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16/09/2014

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Public engagment: a dangerous export?

Think what you wish for, warns Elizabeth Pisani

‘Public engagement’ has been the mantra of the naughties.

I spent much of that decade working as a jobbing scientist in low-income countries, and I have a confession. Until I started hanging out with science geeks in London a couple of years ago, I had never even heard the phrase ‘public engagement’. But I'm pretty sure we were doing it every day. 

Engagement in practice

You can't do research with drug injectors and sex workers without employing them on the team, without their help defining research questions, without drinking endless cups of sticky tea with police, religious  and community leaders. And there would be no point having done the research if we didn't help communities, journalists and policy-makers understand the results.

We drew 100 penises on charts and then drew condoms over 40 of them to help transgender sex workers understand levels of consistent condom use with clients. For HIV infection we had to colour in a heartbreaking 22 of the 100 sex workers on the chart.

In response, the sex workers proposed a ‘No condom, no sex’ campaign. So we produced more conventional PowerPoint graphics they could show to politicians. We gave journalists a lot of background information so that they could cover discussions between sex workers and politicians sensibly, and the campaign got funded.

We didn't think of it as public engagement, we thought of it as part of our job as public health researchers. Certainly, it doesn't match up to some of the exciting science/art/comedy crossover activities that fall under the public engagement rubric in the UK. And that's as it should be.

Culturally specific

In the biomedical sciences, we look for technical solutions that work equally well for anyone. When we find them, we discover they are not that transferable after all. Technically, antiretrovirals work as well against HIV in a straight Southern African woman as in a gay North American man. But if the woman can't get the pills because her government is sulking about neo-colonialism, or because his government is sulking about intellectual property rights, or her husband believes the pills are poisoned, they don't work so well.

Most of those obstacles are rooted in the vastly complex interaction between science, beliefs, cultures and cash -- the very fulcrums on which public engagement programmes dance. They are by definition situation-specific. The programmes that we devise to engage the public with science in the UK may not be appropriate in Niger or Peru. What's the point having a giant science talent show to get kids excited about science if there are no jobs in science for them to aspire to?

Unless public engagement is driven by local needs, needs that match the current levels of scientific and political literacy in a country, it's likely to remain peripheral.

Dangers of engagement

Real engagement is dangerous, because -- dare I say it? -- the ‘public’ does not always know best. HIV is a classic case. People who are already infected queer the pitch in favour of treatment. Bombastic moralisers won't countenance spending public money helping wicked people do repugnant things more safely. Both of these groups shout more loudly than the millions of sex workers, drug injectors and gay men who need prevention services in, let's say, China or the United States. Of the two, China has the better HIV programme precisely because policymakers don't engage with the public very much.

I believe you can't do good population-based research without real engagement. But too much engagement can trip up your ability to turn research results into good policy. Before we go selling inappropriate models of engagement around the globe, we should think carefully about what we wish for.

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Elizabeth Pisani
Elizabeth Pisani is an epidemiologist and Director of public health consultants Ternyata Ltd. Her blog on public health policy is at www.wisdomofwhores.com
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