are just so much homeopathy: cute-sounding stories about what works leaning more on faith than on evidence. Politicians and civil servants, faced with some fancy new idea, should get into the habit of asking for a proper randomised trial. And we, as citizens, should be equally demanding.

缺失的是对检验哪些政策真正管用的政治诉求。太多的教育、福利及刑事司法政策都不过是顺势疗法(homeopathy):讲一些什么会见效、听上去很奇妙的故事,更多地依靠信仰,而非证据。面对一些别出心裁的新想法,政客和公务员应养成要求进行规范随机试验的习惯。而我们作为公民,同样应该如此。

It's no coincidence that one of the few fields of social policy to feature more than 100 robust trials is the study of how to get voters to turn out in elections. Politicians seem perfectly happy to turn to scientific method if it will get them elected. They are less interested in using it for the good of the people they govern.

并非巧合的是,仅有的几个进行了100多次健全试验的社会政策领域中,有一个就是研究如何让选民参与选举。只要能让自己当选,政客们似乎完全乐意求助于科学方法。而对于利用这些方法来为统治下的民众谋利,他们就不那么有兴趣了。

It is embarrassing even to have to make the case for randomised trials in social policy. For medical researchers, such trials are just the start. Realising that inconvenient – or just plain boring – trial results are less likely to appear in print, medical journals now refuse to publish trials that were not logged before they started in a register of trials. Such registers ensure embarrassing results cannot be made to disappear. This is vital in medicine, and just as important in social policy.

社会政策中的随机试验竟然还需要大力提倡,这本身就很丢脸。对于医学研究人员而言,这种试验仅仅是个开始。由于认识到“不方便”(或者仅仅是乏味)的试验结果不太可能付印,现在医学杂志拒绝发表那些没有预先在试验登记册上登记的试验。这种登记确保了令人难堪的结果不会被人为抹去。这在医学中极其重要,在社会政策中也一样。

Trial registers also feed into systematic review bodies such as the Cochrane Collaboration, which is an international offshoot of a National Health Service initiative. In less than two decades, the Cochrane Collaboration has published 4,000 systematic reviews of medical treatments, digging up data from unpublished trials, and providing the information to save many lives. A parallel body for social policy has far fewer trials to evaluate.

试验登记册还要提交给系统评价组织,如“Cochrane协作”(Cochrane Collaboration)——英国国民保健服务(NHS)发起的一个国际组织。在不到20年的时间里,该组织就发表了4000份针对各种治疗方法的系统评价,从未发表的试验中挖掘数据,为挽救众多生命提供资料。而一个类似的社会政策组织,所需要评估的试验要少得多。

The Cochrane Collaboration has become a byword for a fair and comprehensive review of a treatment – the latest word (never the last word) about what works. We need the same shorthand in policy, a quality kite-mark that tells us politicians have actually done some homework before they roll out their latest brainchild. We've had FairTrade coffee – what about FairTest policies? Most voters don't know much about randomisation or trial protocols, but they'll know when they see the FairTest logo that a policy has had a proper, scientific test to see if it works.

Cochrane协作已成为对一种疗法进行公正全面评价的代名词——是有关哪些疗法管用的最新结论(永远不是最终结论)。我们需要对政策进行同样的提炼,打上一个质量证明标记,告诉我们最新的政策出炉之前,政客们真的做过一些准备。我们已经有了“公平交易咖啡”(FairTrade coffee),何不来一些“公平试验政策”(FairTest policies)呢?多数选民对随机化或试验方案了解不多,但如果看到公平试验标记,他们会知道这项政策已经过规范的科学试验,以检验其是否有效。

Many social, educational and economic policies are the modern equivalent of Dr Spock's advice that babies should sleep face down: well-meaning, authoritative – and wrong. No doubt it would be awkward to see the wisdom of experts punctured and the pet policies of politicians discredited on a regular basis. But if politicians really cared about those they represent, they would insist on more randomised trials and more systematic reviews of what works. Honest policy mistakes, quickly reversed, should embarrass nobody. As voters, we should demand more such mistakes.

许多社会、教育和经济政策就相当于现代版的斯波克教授让婴儿趴着睡的建议:善意、权威,但却是错误的。毫无疑问,频繁看到专家的学识出现漏洞,或者政客们特别倾心的政策名誉扫地,是件尴尬的事儿。但如果政客们真的在意自己所代表的选民,他们会坚持进行更多随机试验和更多系统化评价,确定哪些政策管用。只要迅速撤销,政策上的无心之过不应让任何人感到难堪。作为选民,我们应该要求更多这样的错误。

The writer is the FT's Undercover Economist

本文作者为英国《金融时报》“卧底经济学家”

译者/何黎

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蒂姆•哈福德(Tim Harford)是英国《金融时报》的经济学专栏作家,他撰写两个栏目:《亲爱的经济学家》和 《卧底经济学家》。他写过一本畅销书也叫做《卧底经济学家》,这本书已经被翻译为16种语言,他现在正在写这本书的续集。哈福德也是BBC的一档节目《相信我,我是经济学家》(Trust Me, I’m an Economist)的主持人。他同妻子及两个孩子一起住在伦敦。